Mined on a Novel Method by Dissecting Off a Flap from Finger, Carried

After much deliberation, Professor Senn deter- PERITONEAL SUPPORTS\p=m-\(LIGAMENTUM mined on a novel method by dissecting off a flap from the dorsum of the hand, adjoining the thumb, leav- PERITONEI). ing both ends of the flap attached, and slipping it BY BYRON ROBINSON. over the the thumb into the place vacated by excised PROFESSOR OF GYNECOLOGY POST-GRADUATE SCHOOL. -scar. CHICAGO. (Continued from page 110.) The splenic artery perhaps throws more light on the disposition of the mesogaster than do the gastric and hepatic arteries. The splenic artery arises from the celiac axis and passes at first, slightly downward and then toward the left along the upper border of the pancreas. It is a large spiral artery, but does not project the peritoneum into a very prominent fold, yet the outline of the fold is especially prominent in those animals in which the omentum and transverse colon do not have contact relations, especially at the left end. The prominent feature of the splenic artery in regard to the mesogaster is that the artery in its course lies to the left of the right blade of the meso- until it turns to access A.—Volar aide with flap in place. Dorsal side with outlines of flap. gaster suddenly upward gain B.—Grafted triangle. An incision was started from the base of the first finger, carried obliquely upward to near the base of the metacarpal of the thumb; the second incision was parallel to this, about one inch toward the middle finger. The flap was carefully dissected off, pre- serving the subcutaneous veins. The doubt as to the possibility of slipping it over the bent thumb was soon removed by the ease with which it was made to assume its new place, where it was anchored by two rows of interrupted sutures. A small triangular de- fect between the flap and the base of the little finger was filled by Thiersch's grafts. The dorsal wound was easily united by interrupted sutures and the usual splint and dressings applied. At the clinic, a week later, the child was exhibited ; the flap had united per primam, the grafts adhered, the dorsal wound was closed and the thumb in its proper place. The prospect of permanent cure of the contracture was assured. ENEMATA OF WHITES OF EGGS. MEMORANDUM. BY JOHN ASHBURTON CUTTER, M.D. Fig. 22 is copied from the excellent anatomy of Prof. Gegeubaur German It is the of an emi- NEW YORK. (1884 edition). chiefly to represent views nent comparative anatomist as regards the transverse colon and omen- Albumen of eggs is valuable to feed when tum. It may be ooBerved that his idea is that of coalescence, for his patients mesocolon transversum consists of four layers (Xo. 3). 1, gastro-hepatic other forms of nourishment can not be taken or to omentum; 5, lesser omental cavity; p, pancreas; 3, mesocolon trans- other I versum; 4, mesenterium; dt duodenum; c, colon; 2, anterior layers of reinforce nourishment. have known patients great omentum; r, rectum; 6, great omental cavity; 7, reflections of to take the whites of eggs in one with coronary ligament; ,/, intestine. However, Gegenbaur mentions in his eighteen day text-book the displacement theory without committing himself to it. evident advantage, in some cases the result appearing almost life-saving. to the space between the blades of the ligamentum Exhibition by the mouth is made in three ways: gastro-lienalis, but the other equally important fea- 1, raw; 2, raw with milk; 3, dropped in boiling water ture is that the splenic artery for all its straight and slightly cooked. horizontal course lies against the posterior abdom- Enemata of uncooked whites I have lately used inal wall, *. e., it does not lie against the left blade of with decided benefit. Administration by a Davidson the mesogaster, for that blade has by developmental hard rubber syringe No. 494, one ounce. Eggs vary processes been re-adjusted, displaced, or as some in size and weight and should be sold by weight; the would argue, coalesced. In the process by which the albumen of an egg varies in bulk from one-half to liver forced the stomach to the left and downward one ounce as eggs run. and gave origin to the elongated mesogaster and Drugs can be administered with the raw albumen; lesser omental bag, the left blade of the mesogaster sometimes a little laudanum is needed, but rarely, to has been displaced to the left, hence the left and quiet bowel. Patients state that an enema relieves posterior surface of the splenic artery is without a the faint gone feeling in stomach, and such relief is eerous cavity for the most of its trunk, or until it longer than when the whites are administered by the turns upward into the gastro-splenic ligament. The stomach. splenic artery being devoid of its serous covering for Equitable Building, New York. the length of the chief trunk, on the left side reveals Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/07/2015 a developmental process in the original process of for- of man. So that the thread of development can be mation of the mesogastrium posticum or great omen- demonstrated by investigations in embryologic and tum. This bearing of the splenic artery gives an actual mammalian life, far below man in structure. demonstration that the left blade of the mesogaster In one series of fifty autopsies, I recorded the posi- is displaced to the left by some force. In fact, the tion of the omentum in regard to the cecum and left blade is displaced several inches or more to the found the omentum covered the cecum in about eight left of its original insertion. cases. This is significant, as the omentum is a highly The process of re-adjustment, displacement (or important organ in an inflammatory peritonitic dis- even coalescence) is in accord with the previous trict like the appendicular. The omentum when it assertion that serous cavities and their walls are no- lies out of its normal position is apt to be rolled up where primary, but always a secondary process which behind the transverse colon. This, I think, is due to the emptying and filling of the colon with gas and feces. It may also be due to an occasional sudden filling and emptying of the small intestine with gas (Pl^ Fig. 27 (after Toldt, 1879) represents the three layers which compose a mesentery: mp, membrana propria mesenterii, i.e., the real neuro- vascular visceral pedicle; s a, subserosa; p p, peritoneal layers of epithelium. It is drawn from a cross section of the middle portion of the old times. mesenterium of a four year boy. Enlarged seventeen . by acute indigestion, from disproportionate secre- tions and consequent fermentation. In some autopsies it was evident that the great omentum had been rolled up behind the transverse colon for some time, for it was fastened there by bands. Also Fig. 25 (after Luschka, 18G3) is a beautiful and accurate transverse peritonitic cut at the level of the twelfth dorsal vertebra. This figure corresponds it seemed to become rolled up behind the colon by a more with own dissections as the relations exactly my regards splenic slow It is not a of the peritoneum than any known to me. 1, liver; 2, stomach; 3, gradual process. suddenly acquired spleen; 4, kidney; 5, adrenal; t>, diaphragm; 7, thoracic aorta; 8, infe- The omentum was found rolled up over the rior vena cava; 9, cavity of the lesser omentum. Observe that there are position. two points where the is uncovered by peritoneum, i.e., a strip at colon some six to times in one hundred cases. spleen near the adrenal No. eight its bilus and a strip at its posterior border, e.g., at near the flexura 5. This elegant and natural cut was also adopted by Dr. Bochdaleck, The chief rolling is accomplished Jr., in 1867, as a natural model. coli lienalis, but in one case in a series of fifty autop- is very active up to the sixth fetal month. Now, as the developmental process is the only key to the adult condition, we can only expect to understand the origin and formation of the great omentum by sticking close to the evolutionary processes in ani- Fig. 28. I present cut to illustrate a cross section of the peritoneal cavity at a level of Winslow's foramen. Pp, parietal peritoneum; vp, "^*_Or V_^_Jgfc^~~^|^ visceral peritoneum, stomach ; JS, round ligameut of the liver; L o, lesser omentum; P.pancreas; T'.venacava; .1,aorta; IT, kidney, F of Wy foramen of Winslow (the arrow points to lesser cavity of omentum). By this figure it will be noted that the spleen is uncovered in two strips, viz.; and on border. Fig. 26 (after Toldt, 1879) is introduced to show the shape of the hilus strip posterior epithelium which covers the surfaces of the mesentery. It is taken from the surface of the great omentum of a six weeks old child. It is sies, I noticed that it was rolled up over the magnified by Hartnack's xi ocul. 8. definitely system, flexura coli hepatis ; however, old peritonitis existed mals. Man's embryo passes through all lower mam- in this case. No doubt the position of the omentum malian stages, but the transitions are so rapid and is due to peculiar contractions and dilatations of the complicated that it is almost impossible with limited bowel, due to gases and feces and also to local peri- material to establish consecutive and logical facts in tonitis.

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