STUDIES RELATIVE TO TORSION OF
THE BOVINE CECUM

Thesls for “we Doqrca 05 M. S.
MICHIGAN STATE UNIVERSITY

Mark P. Rines
1958-

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STUDIES RELATIVE TO TORSION OF THE BOVINE CECUM

by

Mark P. Rines

AN ABSTRACT

Submitted to the College of Veterinary Medicine of
Michigan State University of Agriculture and
Applied Science in partial fulfillment of

the requirements for the degree of

MASTER OF SCIENCE
Department of Surgery and Medicine

1958

Approved j AZFJZ U2, (:3: wry/”.114,

 

2

MARK P. RINES ABSTRACT

Ten cases of torsion of the bovine cecum are reviewed.
Seven of these were diagnosed at the Michigan State Univer-
sity Veterinary Clinic, the first in May 1953. Another
occurred in Iowa in December 1953, and two were reported in
1957 from Oklahoma. The symptoms observed were similar to
other types of intestinal obstruction in the bovine except
that three of the cases had a watery diarrhea rather than
the usual scanty, mucus covered feces. Blood did not
regularly appear in the feces.

The condition is best diagnosed by rectal palpation
of the distended cecum, but an unusual fullness of the right
paralumbar fossa may be discernible. The failure to dif-
ferentiate this condition from other types of intestinal
volvulus and obstruction is proposed as an explanation for
the limited number of recorded cases.

Although the earlier cases were successfully corrected
'by detorsion of the cecum Via a laparotomy, the advisability
<3f replacing ceca distended to four or five times their
Inormal size, some with areas of avascular necrosis, was
<questioned. Recurrence of the torsion, the toxic effects
<>f necrotic tissue, and the release of venous clots were
Clonsidered as possible complications. One of the two cases
IPeported from Oklahoma did recur, accounting for the only

IDOSt-corrective fatality.

3
MARK P. RINES ABSTRACT

The desire to improve the operative correction of this
condition led first to a study of the normal anatomy and
then to the involvements of a torsion. Attempts to experi-
mentally produce a torsion of the cecum were unsuccessful.

A normal animal and a clinical case with a torsion were
embalmed and studied in detail. These findings were com-
pared with other clinical cases and other normal cadavers.

Mobility of the cecum in the normal bovine was found
to vary considerably due to the width and extent of its
only mesenteric attachment, the ileocecal fold of mesentery,
and could predispose these structures to a torsion. The
blood vessels to the area formed a consistent network which
was described and illustrated. The nerves, for the most
part, followed the blood vessels.

Torsions of the cecum cause a partial to a complete
obstruction of the initial colon with either a clockwise
or a counterclockwise rotation, when viewed through the
right side of the abdomen. Ingesta passing through the
relatively thick walled ilewm distends the cecum, increasing
the tension on the obstructed colon and on the associated
blood vessels. In all but two of the clinical cases the
cecum had displaced the greater omentum cranially and
medially, allowing the cecum direct contact with the right

abdominal wall.

u

MARK P. RINES ABSTRACT

The method of repair deemed most applicable for this
condition was surgical removal of the entire cecum posterior
to the ileocecal Junction. A satisfactory operative pro-
cedure was evolved through ten cecectomies performed on
normal animals. This procedure was then successfully used
to repair a clinical torsion.

To ascertain the effect of cecectomizing a normal
animal, four steers were put on a series of three digestion
trials-~one previous to the removal of the cecum, one two
weeks after its removal, and then a final trial several
months later. The coefficients of digestibility for their
alfalfa hay ration showed no significant variance between
the trials. In addition, three calves cecectomized when
very young were compared to three similar, normal calves
at about six months of age to detect any compensatory
enlargement of the remaining intestines. No consistent
increase in capacity of either the large or small intestine
was apparent.

All experimentally cecectomized animals were observed
after surgery for any sign of altered function. All recovered
normally, and post mortem examination failed to reveal any
post-operative complications. Periodic reports from the
owner of the clinical case cecectomized by this procedure
indicated that she had fully recovered and was performing

creditably.

STUDIES RELATIVE TO TORSION OF THE BOVINE CECUM

by

Mark P. Rines

A THESIS

Submitted to the College of Veterinary Medicine of
Michigan State University of Agriculture and
Applied Science in partial fulfillment of

the requirements for the degree of

MASTER OF SCIENCE

Department of Surgery and Medicine

1958

7’5-

“N

E “’54: a
(w *3 -LI‘&

ACKNOWLEDGMENTS

The writer wishes to express his sincere appreciation
to all those contributing to this study either directly or
indirectly. He is especially grateful to Dr. Wade O.
Brinker, Professor and Head, Department of Surgery and
Medicine, for his helpful suggestions and guidance; to Dr.
Harold Henneman, Associate Professor, Department of Animal
Husbandry, for his evaluation and comments; to Dr. George
R. Moore, Professor and Director of the Large Animal Clinic,
Department of Surgery and Medicine, for his encouragement
and constructive criticism; to Dr. Edward K. Sales, recently
retired Professor and Head, Department of Surgery and
Medicine, for his inspiration and understanding; and Dr.
Gabel H. Conner, Associate Professor, Surgery and Medicine,
for his cooperation. Drs. David J. Ellis and Clifford C.
Beck, Instructors, Department of Surgery and Medicine,
Ambulatory Clinic, supplied some of the case material upon
which this study depended, and Dr. Albert R. Drury, Assis-
tant Professor, Surgery and Medicine, photographed the
series on the operative procedure.

The author is deeply indebted to Dr. E. J. Benne,
Professor, Agricultural Chemistry, and other members of
that department for analyzing the samples of feed and feces,

and to Dr. C. F. Huffman, Professor, Dairy Department, for

iii

the digestion trial equipment and his friendly advice.

Dr. Charles Titkemeyer, Assistant Professor, Anatomy Depart-
ment, and other members of that department offered their
cooperation and equipment for the embalming of calves. And
finally, recognition is due the many veterinary students

who assisted in surgery, the embalming of calves, and other

miscellaneous tasks associated with this study.

TABLE OF CONTENTS

Page

INTRODUCTION. . . . . . . . . . . . . . . 1
REVIEW OF THE LITERATURE. . . . . . . . . . . A
SURGICAL ANATOMY . . . . . . . . . . . . . 18
Introduction. . . . . . . . . . . . 18
Experimental procedure . . . . . . . . . 18
Results and discussion . . . . . . . . . 21
Normal bovine . . . . . . . . . . . 21

Clinical torsion . . . . . . . . . . 27
Experimental torsion . . . . . . . . . 31

METHOD OF REPAIR . . . . . . . . . . . . . 3H
Introduction. . . . . . . . . . . 34
Experimental procedure . . . . . . . . . 35
Results and discussion . . . . . . . . . 38

THE CECECTOMIZED BOVINE . . . . . . . . . . . #5
Introduction. . . . . . . . . . . 45
Experimental procedure . . . . . . . . . A5
Results and discussion . . . . . . . . . 48
SUMMARY . . . . . . . . . . . . . . . . 52
LITERATURE CITED . . . . . . . . . . . . . 56
TABLES. . . . . . . . . . . . . . . . . 59

PLATES. . . . . . . . . . . . . . . . . 66

TABLE

mtwm

LIST OF TABLES

Dates of Digestion Trials.

Totals for Seven Day Experimental Periods
Chemical Composition of Hay Samples
Chemical Composition of Feces

Chemical Composition of Hay Samples on a Dry

Basis and the Coefficients of Digestibility.

A Comparison of Intestinal Capacity of Normal
and Cecectomized Calves .

PAGE
60
61
62
63

6A

65

PLATE

II.
III.

IV.

VI.

VII.
VIII.

IX.

XI-A.
XI-B.
XII-A.
XII-B.
XIII-A.
XIII-B.
XIV-A.
XIV-B.
XV—A.

XV-B.

Normal
Normal
Normal
Normal

Normal

LIST OF PLATES

calf,
calf,
intestines,
intestines,

intestines,

embalmed.

cecum exposed

dorso-medial view of cecum.
ventro-lateral view of cecum

drawn with a dorso-medial

view of the cecum . . . .

Normal

intestines,

drawn with a ventro-medial

View of the ileocecal junction.

Clinical cecal torsion, embalmed

Cecal torsion before manipulation.

Cecum rotated back to normal,

Cecum rotated back to normal,
View

Operative procedure,

dorso—medial View

ventro-lateral

initial incision

Cecum exposed through the incision

Injecting the local anesthetic.

Ligating blood vessels

Applying the Payr clamp . . .

Undersewing the Payr clamp .

Oversewing the Payr clamp . . . . . . .

The inverted intestinal stump

The viscera replaced

Suturing the muscles and peritoneum . . . .

PAGE
67
68
69
7 o

72
73
7L1

75

76
77
77
78
78
79
79
80
8o
81
81

PLATE

XVI—A.

XVI-B.

XVII.
XVIII.
XIX.

XX.

Suturing the skin with a buried suture pattern

The cecectomized steer on the day following
surgery . . . .

Steer in the digestion trial stall
Cectomized calf.
The viscera of the cecectomized calf.

Intestinal capacity equipment

vii

PAGE
82

82
83
8A
85
86

INTRODUCTION

- During a three year period starting in May 1953, six
cases of torsion of the cecum in cattle were presented at
the Michigan State University Veterinary Clinic. These
animals varied from three months to six years of age.
Although female Holstein-Friesian cattle accounted for five
of the six cases, this condition was first recorded in a
valuable,five year old, Herford bull on May 7, 1953.

In general, the symptoms most frequently observed in
these six cases were those characteristic of other intestinal
obstructions. Anorexia, decreased milk production, and
abdominal discomfort, followed by scanty evacuation of mucus
covered feces, frequently indicate an obstruction. The cow
may kick at her abdomen or lie down, only to get up again
in a moment. The restlessness is otherwise accompanied by
general depression. A gradual onset of symptoms character-
izes an obstruction due to torsion of the cecum.

Preoperatively, a torsion of the cecum is best differ-
entiated by rectal palpation, although an unusual fullness
of the right paralumbar fossa may be distinguishable in the
thinner cattle. A distended cecum is readily palpable Just
anterior to the brim of the pelvis and to the right of the

midline. Only in the more advanced cases was the fecal

material found to contain any appreciable amount of blood,
comparable to an intussusception.

Operative correction was instigated in five of the six
cases mentioned. Distension of the cecum varied from two
to five times normal size. Two markedly distended ceca had
areas of beginning necrosis, apparently due to impaired cir-
culation. Correction was accomplished by detorsion of the
cecum and associated structures. In three cases the size
of the cecum necessitated temporary exteriorization through
the right paralumbar abdominal incision and performance of
a cecotomy to empty it. In one case having a minimum of
involvement, the cecum was approached from an incision in
the left paralumbar fossa. In all of these cases the cecum,
ileum, and omentum were involved; however, the initial
twisting, it seemed,cou1d be either clockwise or counter-
clockwise, as determined by the direction of rotation nec-
essary to return structures to their normal position.
Recovery followed relocation in all five cases.

A torsion of the cecum reported at Iowa State College
by Francis (11) presented similar symptoms. This three
year old Holstein cow had been off feed for about five days,
showed abdominal discomfort, and passed only small amounts
of watery faces. A rectal examination revealed a large
accumulation of fibrin and mucus in the rectum and a greatly
distended cecum. Correction was made through a right

paralumbar incision, and a cecum, distended to three times

3
normal size, was taken to the outside for drainage. A degree
of uncertainty was expressed concerning the normal positioning
of the emptied cecum and involved intestines. Final
decision was based upon relief of tension on the mesentery.
The case improved daily and was discharged after a week of
hospitalization.

Although the recovery rate in those cases reviewed was
excellent, the possibility was apparent that cases could
develop for which emptying and relocating the cecum would
not suffice. The advisability of replacing within the
abdominal cavity a greatly distended and atonic cecum was
questioned, particularly those ceca having had an impaired
circulation. Not only should the effects of necrotic
tissue and the release of clots of venous blood be consid-
ered possibilities but also the increased probability for
recurrence following the distension and stretching of the
cecum and mesentery. This desire for improving the oper-
ative procedure and extending the knowledge of this condition
led to the following investigations. These have, for con-
venience, been divided into three sections—~(1) surgical
anatomy, including the involvements in a torsion; (2) the
method of repair; and.(3)possible effects of this method

of repair.

REVIEW OF THE LITERATURE

A review of the present veterinary literature could
cause one to conclude that torsions of the bovine cecum are
practically non-existant, but the Michigan State Clinic
records do not seem to Justify such a conclusion. Francis
(11» in a student review, reports a "Partial Torsion of the

I

Cecum of a Bovine,‘ occurring on December 21, 1953. He
also mentions the failure to find reference to this con-
dition in the literature and concludes that ordinarily any
displacement of the cecum would not sufficiently involve

the intestines to cause obstruction.

Recently Jones, Johnson, and Moore (16) reported two
cases of torsion of the bovine cecum. The symptoms observed
were in general those common to intestinal obstruction, vn131
one having diarrhea early in the cOurse of illness. Correc-
tion was by laparotomy,cecotomy, and detorsion, with the
eight year old Jersey cow recovering uneventfully. The
other, a sixteen month old Guernsey bull, relapsed on the
fifth post-operative day with recurrence of the torsion.
Death followed a second detorsion in 36 hours. This animal
reportedly lacked normal suspensory structures to the cecum

and colon, and no attachment of the greater omentum to the

duodenum was found.

A review of the medical texts indicates that a some-
what similar torsion can occur in man. According to Maingot
(20) volvulus of the human cecum is usually attributable to
congenital abnormalities such as the presence of a mobile
mesocecum and mesocolon. Early symptoms are mild, progress
slowly, and present increasingly severe colic. Signs of
intra-abdominal inflammation appear as late manifestations.
With due consideration for the difference in size, attach-
ment, and function of the human cecum, the following review
of the ailment in man.terangensteen.(33, p.385) offers much
food for thought.

Lecéne comments upon the rarity of volvulus of the
right colon and in 1910 says that he could find but
four other cases reported from all of France. Faltin
in Finland reported 28 cases in the five year period
between 1897-1902. Faltin gave as explanation for
this extraordinary frequency the large vegetable diet
(especially potatoes) eaten there. Volvulus of the
cecum is only possible in the absence of fixation
of the cecum or in the presence of a mesocecum and
mesocolon sufficiently mobile to permit torsion.

In such cases the cecum usually exhibits a contin-
uation of the mesentery possessed by the terminal
ileum. Many cases present in addition, failure of
complete rotation of the right colon (Rixford).

Harvey noted unnatural free motion of the cecum
and ascending colon in 13.3 per cent of examinations
performed upon 105 infants at necropsy. Chalfant
stated that unusual mobility of the cecum and
ascending colon were present in about 20 per cent of
persons of all ages.

The ceca of strictly herbivorous animals are compara-
tively much larger than is the cecum of man. Herbivores
require in the course of their alimentary canal roomy
storage compartments for the soaking and fermentation of

their bulky food. In ruminants this requirement is fulfilled

-chiefly by the complex stomach, especially the rumen, and
to a lesser extent by the cecum and colon (5).

The cecum in the adult bovine averages about 30 inches
in length and five inches in width. Its rounded blind end
commonly lies at the right side of the pelvic inlet while
anteriorly the cecum is directly continuous with the proxi—
mal end of the colon (26). The anterior two-thirds of the
cecum attaches to the terminal portion of the ileum by an
ileocecal fold of mesentery (14). The ileum Joins the
large intestine near the ventral border of the last rib,
forming the conventional demarcation between the cecum and
colon. The greater omentum lies between the organs and the
right abdominal wall (26).

Sisson and Grossman (26) describe the angiology of
this general area as follows. The anterior, or cranial,
mesenteric artery arises from the aorta Just behind the
celiac artery. It descends between the pancreas and the
posterior vena cava and then inclines backward, crossing
the colon as the latter emerges from the spiral mass. The
first main branch to the intestines, the middle colic
artery, passes to the colon as it emerges from its spiral
arrangement and runs caudally along the terminal colon.

The ileocecocolic artery, the second main branch, ramifies
on the right face of the spiral part of the colon. It giVes
off the ileocecal artery, which divides into the ileal and

cecal arteries. The third main branch, the ramus

collateralis, runs in the mesentery in a curve along the
ventral border of the coils of the colon. After giving off
these three main branches, the continuing trunk of the
cranial mesenteric pursues a course in the mesentery
supplying all but the initial and terminal small intestine.
It anastomoses at its distal extremity with the ramus
collateralis.

The blood returns via the portal system. The portal
tributaries are in general satellites of the corresponding
arteries. Blood from the entire intestine, with the
exception of part of the duodenum and the rectum, returns
via the cranial mesenteric vein to the portal vein.

The few cecal lymph nodes situated along the attached
surface of the cecum receive their afferent vessels from the
cecum and ileum. Their efferent vessels go to the common
intestinal efferent vessel either directly or via the colic
or ileal nodes. The common intestinal efferent vessel
runs upward and forward on the right side of the spiral
mass of the colon, and reaches the ventral face of the
posterior vena cava where it unites with the common efferent
vessel of the gastric lymph nodes to form the intestinal
trunk. The intestinal trunk proceeds between the aorta and
vena cava, uniting with the lumbar trunk to form the
cisterna chyli.

The neuro-anatomy of the viscera is best reviewed in

the human medical texts. The efferent nerves which supply the

visceral organs are components of the autonomic nervous
system (sympathetic or parasympathetic), while the viscera
areeflfin>innervated by afferent components of the spinal and
cranial nerves (l8).

Preganglionic sympathetic fibers arise in the
thoracolumbar region of the spinal cord and pass out via
the ventral root, white ramus, and sympathetic chain of
ganglia and then either via the lesser splanchnic nerve
through the celiac ganglion, or via the least splanchnic
nerve, to the cranial mesenteric ganglion where the post
ganglionic fibers originate. The right vagus supplies pre-
ganglionic parasympathetic fibers that pass through the
celiac plexus and on to the cranial mesenteric ganglion
where they, with postganglionic sympathetic fibers, Join
the blood vessels to the distal portion of the ileum, the
proximal portion of the colon, and the cecum (23). The
terminal colon and cranial portion of the rectum are
supplied by nerves arising from the caudal mesenteric plexus
with the parasympathetic supply coming from the sacral out-
flow (17). Thus, nerves lying in the mesentery include
preganglionic parasympathetic, sympathetic, and afferent
components (23).

In general, the nerves accompany the arteries through
the mesentery. As they enter the intestinal wall, many
of the sympathetic fibers remain associated with the

intramural blood vessels. Some bundles of vagus fibers

pursue courses through the mesentery not obviously
associated with blood vessels (23).

According to Alvarez (2), when all the extrinsic
nerves are cut, gastrointestinal peristalsis is more nearly
normal than when the vagi alone are removed. When only the
vagi are cut, food moves slowly, while cutting only the
splanchnics causes rapid movement of food. However, the
extrinsic nerves probably have little to do with the rate
of rhythmic bowel contractions.

The motility of the cecum and spiral colon has been
observed in a laparotomized calf and found to resemble that
seen in the sheep. The cecum of ruminants, in comparison
to the ceca of other herbivores, is relatively small and
muscular. It appears to supply the propulsive force to
overcome the resistance of the spiral colon and drive the
ingesta onward. Reverse peristaltic waves also occur (5).
Dukes and Sampson (6), studying the cecal motility in the
sheep, found that at times peristaltic and antiperistaltic
waves neutralize each other. They also note that anti-
peristalsis in the proximal colon and peristalsis in the
cecum may occur alternately, allowing a mixing and exchange
of ingesta.

Phaneuf (24) studies cecal motility in a sheep by
making a closed pouch of the cecum and connecting it to the
outside by a Pezzer catheter. Three types of motility were

observed on the recording tambour due to pressure changes

10
within the cecum: (1) slow tonus changes, positive and
negative, occuring in an otherwise quiet cecum; (2) slow
contractions of increasing amplitude and rhythmicity leading
to (3) strong rhythmic contractions, with smaller changes of
pressure in between. He found cecal motility uninfluenced
by rumination, rumen motility, and the feeding of hay;
however, arecoline did stimulate motility.

Phaneuf also used his cecal pouch to study the
secretory activity of the cecum. He reports that the
cecum of a sheep secretes 50 to 75 ml. of Juice in 12 hours.
The Juice is distinctly alkaline and apparently contains no
enzymes.

Markowitz (21) has stressedthe role of intestinal
secretions in intestinal obstructions of carnivores. Since
the loss of electrolytes through vomition is not a signifi-
cant problem in herbivores, other sources of debilitation
following obstruction must be sought. Markowitz sites
evidence that in the dog when fluid and electrolyte losses
are controlled, obstruction of a portion of intestine
secreting large quantities of intestinal Juices causes
severe distension with fatal consequences. Animals not
suffering from fluid or electrolyte loss die showing a
rather characteristic group of symptoms, commonly referred
to as toxemia.

Hermann and Higgins (15) found that the general

permeability of the colon wall to particulate graphite was

11

not increased by obstruction alone, but in the combined
presence of obstruction and inJury to the mucosa, particu-
late graphite may enter directly into the circulation. In
his review Markowitz (21) points out that distension of

the intestine or strangulation of the blood supply damage
the intestinal wall allowing penetration by the normal
intestinal flora. In this way, bacteria or their products,
in the presence of distension, are responsible for so-called
"toxemia."

When obstruction is established in the lower part of
the ileum, dogs survive much longer than with similar
obstructions in the duodenum. This is explained by the
loss of electrolytes and fluid by vomition in the latter,
while giving electrolytes to.a case affected with an
obstructed ileum fails to lengthen survival appreciably.

In these animals, antibiotics will aid in preventing the
development of toxemia and thereby extend the survival
period, but a patient that is unable to pass feces or flatus
per rectum will surely die (21).

Bundschuh reviewed the literature on 110 cases of
cecal volvulus in man. Of this total number 23 died with-
out operation, and of the 87 submitted to surgery, 52 cases,
or 60 per cent died (33).

Maingot (20) states that in man the clinical picture
of cecal volvulus, or torsion, as a whole is that of a low

small-gut obstruction with marked distention of the cecum.

12
The diagnosis is established or confirmed by x-ray exami-
nation. He recommends correction by detorsion when the
gut is viable, preventing recurrence by performing cecopexy
or right-sided cecocolopexy. He favors draining the cecum
when markedly distended and feels that resection is indicated
when reduction proves impossible or when the involved
segment of gut is gangrenous.

Wangensteen (33, p.391) states his preference as

follows:

In cecal volvulus, detorsion and exteriorization of
the damaged cecum and cecostomy may be considered the
operative procedure of choice in instances in which
the bowel is non-viable. Yet, primary resection with
immediate closed anastomosis, if the distention is not
too forbidding, is probably an even better operation.

In reference to the colon of man, Alexander, Arnett,

511113 Magoun (1) warn of the difficulty in accurately deter-

Dndlloing how far a colon may be damaged by chronic intestinal
S313asis and recover. They mention the uselessness of
<3IDerating upon a colon to rest it by a short circuiting
<DIDeration when the entire wall has already become damaged
IDe‘kyond repair. Frank (12, p.213) expresses the opinion
131'1at "as a general rule volvulus or torsion of the intestine
3113 incurable," when considering the prognosis in farm
Eunimals.

When examining the possible methods of repair for

tTaorsion of the bovine cecum the work of Phaneuf (2A)

Eloquires additional significance. In his studies on the

Inotor and secretory activities of the ovine cecum he

13

separated the entire cecum from the other intestines, making

it into a closed pouch. Following this he observed no change

in the general health of the sheep. The implications of

this observation suggest a review of the function of the

ruminant cecum .
The cecum serves as a reservoir in which cellulose
and other food constituents can soak and undergo bacterial

.fermentation. Cellulose is the main constituent of crude

ifiber of vegetable foods. The important end products of

(zeallulose digestion are a mixture of volatile fatty acids,

easspecially acetic, propionic, and butyric. Cellulose is,

FICJWBVGP, only partially digestible, even by ruminants,
1.51lrgely because of the lack of time for its complete
1E€alfimentation as it passes through the alimentary canal.
FLll‘ther, certain intrinsically digestible constituents may
I>Etsss undigested,owing to their imprisonment in the cellulose
C Overing (5) .

Trautmann and Asher (30, 31) studied the digestion of
<3€33.1ulose in the cecum of the goat through a cecal fistula.

rrlleay concluded that cellulose does not remain in the cecum

:L<311g enough for fermentation to occur. Neither were they

aLbleto demonstrate appreciable digestion of starch or

Eit>sorption of sugars (30, 32) in the cecum. Other reports,

however, dispute the conclusions of these workers.

Barcroft, McAnally, and Phillipson (A), Elsden (7), and

Elsden, et a1 (8), cite the finding of volatile fatty acids

14

in the cecum of sheep as conclusive evidence that bacterial
fermentation does occur there, since none are present in the
abomasum or small intestine. Still further proof is
offered by the finding of these fatty acids in the cecal
vein of sheep. They state that the volatile acids absorbed
from the rumen together with the reticulum, omasum, and
cecum supply a considerable part of the animal's energy
requirements and that these are the only parts from which
esignificant absorption occurs.
In a rather comprehensive review of the digestion in
:rfidminants McAnally and Phillipson (22) give the following

EiCZCOUHD.

The concentration of volatile acids in the cecal
ingesta is high compared with that in the contents
of the abomasum or small intestine where only traces
of the acids are found. . . . Volatile acids have
largely disappeared from the ingesta by the time the
material reaches the abomasum and they reappear in
the large gut where fermentation again becomes active.
Since sugars and other readily fermentable dietary
constituents will most probably have disappeared in
the rumen and small intestine, the source of the
volatile acid in the cecum would seem to be cellulose.

McAnally and Phillipson criticize the work of
UDIVautmann and Asher on two counts: First, that the barium
meal, passed through a cecal fistula already fixed high in
13k1e flank, did not allow normal functioning or response
ffibom the cecum and, therefore, remained there only briefly,

Eund second, that the plant material suspended within the
(lecum had not first been subJected to rumen digestion.
rl‘hey believe that digestion would set in sooner under more

3normal circumstances.

15
More recently Gray (13), working with sheep fed a
ration of wheat straw and lucerne, has collected data con-
cerning digestion in the large intestine. The data indicate
that of the cellulose present in the fodder, 40 to 45 per
cent was digested before the food passed into the abomasum,
and an additional 15 to 20 per cent was digested in the large
intestine. During this second fermentation 7 to 11 per cent
ciisappeared in the cecum and A to 9 per cent in the colon.
bJo appreciable loss occurred in the abomasum or small intes-
txine. Since the cellulose was 60 per cent digestible,
aazoproximately 70 per cent of the cellulose digested was
E>I’oken down in the rumen, 17 per cent in the cecum, and 13
£3621? cent in the colon.
Probably the first attempt at analyzing the ration
EtrlCi the products of excretion and secretion of a cow to
<3<>nnpute the difference was by Boussingault in 1939 (19).
T<>ciaythe procedures for determining ash, crude protein,
E’tSPIer extract, crude fiber, and nitrogen-free extract of
j?ێeed or feces are well defined (30), and although other
"nfiaishods of determining digestibility are used, the total
c3C>llection technique, involving the sampling of the feed
air1dthe total feces while the ration and intake are constant,
1“as changed little since used by Henneberg and Stohmann
a~bout 1860 (9).
Staples and Dinusson (27) compared the relative

Eiccuracy between seven day and ten day collection periods

16

in digestion trials and concluded that the degree of accuracy
secured by the seven day collection period may be sufficient
for many studies. Schneider and Ellenberger (25) insist
that average figures, especially average coefficients of
digestibility, are to be questioned when applied to individ-
ual cases in any kind of exact experimental work. They also
say that the probable errors become smaller as the digestion
(coefficients become larger, because the more digestible
rautrients are influenced less by the factor of irregularity
cof'excretion, and that the longer the trial or the larger
istle sample the more accurate will be the data.

Since much of the work to date indicates that the
<3€3<2um is primarily concerned with the digestion of cellulose
tillea relationship of cellulose to the crude fiber analysis
is important. McAnally and Phillipson (22) state that

in the analysis procedure for the separation of crude
fiber some cellulose is probably broken down and a
small amount of other substance remains behind. How-

ever, the crude fiber fraction in digestibility trials
may be taken to represent cellulose with a reasonable

degree of accuracy.

Additional material of interest in this study of the
bO‘vine cecum pertains to the relative size of the intestines.
SWett, Graves, and Miller (29) made numerous measurements
(31? two cows. Respective meaSurements for a 927 pound Jersey

<low and a 1585 pound Aberdeen Angus cow were length of the
Small intestine, 132.5 feet and 1110.22 feet (or 17.24 and
53.5 feet per 100 pounds of empty body weight), and length
Of‘the large intestine, 34 feet and Al.49 feet (or 4.42 and

17
2.81 feet per 100 pounds of empty body weight). In another
study Swett and Graves (28) examined 311 dairy cows and
found that their total intestinal tract averaged 139.46
feet in length. The small intestine of the living calf
is about seven times the body length, or about one-third
the post mortem length, according to Espe and Cannon (10).
They found that the large intestine does not show as great
.a.difference in length between the living and the post
Incumem stages as does the small intestine, and further that
xnaxdations in the ratio between body length and the length
c>1? the intestine depend more upon individuality than upon

t:kle age of the calf.

SURGICAL ANATOMY
Introduction

Knowledge of the structural relationships in an area

to undergo surgical repair is a necessity so obvious as to

require no special comment. Present literature can supply

much of the desired information; however, written material‘

can only serve as a supplement to personal contact with

tzlne tissue involved, or later, as a review.

In this investigation the abdominal structures were

S tudied in general and the cecum in particular. Efforts

We re directed fir-st toward the normal and then to the

altered relationships in a clinical torsion. Finally, the

tag}: of producing a torsion of the cecum was attempted.

Wrimental Procedure

The initial procedure included embalming a normal

four month old Guernsey calf. Using pentobarbital sodium

for deep anesthesia, the left common carotid artery was

isolated and ligated and the artery proximal to the

ligature cannulated. When bleeding was complete and

the calf suspended in a standing position, embalming fluid
QOlosisting of five per cent phenol and five per cent formalin
Was forced through the carotid artery by gravity flow.

After several days, liquid red latex was pumped through

19
the carotid to fill the arterial system as an aid to

dissection.

Dissection started with exposing the abdominal viscera

through the right abdominal wall. From a point Just anter-

ior and lateral to thetnflmnocoxae the incision through

the skin and musculature, parallel to the midline, was

extended anteriorly to the tenth intercostal space. The

.1ast three ribs were transected and a flap formed by
ciirecting an incision ventrally within the tenth inter-

<2<>stal space and another ventrally from the region of the

t:11bercoxae to the flank. After freeing a portion of the

ci:1¢aphragm, lowering the abdominal flap allowed adequate

exposure of the area.

With the calf remaining in a standing position,
I>f1<>tographs were taken and notations made of the normal

I>C>531tion of the abdominal organs with emphasis on the cecum.

13C) continue the dissection in more detail the intestinal

1317’act was removed by severing its dorsal attachments and

t3IPExnsecting the rectum and proximal duodenum. The distri-

blltion of blood vessels was of particular interest and
C"Friginal detailed drawings were made of the vessels directly

afisociated with the cecum. Further depth was given this

VVCDrk by inspecting numerous cattle at post mortem and
eJ‘iamining the viscera of embalmed cattle of all ages used

111 the anatomy laboratory.

The second stage of the procedure followed very closely

‘the first, except that it involved a clinical case of cecal

2O
torsion. This three month old Holstein calf was referred
to the clinic with a history of inappetence and colic for
the previous four days. Extensive examination of this size
animal per rectum was impossible. After verification of
the tentative diagnosis by laparotomy, the calf was pur-
chased and embalmed immediately. The procedure for em-
balming, inJecting latex, and dissection was similar to
that used for the normal calf. The findings on this case
sand other cases of clinical torsion were compared.

The final phase of anatomical comparison of cecal
13c1rsion and the normal included attempts to experimentally
IDIPOduce this condition. Four normal dairy steers were used

3L1). eight attempts. The initial trials on two yearlings
VV€317€ approached with the idea of twisting the cecum through
51 ILaparotomy incision into the position of a clinical
t3C)r*sion. The approach was tried through both the right
EirlCi left paralumbar fossae. A total of four trials on
Cirlee steer were spaced at intervals varying from two weeks
t3<> two months. Further attempts on two, three month old
‘3EiLLves were altered by first constricting the lumen of the
C3C>lon Just distal to the ileocecal Junction. Number 00,
In£§diumchromic catgut with atraumatic needle attached was
uESed for one trial, burying the suture into the submucosa
a11d circling the colon to form a purse-string suture. In
this case a lumen of one-half inch was left. One month

:Later this same calf was re-operated and the procedure

21
repeated with one variation. A synthetic, nonabsorbable
suture material (0.30 mm Vetafil - Bengen & Co.) instead
of catgut formed the purse-string. The other calf was
similarly handled but the nonabsorbable suture was placed
in a spiral around the colon, constricting it almost com-
pletely for a distance of three inches. In each instance,
after constricting the colon, the cecum was twisted as
much as possible before closing the laparotomy incision.

During these operations the two yearling steers were
kept standing. Two per cent procaine hydrochloride solution
and the paravertebral lumbar nerve block technique supplied
the necessary anesthesia. For the younger calves an ultra-
short acting barbituate (Surital - Parke-Davis) anesthetized
them for the right paralumbar incisions. In all cases a
synthetic suture material (0.30 mm and 0.60 mm Vetafil) was
used to close the incisions. The animals were clipped and
thoroughly scrubbed (Liquid Germicidal Detergent-Park-Davis)

before operating, and aseptic technique employed.

Results and Discussion

 

Normal bovine. An appreciation of the relationships

 

in the normal animal can be gained from Plates I through VI.
Plate I shows the normal calf embalmed. A close-up of the
right paralumbar fossa in II shows the cecum exposed. It
has, however, been lowered from its normal position at the
level of the pubis and displaced laterally toward the viewer.

This allows a View of more related organs.

The approach through the right side of the animal
reveals the greater omentum Just inside the peritoneal cavity.
The greater omentum separates all the intestinal mass,
except the duodenum, from contact with the parietal periton-
eum in the region of the right flank and paralumbar fossa.
In its normal position then, the greater omentum, which
appears as a two-layered continuation of the mesoduodenum,
obstructs the view of the cecum. The free, caudal border
of the greater omentum lies almost directly ventral to the
tuber coxae. This free border may easily be grasped and
displaced dorso-cranially, as in Plate II, exposing the
intestinal mass.

The cecum lies horizontally and longitudinally in the
standing animal, Just medial to the greater omentum. It
rests on the right, dorsal aspect of the mass of spiral
colon which in turn overlies coils of small intestine. The
relative position of the cecum, of course, depends upon the
amount of ingesta present, but the blind end terminates
normally Just cranial to the pelvic inlet and slightly
ventral to the pubis. The cranial end communicates directly
with the colon in the region of the last rib.

The colon, after continuing cranially, turns dorsally
Just behind the liver. Continuing caudally from this turn,
it lies dorsal to the cecum and medial to the duodenum.
'Ventral to the tuber coxae it again reverses directions,

lying medial to its more proximal segment, until again

23
behind the liver it takes a caudo-ventral direction, passing
into the long double coils of spiral colon.

The ileum proceeds dorsally around the caudal end of
the spiral colon. Straightening from the curls and kinks
characteristic of that small intestine attached to the free
border of the mesentery, the terminal ileum points
cranially. It lies dorso-lateral to the spiral colon and
ventro-medial to the cecum and Joins the large intestine
in the region of the last rib. This union serves to dif-
ferentiate cecum from colon. The ileum approaches the
cecum obliquely along its ventro-medial aspect but at its
attachment passes beneath the large intestine, making its
entry through the ventral surface. ‘A comparison of Plate V
and Plate VI will best illustrate this union.

The cecum has one mesenteric attachment. This same
sheet secures the terminal ileum and attaches to the medial,
or ventro-medial,border of the cecum, as shown in Plate III
and Plate V. The proportion of cecum fixed by the ileocecal
fold of mesentery varies from essentially all to less than
two-thirds of its total length. The remainder of the cecum
has no mesenteric attachment, giving great freedom of move-
ment to the blind end. The ileocecal fold of mesentery is
continuous with the mesentery engulfing the spiral colon
and the mesentery to the rest of the ileum and JeJunum.
Therefore, the ileum continues from its rather free position
on the border of mesentery dorso-cranially along the ventral

surface of the ileocecal fold of mesentery which is fixed

24
to the spiral colon ventro-medially and the initial colon
crainally. Plate IV shows the ventral surface of the cecum
and ileum.with the mesentery to the small intestine spread
over the spiral colon.

The degree of mobility of the cecum and terminal ileum
undoubtedly varies considerably with the individual animal.
Not only will the extent of the attachment cause variation,
but also the width and flexibility of the ileocecal mesenteric
fold will vary. The coils of spiral colon, held firmly to
each other by areolar tissue and quite firmly supported by
mesentery, however, do offer a stabilizing force. The initial
portion of colon also has firm attachments. At the turn
dorsally, Just cranial to the ileocecal Junction, the colon
is so firmly fixed by its attachments behind the liver that
it is, for practical purposes, immovable. Its continuation
caudally and then cranially is snugly held by mesentery.

A further stabilizing force, also subJect to variability,
is the bridging of the initial dorsal turn of the coion by
areolar tissue and visceral peritoneum. It does not, how-
ever, ordinarily continue caudally sufficiently to support
the cecum directly.

The cecum receives its blood supply via the cranial
mesenteric artery. Plate III and Plate IV show the arterial
stump where it was cut from the aorta. Plate V and Plate VI
are original drawings made from the embalmed Guernsey calf.

Neither the small cranial mesenteric branches to the

25
pancreas and duodenum nor the middle colic artery supplying
the distal colon are illustrated in these plates.

Plate IV and VI show the pathways of the larger
arteries. The intestinal continuation of the cranial
mesenteric artery supplies the JeJunum primarily. It
anastomoses with the ramus collateralis, which has skirted
the lateral side of the spiral colon, to continue along the
ileum. The ileocecocolic artery gives off branches to the
spiral colon before continuing as the ileocecal artery.
Further branching to supply the initial colon was a constant
finding in all animals examined.

The pattern of anastomosing and branching of the
ileocecocolic artery as it approaches the ileocecal Junction
could cause speculation on the exact division between cecum
and colon. The similarity in the distribution of blood
vessels for a short distance on the colon side of the
ileocecal Junction to those supplying the cecum could be
construed as evidence that the cecum actually continues
somewhat beyond the ileocecal Junction. These vessels may
be seen for comparison from a dorsal view in Plate V;
however, the exact location of the cecocolic Junction seems
more academic than practical.

The definitive arterial supply to the cecum and ileum,
shown in dorsal view in Plates III and V, presents an inter-
esting network. Rather than a simple splitting of the

ileocecal artery into single ileal and cecal arteries, the

26
terminal ileum receives a dual supply which anastomoses with
the cecal artery. This network, although subJect to some
variation, was consistent in essence and surprisingly similar
in detail in all animals examined.

The ileocecal artery, after the initial branching in
the region of the ileocecal Junction continues to the cecum
as the cecal artery. Very small arteries continue along
both sides of the ileum, supplying this terminal portion.
These anastomose with the arterial branches following
cranially along the terminal ileum with blood from the
ramus collateralis and cecal artery. The ileal artery
is the direct continuation of the continuing trunk of the
cranial mesenteric artery and the ramus collateralis. The
artery on the cecal side of the ileum is labeled the
accessory ileal artery in Plates III and V. It has a single
anastomosis with the ileal continuation of the ramus collat-
eralis near the caudal border of the ileocecal fold of
mesentery and crosses dorsal to the ileum. The cecal artery
also anastomoses with both the ileal and accessory ileal at
this point and anastomoses with the accessory ileal at about
three other points spaced along the ileocecal fold.

V It appears that in the normal bovine the terminal
ileum receives its greatest source of blood via the cecal
and accessory ileal arteries. Although partially hidden in
Plate V, the accessory ileal artery maintains a larger size

than the ileal near the ileocecal Junction and receives some

27
relatively large anastomosing branches from the cecal artery.
The ileal artery, on the other hand, is so small Just caudal
to the ileocecal Junction that its supply would seem to come
more from the ramus collateralis than the ileocecal artery.

The venous return from the cecum and ileum parallels
the anastomosing network of arteries. The larger trunks
Join to form veins with names corresponding to the arteries
that they accompany. The blood returns to the liver via
the cranial mesenteric and portal veins.

Although no special effort was made to trace the
lymphatic drainage or nervous innervation, the cecal lymph
nodes are labeled where they appear in Plates III and IV.
The nerves were observed to follow the pathways of the blood
vessels rather closely with an occasional small branch

running independently across the mesentery.

Clinical torsion. The second stage of anatomical

 

observations deals with the findings in an embalmed clinical
case, as illustrated in Plates VII through X. Plate VII
shows the initial exposure of the affected area in rela-
tionship to the entire animal. Plate VIII is a close-up

of this area, taken previous to manipulating the intestines.
NOte that the greatly distended cecum.and colon lie in
direct contact with the right abdominal wall, covering
almost completely the area between the liver and the tuber
coxae. A portion of distended small intestine (probably

ileum) can be seen Just medial to the large intestine.

28
Careful observation will reveal that the cecum is rotated
clockwise in this View with the blind end pointing caudally
in the lower right flank.

In Plate IX the blind end of the cecum has been
rotated nearly 360 degrees counterclockwise from the posi-
tion found in Plate VIII. This straightens the ileocecal
fold of mesentery and presents a greatly distended curve
of cecum and initial colon. The remaining curve, for the
most part, indicates an increase in length over the normal
for this animal. The cecal surface, directed laterally in
both Plate VIII and Plate IX, would face dorso-medially in
the normal animal. In Plate IX the initial colon is seen
passing medial to the caudal fold of omentum where it
assumes its normal size and position.

The ventral surface and ileocecal Junction in Plate X
is shown by elevating the cecum and colon from its position
in Plate IX. The ileocecal Junction had assumed a medial
position in the cecal torsion. Note that the terminal
ileum at the ileocecal Junction is essentially normal in
size, while that Just proximal to it is markedly distended.

Having an embalmed clinical case greatly simplifies
accurately describing the relative positioning of structures
involved in the torsion of a bovine cecum. Plates VII
through X should do much to clarify this description. In
this animal the caudal border of omentum and the iliac

flexure of the duodenum were forced cranially and medially

29
by the expanded cecum and initial colon. The point of
greatest obstruction occurred cranial to the ileocecal
Junction where the initial portion of colon turned medial
to the omentum. This constriction was caudal to the normal
dorsal turn near the liver where the initial colon has its
firm attachments. The fold of mesentery which supports
the terminal ileum, cecum, and initial colon was rotated,
twisting, and thereby diminishing, its longitudinal dimen-
sion. As viewed facing the right side of the animal, the
mesenteric fold had received a clockwise twist sufficient
to rotate the blind end of the cecum nearly 360 degrees.
Of course, the side of the cecum and colon attached by
mesentery remained central and somewhat medial, allowing
’ the opposite side to gain the greatest linear expansion.

The terminal ileum, lying along the ileocecal fold
of mesentery, necessarily passed through the twist. It
received its greatest pressure along a short portion Just
proximal to the ileocecal Junction. Possibly because of
the greater relative thickness of its walls, the naturally
smaller lumen, and greater mobility of its attachments,
the ileum was not so completely obstructed as the colon.
The greater mobility of the ileal attachments refers
to the fact that the terminal ileum ran along the twist
rather than perpendicular to it as did the firmly fixed
cranial portion of initial colon.

That the colon is not completely constricted either,

at least in the early stages, would be indicated by the more

BO

gradual onset of symptoms than in certain other intestinal
obstructions (for example, intussusception). It would seem
logical from the progressively increasing tension along the
small intestine and the marked distension of the cecum and
initial colon that, as the cecum distends, it exerts greater
pressure on the terminal ileum, causing greater distension
of the small intestine. The greater the distension of the
cecum and initial colon, also, the more complete will be
the obstruction of the colon. This will result in more
severe symptoms. Further, as the pressure increases within
the intestinal tract, the pressure exerted upon the
associated blood vessels increases.

By correlating the findings in cases of cecal torsion
operated on in the clinic with those apparent in the embalmed
specimen, interesting points arise. The rather constant
occurrence of increased abdominal fluid, as in other types
of torsion, or volvulus, could indicate impaired circulation.
The thinner walled, low pressure veins and lymph ducts are
more susceptible to occlusion by external pressure than the
arteries. This results in edema and may account for the
increased abdominal fluid. In more severe cases, areas of
beginning necrosis in the cecal wall were the apparent
result of an inadequate blood supply.

As determined by the necessary manipulation to
relieve the torsion, the cecum and its mesentery may become

tWIsted either clockwise or counterclockwise, when viewing

31
the animal‘s right side. In general, other findings were
the same in those cases known to be twisted counterclockwise
as clockwise, however, most of these cases, like the embalmed
heifer, rotated clockwise.

One structure which does occasionally vary distinctly
in location is the omentum. Early in December 1956, the
seventh case of bovine cecal torsion was presented at the
clinic with a history of diarrhea for two days. She had
refused feed and manifested abdominal pain the previous
evening. The distended cecum was palpable per rectum. A
laparotomy revealed the omentum in its normal position,
while the torsion was otherwise similar to those previously
described. Likewise, the recent report from Oklahoma (16)
describes the greater omentum in normal position in one
case, but in the other the omental attachment to the duodenum

was not found.

Experimental torsion. With some understanding of the

 

structures involved in a torsion of the bovine cecum the
next step logically follows: to produce the torsion experi-
mentally.

Relocation of the normal cecum in the position of a
torsion was attempted first. However, the five laparotomies
performed on two yearling steers through either the left or
right paralumbar fossa failed to produce a clinical torsion.
The ileocecal fold of mesentery was stretched and twisted

as much as possible in each attempt, and the repeated

32
operations on one steer increased the mobility of this
mesentery. Adhesions resulting from the trauma of manip-
ulation finally discouraged further attempts with this
animal. No sutures were used to fix the twisted cecum, and
on repeat operations the cecum lay in essentially the normal
position. Following each laparotomy these steers recovered
without interruption.

The possibility that alteration in the normal patterns
of cecal motility could result in a torsion was not explored
further. But knowing that obstruction of the initial colon
does occur in a torsion of the bovine cecum, the idea that
a cecal torsion could follow partial obstruction of the
colon seems plausible. Two, three month old calves were
used in this pursuit,with three attempts.

The laparotomy with artificially produced colonic
obstruction caused decreased feed intake and some abdominal
distress. Symptoms were most apparent about the third day
following surgery, but by the end of one week fecal passage
had returned to normal and recovery followed. When the one
calf was re-operated a month following the initial con-
striction, only scarring remained. Undoubtably, nearly
normal passage was established by the stretching or migrating
0f the constricting sutures.

Obstruction of the initial colon certainly could be
aChieved by transecting the colon Just distal to the

ileocecal Junction and closing both ends. This would ensure

33

complete obstruction with eventual death, but the symptoms
of clinical torsion do not indicate complete obstruction
early in its course. No unusual, consistent findings were
recognized in the clinical cases which would reveal special
predisposing factors. One would strongly suspect, however,
that anatomical variations in the size and attachments of

the cecum could alter individual susceptibility.

METHOD OF REPAIR

Introduction

 

The 100 per cent recovery rate of the first five
bovinesvnjfilcecal torsions received at the Michigan State
Clinic offers no opportunity for improvement of the records.
However, the physical appearance of the more severely
affected ceca as they were replaced seemed less desirable.

Possibilities for altering the original procedure of
laparotomy, cecotomy, when necessary, and detorsion would
include the addition of cecopexy. This should eliminate any
chance of recurrence but certain complications merit men-
tioning. Most obvious is the normal position of the omentum
which separates the cecum from the abdominal wall. Attaching
the cecum to the wall at several points along its course
would prevent the omentum from returning to this position.
Attaching the cecum to other supporting structures (for
example, the mesentery supporting the spiral colon) would
be mechanically difficult. The increased size of the cecum,
even after draining its contents, complicates returning it
to exactly its proper place. And most important, cecopexy
would not improve the physical condition of severely affected
ceca.

Since removal of the cecum could eliminate all prob-

lenfi5<of an atonic, devitalized cecum, as well as the

35
possible recurrence of a torsion, this approach was con-

sidered most worthy of trial.

Experimental Procedure

A total of ten cecectomies were performed on normal
steers or calves varying in age from two weeks to two years.
The surgical procedure was altered as problems arose, in an
attempt to find the best method. The resulting procedure
was then used on a clinical case.'

The first cecectomy was performed on a two week old
Jersey calf. An ultra-short acting barbituate (Surital —
Parke-Davis) provided general anesthesia. The right
paralumbar fossa was clipped and scrubbed (Liquid Germi-
cidal Detergent-Parke-Davis) and aseptic technique employed.
With the calf on its left side a dorso-ventral incision
large enough to admit a hand was made midway between the
last rib and tuber coxae. The cecum was located, brought
to the outside, and ligatures of size A Nylon placed with
a suturator along the ileocecal fold of mesentery on either
Side of a line halfway between the cecum and ileum. By
cutting between these two nearly continuous rows of ligatures
the cecum was freed with little regard for the position of
blood vessels. A pair of Carmalt forceps were applied side
by side as near as possible to the ileocecal Junction. With
the tips of the forceps at the mesenteric border of the cecum
Eflui the Jaws slightly nearer the Junction with the colon,

a good blood supply was assured the remaining part and

36

Virtually all the cecum caudal to the ileocecal Junction

removed. The cranial stump was closed with size 00, medium

chronic catgut and atraumatic needle, using the Parker-Kerr

method of oversewing a clamp. The peritoneum and muscles

of the abdominal wall were closed with a single, simple
continuous, nonabsorbable suture (0.40 mm Vetafil-Bengen &
Co.) and the skin brought in apposition with simple inter-
rupted sutures of the same material.

Cecectomies were performed on two more young calves

in essentially the same manner except that more certainty

was displayed in ligating blood vessels. With a better

understanding of the blood supply to the cecum, the anasto-
mos ing branches between the cecal and accessory ileal

arteries and veins were readily uncovered and double ligated

With size A nylon before cutting them. The three cecectomized

calves were utilized in another portion of this investigation.
All other cecectomies were performed with the animal
Standing. A solution of two per cent procaine hydrochloride
and the paravertebral lumbar nerve block technique provided
anesthesia for the right paralumbar approach in these cases.
FOP the first attempt with a standing animal, a yearling
Here ford steer, the same general techniques were followed
as 1el-Sed on the calves. With a similarly placed incision
lapge enough to easily admit an arm, the omentum reflected
emulially, and the cecum held to the outside, the vessels

were ligated, the mesenteric attachment cut, forceps applied,

37
the cecum removed, the stump inverted, and laparotomy
incision closed. Size A nylon delivered from a suturator
was used for ligation. For the intestinal closure, size
00, medium chromic, intestinal catgut with atraumatic needle
attached was again used, but two, six and a half inch
Carmalt forceps, one directed from either side were neces-
sary to completely traverse the cecum. With this modifi-
cation, the stump was closed by the Parker—Kerr method. The
abdominal suture pattern was the same as previously used but
with.larger material (0.60 mm Vetafil).

Four Holstein steers under study in another part of
this investigation were cecectomized between ten and twelve
nuxiths of age. The procedure was varied to allow for im-
Inxrvements, and two, two year old Jersey steers provided
for further testing. The variations were as follows: moving
the laparotomy incision within the right paralumbar fossa;
inJeacting a two per cent solution of lidocaine hydrochloride
(ZYJ.ocaine Hydrochloride - Astra) around each nerve in the
ilecocecal fold of mesentery before ligating or cutting blood
vesfisels or nerves; using size 00, medium chromic catgut and
0-3C3 mm Vetafil to ligate the cecal artery and vein; sub-
sti13uting nine inch Doyen intestinal clamps with longitud—
inaZL serrations for the six and a half or eight inch
Cann1a1t forceps, or using a 13 inch Payr clamp undersewing

as Vvell.as oversewing the clamp when closing the intestinal

StUInID; using a 0.30 mm Vetafil and either a straight or a

38
curved, taper point needle to close the intestinal stump;
and closing the skin incision with a continuous, buried
suture of 0.30 mm Vetafil.

During the last experimental cecectomy on a Jersey
steer a series of pictures were taken to illustrate the
procedure. Finally, this method of repair for torsion of
the bovine cecum was used December 4, 1956, on the seventh

case received at the Michigan State Clinic.

Results anngiscussion

With no specific surgical procedure already available
for cecectbmizing a bovine, a satisfactory procedure was
evolved by the trial and evaluation of various techniques.
Although all ten experimental cecectomies were successful
to the extent that the ceca were removed without any
fatalities, much valuable information and experience was
gleaned from each.

The removal of the first cecum revealed the need for
thorough knowledge of the blood vessel distribution to
this organ. For an efficient, practical, surgical procedure,
the surgeon must locate and ligate these fat-covered vessels
with a minimum of searching. Excessive probing through the
area is not only time consuming in itself, but capillary
hemorrhage from the disturbed fat will further obscure the
view. The anastomosing branches of the cecal arteries and
veins were located and ligated where they traverse the

ileocecal fold of mesentery (Plate V) and the cecal artery

39
and vein ligated Just caudal to their passing over the
terminal ileum. Transecting these arteries, veins, and
nerves, supplying in part the terminal ileum, causes this
portion of intestine to shrink and lose color, at least for
the duration of the operation.

Transfering from a calf under general anesthesia to
the standing animal created more problems than originally
anticipated. Of course, in the young calf the liver fills
a larger percentage of the abdominal cavity than in the
adult and on the right side extends well behind the border
of the ribs. For this reason, the laparotomy incision was
placed in the middle of the right paralumbar fossa. When
the incision is similarly placed in the older animal, great
difficulty is encountered in exposing the entire cecum due
to the firm attachments of the initial colon. The last rib
defines the cranial border of the paralumbar fossa, and on
the right side, the kidney modifies the dorsal extent of
an incision. Perirenal fat causes a medial divergence of
the peritoneum. Locating the incision ventral to this fat
depot simplifies closure and adequately exposes the cecum.

The change from general anesthesia to local anesthesia
for the standing animal had an accompanying complication.
The paravertebral lumbar nerve block adequately anesthetizes
the right paralumbar fossa but does not anesthetize the
viscera. Ordinarily the intestines can be handled without

anesthesia, however, when large nerves are ligated, cut,

40
or otherwise directly stimulated, as in removing the cecum,
colicky symptoms occur immediately. The animal treads from
side to side and, as restlessness progresses, will invariably
attempt to lie down. After the first standing operation,
these exasperating developments were prevented by inJecting

two per cent lidocaine hydrochloride (Xylocaine — Astra)

around the blood vessels before ligating them and directly

on nerves found free in the ileocecal fold of mesentery.

Further changes in procedure logically resulted from
the increased size of the structures. A suturator equipped
with size eleven needle and size A nylon still satisfactorily
ligated all vessels except the large main trunks of the cecal
artery and vein. For more security either size 00 medium
chromic catgut or 0.30 mm Vetafil was used here.

The size of the cecum itself required an instrument
larger than the six and a half inch Carmalt forceps used on
the calves. The Jaws have two inches of clamping surface,
and eight inch Carmalt forceps have only two and a half
inches of surface. By putting two Carmalt forceps end to
end the necessary distance was bridged but the danger
of leakage was greater. Nine inch, longitudinally serrated,
Doyen intestinal clamps will extend across most ceca and
would seem a logical choice; however, considerable tension
is required to expose the ileocecal Junction, and the danger
of this limber clamp slipping off the cut stump caused its
immediate abandonment. Instead, a 13 inch Payr clamp served

to hold the stump during closure.

41

Along with the various clamps, undersewing, as well as
oversewing, was tried on these larger ceca. A continuous
suture directed back and forth through the apposed intestinal
walls gives added security against hemorrhage and leakage
from the stump. This suture was placed close to the colon
side of the clamp before cutting off the cecum. After
removal of the cecum the clamp was then oversewn using the
Parker-Kerr method. As a substitute for catgut, 0.30 mm
Vetafil was used for closing the stump. This very strong,
non-capillary, nonabsorbable material does not have an
attached needle, but taper point, straight (for undersewing)
and half circle (for oversewing) needles were threaded.

Even though the closure of the laparotomy incision
has less direct affect on the success of the operation, for
variation a continuous buried suture was tried in place of
the simple interrupted skin sutures. Using 0.30 mm instead
of the 0.60 mm Vetafil and a number eight, half circle,
cutting edge needle, the usual pattern of the subcuticular
suture was altered for ease in penetrating the tough bovine
skin. Starting at the dorsal commissure of the incision,
the needle is directed from the subcutaneous side into the
chermis, splitting the thickness of the cut skin edge. The
Ineedle is then inserted at a similar depth into the cut
fudge of the other side and directed out on the subcutaneous
aside. This imitates the regular subcuticular suture, and

true knot is similarly buried in the subcutaneous tissue.

42

From.this start the needle is directed as before, leaving
the subcutaneous side, coming out of the cut edge, into the
other out edge, and out in the subcutaneous area. Thfis is
continued to the ventral commissure where the final knot is
buried in the usual manner. The needle, traveling in this
pathway, penetrates the skin layers with much greater ease
than when directed into the cut edge and out, in a plane
parallel to the skin surface. This, plus the superior
strength of the synthetic suture material, makes it both

a pratical and efficient method of closure.

To combine the variations Judged best in these trials,
Plates XI through XVI illustrate the evolved procedure for
removal of the bovine cecum. Plate XI-—A shows the initial
incision. Note that the incision lies well below the right
kidney near the cranial edge of the paralumbar fossa. The
paravertebral lumbar nerve block gives adequate anesthesia
for the laparotomy incision, and after completion of the
incision, the omentum is reflected cranially and the cecum
exposed (Plate XI--B). The inJection of the local anesthetic
(two per cent Xylocaine) around the blood vessels and nerves,
as in Plate XII-~A, is done with a sterile syringe and needle
before ligating or cutting these structures. The ligation
of all vessels except the main cecal trunks is performed
with the aid of a suturator using size A nylon (Plate XII-~B).
The anastomosing branches of the cecal artery and vein are

Imocovered and ligated twice, about midway between the cecum

43
and terminal ileum, and the ileocecal fold of mesentery cut
on a line between the ligatures. The larger cecal artery
and vein are ligated Just caudal to the ileocecal Junction
with 0.30 mm Vetafil and then out.

With the mesenteric attachment of the cecum freed, a
13 inch Payr clamp is applied Just caudal to the ileocecal
Junction (Plate XIII--A). The tips of the clamp are placed
nearest the terminal ileum, keeping the angle of the Jaws
cranial to assure a good blood supply to the remaining
intestine. As illustrated in Plate XIII--B, the clamp is
undersewn, using 0.30 mm Vetafil and a straight, taper point
needle, before the cecum is removed. To prevent leakage at
the time of removal a nine inch Doyen intestinal clamp can
be placed close to the Payr clamp. A scapel is used to
trim the cecum from the Payr clamp, and then the clamp is
oversewn with 0.30 mm Vetafil and a number two, half
circle, taper point needle, as in Plate XIV-~A. By releasing
the clamp gently and holding the free ends of suture used to
oversew the clamp, the clamp is slipped out and the stump
inverted. To complete the procedure known as the Parker-Kerr
method of closing an intestinal stump, one end of the suture
may be continued back along the closure with a continuous
Lambert stitch and tied to the original end. The end is
completely closed in Plate XIV--B ready to go back into the
abdominal cavity.

When the intestinal stump at the ileocecal Junction

falls back into the abdominal cavity, the omentum will again

44
obscure its view (Plate XV-—A), and the operation is com-
plete except for closing the abdominal incision. A simple
continuous suture of 0.60 mm Vetafil placed well back from
the cut edges closes the peritoneum and muscle layers.

This suture, shown in Plate XV--B, should be pulled very
tightly before tying. The buried skin suture of 0.30 mm
Vetafil, being placed in Plate XVI--A, gives good skin
closure and does not require removal. The closed incision
is shown in Plate XVI--B the day following surgery.

An alternate closure for the skin is the simple inter-
rupted sutures of 0.60 mm Vetafil placed well back from the
skin edges. These exposed sutures have caused no absces-
sation when left for over a year, but normally they are
removed after eight to ten days.

When a three year old cow with symptoms of abdominal
discomfort following two days of diarrhea was diagnosed on
rectal examination as having a torsion of the cecum, the
method of repair Just described was used. The procedure
was followed without difficulty, and uneventful recovery
resulted. Although off feed and down on milk when brought
to the clinic, she began eating soon after surgery, milk
production increased, and six days after the cecectomy she

returned home.

THE CECECTOMIZED BOVINE

Introduction

 

A new corrective procedure requires evaluation, not
only of the techniques involved, but also of the end product.
Ideally the result should eliminate the undesirable without
impairing the desirable. Engaging in this line of reasoning,
certain factors were examined to evaluate the normalcy of
the cecectomized bovine.

Since cellulose digestion is believed a primary func-
tion of the cecum, the ability of the cecectomized bovine
to digest cellulose should be given primary consideration.
The possibility that the cecum supplies a propulsive force
to push the ingesta through the spiral colon rates thoughtful
observation and comment, while gross compensations by other
organs to perform the functions of the cecum receive conser—
vative comparisons. To these more specific considerations
are supplemented observations of operative recovery, post

Inortem examination of experimental cases, and the response

of a clinical case.

Experimental Procedure

To estimate the effect of removing the cecum on cellu-
.lose digestion, four similar Holstein-Friesian steers were

Inxrchased. After a variable period, exceeding one month,

40

for observation and clinical examination, these normal
steers were singly put on digestion trials. With a normal
established, the ceca were removed and a second digestion
trial started in two weeks. A third series of trials fol-
lowed the cecectomies by a period varying from three and a
half to five months. The same procedures were followed for
all trials.

Using seven day preliminary periods and seven day
experimental periods, the steers were fed only alfalfa hay
from the same lot previous to and during the trials. The
daily feedings were kept as near constant as possible for a
given trial and hay samples were saved for grinding into a
composite at the end of each experimental period. One per
cent samples of the daily aliquot of feces were refriger-
ated as composited, and concentrated hydrochloric acid
totaling 15 milliliters was added to each. These samples
of hay and feces were analyzed, according to the procedures
described by the Association of Official Agricultural
Chemists (3) for ash, crude protein, ether extract, crude
fiberg and nitrogen-free extract. Water intake was recorded
axuxmnatically with a meten and steer weights were recorded
eat the beginning and end of the experimental period. The
steers remained on the digestion trial stand throughout the
trdgils except for a trip to the scales at the start of the
experimental period.

All of the steers and calves cecectomized for the

diffifiarent portions of this study were carefully observed

47
following surgery, but no medication was administered after
the day of surgery. The three young dairy calves used for
performing the initial cecectomies were kept until between
five and six months had transpired after the operations.
They were kept with three similar, normal, dairy calves
until between six and six and a half months of age. At
this time they were euthanized with electricity and examined.

After the general visual comparison between these
normal and cecectomized calves, the entire intestinal
tract was immediately stripped from its mesentery. The
intestines were kept intact with the small and the large
intestine separated. A hose inserted into the end of
each length of intestines connected it to a metal cylinder.
Water running into the cylinder washed the ingesta from the
intestines. The open end of the intestines was then tied
and the cylinder allowed to fill to a constant height above
the floor. This ensured having the same pressure in each
length of intestine. When the water reached the given
height, the water within the intestine was held there and
the intestine gathered into pails. By draining the intes-
tine and saving all its contained water, a volume figure at
a standard water pressure was recorded.

The viscera of the four steers used for the digestion
trials were also visually examined at the time of slaughter,
between five and eight months after surgery. The size,

condition, and appearance of the terminal ileum and initial

48

colon were carefully noted and further examinations made

for adhesions or other complications caused by surgery.
Periodic inquiry about the performance of the clinical

case operated in December 1956, completed the evaluation

of the cecectomized bovine.

Results and Discussion

The dates of the digestion trials and cecectomies
for the four Holstein-Friesian steers are listed in Table l.
The steers are designated by their ear tag numbers, and
steer number 4947 is shown on the digestion trial stand in
Plate XVII. Table 2 contains the total intake of hay and
water, total excretion of feces, and the weight gain or
loss during each seven day experimental period. Two of the
steers, 4949 and 4948, consumed less hay in their second
trials than in their first and failed to maintain their
weight. This could indicate retarded recovery from surgery;
Inavertheless, they appeared healthy in every other way.

Tables 3 and 4 list the chemical composition of the
hay and feces respectively for each of the trials. Although
tine hay was all from the same lot, some slight variation in
cummposition exists. A comparison of the hay samples on a
ciry basis is available in Table 5 along with the coefficients

of‘<iigestibility for dry matter, protein, crude fiber, and

e ther extract .

Since this study is concerned with whether or not

timese steers digest their ration as well without a cecum

49
as with one, the percentage of the nutrient digested, or
the digestion coefficient, is a useful point of reference.
With cellulose recognized as the principle constituent
digested in the cecum, the coefficients of digestibility of
crude fiber should show the greatest variation between the
first trials and the second and third trials. However, an
analysis of variance for the four steers of the digestion
coefficient of crude fiber, and each of the other digestion
Coefficients, showed no significant variation between the
three trials. Therefore, these data indicate that these
steers digested their ration of alfalfa hay as well without
their ceca as with them.

That the cecum serves as a propulsive force to start
the ingesta through the spiral colon can not be entirely
disputed on the basis of this study, but observations of
cecectomized animals immediately following surgery fail to
emphasize it as a necessary force. Rumination, peristalsis,
and defecation proceeded with little or no interruption.
Nothing simulating an adJustment period was discernible.

Conceivably some gross compensation by the large or
even the small intestine could replace the cecum in function.
Because one would expect this to develop in a young, growing
calf, if at all, and because three such calves were cececto-
rnized early in the investigation, the capacity of the large
and small intestines of these three calves were compared

with the capacity of three similar, normal calves

50
grown in the same environment. The volumes in liters are
listed in Table 6.

Although this comparison is limited in scope as well
as numbers, these figures indicate no consistent enlargement
of the intestines of the cecectomized calf over the normal.
Plate XVIII shows cecectomized calf number 4906 Just before
euthanasia, while Plate XIX shows the viscera of this same
calf. The only difference observable between the intestines
of these two groups was either the presence or absence of
the cecum. In this volume study the standard water pressure
was sufficient to distend the entire length of intestine
equally, when the maximum pressure was reached gradually.
Plate XX shows a length of small intestine under pressure.

A post mortem check of all cecectomized animals failed
to reveal any post—surgical adhesions. The laparotomy
incisions had healed smoothly. No remnants of a cecum caudal
to the ileum persisted (Plate XIX). In fact, the ileum
seemed to enter directly into the end of the initial colon
rather than at an angle. Even though severing the nerves
and vessels to the terminal ileum caused it to shrink and
lose color during surgery, several months afterward this
portion of ileum appeared like the rest. Remains of the
mesentery formerly attaching the cecum to the terminal
ileum had disappeared, and lesions indicating that a cecwn
was ever present were practically non-existent.

The proof of any new surgical procedure can only fol-

low its application to clinical cases; therefore, the

51
progress of the three year old Holstein, from which the
cecum was removed as a means of eliminating the cecal
torsion, was followed with anticipation and great expectation.
This cow had calved about five or six weeks before the attack.
Milk production dropped to nearly nothing during two days
of distress, but she returned home six days after surgery
and, according to the owner, within another week had re-
gained her previous production level. She was bred to calve
at the regular yearly interval,and eight months following
surgery she was normal in every way. At this time the owner
enthusiastically reported that her milk production for the
lactation had, except for the period of illness, paralleled
and equalled that of her half sister of the same age. These
two cows calved within a few days of each other, were both
bred to calve again about the same time, and stand side by

side in his barn.

SUMMARY

A total of ten cases of torsion of the bovine cecum
were reviewed. Symptoms similar to those associated with
other types of intestinal obstruction characterize the
illness with an additional finding of watery feces, or
diarrhea, in three of the cases. The feces did not contain
quantities of either fresh or decomposed blood. Palpation
of the distended cecum per rectum provides the best means
of differentiating this condition. Failure to differentiate
torsions of the cecum from similar types of volvulus and
obstruction may account for the limited number of cases
recorded.

Seven of these ten cases were diagnosed at the Michigan
State University Veterinary Clinic. The first five were
successfully corrected by detorsion via a laparotomy.
Another case, reported in Iowa, was successfully handled in
the same manner, but the possibility of recurrence and the
generally poor condition of the ceca in some of these early
cases stimulated the pursuit of a superior corrective
jprocedure. Of the two cases reported recently from Oklahoma,
cums recovered following detorsion, but the other did recur,
.accounting for the only post-corrective fatality.

The investigation proceeded first with a study of the

ncnflnal anatomy involved and then with the involvements of a

53
torsion. An embalmed, normal animal and one of the clinical
cases, embalmed without correcting the torsion, enabled
detailed examination and comparison. Additional findings
gleaned from the other clinical cases and examination of
other normal cadavers broadened the scope of this study.

The cecum has only one mesenteric attachment, the
ileocecal fold, and the extent of this attachment varies
greatly. Thus, the natural mobility of the cecum varies
with the individual bovine. Less variation was observed
in the normal distribution of blood vessels. A rather
consistent network of vessels lies in the ileocecal fold
of mesentery. These were described and illustrated, while
the nerves, for the most part, were found accompanying the
vessels.

In a cecal torsion, this normally horizontal structure,
when viewed through the right side of the standing animal,
may rotate either clockwise or counterclockwise, twisting
and partially obstructing the initial colon. Ingesta in
the relatively thick walled terminal ileum continues to
force its way into the cecum, distending it. A distending
cecum can eventually completely obstruct the flow of ingesta
through the initial colon and may impair its own blood
supply. In two of the clinical torsions reviewed the omentum
lay in its normal position between the large intestine and
the right abdominal wall, but commonly it was displaced

cranially allowing the cecum direct contact with the wall.

54
Several attempts to experimentally produce a torsion of the
cecum were unsuccessful.

With a better understanding of the existing problem,
the development of a procedure for an improved method of
repair was undertaken. The chosen approach involves removal
of the entire cecum caudal to the ileocecal Junction. The
techniques evolved through a series of ten experimental
ceCectomies on normal bovines. This procedure, described in
detail, was then used to repair a clinical torsion presented
at the Michigan State Clinic.

The evaluation of this method of repair was attacked
from several different angles. The cecectomized animals
were watched for signs of altered functions, but all re-
covered without complication. Since the cecum functions
primarily as a storage compartment for the digestion of
cellulose, four similar steers fed a ration of alfalfa hay
were each put on a series of three digestion trials. With
the first trial serving as a normal, the ceca were then
removed, and surgery was followed in two weeks and then
several months by the second and third trial. The coeffici-
exits of digestibility for the constituents of the alfalfa
iuay ration showed no significant variance between the three
'trials, indicating that these steers digested this same
ruiy as well without their ceca as they did with them.

Post mortem examination of the animals revealed no

nuirked alteration in the viscera except the absence of a

55
cecum and its attachment. The intestines of three calves
cecectomized when young were compared with three normal and
similar calves at about six months of age. No consistent
increase in capacity of either the large or small intestine
was apparent.

The effort that went into perfecting this corrective
surgical procedure seemed Justified and such points as the
exact location for the laparotomy incision, the use of a
local anesthetic on the mesenteric nerves to prevent colic,
the pattern of blood vessels in the ileocecal fold of
mesentery, a satisfactory intestinal clamp, and improved
materials and methods for closing an intestinal stump
gained real meaning when actually applied to a case of
cecal torsion. The result was a smooth operation and a
rapid recovery. The performance of this case alone expresses

sufficient gratitude for the work involved.

lO.

LITERATURE CITED

Alexander, J., Arnett, J. H., and Magoun, J. A. H.:
Experimental Studies in Colonic Dilatation. Surg.
Gynec., and Obst., 24 (1917): 484-486.

Alvarez, Walter C.: The Mechanics of the Digestive
Tract. 2nd ed. Paul B. Hoeber, Inc., New York,
N. Y., 1928.

Association of Official Agricultural Chemists: Official
Methods of Analysis of the Association of Official
Agricultural Chemists. 7th ed. Agricultural Chemists,
Washington 4, D. C., 1950.

Barcroft, J., McAnally, R. A., and Phillipson, A. T.:
Absorption of Volatile Acids from the Alimentary
Tract of Sheep and Other Animals. Journ. Exp. Biol.,
20 (1944): 120-129.

Dukes, H. H.: The Physiology of the Domestic Animals.
7th ed. Comstock Publishing Co., Inc., Ithaca, N. Y.,

1955.

Dukes, H. H., and Sampson, J.: Gastro-intestinal
Motility in the Ruminant. Cornell Vet., 27 (1937):

139-149.

Elsden, S. R.: The Fermentation of Carbohydrates in _
the Rumen of the Sheep. Journ. Exp. Biol., 22 (1946):
51-62.

Elsden, S. R., Hitchcock, M. W. 8., Marshall, R. A.,
and Phillipson, A. T.: Volatile Acid in the Digesta
of Ruminants and Other Animals. Journ. Exp. Biol.,
22 (1946): 191-202.

Ely, Ray E.: Studies on the Digestibility of Orchard
Grass with Dairy Cattle. Thesis. Michigan State
College, 1952.

Espe, Dwight,and Cannon, C. Y.: The Length of the
Intestine of Calves and its Bearing on the Absorption
of the Nutrients from the Chyme. J. of Dairy Sci.,
23 (1940): 1213.

11.

12.

13.

l4.

l5.

l6.

17.

18.

19.

20.

21.

22.

'23.

24.

25.

57

Francis, James D.: Clinical Medicine: (4.) Partial
Torsion of the Cecum of the Bovine. Iowa State
College Vet.,16 (1953-4): 89-90.

Frank, E. R.: Veterinary Surgery. Burgess Pub. Co.,
Minneapolis, Minn., 1953.

Gray, F. V.: The Digestion of Cellulose by Sheep.
Journ. Exp. Bibol., 24 (1947): 15-19.

Habel, Robert E.: Guide to the Dissection of the Cow.
2nd ed. Cornell Cooperative Society, Ithaca, N. Y.,

1951.

Hermann, S. F., and Higgins, G. M.: Intestinal Perm-
eability in Obstruction in the Colon: An Experi—
mental Study. Am. J. Med. Sci., 179 (1930): 365-370.

Jones, E. Wynn, Johnson, LL, and Moore, C. C.: Torsion
of the Bovine Cecum. J.A.V.M.A., 130 (1957): 167—170.

Kuntz, Albert: The Autonomic Nervous System. 3rd ed.
Lea and Febiger, Philadelphia, Penn., 1945.

. A Text-book of Neuro-anatomy. 5th ed.
Lea and Febiger, Philadelphia, Penn., 1950.

 

Lusk, Graham: The Elements of the Science of
Nutrition. 4th ed. W. B. Saunders Co., Philadelphia,
Penn., 1928.

Maingot, Rodney: Abdominal Operations. 2nd ed.
Appleton-Century-Crofts, Inc., New York, N. Y., 1948.

Markowitz, J.: Experimental Surgery. 3rd ed. The
Williams and Wilkins Co., Baltimore, Md., 1954.

McAnally, R. A., and Phillipson, A. J.: .Digestion in
the Ruminant. Bio. Reviews, 19 (1944): 41-54.

Netter, Frank H.: The Ciba Collection of Medical
Illustrations, Nervous System. Ciba Pharmaceutical
Products, Inc., Summit, N. J., 1953.

Phaneuf, L. P.: Studies on the Motor and Secretory
Activity of the Cecum and Small Intestine of the
Sheep. Thesis. Cornell University, 1952. Cited
in Dukes, 9p; git.

Schneider, B. H., and Ellenberger, H. B.: Apparent
Digestibility as Affected by Length of Trial and
Certain Variations in the Ration. Vermont Agr. Exp.
Sta. Bull. 270, 1927.

26.

27.

28.

29.

30.

31.

32.

33.

58

Sisson, Septimus, and Grossman, James Daniels: The
Anatomy of the Domestic Animals. Rev. 4th ed. W. B.
Saunders Co., Philadelphia, Penn., 1953.

Staples, G. E., and Dinusson, W. E.: A Comparison of
the Relative Accuracy Between Seven-Day and Ten—Day
Collection Periods in Digestion Trials. J. of
Animal Sci., 10 (1951): 244-250.

Swett, W. W., and Graves, R. R.: Relation Between Con-
formation and Anatomy of Cows of Unknown Producing
Ability. J. of Agr. Res., 58 (1939): 199-235.

Swett, W. W., Graves, R. R., and Miller, F. W.: Com-
parison of Conformation, Anatomy and Skeletal Structure
of a Highly Specialized Dairy Cow and a Highly
Specialized Beef Cow. J. of Agr. Res., 37 (1928):
685-717.

Trautmann, A., and Asher, T.: Digestion and Absorption
of Carbohydrate in the Large Intestine of Ruminants
(Trans. title). Ztschr. Tierernahrung Futternittelk,
3 (1939): 45-52. (Abstracted in Nutr. Abs. and Rev.,
10 (1940-1): 1632.)

The Problem of Cellulose Digestion.

 

‘Further Observations on the Breakdown of Cellulose in
the Cecum and Colon of Ruminants (Trans. title).
Arch. wiss. prakt. Tierheilk, 76 1941): 317-328.
(Abstracted in Nutr. Abs. and Rev., 11 (1941-2): 591.)

: Glucose Absorption from and Excretion into
the Large Intestine of Ruminants (Trans. title).
Deutsch. tierarztl. Wochenschr., 49 (1941): 585-589.
(Abstracted in Nutr. Abs. and Rev., 12 (1941-2): 73.)

 

Wangensteen, Owen H.: Intestinal Obstructions. 2nd ed.
Charles C. Thomas, Springfield, 111., 1942.

TABLES

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mm-:a-m op mmImIm
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mm-em-m op mm-am-m
mmIHmIH op wmummufi

mmIHHIQH on mmImuoa

mm-oH-w on mm-s-w
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mm-sm-w op mm-ma-w
mm-ea-e so mm-aame

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9

 

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77

 

Plate XII--A. Injecting the local anesthetic

Plate XII--B.

 

Ligating blood vessels

78

79

 

Plate XIII--A. Applying the Payr clamp

 

Plate XIII--B. Undersewing the Payr clamp

8O

 

Plate XIV-~A. Oversewing the Payr clamp

 

7,——

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Plate XV--A. The viscera replaced

 

Plate XV--B. Suturing the muscles and peritoneum

81

82

 

 

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