Lime-water, the appearance of carbamic acid | Peculiar course of septico-pyæmic affections, in the urine after the continued adminis- Lipoma of the spermatic cord, 57 Liver, gaseous infiltration of, found at the the antitoxic function of, 34 Lung, congenital absence of, 137 erythematosus, generalized, 19 Lymphatic varices of the labial mucous mem- McGuigan, John I., pannus, 51. McKeehan, C. W., the professional nurse, 324 Malignant lentigo of old people, 459 Mount-Bleyer, J., tone-blindness (klang farben urinary system, formation of, 318 Mucous membranes, absorption of virus by, 12 Pelvic abscess simulating extra-uterine preg- Penrose, Charles B., a case of abdominal hys- Pental, death from the use of, 73 Peritonitis, tuberculous, cured by repeated ap- Pharyngeal tonsil, hypertrophy of, 457 Pleurisy, hæmorrhagic, left-sided-demonstra- Presence of hæmatoporphyrin in the urine after Pruritus vulvæ from jealousy, 319 Ptomaines of the urine in chronic diseases, the, Puerperal parametritis and ascites, 137 Rapidly-fatal atrophic gastritis, 460 Nails, the influence of disease in arresting Reflex psychopathic symptoms of nasal origin, nutrition of the, 342 Nizza, the jewel of the Riviera, 417 257 Removal of the stapes; stricture of the external auditory meatus, 403 Renal section in the treatment of certain forms of anuria, 461 Nuclein, subcutaneous injections of, in lupus, 18 Respiration, the nervous apparatus of, 212 Odors, influence of, upon the voice, 460 Ophthalmia neonatorum; contraction of eye- Osteomalacia, the diagnosis and therapy of, 20 Ott, Isaac, the nervous apparatus of respiration, 212 Rheumatism in children, 99 Rickets and its relation to spasmodic affections, Rosenthal, Edwin, a report of one hundred cases Salacetol, 305 Salicylic acid, action of, upon the uterus, 12 Schnee, Emil, Nizza, the jewel of the Riviera, Packard, John H., verbal report of three cases of Seborrhoeic eczema produced by borax, 56 left inguinal colotomy, 170 Paget's disease of the nose, 352 Pannus, 51 Parachlorophenol in tuberculosis of the upper Paradoxical displacement of the heart, 301 Selenium and tellurium, action of, upon the Shoemaker, John V., a clinical demonstration | Theobromine-lithium, a new diuretic preparation, of psoriasis, with special remarks upon treatment of diseases of the nails, 125 Soya beans, on the use of, in diabetes mellitus, Stewart, W. Blair, a midway Southern health a synopsis of an introductory lecture on success in practice, 323 Success in practice, 323 Sudden death during coitus, 421 in the treatment of the insane, 58 Syphilis, early, visceral disease in, 475 Tabes, lesions of the auditory apparatus in, 459 Tendons, divided, how to find the upper ex- The etiology, diagnosis, and treatment of chronic The liquid of albuminous periostitis, 134 The reciprocal relations of the two ears, 97 The valedictory address of the graduating class 25 Therapeutic action of methylene blue, 259 Tobacco-deafness, a case of, 476 Tone-blindness (klang farben blindheit) and the Tonsil, calculi of, 12 Tricresol in typhoid fever, 420 the preparation of cresols as a disinfectant 8281 LIBRARY ASS'N MEDICAL BULLETIN VOL. XVI. A MONTHLY JOURNAL OF MEDICINE AND SURGERY PHILADELPHIA, JANUARY, 1894. CLINICAL LECTURE. THE SYMPTOMS AND DIAGNOSIS OF INTESTINAL OBSTRUCTION FOLLOWING INTRA-PERITONE AL OPERATIONS.* BY WILLIAM EASTERLY ASHTON, M.D., Professor of Gynecology in the Medico-Chirurgical College of Philadelphia. GE ENTLEMEN: The patient I bring be. fore you this morning is suffering from chronic intestinal obstruction following an abdominal operation several months ago. I shall take advantage of this opportunity to discuss with you the symptoms and diagnosis of intestinal obstruction following intra-peritoneal operations. This subject is one of great interest and importance, especially in the postoperative management of abdominal cases, as the life of a patient frequently depends upon the correct conception of the symptoms present. First, however, let me briefly outline the pathology of these obstructions, in order that you may have a clear idea of their cause and development. By far the greater number of intestinal obstructions are due to adhesions between the intestines and neighboring parts, as the result either of raw surfaces left at the time of operation or of traumatic inflammation. Thus, a knuckle of gut becomes adherent; a kink results, and obstruction of the bowel follows. Kinking, however, does not necessarily result unless the bowel adheres in an abnormal position. Again, obstruction may be caused by paralysis or local spasm of the intestines, or it * A clinical lecture delivered at the Medico-Chirurgical Hospital. No. I. may be due to impacted fæces. The explanation of obstructions due to these causes will most probably be found in a study of the influence of various stimuli upon the nerves controlling intestinal peristalsis. The intestinal walls, as you are aware, contain an automatic motor apparatus,-the plexus of Auerbach,which influences the peristaltic action. If this centre is not affected by any stimulus, the movements of the intestines cease and the bowel is in a condition of "aperistalsis." On the other hand, stimulation increases the peristaltic action, which becomes very violent if the irritation be immoderate. This condition of excessive contraction is termed "dysperistalsis." Finally, the continued presence of a strong stimulus causes dysperistalsis to give place to paresis or exhaustion. During the first twenty-four or forty-eight hours after an abdominal section, if the case be doing well, the intestines are in a condition of aperistalsis. Naturally, there are several factors concerned in bringing about this state. In the first place, the preparatory treatment of the bowels with salines, the liquid diet, and the absence of food and drink after section leave the intestines empty, thus removing their contents as a factor in stimulating peristalsis. Again, the rest in bed for several days before operating and the enforced quiet afterward add largely to the absence of intestinal activity. The causes of operative stimulation of the intestines are: exposure to the air, lowering of the temperature, bruising the bowel, irritating fluids, and septic materials. Dysperistalsis and paresis depend, as we have seen, upon the same cause, namely, an and the difference between the two conditions irritation of the motor centre of the intestine; symptoms develop aid us in making a differential diagnosis? Leaving out of consideration, for the moment, cases of traumatic peritonitis, I believe we may safely state that symp is determined simply by the intensity and duration of the abnormal stimulation. For example, simple congestion would most probably, even if long continued, result in a condition of dysperistalsis; while a severe inflam-toms occurring almost immediately after section mation, on the other hand, would cause paresis. In cases of obstruction caused by fæcal impaction there exists, primarily, paresis due to inflammation, and while the bowel is in this state accumulation of fæces takes place. Inflammatory lymph is another cause of postoperative obstruction. As the result of intraperitoneal inflammation lymph is poured out upon the intestines, and coils of the bowel become more or less adherent. As a rule, no bad results ensue, unless the adhesions cause kinking or constriction. Finally, there is a class of obstructions dependent upon a careless or faulty operative technique. I refer to kinking or twisting of the intestines, to the slipping of a coil of bowel through a slit or aperture, and also including the gut within the loop of an abdominal-wall suture or between the edges of the incision. Having thus briefly studied with you the pathology of post-operative obstructions, we will now consider their symptoms and diagnosis. In the majority of instances the symptoms begin to develop between the second day and the end of the first week, although they may appear earlier or be delayed much longer. This variation in the date of the outset of symptoms is readily understood when we take into consideration the causes of these obstructions. Thus, for example, if a kink or twist in the bowel is the result of an immediate and decided traction an obstruction occurs at once, and the symptoms will manifest themselves almost from the start. On the other hand, however, the constriction of the bowel in the beginning may be very slight; consequently the obstruction will be slow in forming. Thus, an obstruction caused by bands of inflammatory lymph, as a rule, is late in developing for the reason that the bowel is not seriously constricted until the exudate begins to organize and contract. It is evident, therefore, that the rapidity with which an obstruction occurs depends entirely upon the cause and character of the constriction. are due to obstruction, and not to sepsis. We must, however, qualify this statement by excluding, first, incomplete operations, especially when pus is present, and, second, cases septic at the time of section. Furthermore, cases which do well up to the end of the first week and then develop bad symptoms are almost certainly bowel obstruction and not septic peritonitis. Unfortunately the majority of cases of obstruction, as well as of sepsis, develop within the same period, namely, from the second or third day to the end of the first week. We are, therefore, unable in these cases to take the period in which the symp toms develop as an aid in making a differential diagnosis. Traumatic peritonitis occurs, to a greater or less extent, after all intra abdominal operations as the result not only of the injuries sustained by the peritoneum during the necessary operative manipulations, but also in the healing of raw surfaces. The symptoms of this form of inflammation appear immediately after section unless they develop late as a secondary condition due to the irritation produced upon the serous coat of the bowel by an obstruction. The most prominent symptoms of obstruction of the bowels are vomiting, tympany, pain, elevation of the temperature, rapid pulse, constipation, and a discharge of mucus by the rectum. Vomiting is not only a constant and early sign of obstruction, but it is also, as a rule, persistent. In about one-third of the cases it becomes fæcal in character. In early obstructions it is difficult, and at times even impossible, to say whether the vomiting is due to the anesthetic or to a beginning trouble in the bowel. In determining this question much will depend upon a personal knowledge of the case, especially as to the preparatory treatment and the length of the operation. In my experience ether-vomiting is a rare post-operative complication. I attribute this to the fact that my patients are carefully prepared for one Naturally the question at once arises, when a patient is doing badly after an abdominal sec-week prior to section, and that the operations tion, Are we dealing with an obstruction, or is the condition due to a traumatic or septic peritonitis? Again, does the period in which the are rapidly performed. If, however, the preparatory treatment has been imperfectly carried out or the operation has been a prolonged one, vomiting is almost certain to occur,-the result | of constant suffering from colic and constipaeither of the condition of the alimentary tract tion. Upon opening the abdomen the omenat the time of section or to ether-saturation. In obstructions beginning after the second or third day nausea and vomiting are signs of great value. As a rule, the gastric irritability is persistent, and gradually increases in severity, although in some instances it is not continuous. Unfortunately, there is no rule to guide the surgeon as to when to expect the presence of fæces in the matter vomited. Tympany is almost always present, to a greater or less extent. It may develop in some cases before vomiting occurs; or, again, it may show itself as a later symptom. Like vomiting, tympany is usually continuous, becoming more and more marked as the case progresses. The extent of the abdominal distension depends largely upon whether the obstruction is complete or not, and the time of its outset is influenced directly by the state of the alimentary canal at the moment of operation. In some instances the distended coils of intestine can be seen through the bellywall, thus aiding in making the diagnosis. It is interesting to note that tympany may be absent as a symptom of obstruction, on account of extensive adhesions between the intestines and the abdominal walls. Thus, in a case reported by Shively, "there were extensive adhesions of the intestines to the sides and posterior wall of the abdomen, binding them firmly down and preventing the appearance of tympany." Excessive pain and tenderness are, as a rule, not marked in post-operative obstructions. In cases developing early, however, where these symptoms are present it is impossible to differentiate the pain produced by the traumatism of the operation from that which may be the result of the local bowel trouble. In late obstructions pain, as a symptom, is of decided value. The colicky pains felt in some cases after an operation are due to abnormal fixations of the intestines. In these cases, although actual obstruction does not exist, yet the bowel is in such a condition that a sudden and serious blocking may take place at any time. In December, 1892, I operated upon a woman, with the following interesting history. One year prior to consulting me she had been operated upon and both of the uterine appendages were removed. Her history from this time on until she came under my care was one tum was found adherent to the stump of the right pedicle, while a knuckle of the ileum was attached to the left. The patient made a good recovery from the secondary operation, with entire relief from all of her former symp toms. The temperature of the patient throws but little light upon the diagnosis of these obstructions. Thus, in cases which develop early, and are associated with a temperature of 100° to 101° F. or more for the first fortyeight hours, the elevation is not due to the obstruction, but is simply the post-operative reaction seen in most patients after section. Again, it must be remembered that we may have present with the obstruction a septic or traumatic peritonitis, causing an elevated temperature. Cases of obstruction due to impacted fæces sooner or later develop a high temperature, which is caused by the absorption into the general system of the micro-organisms found in the intestinal canal. A rapid pulse is one of the earliest and most constant symptoms of post-operative obstruction. The heart-beat ranges from 100 to 140 per minute; it may, however, become even more rapid, or, in exceptional cases, fall to almost normal. A slow, full pulse after an abdominal operation is an almost certain sign that the patient is doing well, while a rapid pulse indicates, as a rule, some impending trouble. Constipation is an important factor in the diagnosis of these cases, although at times the symptom may be more or less misleading. Failure to procure free evacuations within forty-eight hours after section is a cause for uneasiness, especially if raw surfaces were left at the time of operation. If gastric irritability and rapid pulse be associated with the constipation, the question of obstruction becomes very grave. The passing of scybalous masses per rectum must not mislead the surgeon into the belief that the bowels have acted. Again, the bowels may move freely for several days before signs of obstruction manifest themselves. Finally, there may be obstinate constipation from the first, which may be followed in a few days by several loose movements, and again the bowels become obstructed. The various degrees of kinking and constriction of the intestines account for this want of uniform |