TONIC AND SPASMODIC INTESTINAL. CONTRACTIONS WITH REPORT OF CASES.* X. O. WERDER, M.D. Ar the last meeting of this association, one of our fellows, Dr. Long, read a very interesting paper on "Dynamic Ileus," reporting five cases of this disease, two of his own, one of Dr. Murphy's, and two which occurred in my practice. The novelty of this subject and some further experience with cases that are at least analogous, and may help to throw some additional light on this interesting, but rather obscure condition, are my only excuse for bringing this matter before you at this meeting. I hope you will pardon me, if, for the purpose of facilitating an intelligent discussion of the subject, I present a brief history of the cases observed. Dr. Long's first case was a young, neurotic woman 21 years of age who, when she came under the doctor's care, had had no movement from the bowels for four weeks, excepting what was washed away with the colon tube; with frequent attacks of nausea and vomiting, abdominal pains and distension. When the abdomen was opened, no mechanical obstruction was discovered, but at three different points of the intestinal tract, two in the *Read before the American Association of Obstetricians and Gynecologists at Niagara Falls, N. Y., August 17-19, 1897. ileum and one in the sigmoid flexure, there were contractions constituting almost complete occlusions of the lumen of the intestine thus affected, and accompanied by considerable distension above the contracted portion. The sections of bowel thus contracted were dilated by "milking the intestinal contents along"; after which the abdomen was closed. The patient made an uninterrupted recovery and seems to have been completely relieved of the symptoms of ileus. His second case, man, 21 years old, epileptic, had appendicitis in April, 1894, from which he had never fully recovered. December 22d of the same year the abdomen was opened and the appendix enucleated from a mass of adhesions. At a point two feet from the ileo-cæcal junction, the ileum was contracted for a distance of five inches to one-third its normal size, causing the parts to look as though "a section of a very small gut had been let into a large one." This contracted portion slowly dilated to nearly normal size while exposed to view. The patient made a good recovery, but had several attacks subsequently of "obstruction of the bowels," lasting 36 hours and subsiding without operative treatment. Dr. Murphy's case was a inan, 40 years old, who had been treated for a number of attacks of lead colic; he was attacked with acute intestinal obstruction lasting five days when the abdomen was opened, an enlarged coil of intestine grasped and drawn. into the wound. With it came eight inches of a contracted portion which resembled a solid cord three-eighths of an inch in diameter, and was as stiff as a rope of the same size. The intestine above the contracted portion was much distended. After ten minutes' exposure to the air, the spasm relaxed and slowly expanded to about one inch in diameter. The abdomen was closed and the bowels moved within three hours; no further trouble was experienced. My own cases were post-operative forms of ileus and their history is briefly as follows: CASE I-Mrs. W.; salpingo-oophorectomy October 9, 1895, for "small round-cell sarcoma" 1 cm. in diameter, of right tube. During first five days her condition was excellent, pulse varying between 70 and 90, and temperature only once reached 100°. Spontaneous bowel movements. On sixth day she was given an egg-nog which was followed some hours later by severe cramps, nausea and vomiting. These symptoms were less severe the following day, but persisted and became serious two days later, when she became very nervous and excitable, delirious at times, with profound depression, temperature 100°, pulse rapid and feeble (150 to 170) in spite of repeated and energetic stimulation. Nausea, retching and vomiting continued and only yielded temporarily to lavage; she had severe cramps all over the abdomen, with visible peristalsis with an abdomen that was flat but not tense or tender. Cathartics, enemata, tubage, all failed to expel gas or fæces at this time, though a small amount had been passed prior to this date. She died on the eleventh day after operation. It was learned from the patient and husband, that she had several such attacks previously from which she nearly died, that milk always disagreed with her, and that egg-nog usually caused pain and vomiting. At the autopsy, four hours after death, the ileum was found distended with gas to 4.5 cm. to within 55 cm. of the ileo-cæcal valve. From that point to the anus, the bowel was in a state of firm contraction, the ileum being 1.2 cm., and the whole large intestine 1.2 to 1.6 cm. in diameter. Its peritoneal covering was glistening, normal; no adhesions anywhere; no evidence of peritonitis. The walls of the firmly contracted portion were slightly anæmic. A section removed quickly relaxed to its normal calibre. The pedicle was covered by smooth, glistening, transparent endothelium, with no adhesions or exudate. Abdominal wound firmly healed. CASE II.-Mrs. S.; vaginal hysterectomy June 15, 1896, by multiple-clamp method for small uterine fibroid with marked dysmenorrhoea, menorrhagia and metrorhagia. Patient very anæmic and neurotic. Operation uncomplicated, easy. A little pain, some nausea and considerable restlessness after operation; flatus passed within 24 hours. When clamps were removed, 48 hours after operation, she became weak, her skin was cold and clammy, her temperature 97.4°, pulse rapid and feeble. She responded fairly well to stimulation. Numerous attempts were now made to move her bowels, but neither gas nor faces came away. The third day after operation the abdomen was soft. There was very little distension, general peristalsis, no tenderness, some vomiting. A very little gas was expelled after one enema. Her pulse rate had varied from 112 to 132, her temperature va ried from 97.4 to 99. About the middle of the fourth day, she sank into collapse and died. In glancing over a brief abstract of the transactions of the meeting of the last German Surgical Congress held in April of this year, I found a statement made by L. Heidenhain in a discussion of ileus, in which he claims that a complete and apparently insuperable obstruction may be produced by a firm tonic intestinal contraction as a result of an enterospasm of a portion of the intestinal tract. He bases this assertion on an experience covering three cases observed at the Greifswald University clinic. The first case was discovered accidentally while performing a cæliotomy in a patient suffering from a dense cicatricial stenosis of the upper portion of the rectum, for the purpose of doing an enterostomy. After opening the abdomen a coil of greatly distended small intestine protruded, followed by a section of bowel of considerable size which was perfectly empty and firmly contracted, though no organic occlusion could be found at the junction of these two segments of bowel. I have, unfortunately, been unable to obtain a full report of the transactions, so that I cannot give the other cases in detail, but Heidenhain states that in all |