TWO CASES OF ACUTE INTES- TINAL OBSTRUCTION; OPER- ATION; DEATH. BY ERNEST F. TUCKER, M.D. Harv., Lecturer on Clinical Gynaecology in the Medical Department of Oregon State Universitv; Attending Gynaecologist to St. Vincent's Hospital. REPRINT FROM American Medico-Surgical ^Bulletin, June 15, 1894. TO CONTRIBUTORS. 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TUCKER, M.D., Harv., Lecturer on Clinical Gynaecology in the Medical Department of Oregon State University; Attending Gynaecologist to St. Vincent's Hospital. TWICE I have been called upon to operate for the relief of acute in- testinal obstruction, and both times, although successful in relieving the obstruction, I have lost my patients, their death being due to postponement of the operation from day to day ; and I wish now merely to add my slender testimony to that of others against the disastrous results of delay. My first case occurred some years ago, while I was still living in New York, and as I have lost the records of the case I will have to relate it from memory. About September, 1886, I was called to Rondout, N. Y., to see a Mrs. B. This pa- tient, eighteen months before, had had an abdominal section performed for diseased appendages at the Woman's Hospital in the state of New York, in the service of the late Dr. James B. Hunter, whose house surgeon I was at the time. The operation was fol- lowed by an attack of peritonitis which, however, ended in perfect recovery. She had had peritonitis once before this, follow- ing an abortion at five months. Since then up to the present time, she had apparently enjoyed perfect health, although there was some tendehcy to the formation of a hernia in the line of the abdominal incision. 1 On my arrival at Rondont, I found the patient in fair condition. She gave me her own history as follows : The week pre- vious, she had attended a piciiic and had eaten considerable fruit; on her return home she was seized with diarrhoea which lasted several days, and for which she took no medicine ; four days ago the diarrhoea suddenly ceased, since when she had not been able to obtain a movement of the bowels ; she had had some pain referred to the region of the umbilicus, and since the day before she had been vomiting consider- ably, and now could retain absolutely no- thing on her stomach. Her local attendant had administered various cathartics, but to no purpose. Being so well acquainted with her previous history, I at once suspected an obstruction from some intestinal adhe- sions. On examination I found her only slightly prostrated, her abdomen somewhat distended and tympanitic, but nothing like any distinct tumor could be felt. I remained with the patient overnight, giving her mor- phine, subcutaneously, to relieve her pain, and tried by means of a long rectal tube and various kinds of enemata to obtain a passage from the bowels, but without success. The patient was growing worse, and I accordingly suggested the advisabil- ity of an operation, if there should be no improvement in the next twenty-four hours. The patient herself readily assented, but the family and attending physician would not listen to anything of the kind. I gave up the case and returned home. Tnree days later, I received a telegram to go up to Rondout prepared to operate at once. Accompanied by Dr. C. C. Osborne, ot 2 New York, and a trained nurse, I returned to Rondout, only to find my patient practically moribund ; she was semi-coma- tose, almost pulseless, and had had ster coracious vomiting for two days. At first, I refused to operate, but at the earnest so- licitations of her husband, who said he would prefer to have her die on the table than to let her die without having anything done, I consented. Stimulants were freely administered, and, under an anaesthetic, I made an incision in the median line by 'he side of the old cicatrix. On opening the peritoneal cavity, the distended intestines presented almost black. I soon found a knuckle of intestine doubled on itself and surrounded by an old adhesive band. The adhesion was at once divided, and immediately the intestines below the obstruction became distended with gas; no other obstruction was found, the wound was closed and the patient was returned to bed. Almost before she was out of ether, she had a very loose and of- fensive passage from the bowels. She re- gained consciousness perfectly, but died in a few hours. This patient was a young woman of about twenty-four years of age, and a timely operation would undoubtedly have saved her life. On the 26th of last October, I was called about six miles from Portland to see a Mrs. F., German, 60 years old, and mother of a family, who was complaining of pain in the abdomen and constipation. She had been in town the day before, and had obtained some medicine which she took without ef- fect. She informed me that she had always suffered from constipation, sometimes going a week or ten days without a passage from 3 the bowels; at the present time she thought it must be two weeks since her bowels had moved. On examination I found her well-nour- ished; her pulse and respirations excellent. On inspecting her abdomen, which was somew'hat distended and tympanitic, a tu- mor the size of a foetal head was apparent, occupying the right iliac region ; this tumor wras also soft and tympanitic. Rectal ex- amination was negative. There was con- siderable pain over the abdomen, but no particular tenderness. Enemata of soap- suds and sweet oil administered through the long rectal tube yielded no result. I ordered such enemata repeated every three hours ; small doses of belladonna fre- quently repeated and gentle abdominal massage. On my visit the next day, I found the pa- tient in about the same condition, nothing having passed the bowrels. Having made up my mind that the tumor in the iliac re- gion could be nothing but the distended cae- cum, caused by obstruction in the colon, I advised her immediate removal to St. Vin- cent's Hospital in Portland, at the same time expressing a belief that an operation might be necessary, as by deep palpation I could detect nothing which would sug- gest a mere faecal accumulation. The pa- tient acquiesced, and the patient was brought to towm at once. The same afternoon, a consultation was held with a prominent sur- geon of this city. The long rectal tube wras again brought into requisition, and this time some flocculent faecal matter came away. I was consequently dissuaded from operating. On the following day the ene- mata were still persevered in w'ithout any 4 further result, and owing to the fairly good condition in which the patient was, it was still deemed advisable to wait. The next day, the 29th, the patient was somewhat weaker, considerable retching and vomiting began to take place, and toward even- ing the tumor in the abdomen, which had been distinct up to this time, disappeared entirely, and the abdomen was now uni- formly distended and tympanitic. Through the day, a small ribbon of faecal matter had been passed with several small blood-clots. A second consultant was now called in by the family, who, agreeing with me, advised an immediate operation. I regret here to say that the operation was again delayed until the next morning, owing to the ab- sence of one of the relatives whose pres- ence was deemed absolutely necessary by the patient. Early on the morning of the 30th, every- thing was prepared for operation. On see- ing my patient, it was hard to realize the change she had undergone since the day previous. She had suffered through the night from almost constant retching; she was very weak, her pulse was quite feeble and rapid, her expression pinched and anx- ious, her abdomen was very tender, over which the skin was tightly stretched ; on the morning before there was almost nothing to indicate any immediate danger beyond her history, and now she was almost collapsed. Stimulants were administered subcutane- ously after she was anaesthetized and placed on the table for operation. Assisted by Dr. William Jones and in the presence of Drs. Wells, Bodom, and the house staff of the hospital, I made an in- cision through the abdominal walls in the 5 median line from the umbilicus to the pubis. On dividing the peritoneum, a puff of gas es- caped from the general peritoneal cavity, evidence of a perforation which undoubt- edly was simultaneous with the disappear- ance of the tumor on the day before ai d since which time her symptoms had grown so rapidly worse. A few knuckles of in- tensely congested and distended small in- testines presented themselves at the wound; one of them was tapped with a very fine as- pirator and sufficient gas withdrawn to allow their being replaced ; on withdrawing the needle a small jet of liquid faeces followed and kept oozing, so that it was necessary to take three stitches in the intestine to pre- vent further leak tge. The ascending colon was found considerably distended, the small intestines adherent to its inner free margin, by freshly effused lymph ; at one place where these were gently torn away, a recent perforation was found, the size of a three-cent piece, out of which oozed liquid faeces. The intestines were wiped clean, the perforation picked up, its edges pared and closed with Lambert sutures. The trans- verse colon was found to be collapsed and empty. The abdominal incision was now extended for about three inches above the umbilicus. On following up the ascending colon, in the neighborhood of the hepatic flexure, everything seemed to be densely adherent and as near as I could make out at the time, the large intestine seemed to be bound down or doubled on itself and held by old and firm adhesions, showing some chronic inflammatory process. These ad- hesions were partly torn and partly divided with scissors until the transverse colon be- gan to fill up with gas. The rest of the large 6 intestine was palpated and found to be un- obstructed and filling with gas. The ab- dominal cavity was wiped clean and closed without drainage. After the operation the patient rallied well and passed enormous quantities of gas. The following day the patient was ap- parently doing well, her expression was much improved, she complained of no pain, her temperature had not been above 99.6, although her pulse was rapid and not very strong. She continued to pass gas at inter- vals. On Nov. 1, not having yet had a passage of the bowels, small doses of calomel were administered • Nov. 2. No passage yet. Calomel dis- continued, and a dose of magnesium sulphate administered. In the afternoon the patient got out of bed and sat over a commode, and had a copious passage from the bowels. Nov. 3. Patient very weak and listless; some vomiting. Nov. 4. After a very restless night, the patient died at 4 a. m. In this last case I may have committed a serious error in not using any drainage, as the peritoneal cavity was naturally septic. I merely wiped the intestines clean and dry, not flushing the abdominal cavity with fluids, as I believe, unless it is very thor- oughly done, the chances of septic absorp- tion are increased. As to the drainage tube, it does not seem to me that it could have drained the whole abdominal cavity, which would have been necessary in such a case as this. What I regret most, however, was my attempt to move the bowels so soon after the operation, for until the time that this occurred my patient was doing well. If 7 any damage was done at that time, I never could find out, as I was not allowed to make an examination of the body after death. Beyond this, the history of these two cases seems to me to emphasize the great and serious danger of waiting for alarming symptoms to supervene before op- erating; that good results can only be looked for when the patient is still in good condition; that a small amount of faecal matter might be passed and an obstruction dangerous to life still exist; and above all that tapping the intestines, when distended with gas, through the abdominal walls is by no means a procedure devoid of danger, as seems to be generally believed. Portland, Oregon. 8 SEVENTH YEAR. $2.00 per year. American Medico=Surgieal Bulletin A SEMI-MONTHLY JOURNAL OF PRACTICE AND SCIENCE. Issued on the 1st and 15th of each month. 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