REPRINTED FROM 
The Journal" of Gynecology, 
SEPTEMBER, 1891. 
Cases of Intestinal Obstruction : 
LAPAROTOMY: 
REMARKS. 
DAVID BARROW, M D„ 
LEXINGTON, KY. CASES OF INTESTINAL OBSTRUCTION; 
LAPAROTOMY; REMARKS.2 
DAVID BARROW, M. D., LEXINGTON, KY. 
On the night of August 23d, Dr. M. T. Scott and myself 
saw Mrs. P. in consultation with Drs. W. L. and H. S. Atkins. 
Intestinal obstruction had been diagnosed, and the following 
history was furnished: 
On the 20th of August she was taken sick with symptoms 
of indigestion. At that time there was pain in the abdomen 
and vomiting. The bowels had moved on the 19th. A mild 
purgative was given, and nothing serious was thought to be the 
matter. On the 21st the symptoms were about the same as on 
the previous day, but the vomiting was more frequent. Pur" 
gatives were continued and enemata ordered. 
On the 22d vomiting was very distressing; there had been 
no movement from the bowels, and tenderness and pain existed 
throughout the abdomen. Temperature and pulse were normal. 
On the evening of the 2-3d the vomiting had become stercora- 
ceous; no movement from the bowels had occurred and the ab- 
domen was slightly distended and tympanitic. Pain was quite 
severe, the temperature and pulse were normal, and the expres- 
sion was good. No food had been retained for three days. It 
was midnight when I saw her. She was 68 years old, quite 
fleshy, and well preserved for one so old. Had always enjoyed 
good health, and with the exception of a little indigestion and 
occasionally "a slight bilious attack" she had never been sick. 
For two months before the present attack, she sometimes had 
felt a desire to evacuate the bowels, but on going to stool was 
unable to do so. Pain in the abdomen was rather severe, and 
she complained of it more on the right side than elsewhere. 
There were tympanites and distension, and some tenderness on 
pressure; the vomiting was frequent and stercoraceous and con- 
stipation was complete. Temperature was normal and pulse 
85; and her expression good. Nothing unusual could be de- 
tected by manipulating the abdomen, nor by rectal examination. 
A long rectal tube was passed and a gallon of warm water with 
CASE 1. 
2 Read before the Kentucky State Medical Society, at Lexington, May 29,1891. 2 
some glycerine in it was injected into the colon. She retained 
this for some time, but when passed it came away clear The 
enemata were ordered given every three hours, and every two 
hours 15 grains of calomel were administered. 
On the 24th the patient seemed better, vomiting was not so 
frequent and was no longer stercoraceous; with the enemata 
came away quite a number of blackberry seeds and two grains 
of corn; the abdomen was not so distended, nor was there so 
much tenderness. Four inches to the left of the umbilicus there 
was slight dullness, and we thought some induration. The same 
treatment was continued. 
On the 25th the patient was not so well. Stercoraceous vom- 
iting had returned and the enemata had failed to bring anything 
further away. The expression was not so good, the appearance 
of the abdomen about the same. Temperature was normal and 
pulse 90, strength was fairly good notwithstanding nourish- 
ment had been rejected for five days. Operation advised and 
accepted. 
At 1 p. m., assisted by the physicians present, I opened 
the abdomen through the linea alba with 2^- inches in- 
cision, two fingers were passed into the peritoneal cavity and 
after slight manipulation the cause of the obstruction was found 
in the ileum, and when removed proved to be a gall-stone 
measuring 3f inches in circumference. The loop containing 
the stone was delivered through the incision and was in fair 
condition; the peritoneal cavity was carefully protected by pack- 
ing the incision with sponges before incising the gut. The in- 
cision in the gut was closed with the Lembert suture, using fine 
intestinal silk for the purpose, and after cleansing the loop 
thoroughly it was returned to the cavity; the abdominal incis- 
ion was closed with interrupted sutures, and the dressings were 
applied. 
Irrigation and drainage were thought unnecessary. It was 
forty minutes from the time the knife was used until the pa- 
tient was put to bed. Ether was the anaesthetic. Just after 
the operation her pulse was 90 and regular, face and extremities 
slightly cyanosed; temperature in the axilla 97-^°. Hot bottles 
were placed about the patient and in a little while she seemed 
to be reacting, although the temperature remained 97^°. On be- 
coming conscious she complained of the bandage being too 3 
tight and it was loosened. For five hours the pulse remained 
less than 100, and all symptoms seemed favorable except the 
subnormal temperature and the cyanosis. Suddenly the pulse 
became weak and rapid, and in six hours after the operation 
she died. 
At my first visit it was evident that there was intestinal ob- 
struction but we were inclined to believe that the obstruction 
was due to fsecal impaction, and might be overcome by non- 
operative measures. This opinion was further strengthened at 
the second visit, by the patient passing a great number of black- 
berry seeds, and two grains of corn, by an improvement in her 
condition after the movement, and by a cessation of the stercor- 
aceous vomiting; also, by the belief that we detected an indu- 
rated area, and some dullness to the left of the umbilicus. At 
my third visit the symptoms were not favorable. The stercora- 
ceous vomiting had returned, and there had been no further 
movement from the bowels. The patient's condition still 
seemed good and it was thought the time had come to do lap- 
arotomy: and the condition found demonstrated that in the op- 
eration was her only chance of being saved. She was 68 years 
old and weighed probably 200 pounds. The abdominal 
wall was at least two inches thick. The heart sounds 
seemed normal, but the mode of death, with the tendency to 
the accumulation of fat throughout the body, caused me to be- 
lieve that she had a fatty heart. Had the operation been done 
when I first saw the patient, the termination might have been 
different, and as there was stercoraceous vomiting at that time, 
I feel that the procrastination was unjustifiable, and proved a 
fatal mistake. 
CASE 2. 
H. S.: Aged 82 years, on the evening of January 19th 
was taken suddenly with a pain in the right inguinal region. 
For eight years he had worn a truss for a small direct inguinal 
hernia on the right side, but had never experienced any trouble 
in preventing its descent. At the time he was returning from 
a short drive, and had gotten out of the buggy to open a gate, 
when he experienced a severe lancinating pain in the region of 
the hernia, and soon became nauseated and very weak, and just 
at the external abdominal ring he noticed a slight swelling. 4 
He was a tall, thin man, and for several months had 
suffered with great debility. A physician was soon summoned, 
and making a diagnosis of strangulated hernia, attempted its 
reduction, but failed alter persistent taxis to relieve him. His 
pain was partly controlled during the night by the adminis- 
tration of opium, but he continued to suffer a good deal, and 
on the morning of the 20th, I saw him with Drs. Whitney and 
Holloway. At that time there was a good deal of pain and 
restlessness. 
The pain on manipulation was considerable, so chloroform 
was administered and taxis again employed, but we failed to 
reduce permanently the swelling. 
There being evidently intestinal obstruction, we advised 
surgical interference, although his advanced age and weak 
condition made the case a very unfavorable one. After a 
thorough discussion the patient and his family consented to an 
operation. 
Everything was gotten ready, and at 12 M. I operated, 
assisted by Drs. Whitney and Holloway. 
I thought the case was simply one of strangulated hernia, 
and expected to find the constriction at the external ring ; but 
in this I was mistaken as the operation demonstrated. 
OPERATION. 
Chloroform being administered, an incision was made over 
the swelling parallel to Poupart's ligament. The skin and 
superficial tissues were divided until the sac was reached ; and 
at that point some difficulty was experienced in determining 
whether I was upon the sac or gut. The sac was injected and 
on incising it, a nuckle of the small gut presented, very dark, 
but firm and apparently viable. On passing my finger down 
to the ring, within the sac, the constriction could not be felt, 
and the gut was quite movable within the ring. After a little 
manipulation I was convinced that the constriction was inside 
of the abdominal cavity, and to reach it I would have to extend 
the incision and convert my herniotomy into practically a lapa- 
rotomy. This I did by deepening the incision already made, 
and by extending it outward and upward, entering the cavity 
with an incision two inches long. There was considerable fluid 
in the peritoneal cavity, but its presence was due, I think, to 5 
some degenerative change, and was not dependent upon the 
strangulation present. 
Passing my finger into the cavity I felt a constricting band 
about one-half inch back of the external abdominal ring, and 
this I divided without trouble. The gut, after being released, 
was delivered through the incision and carefully inspected ; the 
lumen was entirely occluded, but the mesentery, was not in- 
volved. Warm cloths were applied for a few minutes to the 
gut before returning it to the cavity ; the incision was closed 
with silk sutures, and the dressing applied. Duration of oper- 
ation about half an hour. 
Towards the end of the operation, the pulse being rapid 
and irregular, hypodermics of digitalis and whisky were given. 
He was put to bed, hot bottles placed about him, and he soon 
reacted fairly well, although for some days his pulse continued 
rapid and irregular. 
The patient was extremely restless during his entire con- 
valescence, and on account of this and his general debility, 
morphine and stimulants were given for about ten days. His 
bowels moved regularly after the second day. 
Several times he saturated the dressing with urine and the 
stitch-holes discharged pus for about a month, due, I think, to 
infection from this source. At the end of five weeks the 
wound had entirely healed, and he could dress himself and 
walk about his bed-room. 
The symptoms in this case were sudden and pronounced, 
foetid vomiting appeared in 18 hours after he first noticed the 
pain. The diagnosis of intestinal obstruction was clear, and 
previous to the operation the constriction was thought to be at 
the external ring, and the incision usual for herniotomy was made. 
In this case the incision served my purpose better than the 
median incision could have done. Had it not been for the 
swelling present, and the history of an old hernia, I would 
have opened the abdomen in the median line. There had 
probably been some peritoneal inflammation in the region of the 
external ring, caused probably by the existing hernia, and a 
band had at some time previous been thrown out. and behind 
this band the gut became constricted. The constriction being 
near the external ring, the strangulated gut projected into the 
the dilated canal and produced the swelling that was present. 6 
This accounts for our ability to reduce the swelling, and 
also for the fact of its returning when the pressure was 
removed. 
The favorable termination of this case was due largely to 
the early co-operation of the attending physicians and in the 
prompt operation, it being done within twenty-four hours after 
the first symptoms of obstruction appeared. 
In reporting these cases it is not my desire to speak 
of the forms of Intestinal Obstruction nor of the symp- 
toms or operative procedures, but more to urge upon the sur- 
geon the necessity of prompt action, and upon the general 
practitioner, the importance of . having the surgeon called 
early in consultation. 
The general practitioner should not wait to make a diag- 
nosis before summoning the surgeon, but should have him 
called as soon as intestinal obstruction is suspected and the two 
should then watch the case jointly, ready at any time to inter- 
fere should it become necessary. We must remember that the 
symptoms in some of these cases are not indicative of so 
serious a condition as really exists, and sometimes when there is 
complete closure of the gut, the patient's general condition may 
seem fairly good, even to the time of gangrene appearing. 
Should we wait to make a positive diagnosis in some of these 
cases before operating, the operation will certainly be too late 
to offer much prospect of relief. The danger of an exploratory 
incision per se is not great, and should unhesitatingly be re- 
sorted to when necessary. It is only when there is already 
marked depression that the shock attending laparotomy is so 
quickly fatal. The large mortality in laparotomy for intes- 
tinal obstruction in the past should not deter the surgeon. 
The operation has usually been done as a dernier resort 
and upon dying patients, and death was, of course, the inevita- 
ble termination. There can be no reason why many cases of 
intestinal obstruction should not recover after laparotomy, pro- 
vided the operation be done in time. The operations are often 
simple, and the necessary manipulation to remove the obstruc- 
tion may be slight. In doubtful cases where exploration has 
been resorted to, I have never seen the abdomen opened without 
finding a condition justifying the operation, but have occasion- 
REMARKS. 7 
ally seen the procrastination continued until the patient was 
beyond any possible relief. Have also known patients to die 
without any surgical effort to relieve them. 
The medico-legal aspect of these cases must influence the 
surgeon's action, and with the present unsettled state of the 
professional mind, relative to exploratory incisions, a con- 
scientious and competent surgeon might be greatly harrassedand 
injured in reputation and financially, should he open the abdo- 
men and find nothing there requiring such a procedure. After 
using the recognized non-surgical methods to perfect his diag- 
nosis, and failing, the symptoms continuing to indicate intesti- 
nal obstruction, the surgeon should make an exploratory incision, 
and the profession should support him in the procedure, even 
if he fail to find a local condition requiring the operation. In 
chronic cases, the operation, even when the diagnosis is clear, is 
often put off from day to day on account of some deceptive 
improvement, and when it is finally resorted to, the patient is 
much exhausted, and is in a most unfavorable condition for an 
operation. If there be one thing that must impress the physi- 
cian, in studying the past history of intestinal obstruction, it is 
the very evident fact that all surgical interference, when it has 
been resorted to, has usually been done when the case was 
hopeless, and that in the future, if we can ever succeed in de- 
cidedly reducing the present mortality rate, it will be due 
largely to the early co-operation of the general practitioner and 
the surgeon, and in the prompt performance of laparotomy 
when it becomes necessary. 
H. C. aet. 49, first consulted me in June, 1890. He had 
been sick a year. Chronic diarrhoea was the marked symptom 
of which he complained, and at times there was a severe pain 
over the descending colon. His general health seemed good. 
Nothing could be detected by manipulating the abdomen nor 
by rectal examination. 
I diagnosed the case chronic colitis, but after several 
month's treatment there was no improvement. The diarrhoea 
continuing, the blood and mucous increasing, the pain not 
diminishing, and the evacuations being constantly fluid in 
consistence, I concluded there was intestinal obstruction, 
and so informed the patient, advising him to submit to an 
operation. 8 
He continued in this condition till May 2nd, 1891, when I 
was called to see him. There was then total obstruction. For 
two days he had been unable to evacuate the bowels oi pass gas; 
the abdomen was distended; vomiting frequent and severe, and 
the pain intense. Enemata of Epsom salts and glycerine finally 
relieved him. On June 2nd there was again total obstruction, 
and the enemata once more were effective. After this attack 
he was much prostrated, and decided to have the operation done. 
The point of obstruction could not be located with cer- 
tainty, but was thought to be in the sigmoid. 
OPERATION. 
On June 23rd I operated, assisted by Dr. McMurtry, of 
Louisville, and Dr. Kinnard. An incision three inches in 
length was made in the linea alba. The obstruction was at the 
junction of the sigmoid and rectum, and was due to an indu- 
rated mass about the size of an egg which we considered can- 
cerous. On manipulating the mass, there was some hemorrhage. 
The incision for left inguinal colotomy was made and the 
colon was stitched into the opening. The peritoneal cavity 
was flushed, a glass drainage tube inserted, and the incision 
closed with silk-worm gut. The tube was removed in eighteen 
hours. Artificial anus was established on the fifth day. Con- 
valescence has been smooth and uneventful. 
July 28th. Patient goes about the city and is com- 
fortable, eats well, has gained ten pounds and is glad the 
operation was done. Of course, he has not been cured, but 
his life has been prolonged and made much more comfort- 
able. 
1 This patient was operated upon June 22d, 1891, nearly one month after the meet- 
ing of the Kentucky State Medical Society, and is added to the report then made.