1896 Journal of the American Medical Association  
The internal hernia, so-called by the early authors, possesses an entirely new and increased interest, since intestinal obstruction occurs more frequently than formerly, as a sequel to the surgical invasion of the abdominal cavity. I believe also that this is a far more common cause of death than usually supposed, since the success attending the surgery of the abdomen has emboldened many surgeons to undertake a great variety of operations, considered unwarranted a decade ago. Before entering
more » ... Before entering into any general discussion of the subject, it has seemed instructive to give a brief report of all the cases of intestinal obstruction following laparotomy, which have come under my observation. Case 1.\p=m-\Mrs.C., aged 31, married, has three children. April 14, 1890, I removed a dermoid cyst of the left ovary weighing eight pounds. Right ovary size of an egg, capsule thick and friable. Peritoneum covering pedicle parted easily under constriction of the suture. Marked nausea after etherization. The stump was touched with liquid carbolic acid and covered with iodoform. The uncovered peritoneum was scarcely larger than a split pea. Convalescence comfortable, with primary union of the abdominal wound, which was closed without drainage. Bowels moved the third day ; kept open by saline laxatives. On the seventeenth day symptoms of intestinal obstruction supervened, with nausea and vomiting, slowly becoming more pronounced. On the twenty-second day it was evident that grave danger was imminent, every effort to evacuate the bowels having proved futile. Assisted by the late Dr. Trenholme of Montreal, I reopened the abdomen and found two Joops of the lower portion of the small intestine firmly adherent to the stump of the right ovary. The adhesions were separated with difficulty. The intestines were not very much exposed, and yet the shock was very pronounced and for some hours danger of death seemed imminent. Convalescence was slow but satisfactory. The patient remains well up to the present, entirely free from abdominal pain. Case 2.-Mrs. L., aged 35, married, has borne children. General health fair. On July 13, 1892, I performed vaginal hysterectomy for cancer. Operation less difficult than usual. The broad ligaments were constricted by clamps which were removed the second day. The third day nausea and vomiting supervened, rapid elevation of temperature and death occurred on the fifth day from intestinal obstruction, not clearly recognized until autopsy, since it was believed that septic peritonitis was in process of development. On examination it was found that a loop of the lower portion of the small intestine was adherent to the stump of the right broad ligament, but the lymph adhesion was easily separated. The intestine above was filled with a large quantity of dark-colored fetid fluid, and it is believed that the symptoms of septic poisoning came from the absorption of the products of decomposition of this fluid. There was no peritonitie and the pelvic wound was uninfected. The adhesions could have been easily freed by an abdominal section. Case 3.-Mrs. C, aged 42. General health fairly good, although she had suffered long from pelvic troubles. Two years previous I had removed the right ovary, which was cystic, resulting in an adherent tumor eocoanut size. Recovery was rapid and uneventful. For six months prior to the second operation a cystic tumor of the left ovary had developed until it reached a point above the navel. Operation Nov. 28, 1892, Dr. James R. Chadwick present. The omentum was found somewhat adherent on the line of the old cicatrix. The tumor was removed with difficulty, owing to its being bound down by adhesions. Recovery from the operation was not satisfactory, shock pronounced and nausea persistent from the first. All the symptoms became slowly more aggravated, until at the end of the third day it was apparent that intestinal obstruction was threatening the life of the patient. Upon re-opening the abdomen a loop of small intentine was found constricted by an old omental band of adhesions upon the left side, just above the brim of the pelvis. It is very probable that the intestine became entangled at the time of operation. It was easily freed and the operation was completed in a short time, but the shock following was very pronounced, the patient never rallying from it, and death supervened in a few hours. Case 4.-Mrs. G., aged 52. General health good. She had suffered severely from a rather rapidly growing multiple uterine myoma, which was impacted in the pelvic cavity and extended to the umbilicus. Operation Oct. 24, 1895, assisted by Drs. H. D. Didama, Syracuse, and D. T. Nelson, Chicago. The operation was not difficult, the most noteworthy feature being that a small firm lobe of the tumor was so fixed to the right lower vaginal cul-de-sac that upon removal the adjacent peritoneum, although not bleeding, was dotted with minute red points. At. the time of operation it was remarked that such a condition of the pelvic peritoneum would favor intestinal adhesions. Th» tumor was dissected to the cervical neck, resected and the. arteries separately ligated and the peritoneum intra-folded by a running continuous buried tendon suture which left no abraded peritoneum other than the portion already described. It was deemed unwise to drain the depressed portion through the vaginal canal and for better protection it was covered freely with sterilized aristol. There was considerable shock followingthe operation, but the patient rallied well and for forty-eight hours gave every promise of easy recovery. Nausea and vomiting then ensued with elevation of temperature and abdominal distension. Intestinal obstruction was recognized, but the danger was not thought sufficiently imminent to warrant surgical interference, until suddenly the condition became too grave to render the procedure, even as a folorn hope, advisable. Death occurred about seventy-five hours after the operation. Nausea and vomiting persisted to the end. Six hours before death the temperature began to rise from about 101 degrees until at death it had reached 107 degrees. Autopsy showed adhesion of the lower part of the small intestine to the punctated portion of the peritoneum. It was readily separated. The intestine about the point of adhesion was greatly distended by a large quantity of dark-colored fluid, evidently having undergone decomposition prior to death. The line of union of the intra-folded peritoneum was perfect. There had been no pelvic serous exudation and no septic infection. . The operation was long and tedious, followed by pronounced shock. Rallied well and on the second day the conditions seemed favorable for recovery. Nausea and vomiting commenced about thirtysix hours after the operation. Not very pronounced until twelve hours later, when it was evident that intestinal obstruction had supervened. I reopened the abdomen and found a loop of the lower part of the small intestine involved in adhesion of the omentum, situated in the right iliac region. The small intestines were greatly distended by gas and fluid, and were manipulated with some difficulty. At the time of the operation temperature was 101 ; immediately following the operation there was a large fluid dejection. Within an hour it was noted that she was in profound shock, from which she never rallied, death occurring some hours later. The most noteworthy feature was the elevation of temperature, which rose steadily about a degree an hour, reaching 107 degrees before death. I twice used an intravenous injection of saline solution, each time introducing nearly a pint. The flagging heart immediately responded, giving a comparatively slow, full, compressible pulse. The effect, however, soon subsided, notwithstanding the use of digitalis, strychnin and nitro-glycerin, used freely hypodermically. Case 6.-Mrs. K., aged 34, never pregnant, married eight years, advanced cancer of the cervix from which she had suffered seevrely in her general health. Vaginal hysterectomy Dec. 7,1895, assisted by Dr. C. E. Miles of Boston. Operation difficult, owing to a long narrow vagina and the extent of the disease. I sutured the broad ligaments and introduced gauze drainage. Convalescence seemed well established the tenth day, when symptoms of intestinal obstruction supervened. Upon opening the abdomen a loop of the lower portion of the small intestine was found incarcerated by an old band of adhe.sions which crossed the pelvis in the region of the right ovany-.. This was easily divided and the intestine freed. The abdomi-. nal wound was closed without drainage. Fecal evacuationsŝ oon followed with speedy relief. The shock following the., operation was pronounced, but the convalescence was une-_ ventful. The patient is well at the time of writing. Case 7.-Mrs. D., aged 42. Very nervous organization, but in fair general vigor, although a severe sufferer for some years Downloaded From: by a UQ Library User on 06/15/2015
doi:10.1001/jama.1896.02430840005002 fatcat:qyaazbsklvgidh6xd7cdqyr72e