Laparotomy for apparent intestinal paralysis which caused arrest of the intestinal contents and was equivalent to intestinal obstruction / by W.W. Keen.

  • Keen, William W. (William Williams), 1837-1932.
Date:
[1893]
Catalogue details

Licence: Public Domain Mark

Credit: Laparotomy for apparent intestinal paralysis which caused arrest of the intestinal contents and was equivalent to intestinal obstruction / by W.W. Keen. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Inasmuch as she seemed to be going down hill very rapidly and as she would cer- tainly die very shortly if nothing was done, I recommended an exploratory laparotomy on the next day, unless a large enema, with elevation of the hips, should be followed by any result. Dec. 25th, 1890. Dr. McCoUin reports that almost a gallon ot fluid was injected last night and the hips were elevated. The entire enema was retained. She was even more delirious last night than before. Operation.—An incision was made in the median line, which was eventually exten- ded to a little above the umbilicus. As it was found that there was a marked tendency towards an umbilical hernia the entire umbilicus was dissected out and removed. There were no adhesions, no fixation of the pelvic viscera, no intussusception (which to my mind in spite of her age was the most likely prior diagnosis) and no band or other ob- struction to be found. The large intestine, as had been determined by percussion before the operation, was enormously distended and the small intestine in its lower half was contracted and empty, but in its upper half evidently contained faBces. The large bowel had a rather sharp V-shaped attachment to the spleen, but not enough to produce any obstruction. At two points in the ascending colon and the sigmoid flexure an incision over half an inch long was made in the large bowel and an enormous quantity of gas let out. The intestinal incisions were then closed with Cushing's right-angled continuous suture. The large bowel was followed from the rectum to the cjecum and the small bowel rapidly gone over from the caecum to the duodenum, but no obstruction was found. The gall-bladder was distended with bile. Both it and the liver were healthy. 'J he ab- domen was then closed as speedily as possible. A glass drainage tube was inserted, go- ing down into Douglas' cul-de-sac. Before the patient had been removed from the table the bowels were freely moved. During the operation she suftered deeply from shock. This was admirably relieved by hyperderniatics of strychnine. The urine had been exam- ined i-epeatedly and found normal, but urine drawn a few minutes before the operation and examined afterwards, showed moderate albuminuria. Dec. 26th, 1890. She passed a very bad night, being almost wildly delirious at times, so that she had to be restrained by physical force. She has made no complaint of pain, but if the abdomen is pressed upon she winces as though hurt. Just after the ope- ration the drainage tube was cleaned by suction every 15 or 20 minutes, blood-stained serum t)eing removed. The intervals were rather rapidly lengthened, until this morning after five hours only one drachm had accumulated. This fluid is entirely sweet. Her temperature is only a little above 100, tongue coated, breath still very foul. Her pulse has increased in frequency to 124 and has lost in force. Since the operation absolutely nothing has been given her except a little ice and champagne, and a little brandy and water. In view of the paralysis which had existed, at least in the large bowel and possi- bly in the lower part of the small bowel, I deemed it best for her simply to be stinmlated moderately and have no food whatever for at least 24 hours. At 11 A. M. to-day a dis- tinct gurgling was heard in the intestine and has continued at intervals since. A rectal tube was inserted once in four hours and has given exit to some gas, and she has also passed some spontaneously, the first in seven days. Tlie drainage tube was removed after 28 houi-s, there being scarcely any further ac- cumulation of fluid in it. Her general condition was very bad and it looked as if she could live only a few hours. The wound itself looked perfectly well. During the after- noon she rapidly failed, and for a short time there was no appreciable pulse even at the wrist, while her respirations were shallow, quick and irregular. Once or twice it seem- ed that the respirations were permanently suspended. There again sti-ychnine hypoder- matically administered was of the greatest value. Dec. 29th, 1890. On the 27th, (2d day) to my surprise, she was somewhat better, and we began cautiously to feed her a little milk and liquid peptonoids only. Flatus oc- casionally escaped spontaneously, and almost always whenever the tube was inserted, and