41TREATMENT OF ILEUS FOLLOWING OPERATIONS.

Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CCLVII—TREATMENT OF ILEUS FOLLOWINGOPERATIONS.

ILEUS or intestinal obstruction secondary tooperation may be of two types-paralytic, whenit results from failure of peristaltic action, andmechanical when it is due to some organic block ofthe bowel.

Paralytic Ileus.-In this variety there is paralysisof some portion of the intestine and the effect may betransitory. Such ileus may follow the reposition oflarge strangulated herniæ. but the most importantcause of all is acute peritonitis either localised ordiffuse. In this condition the intestine becomesinflamed and is unable to propel its contents.

In mechanical ileus the intestine may be strangu-lated or kinked by bands or cords, the result ofperitoneal adhesions following operation, or a tearin the omentum or mesentery made by operativetrauma may lead to intestinal’ obstruction. Ileusmay also be produced as the result of cicatricialcontracture affecting the wall of the bowel followingan artificially made anastomosis.

Mortality.The mortality from acute intestinal obstruction

has fallen very little during recent years. The death-.rate after operation in early cases is not less than20 per cent., whilst in any large collection of casesit may reach 50 per cent. It seems to be generallyagreed that the high and rapid mortality in obstruc-tion of the small intestine is due to the absorption oitoxic material developed within the bowel. Evacua-tion of the bowel contents is therefore of first impor-tance, but restoration of peristalsis is also essentialfor recovery. If the bowels can be made to act thepatient frequently recovers, whilst if they fail to act,he will die. In the late stages of fatal cases of acutEperitonitis paralytic obstruction develops and this islargely responsible for the symptoms of toxaemiaThe most common cause of peritonitis met with bythe general surgeon is acute appendicitis. Of casesdying of peritonitis 5-10 days after operation foappendicitis probably 75 per cent. are due to intes.tinal obstruction, which is a most difficult ancdangerous complication. If intestinal obstruction doe:not supervene peritonitis often yields to treatment.The treatment of paralytic ileus has always beer

unsatisfactory. The efficacy of drugs such as casto]oil, calomel, eserine, or pituitary extract depends orcontraction of the bowel. If the bowel is paralysecthese drugs will fail to act and will add to the strairon a heart already damaged by toxaemia. Enterostomy in the paralysed bowel in such cases onldrains the affected loop, and therefore is of butlimited value. It is, therefore, apparent that iicases of paralytic ileus attempts to stimulate peristalsis in the bowel should be avoided. The moseffective measure is to give it complete rest, an(

thereby a chance to recover its power of activcontraction. This treatment, combined with aenterostomy above the affected portion of the boweldoes undoubtedly prove successful in many cases

Enterostomy is an easy and quick operation and makelittle demands on the patient’s vitality. In additionglucose and sodium bicarbonate can be run into thbowel and is absorbed better than from the recturor elsewhere. The toxins are thus diluted, and thiprocess is of distinct advantage to the patient.

Clinical Features.

Post-operative ileus is usually seen at two periodafter operation-early, within the first two or thredays, or later during the convalescent period. Thtreatment to be adopted will depend on the stage awhich the condition arises. The management (

early cases arising after operations for peritonitis dueto acute appendicitis presents a most anxious anddifficult problem. These cases are usually due tomultiple kinking of inflamed bowel by plastic lymph.This condition chiefly affects the lower ileum,having been set up by perforation of a gangrenousappendix. The bowel becomes acutelv inflamed andthen paralysed by extension of the inflammation tothe muscular wall. Death in these cases is due tointestinal obstruction and not to peritonitis. Theclinical picture is fairly typical. The patient showslittle or no improvement after operation, and theabdominal distension becomes more marked ; vomit-ing is progressive and enemas produce no satisfactoryresult. About the fourth or fifth day after theoperation the signs of intestinal obstruction becomewell marked and further operation is then essential.

Enterostomy.When obstruction develops shortly after operation

it is rarely complete and the intestine will not infre-quently recover its function if given a reasonablechance. In these cases all nourishment by mouthmust be entirely stopped so as to avoid further over-loading of a distended bowel. Fluids should be givenfreely by the rectal and subcutaneous routes. Wherevomiting is troublesome gastric lavage is valuable,and can be repeated as often as necessary. Morphinein doses of gr. 1/6 gives relief from pain, and in spite ofapparent contra-indications will be found useful.

If improvement does not follow this treatment inabout 48 hours operation will be necessary. Thisinvolves drainage of the small intestine by an enter-ostomy above the site of obstruction and above thelevel at which the bowel is paralysed. It is anextremely easy procedure and should be carried outby the following method.

Technique.—A local anaesthetic (2 per cent. of novo-caine) is used. A left paramedian or rectus splittingincision just above the umbilicus is made, and thefirst distended loop of intestine that presents is with-drawn into the wound. This is clamped after it hasbeen emptied, and a tube or large catheter with aterminal opening is sutured into the bowel by Witzel’smethod. According to this method the tube is laidfor 3 or 4 inches along the bowel, and the serous andmuscular coats sutured over it. The tube is thenbrought out through a gap in the omentum and thewound closed round it. This enterostomy of thevalvular type will close when the tube is removedwithout the necessity of a second operation. Theintestine will empty itself of its toxic contents throughthe enterostomy, and irrigation with sodium bicar-bonate can also be carried out.

. This is the easiest and safest procedure to adopt

.

when the patient is in a poor condition. It is often alife-saving measure and will tide the patient over anapparently hopeless condition. After the intestine has

emptied itself through the tube the lumen of the’

bowel is usually restored and the contents begin to,

pass normally. The tube can then be removed and’ the fistula will close spontaneously.

Ileus Duplex.Sampson Handley has described under the name of

ileus duplex a condition where there is paralysis of the bowel below the level of the pelvic brim-that is,in the lower coils of the ileum and the terminal

portion of. the colon. He recommends as treatment: for this condition short-circuiting of the ileum by a3 jejuno-colostomy with drainage of the large bowel by a

caecostomy. This operation would appear rather severein a patient whose condition is desperate. Enterostomyis a quicker and simpler operation and can readily be

performed by any surgeon with far less strain on the

patient.. Ileus.Mechanical Ileus.Patients may develop symptoms of intestinal

s obstruction any time after the tenth day followinge operation. At this period the obstruction is due toe fixation of the bowel by adhesions, and an operationt to separate the adhesions and free the bowel willf always be necessary. If it is thought desirable, an

42 PRESERVATION OF LIFE IN SHIPWRECKED INDIVIDUALS.

enterostomy may be added to drain the bowel for afew days. The outlook in such cases is fairly goodprovided that operation has not been unduly delayed.

Anti-gas Serum.—It has been suggested that thesevere toxaemia of acute ileus is due to the presenceof the toxins of the B. welchii in the fæcal contentsof the bowel above the site of obstruction, theabsorption of this toxin by the damaged mucosaleading to the grave general condition of the patient.The symptoms certainly resemble those seen in casesof gas gangrene. The natural outcome of this sug-gestion was the administration of anti-gas serum topatients, and this has been tried by B. W. Williams1during the past two years with encouraging resultsand noteworthy reduction in the mortality-rate. A

prophylactic injection of serum before operation maylead to still better results. The initial dose of serumshould be 80 c.cm. given intramuscularly, and later40-80 c.cm. should be given daily intramuscularlyuntil the bowels are acting effectually.

Administration of Bile.-More recently R. St. L.Brockman 2 has suggested that the symptoms whichdevelop in cases of intestinal obstruction are forthe most part due to the prevention of the passageof the bile along the alimentary canal. The adminis-tration of bile by the rectum has given encouragingresults, the vomiting and toxaemia being diminishedin some cases. The dose given was human bile 2 oz.in 4 oz. saline per rectum every four hours and reliefwas almost immediate. The toxic symptoms may befurther controlled by the use of hypertonic saline givenintravenously. A quart of 3 per cent. saline given beforeand again after operation gives favourable results.

Spinal Ancesthesia.--Spinal anaesthesia may beregarded as a valuable alternative to general anws-thesia in cases of intestinal obstruction. Thisanaesthetic gives perfect relaxation and allows mani-pulation of the distended coils of bowel to be carriedout with great ease. Not infrequently, after the injec-tion of a spinal anaesthetic, the bowels act spontane-ously on the operating table, and such injections havebeen suggested as a line of treatment in cases ofparalytic ileus.

-7’reventive Treatment.With the practice of earlier operation for acute

appendicitis the number of cases where post-operativeileus arises is likely to decrease. This probability issufficient reason for immediate operation in acuteappendicitis as soon as the diagnosis is clear. If theappendix can be removed before it has perforatedileus will not arise. The avoidance of a drainage-tube is an important factor in preventing the forma-tion of post-operative adhesions, for intestinalobstruction is far more common when a drainage-tube has been used. In some cases of acute appen-dicitis the presence of ileus may be recognised beforeor actually at the time of operation, and for this reasonan adequate incision is necessary to enable the lowerileum to be inspected. For this purpose either theparamedian or the Battle incision is to be recom-mended. After the appendix has been dealt withthe condition of the ileum is examined. If it is fixedby recent adhesions it is gently freed and its mobilityrestored. Where the gut appears inflamed, soddenand apparently paralysed, either an enterostomy orileo-colostomy and cæcostomy as advised by Handleyshould be performed. The early administration ofpurgatives should be avoided after operation foracute appendicitis. In the treatment of strangulatedintestine following hernia operations, a lateral anasto-mosis to short-circuit the damaged loop is often avaluable procedure where the condition of the bowelis doubtful. Finally, a further cause of ileus afterabdominal operation is the over-purgation of patientsprior to operation, and the use of castor oil, whichcauses severe intestinal irritation, should be avoided.

A. H. SouTHAM, M.D., M.Ch. Oxf., F.R.C.S.Eng.,Hon. Assistant Surgeon, Salford Royal Hospital; Assistant

Surgical Officer, Manchester Royal Infirmary ; Lecturerin Operative Surgery, Manchester University.

1 THE LANCET, 1927, i., 907.2 Ibid., 1927, ii., 317.

Special Articles.OBSERVATIONS CONCERNING THE

PRESERVATION OF LIFE IN SHIP-WRECKED INDIVIDUALS.

BY J. ARGYLL CAMPBELL, M.D., D.SC. EDIN.,AND

LEONARD HILL, M.B. LOND., F.R.S.

(From the National Institute for Medical Research.)

A FEW years ago (1923) 1 we advised the wearingof thin mackintosh or rubber " overalls " for ship-wrecked individuals, to keep out wind and waterwhilst sitting on rafts or in lifeboats, and thus preventexcessive loss of body heat by chilling. As a conse-quence of our observations special rubber " overalls "’have been designed for this purpose, and we haveemployed the suit termed the " warmalonga " insome further experiments. This suit is completein one piece, and may be readily slipped on and fixedin position. It is not absolutely water-tight, sinceit has four openings near the feet and wrists to allowwater to escape readily, and thus prevent over-

cooling of the feet and arms whilst sitting on a raftor in a lifeboat after immersion in the sea. Thissuit is probably ideal for a person sitting on a raftor in a lifeboat and exposed to wind and splashings.Our present observations were undertaken to deter-mine whether such a non-water-tight suit possessesany advantage towards preserving body heat overordinary warm woollen clothing when the subject iswholly immersed in water. Our results indicatethat such a non-water-tight rubber suit is not obviouslysuperior to ordinary warm clothing for preservationof body heat when the subject is fully immersed inwater.

The Plan of Research.Our plan of research was as follows. The subject,

a diver of experience, sat quietly on a chair for about20 minutes wearing ordinary clothes or specialclothes for the experiment. At the end of 20 minuteshis heat loss was estimated, usually over a periodof 10 minutes, from the oxygen consumption deter-mined by Douglas and Haldane’s technique, as

recommended by Cathcart. 3 These results formedthe base-line for comparison of the effects of immersionin a bath under different conditions as regardsclothing. The temperature of the bath was kept atabout 22-23° C. The subject lay as quietly as possiblein the bath, any movement being due to shiveringand quite involuntary. Two experiments (1 and 2)were carried out in which the subject was naked inthe bath. In from five to ten minutes he was shiveringso badly that the experiment was terminated. Ofcourse, had he been allowed to move-e.g., makeswimming movements-he would not have shiveredso soon nor so violently. The shivering caused anaverage increase in oxygen consumption of over

150 per cent., and was accompanied by heat loss ofover 160 per cent. (see table). In the next experi-ment (3) he wore ordinary clothing whilst lying inthe water for ten minutes, and the clothes markedlyreduced the heat loss due to cooling by the water.Now the increase in heat loss due to ten minutesimmersion was only 57 per cent. instead of over150 per cent. for a shorter period when naked. InExpt. 4, in addition to ordinary clothing, he worealso the rubber suit whilst in the water. Here, again,the clothes protected to a considerable extent, theincrease in heat loss due to the water being only about

1 Medical Research Council Special Report Series, No. 73,p. 179.

2 Made by Messrs. Siebe German, Westminster Bridge-road,London.

3 Jour. Roy. Army Med. Corps, 1918, xxxi., 339.