Gastrotomy for Intestinal Obstruction. (Under the care of Mr.
Hancock in Charing-cross Hospital.)—It occurs, unhappily but too
often, that cases of unconquerable obstruction of the bowels are met
with in our hospitals; and in casting a retrospective glance at our
series of nosocomial reports, we find that we have had to record several
cases of this kind. Another instance of intestinal obstruction has just
taken place at Charing--cross Hospital, and we hasten to lay before our
readers the particulars of the case.
Ann H--------, aged 52, single, following the occupation of cook, and
residing at Ham Common, was admitted on the 11th of February, 1853,
Under the care of Mr. Hancock. The patient had enjoyed very good
health until ten months before admission, when she was suddenly seized
With a severe pain in the bowels, which latter became much distended,
and remained constipated for five days. She was attended by Dr. Has-
sall, and took various purgative medicines, without effect, up to the
fifth day, when an enema was administered through a long tube (which
the patient stated was passed some distance into the bowel), and the
same evening a motion was passed. After this she appears to have im-
proved, but has ever since been obliged to take aperients frequently to
keep the bowels open, and has observed that the motions have been
getting smaller—-that is, long and thin, being at last about the size of
her little finger.
About a month before admission, the patient began to suffer much
from distension of the bowels, and considerable flatulence, which at
times was so inconvenient that she was obliged to lie upon her bed until
the flatus passed off. This state of things lasted for about a week, the
bowels being at the same time rather constipated. Three weeks before
the woman Came to the hospital, she became so unwell that she was
obliged to give up work and go to bed ; and during the whole of that
day and night she had violent vomiting and retching. An injection
Was administered during the day, and a motion passed. Enemata were
given several times during the following woek, with the same effect, the
motions consisting of small scybala, the last one having been passed
fifteen days before admission. At that time the motions, according to
the patient’s statement, had assumed the form of pills. Frequent
Vomiting took place up to the time of admission, when it ceased, and
from this time it did not occur after food, but generally after taking
any aperient medicine. The matter brought up was yellow, brown or
greenish, and had a bitter, sourish taste, the smell not being particularly
disagreeable.
The bowels had been much distended, and they were greatly so on
admission. At times there was difficulty in passing urine, the latter
coming away in small quantities. The patient did not suffer much pain
except from borborygmi, which were relieved as soon as the flatus
escaped, which at this period always occurred upwards, excepting after
an injection, when a little passed downwards. No pain in any particu-
lar spot was complained of, excepting from a little distension about the
umbilicus. The patient stated that the enemata did not appear to go
beyond a certain point—a little above the crest of the left ilium; and
she thought that nearly a quart of injection has been retained at one
time. She was bled the night before admission, and had calomel and
opium. Mr. Hancock ordered two grains of calomel and a quarter of a
grain of opium to be taken every second hour.
Second day : Pulse 108, rather small, but not particularly feeble;
tongue furred, brown in the centre and red at the top and sides ; surface
warm; no perspiration; countenance not at all anxious. The spirits
are pretty good, and the woman is tolerably cheerful. She does not
sleep well; appetite very bad; abdomen tympanitic, supple and pain-
less. There is rather a faecal smell about the patient. Third day :
pulse weak, 112; does not feel so well as yesterday, and is very low;
is in great pain with flatus. She vomited a small quantity of yellow
bitter matter this morning. Tongue more furred ; skin cool and dry ;
urine passed freely.
A consultation was held at two o’clock, and it was decided to give an
enema, and meet again at four o’clock. The enema was administered
through the tube of a stomach pump, which was introduced in its
whole length into the bowel, and about a quart of injection used,
as no greater quantity could be employed. It returned, however,
almost directly, untinged by faecal matter, but accompanied by a small
quantity of flatus. The temperature of the ward was raised as much as
possible, and warmed sheets and towels provided, to cover the patient,
should the operation be performed.
Fourth day, four P. M.: Nothing having passed from the bowels, and
it being now the seventeenth day since anything had done so, the opera-
tion was decided upon, and chloroform administered. As there were
not sufficient indications as to the situation of the obstruction, Mr.
Hancock determined to commence by an incision in the median line
from the umbilicus to the pubis ; the intestines, distended by flatus,
escaped through this opening, and were immediately covered by warmed
towels, to preserve their temperature. The transverse colon being dis-
tended, the cause of obstruction was sought beyond, and found, without
any difficulty, at the sigmoid flexure, in a portion of the bowel about an
inch in length, constricted by a band about half an inch wide, but of so
long standing as to have thickened the intestine and obliterated its
canal. This band was divided, but the gut was so changed in structure
and compressed, that it was evident the only chance of recovery con-
sisted in opening the colon, and forming an artificial anus above the
obstructed point. A transverse incision was therefore carried through
the abdominal parietes, from below the umbilicus to the crest of the
ilium on the left ssde, and an opening being made in the colon about an
inch in length, the cut edges of the gut were attached by sutures to the
margins of the integumentary wound; after which the intestines were
returned into the cavity of the abdomen, the wound brought together
by sutures, and the patient sent to her bed.
The patient bore the operation very well, her pulse remaining pretty
good throughout, and being 126 at its termination. Stimulants were
administered two or three times during the operation, which lasted forty
minutes from first to last; and a little brandy, with fifteen minims of
laudanum, immediately after. Twelve P. M.: Pulse stronger, 126 ; sur-
face of body cold; a large quantity of fecal matter has passed through
the opening; the patient complains greatly of pain in the part
incised. Mr. Hancock saw her at nine o’clock, and as she then ap-
peared extremely low, ordered her laudanum and ammonia, in camphor
mixture, every four hours. The pain, which was most severe, now
became less intense.
First day after the operation, eight A. M.: Mr. Hancock found the
patient better ; her pulse was fuller; skin warm, and covered with warm
perspiration; bowels have acted very copiously during the night through
the artificial opening, and the vomiting has ceased ; pain has diminished,
and the woman has had some sleep. Ten A. M. : not quite so well;
pulse more feeble; in other respects much the same. Three p. M. :
Much worse; is in great pain; countenance anxious; very restless;
uppei* and lower extremities cold; pupils contracted; tongue dry and
parched; pulse cannot be counted; can bear pressure without much
increase of suffering. The patient died at a quarter past three
o’clock.
No regular post-mortem examination took place, but it was easily
ascertained that the obstruction lay principally in the locality which
has been mentioned above.—Lond. Medical Circular.