POST-OPERATIVE PARALYTIC ILEUS
BY O. S. FowLx, M.D.
or DENVzR, Cow.
ILEUS has been defined as a retention of the intestinal contents. I
wish at once to make a clear distinction between ileus from a mechani-
cal obstruction and ileus from a paralysis of the musculature of the
intestine; in this paper I will deal only with the latter, and the two
must not be confused with each other.
retention from complete muscular atony and not from an organic
obstruction; yet many authors will speak of a paralytic obstruction.
In this there is no onward movement of the intestinal contents and no
attempts at the same, therefore, there can be no obstruction unless
something is being prevented from passing on.
claims that the clinical picture is the same in both conditions; with
this we cannot agree, as our observations have shown them to be most
This will be described more fully later on.
This serious post-operative complication has not received the atten-
tion it deserves.
Although much has been written upon the subject,
it is really not well understood and we believe not recognized readily
Relatively little is known as to its etiology and there has been
but little research work upon the subject, and what has been done has
been mostly to determine the cause of death, by showing which portion
of the intestinal secretion and contents were more poisonous; how-
ever, the research has been of distinct therapeutic value. We know
better what to do in case it arises than we do what causes it or how
to prevent it. Our text-books are peculiarly silent upon the subject or
have it jumbled up with all kinds of mechanical intestinal obstruction.
There is a certain amount of paralytic ileus after every abdominal
incision as is evidenced by the usual accumulation of gas with which
we are familiar and which gives us no grave concern.
Occurrence.-It may occur after any abdominal operation or even
after only the administration of an anaesthetic; however, it is said by
some to occur more frequently after certain operations, e.g., after
resection of the omentum, rough handling of the intestines in any
operation in the abdomen, or following an operation for relief of vol-
vulus or intussusception, where the mesentery is more or less injured.
Lack of pelvic drainage is claimed by Mr. Hicks as a causative factor.
The same author says that it has occurred in his practice five times
in three hundred abdominal operations; in my own experience it has
occurred four times in approximately seven hundred operations. Rather
oddly it has occurred to me three times in the last year, and I trust
Paralytic ileus is wholly a
POST-OPERATIVE PARALYTIC ILEUS
that now the rather fateful occurrence of serious or odd things
happening "three times in succession" has been satisfied and that I
may be spared this perplexing complication for some time again.
We believe very firmly that this condition is often incorrectly
diagnosed as an acute dilatation of the stomach and treated as such,
and in its later stages for a general peritonitis.
It may involve either the whole intestinal tract, only the upper
portion of the small intestine, only -the large intestine, or only the
lower portion of the small intestine, but the more common site is the
jejunum or upper portion of the jejunum.
Etiology.-There is little definitely known as to its etiology. Some
claim that it is always due to a rapidly spreading peritonitis or to a
This is hardly reasonable, as it occurs fully as
frequently after clean operations as after pus cases. McKenna thinks
it is due to a disturbance of the innervation through the splanchnic
nerves of these certain portions of the intestine.
cannot offer explanation of the factor producing the disturbance, other
than it is due to the absorption of certain toxins.
a peculiar response, an idiosyncrasy, so to speak, from the shock
occasioned by either infection or trauma from the operation.
my own suggestion, but it cannot be really an explanation, because
we do not know why an idiosyncrasy does occur.
In general peritonitis we have a paralytic ileus and the etiology here
is very evident, but we probably cannot reason from this that it is
always caused by a peritonitis of some type.
Diagnosis.-Onset is usually within thirty-six to sixty hours, with
a mild distention in the upper abdomen, usually, and has the appearance
now of a slightly dilated stomach.
through and without shock until later in its course.
soft doughy or " gassy " sensation upon palpation, which is increased
and very marked later on as the belly becomes more distended.
cussion may show a varying dulness and gaseousness with changes in
position, due to both fluid and gas in the intestine; this has been
referred to as a " pseudo-ascites."
has been passed with enemas previous to the onset; this comes from
the lower unparalyzed portion of the gut.
ticular rise in the temperature nor in the pulse in the early stages,
but later the pulse always increases and the temperature usually;
respirations are normal in the beginning and increase as the pressure
from below embarrasses both lungs and the heart. The patient him-
self always says he feels fine even when death is impending.
of my patients demonstrated this most remarkably when I entered
the room forty minutes ibefore death, I spoke as cheerfully as I could,
"Well, Charles, how are you feeling? " He answered at once, quickly
and brightly, "Feeling just fine, Gee" (calling me by my college
nickname), yet the whole appearance was that of impending dissolu-
This is true, but he
At any rate, it is
It is without pain all the way
It has a peculiar,
It may be that more or less gas
There is usually no par-
0. S. FOWLER
tion; to me, yet, the cheerfulness of this remark remains as being
I wish also to offer, as a diagnostic sign in this
condition, my observation in each of my four cases, namely, a peculiar
complacent appearance of the face amounting to a sort of kindly,
benignant expression, such as is sometimes seen upon the faces of
elderly phlegmatic persons; this in contradistinction to the hippo-
cratic facies of general peritonitis and in mechanical obstruction of
the bowel, where they are suffering great pain from the peristaltic
There is usually a gulping up of bile-stained fluid early and
the stomach washing relieves this only for a short time, often requiring
several galltDns of soda solution before it is returned clear; in fact,
in one case I used as much as seven gallons in one washing and even
then the fluid was not clear. Vomiting is without pain and nausea.
One is often fooled by the unalarming appearance of the patient
and may be lulled into a false sense of security by this, for the critical
stage is reached so gradually that you can hardly realize that death
is impending, for, as mentioned above, the mental condition may
remain normal, and, at most, there is little more than a mild delirium.
I think this is most unfortunate, for it almost urges us to delay sug-
gesting more radical procedures, and I might interpolate here that I
regard this condition as one not only requiring but demanding imme-
diate operative, mechanical relief.
timid surgeon or internist who calls procrastination by the soothing
term " conservatism;" the emergency is present and your patient's life
depends upon relief from the poisons retained in the upper intestine,
and it is no time for you to consider what the relatives and friends
will think of your ability or whether they will criticize you in advising
to your profession to refuse to consider the possible effect upon your
standing, but to offer him perhaps only a gambler's chance for his life.
Differential Diagnosis.-(a) Ordinary post-operative gas disten-
tion: In this condition there is always pain; there is no gulping; there
is tenderness always over the whole abdomen; the distention does not
markedly increase; pulse-rate may be slightly increased.
(b) General peritonitis:
Here pain and tenderness are usually
present; temperature is increased; pulse is rapid and perhaps weak;
temperature usually precedes the distention; hoppocratic facies present;
vomiting is preceded by other important symptoms of temperature,
rigidity, pa"in, etc.
(c) Mesenteric thrombosis: Practically the same as in acute intes-
(d) Acute intestinal obstruction: From records of thousands of
cases of acute intestinal obstruction, pain is a constant symptom in the
early stages, coming on intermittently; tumor mass often present;
peristalsis often observed, especially through thin belly walls; vomiting
is forcible and not a gulping; may be blood by the bowel; distention is
This is certainly no place for the
It is something that you owe to yohlr patient and
POST-OPERATIVE PARALYTIC ILEUS
very much less marked and rigidity and tenderness is always present.
From the above and from my own observation I cannot see any
marked resemblance between paralytic ileus and any of these other
abdominal conditions, except acute dilatation of the stomach, notwith-
standing the assertions of other men; and certainly to me there could
be confusion only with a dilated stomach from the clinical findings.
It is my opinion that the differentiation can be made exact only with the
X-ray, with a small amount of bismuth in the stomach. The X-ray is
always advisable in either paralytic ileus or acute dilatation of the
stomach, and clinches the diagnosis by demonstrating the enlarged
stomach or the distended loops of the small gut sometimes as much
as three inches in diameter, as shown in two of my cases, one of
which came to autopsy.
centage of the cases diagnosed clinically as dilated stomachs are paral-
yses of the intestine.
This was quite certainly demonstrated in one
of my cases in a ward at St. Joseph's Hospital.
the surgeons and internists in to see this case, and all of us, with the
exception of Dr. Arneill, called it stomach.
stomach and treated for same, I had an X-ray taken with some bis-
muth in the stomach.
This organ was crowded up high into the
diaphragm and not dilated and the immensely distended small intes-
tines filled the entire belly cavity.
Hospital Staff meeting last year in connection with Case II reported
Cause of Death and Morbidity.-Bonney4 asserts that the fatal
results are due to toxic absorption from the upper intestinal tract,
brought about by the ascending infection of Bacillus coli communis
and other organisms of the lower gut in a state of exalted virulence
and activity. This view is held by many men.
cause of death is due to the loss of fluids with consequent drop in
blood-pressure and resulting carebral anaemia, with the upward pressure
upon the heart and lungs and with toxaemia.
lieves that the critical symptoms and death are due to loss of body
fluids, and Hartwell and Hoguet have demonstrated experimentally
that animals with experimental mechanical ileus can be kept alive
almost indefinitely by the administration of quantities of saline in-
fusions to replace the fluids lost. McLean refutes all these after jro-
ducing experimental ileus upon animals, and asserts that it is either
the secretions or the altered physiological relation of the secretions
of the duodenal mucosa that produce both the alarming symptoms and
death. He is upheld in this by the experimental studies of Whipple,
Stone and Bernheim.7
My own treatment of the two fatal cases would certainly eliminate
the loss of fluids as being a factor in death, for both were given large
quantities of fluids and their blood-pressure remained normal until
soon before death.
To my mind toxxemia is the cause of death and
I further feel very sure that a good per-
I invited several of
As I, too, had called it
This plate I showed at a County
Kelsall5 believes the
0. S. FOWLER
I do not believe that we can separate effects of toxins of bacterial
origin and those of changed glandular secretions.
pretty well demonstrated, and that is, in retention of the upper bowel
contents, from high obstruction or paralysis, the mortality is higher.
This might add weight to McKenna's8 idea of upset physiology in
REPORT OF CASES
CASE I.-Mr. E. T. N., aged forty-two, was operated by me
August I9,I9q2,for a very large right-sided inguinal hernia and
a very large left-sided hydrocele.
sitting under local anaesthesia of novocaine.
fat and so much omentum being in the hernia, I felt it was advis-
able to resect the portion of omentum which was in the hernia.
This I did. On the second day the patient became distended in
upper abdomen, which I diagnosed as a dilatation of the stomach
and gave the usual treatment for the same, but he did not respond.
We did not have the typical findings from the stomach washing,
but a number of my surgical and medical friends, ten in all, saw
him and all but one diagnosed acute dilatation of the stomach.
I then had an X-ray taken by Dr. Stover with a small amount
of bismuth in the stomach, and we found that the stomach was
normal and the small intestines were enormously dilated, even
as much as three inches in diameter.
remained good, and he did not pass gas nor faeces until the tenth
day; however the distention was the same throughout and I feared
it would prevent the hernia from properly healing; but it did not,
nor did the wound become infected.
described below was used here after the proper diagnosis was
reached. To me this is a most astonishing case-this man's abdo-
men was as large as a tub, but his mental condition remained
normal and he joked with the other ward occupants about the
size of his belly.
CASE II.-Mr. G., aged seventy-two, County Hospital. Janu-
Operated under local anasthesia for a very large
This hernia contained probably not less than
ten or twelve feet of the small intestine with caecum and appen-
dix; the bowels were entirely empty, as he had undergone pre-
paratory treatment for the operation. On the third day he was
distended evenly over the entire abdomen, no pain nor tender-
ness, some gulping of fluid, but did not become stercoraceous at
any time; the pulse and temperature were only slightly elevated;
no hippocratic facies. He was treated by hot stupes and pituitrin,
with many gas enemas, and when results from the enemas were
evident, cathartics were given.
covery, nor was the healing of the wound interfered with.
CASE III.-Mr. C. A. was operated for appendicitis.
appendix was retroperitoneal and lying high in the abdomen; in
fact, the tip of it was posterior to the second portion of the duo-
denum, and was removed with much difficulty.
One thing has been
Operations were done at one
The patient being
This patient's condition
The medical treatment
Patient made an excellent re-
He was given
POST-OPERATIVE PARALYTIC ILEUS
ether and took it badly, having to be resuscitated during the
His condition, however, was good the next day and
also the second day, when the distention began to appear in upper
abdomen. He was given gastric lavage, pituitrin and salt solu-
tion under the skin, lavage was continued right straight through
at regular intervals day and night, but rarely did we get the fluid
to return clear, even with as much as seven gallons of soda water;
large amounts of stimulants were used, as the heart became rapid
The patient's mental condition remained clear until
the end, except for slight delirium, but he would talk normally
when spoken to, even until a short time before death, which
occurred five days after the appendectomy.
examination was made and the stomach was normal in size, also
the duodenum; the jejunum and all of the ileum except the last
forty inches were distended to about two and one-half to three
inches in diameter; the lower ileum and colon were normal, there
was no obstruction to the gut anywhere, and the line was abrupt
and definite between normal and dilated ileum.
Consultation was held with four doctors and surgeons and a
jejunostomy was proposed, but thought then to be too late.
made up my mind from that case that I would not trust to medi-
cal measures in the future even though I had been successful in
Cases I and II by non-operative measures.
CASE IV.-Mr. R., aged forty-two, referred to Dr. Horace
Heath, was operated for a ruptured appendix, under novocaine
Patient was in excellent condition until evening of
the second day, when there was a mild painless distention in upper
abdomen; no increase then of either temperature or pulse. Patient
said he never felt better. The distention increased gradually with
slight increase of temperature and pulse; some fluid was gulped
up; stomach washed and fluid returned clear. On the third day
his condition was worse, and we did an anastomosis between a
dilated portion of the jejunum, which later proved to be about
five feet from its beginning, and the sigmoid.
was also done under novocaine, and that night and the next day
a good quantity of brownish material and gas was passed by the
bowel. A suture, side-to-side anastomosis was made. We did
this in order to not have a fecal fistula upon the surface, feeling
also that it would make the later operation less difficult. We de-
bated whether we should put in tubes from the rectum through
the anastomosis, but did not; notwithstanding the passing of
several pints of fluid from the bowel, the patient got steadily
worse, and death seemed certain upon the fifth day, when we
decided to again open the belly and bring a loop of dilated gut
to the skin.
This was done while the patient was practically
moribund. We drained off a very large quantity of gas and
brownish fluid by changing his position upon the table; it was
a sort of last chance with nothing to lose. The patient died two
hours later. A post-mortem examination showed the first anas-
tomosis in excellent position to drain the upper jejunum and I
0. S. FOWLER
believe that a Murphy button anastomosis would have done this
probably better than a suture.
demonstrated at this time.
The upper gut, practically only the
jejunum, was dilated, as was shown by an X-ray taken on the third
day and proved at post-mortem examination. The blood-pressure
in this case remained normal until a short time before death, the
pulse was rapid and weak the last twenty-four to thirty-six hours.
I have one keen regret in this case, and that is that we did not
bring the loop of gut to the skin at the time of anastomosis.
CASE V.-M'rs. J. A. K., referred by Dr. Robert King, aged
twenty-four; married; was pregnant two months when she in-
strumented herself to induce abortion which was accomplished
three days before I saw her; condition now one of general peri-
tonitis in desperate condition-Hippocratic facies, temperature
IO30, pulse I2I, respirations 28.
I. B. Perkins and we decided that the abdomen should be opened
This I did, found a general peritonitis with consid-
erable involvement of the appendix, which I removed.
went along fairly well and looked as though she would recover;
this was at the end of about a week.
markedly in the upper abdomen. At this time I left the city for a
week, but advised Dr. James A. Philpott, my associate, that he
would probably have to drain the jejunum; this he did later,
assisted by Dr. J. F. Roe.
At operation it was found that the
jejunum was dilated to approximately four inches in diameter.
A loop was brought to the skin and opened and drained from both
She was immediately relieved of the distention and
again in a few days it seemed very favorable for her recovery;
however, on the seventeenth day she began to lose ground and
died on the twentieth day from a general septic conditiqn.
none of the wounds did healing proceed satisfactorily. A post-
mortem examination showed some very interesting facts-the
jejunostomy was found to be four and one-half feet from its be-
ginning, the abdomen was filled with adhesions of the loops of the
intestines throughout, all the gut below the opening was of normal
size and normal in all ways except for the adhesions; no definite
point of obstruction could be demonstrated; above the opening was
found a most interesting condition.
intestine had reduced to normal
ten-inch portion was fully four inches in diameter in half its
length and the balance about two inches in diameter.
seen the drainage did really produce a recovery in the immensely
distended jejunum, thus proving the efficiency of jejunal drainage
in this condition.
Just why the one portion did not recover I
cannot offer an explanation.
Treatment.-(I) Medical: The usual treatment for post-mortem
gas should be instituted early, including enemas, hot stupes to belly,
eserine I/IOO to I/50 gr., pituitrin I c.c, each hour for three or four
There was no peritonitis to be
Consultation was had with Dr.
She then began to distend
All except ten inches of the
size and appearance;
Thus it is
FIG. I.-Post-mortem specimen of Case V.
nostomy; B. the large remaining dilated portion, four inches indiameter; C, a portion two inches in
diameter; D, the point of jejunostomy with a tube in each direction.
A, normal jejunum above and below the jeju-
POST-OPERATIVE PARALYTIC ILEUS
hours at occasional periods, unless it has a bad effect upon the heart.
Goth recommends physostigmin salicylate I/64 to I/32 of a grain,
digalen minims I5 each three hours and strychnine grain 1/30 to
I/15 each three hours, and caffeine sodium benzoate grains ii-iii
each three hours, these last three alternating one each hour to support
Cathartics are useless and perhaps damaging; gastric lavage
hourly or two or three hours; but the best of all is large quantities of
water both by bowel and by hypodermoclysis, ten to sixteen pints
each twenty-four hours. Bonney suggests adding one ounce of brandy
to each quart of saline infusion.
(2) If the above medical measures fail to give relief within twelve
to eighteen hours after instituting them, or if your patient should get
worse in the meantime, then resort must be had to surgery without
further ifs and ands, or a continued waiting policy.
gut must be drained at once if one wishes to save the patient; and
when we know that this operation was successfully done in 1787 by
Renault, following the suggestion of Louis in 1757, and was later
revived by Nelaton in I840, we should not hesitate to undertake it for
the want of su,fficient preceden.t or for the lack of the stamp of age
As to the method of surgical attack, we have the choice of several
procedures that have been done and advocated by various surgeons.
We may do, as suggested and used by Thompson,10 an anastomosis
between any loop of dilated gut that we may happen to pick up and
the ileum just before the entrance to the caecum, and this combined
with an appendicostomy or a cacostomy; altogether, we think this
entirely too large an operation to be satisfactorily used in these des-
You may also do an anastomosis between any portion
of the dilated gut and any portion of the large intestine, preferably,
we think, the sigmoid.
If the caecum is dilated along with the small
intestine, then you may do a cacostomy as used by VictorBonney,)"
but we believe that by far the best procedure to undertake is the easiest
and simplest of all and will be more likely to get the patient over
the present dangerous condition; and that is to simply bring a loop of
dilated gut to the skin, endeavoring to get a loop as high as possible,
for it is important to get drainage as near the duodenum as one can,
for this has been aptly called, by Bonney, " the reservoir of toxicity ;"
this measure is upheld by McKenna, Whipple, Bernheim, Stone and
others, after the gut is brought to the surface and opened imme-
diately after suture to the peritoneum, and a tube passed into the gut
in both directions for drainage of both gas and fluids and also to
irrigate the intestine with salt solution. McKenna says this operation
should always be done under local anaesthesia and we agree with him.
Bonney reports ioo per cent. of cures in all of his five cases, and
asserts " that no patient with fecal vomiting should be allowed to die
0. S. FOWLER
for the want of this operation.
markable; in all of them there has been an immediate cessation of
vomiting, and all the patients have recovered."
This, of course, requires a later operation within a few weeks to
correct the fistula.
You may be criticised on account of this later
operation, but when one considers that a live candidate for a second
operation is of so much more value than a patient dead for the want
of a fistula of the jejunum, you will have little hesitancy in urging
such an operation in these extremely serious cases.
that all one needs to do is to stir up the intestines in these cases and
to wash out the peritoneal cavity.
Site of Incision.-The incision should be made upon the left side
of the belly, as here you are more likely to pick up the jejunum within
a reasonable distance from the duodenum, so that the "reservoir of
toxicity " will be better drained.
Recovery of the tone of the intestine comes on quite suddenly,
within a few to several hours after operation; and in two of my
cases treated medically, tone was regained coimpletely in the course
of several hours after recovery really began.
Its effect in my cases has been re-
(i) Exact diagnosis can be made only with the X-ray which should
always be used in every case of suspected dilated stomach or intestinal
(2) Operation must be done early to obtain the best results in this
very serious complication.
(3) Do the simplest, easiest and quickest operation, and it must
be done under local anmsthesia.
(4) The vomiting (gulping) and the pulse are the best guides to
follow as to when to operate. Do not be misled by the patient's state-
ments " That he feels fine," etc.
1McLean: ANNALS OF SURGERY, March, 1914.
'Hicks, H. T.: Brit. Med. Jour., July i, I9I6.
'McKenna: A. M. A. Jour., vol. lii, p. I239.
4Bonney: Brit. Med. Jour., April 22, I9I6, P. 583.
'Kelsall: Am. Jour. Surgery, February, i9i6.
'Andries: Mich. State Jour., February, I9I5.
'Whipple, Stone and Bernheim: Johns Hopkins Bull., June, I9I2, p. i59.
'McKenna: Surg., Gyn. and Ob., vol. xvii, p. 674.
'Senn's Practical Surgery, p. 76I.
0Thompson: Surg., Gyn. and Ob. .vol. xxii, p. 688.
Brit. Med. Jour., April 22, i9i6, P. 583.
"Gage: Kansas St. Med. Joue., May, i9i6, p. 139.