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
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.