kidneys on both sides. The first case had a retroverted, enlarged uterus in addition, with very much relaxed vaginal outlet. Both of them had been aware of a lump in the abdomen for some time. As far as I know, this spasmodic form of enterospasm is a condition which has never been described before. While not of such a serious nature as the tonic form, it is, nevertheless, of much clinical interest and of considerable importance in a diagnostic point of view. Both forms have, no doubt, the same etiological origin. They are, in my opinion, neuroses, probably of a reflex character, produced by some irritation located somewhere in the peritoneal cavity or in the intestinal canal. This irritation, through the nervous system, produces an increased activity of the circular fibres of the muscular coats of the bowels, which in one case may excite an enterospasm of a spasmodic character, while in the other a tonic, tetanic condition of these muscles is produced. All the cases who came under my observation were of a markedly neurotic habitus; the same may be said of Dr. Long's cases; they were, therefore, subjects especially inclined to such nervous disturbances.

What the existing cause in each individual case was is, of course, very difficult to determine. In my first case we suspected tyrotoxicon poisoning, from the fact that milk in her case seemed to bring on such attacks. This suspicion is more than justified by the fact that tyrotoxicon not only causes very severe vomiting, with intestinal cramps and very obstinate constipation at times, but experiments on cats, as well as autopsies on human subjects, have demonstrated the presence of firm tonic contractions in portions of the intestinal canal. Unfortunately, no bacteriological examinations were made in our case to confirm the suspicion.

That certain conditions in the peritoneal cavity may be accompanied by a nervous or reflex ileus has been repeatedly demonstrated. An incarcerated testicle, twisted pedicle of an ovarian cyst, biliary colic, etc., have given rise to at least temporary acute obstruction. I myself saw a case with my friends, Drs. Goulding and Ward, with a view to operation, in which a complete obstruction of the bowels had existed for almost two days, with constant vomiting, considerable tympany, and abdominal pains. As it was midnight, and the case was not urgent, it was

1 "Ptomaïns, Leucomaïns, Toxins and Antitoxins," by Vaughan. Obst Soc

19

decided to defer operation until next morning. Early in the morning the pains subsided, and shortly afterward he passed a large renal calculus, which was followed at once by complete relief of all symptoms of obstruction.

Is it not possible that in these cases a condition of enterospasm exists which, when the exciting cause is removed, relaxes and allows the bowel to resume its normal physiological action? At any rate, whether the temporary ileus be due to an enterospasm, or an intestinal paresis, the cause is undoubtedly of nervous origin, produced by reflex action.

The same explanation, I think, holds good in the cases of enterospasm reported in this paper.

We are, I believe, justified from the experience of these cases to conclude that there is a disease which we may term enterospasm, characterized by spasmodic contraction of the circular muscular fibres of portions of intestines of various sizes.

This assumes different forms which are, in my opinion, simply different degrees of severity of the same disease.

The mildest form is that in which contraction and relaxation alternate, and in which the symptoms are a peculiar sensation of quivering and commotion in that part of the peritoneal cavity in which the affected bowel is located.

A

Pain accompanying these contractions is rarely complained of. Aside from other digestive and nervous disturbances, very obstinate constipation, but little influenced by very powerful cathartics, is the most marked symptom, according to my observation. severer form is that found in the cases reported by Drs. Murphy and Long, in which the contraction becomes tonic, unyielding, and may result in complete ileus, requiring operative treatment for relief, but which relaxes on exposure to air and manipulation.

This tonic contraction may become tetanic and absolutely fixed, which does not even relax after death, as in the cases of the writer, and this is the severest and most dangerous form.

The severity of the form no doubt depends largely on the nature and degree of the primary irritation which excites it.

More careful observation and frequent autopsies in cases which have died from symptoms of ileus will no doubt show that enterospasm is by no means as rare as it appears at the present time, and will shed further light on this still obscure condition.

DYNAMIC ILEUS FOLLOWING OPERATIONS INVOLVING THE ABDOMINAL CAVITY, WITH REMARKS ON ADYNAMIC ILEUS.

BY F. BLUME, M.D.,

ALLEGHENY.

INTESTINAL obstruction following operations involving the abdominal cavity has within the past few years been frequently the subject of discussion in societies and journals. Quite a number of cases have been reported, and from the evidence which they present we are led to conclude that this grave complication is by no means of such rare occurrence as hitherto believed, and that it demands our earnest consideration to correct old views and to establish more precise indications, which may guide us in diagnosis and treatment.

A decided progress in this direction was made when Olshausen1 in 1887, in an article read before the Berlin Obstetrical and Gynecological Society, called attention to a form of intestinal obstruction which had not yet been recognized, a paralysis of the intestine not dependent upon septic peritonitis. The symptoms in these cases are temperature normal or but slightly elevated, in some instances even subnormal; pulse-rate increased, some vomiting. On the second or third day after operation, or even later, the symptoms of collapse manifest themselves. The pulse is rapid and feeble, the abdomen becomes more and more distended, retching and vomiting more frequent. Neither gas nor feces are expelled by the rectum. The general condition of the patient during the first few days appears to be good. Nothing is observable by which the development of so serious a complication can even be suspected until the abdominal symptoms become more pronounced. Death ensues between the fourth and tenth day after the operation,

1 Zeitschrift für Geburtshülfe und Gynäkologie, vol. xiv. p. 619.

and results from intoxication of the decomposed intestinal contents. Post-mortem examination reveals the absence of peritonitis. Olshausen sees in prolonged eventration of the bowels an important etiological factor of this condition.

Notwithstanding the fact that competent observers have confirmed the investigations of Olshausen, there is still difference of opinion in regard to the causes of this variety of adynamic ileus. The opponents of this theory are not satisfied with the ordinary post-mortem examination; they insist on bacteriological examinations to exclude sepsis. It is not my intention to enter upon a discussion of this theory. I will but briefly refer to an interesting article of Otto Engstrem,' published this year. This author gives his experience with four cases of intestinal paralysis following abdominal operations. Every one of the patients died, although in two of them a secondary operation was performed. Post-mortem examinations showed the absence of peritonitis. In the last case a careful bacteriological examination was made with negative result. Reviewing the investigations of other observers, he arrives at the conclusion that paralysis of the intestines can and does occur after operations involving the abdominal cavity without infection at the time of operation. Eventration and prolonged manipulations of the bowels are the most potent etiological factors, causing irritations of the nerves of the mesentery and the gut-wall, and leading to changes in the circulation. From his own experience he can confirm the statement of other observers that a paresis of the intestinal wall can be produced by strong saline purgatives, and it appears to be by no means impossible that, as a consequence of their use, a weakened condition of the gut-walls is created before the operation. He looks upon the increased susceptibility of the nervous system, often so marked in patients before operation, as a predisposing etiological factor.

There is hardly a surgeon who cannot recall a case in which the symptoms described above presented themselves, where the prognosis seemed to be favorable during the first few days, and which ended fatally from intestinal obstruction before a week had passed by. The diagnosis remained uncertain; even the autopsy did not give a satisfactory explanation. Such a case came under my ob

1 Ibid., vol. xxxvi. p. 399.

servation in April, 1896. The patient from whom I had removed a right pyosalpinx was very restless after operation, and could scarcely be managed. General condition good on the second and third day. In the middle of the fourth day the symptoms of intestinal obstruction developed; temperature 99°, pulse 130. Peristalsis was perceptible from the second to the fourth day. Collapse in the morning of the fifth day; temperature 97°, pulse 142. Death toward the end of the fifth day. Autopsy: the intestines enormously distended, their peritoneal covering slightly injected, but otherwise normal in appearance. No adhesions, no evidence of peritonitis. This post-mortem examination made a deep impression upon me.

I have presented to you this brief sketch of one type of adynamic ileus to bring out certain points and conditions which more or less are associated with every form of intestinal obstruction, and to which reference will have to be made repeatedly later on. It may serve, therefore, as an introduction to the study of dynamic ileus, to which I now invite your attention.

The first case of dynamic ileus following operation which I have been able to find in the literature at my disposal, occurred in 1887 in Olshausen's clinic, and was published in 1888 by P. Reichel,1 one of his assistants. It was a case of vaginal hysterectomy for cancer of the cervix uteri. The patient did well the first days. No rise of temperature. Nausea, but no vomiting. The pulse-rate remained above normal, and increased to 140 on the third day. Abdomen distended, marked peristalsis, visible through the thin abdominal walls. No gas or feces expelled by the rectum. Enemata and stomach-washing gave no relief. The abdomen was opened on the seventh day. The small intetines were greatly distended, their serous coat strongly injected, but smooth and glistening. The lower part of the ileum, about five inches from the ileocecal valve, and a portion of the mesentery were adherent to the vaginal wound. On separating the adhesions three to three and one-half inches of this part of the bowel were found to be firmly contracted, resembling a solid cord. All efforts to move the intestinal contents along by compression, and thus dilate the contracted portion, failed. The patient died on the table.

1 Ibid., vol. xv. p. 37.