physiognomy
of the poor
sufferer,
as
powerful
muscular contractions of the voluntary or involuntary muscular tissues. We see it exemplified in cases of tetanus and hydrophobia, cholera, colic and bowel obstruc-
welcome to continuance of intense agony. I was called to see a patient one morning during my rounds by a gentleman who stated that the poor sufferer had been in agonies for fifteen hours at a stretch,?that the Hospital Assistants and Assistant Surgeon's treatment had been tried without avail. On arriving at his bedside, the following was the history of the case:? General history.?The patient was a tall, thin, spare individual, about 50 years of age, had always had a fair measure of health, his occupation being that of a cook.
tion,?death being
Family history.?Nothing noteworthy.
Past state of health.?Fair, except that he had had occasionally attacks of colicky paiu, which were soon relieved with a purgative. Present illness.?Came on suddenly after a meal of kitcherry. A dose of castor oil was administered by the master, but soon rejected by patient. The Hospital Assistant and Assistant Surgeon had given enemas of castor oil, but without any good effect, and that the patient was now suffering for fifteen hours from severe pain which was exhausting him rapidly, requiring a careful examination of his condition. Present state.?A thin, spare and tall individual, decubitus dorsal, with an expression of great pain and auxiety on his countenance, rather a woe-begone appearauce, with limbs out-
AN OBSTINATE CASE OF OBSTRUCTION OF THE BOWEL?TREATMENT?RECOVERY. By Surgeon-Captain G. H. Fink, i.m.s., Civil Surgeon, Bijnor District, N.-W. P. and Oudh.
The various-
causes
of bowel obstruction
stretched.
are
Shin.?Cold, and clammy on surface. Pulse.?Feeble, quick, regular and becoming
too well known to the physician and surgeon to need any description of an elaborate kiud; value to be able to rapidly but that it is of
imperceptible. Tongue.?Dirty yellow-brown tip, small and very dry. Temperature.?Sub-normal.
somewhat
great
and correctly diagnose your patients condition, and to adopt surgical or medical measures for the relief of the wretched sufferer, every practical surgeon or physician must in the course of his experience have come to fully recognise the deep importance of. Delay in diagnosis of your patient's state is not only dangerous, but it shakes the confidence of the patient's friends and others, although in bowel obstruction it is always necessary to wait for some urgent symptom to justify surgical interference even in these days of antiseptic abdominal surgery. The surgeon who has fully considered his case, and has given his patient all the opportunities which medicinal treatment can accomplish, must make up his mind, however, to operate ere the sufferer has reached that lowered stage when surgical interference would give him very little hope of recovery. There is no complaint which the human body js subject to, which gives rise to such intense Buffering and anxiety aa is depicted iu
at
Physical
on
dorsum, red
examination.
Inspection.?Muscular tension
of abdominal
muscles.
Palpation.?Hardness of a board over surface of abdomen generally,?tenderness in the right lumbar and iliac regions, with hardness and resistance
on
pressure.
Percussion.?Dulness of abdomen generally. On lifting the thighs and flexing thenTou abdo-
men> he complained of pain on movement; he felt relief in the position assumed, so was maintained to relief.
position
The bowels
vomit, although
,
the^l
were a
keep
up
constipated,
little
food of any kind
was
the attack ; thirst
was
no
but this
desire
to
present. No nor taken since
nausea was
desired
great. Diagnosis.?Obstruction of the bowel. Nature?doubtful, but in favour of scybalous mass impacted in the intestine.
INDIAN MEDICAL GAZETTE.
136
Prognosis.?Somewhat unfavourable, owing rapid exhaustion.
to
Treatment.?Rest in bed with the thighs flexed on abdomen and maintained in this position by pillows. Strong beef tea with a little rum to be given every quarter of an hour in small quantities to maintain the strength and overcome rapid #
o
%
exhaustion. Solid opium
pill gr. i to relieve pain and give the bowels rest and to cause sleep to overcome exhaustion and pain after fifteen hours of unrest and agony. Hot fomentations and turpentine over belly every hour with massage in downward direction towards the pelvic outlet, with a little mustard oil to be rubbed over the abdomen with friction. but not
Result.?Relief,
following
Patient
permanent.
seemed better in every way,
so
I ordered the
enema:?
Rj Castor oil
Turpentine
Warm water
...
...
...
...
...
...
...
...
...
Mix.?Sg. Inject gently
3 iss. m. 40 O iss.
into the bowel per
rectum.
about the size of This indicated that there was a scybalous mass present; and if it could not be brought away by inducing action of the bowels, it would have to be broken down by mechanical means to remove the obstruction early, since perityphlitis or peritonitis might set iu from the severe pressure exercised by such a hard mass.
Result.?One small
goat's dung
ecybala
and very hard.
I next ordered another enema, with
no
result
this time. I then injected glycerine jiv into the bowel straight away, and in less than half an hour a huge motion occurred with scybalous masses in The injection of glycerine was repeated in it. two hours with
a like result. Geutle massage the belly with mustard oil and hot fomentations with turpentine were continued, and the patient made au excellent recovery and is now
over
happy. Remarks.?It is worthy
of note in this
case
that,
required to pain, it was also necessary to husband his strength which had been so very lowered through the long continualthough very prompt measures were relieve the patient from his agonising
of his troubles which had lasted fifteen hours I arrived at his bedside, since, whatever might be the cause of the obstruction, au operation under chloroform would have eventually been the only means of saving the patient's life, " has he got the ftnd the question would arise, to endure a severe operation or mechangtrength down of the scybalous mass in ical breaking " ? bowel the ance
ere
Nausea case
was
looked
as
present, if it
be it
were
remembered,
going
on
and the
towards actuaj
[Ar*it
1894.
vomiting, if relief did not come very soon, and then operative interference would surely be called for if the patient could bear the operation which might have been a protracted one or otherwise, depending of course on the nature of the obstruction. The passage of the scybala was some reason for supposing it to be one of foecal impaction ; but the triumph was not due to enemas of castor oil and turpentine, but to glycerine injections in large doses of 3iv twice per rectum; the results were astonishingly rapid and effectual. feel also that the administration of solid in pill, together with the careful nourishment and small doses of stimulant at frequent iutervals, gave strength to the patient's whole system, and enabled the bowel after rest to evacuate its contents, by the restoration of the nervous system which controls bowel action. This was only a commonsense method of reasoning out the probabilities of the case. I
opium
I feel that perhaps I would have acted more if I had administered morphia instead of solid opium, for reasons which need no explanation ; but as a rule natives indulge in opium as a prophylactic against various diseases ; and had I failed in my wished-for-effect of the opium pill, I would certainly have given morphia, hypodermieally, a fair trial.
wisely
Now
question of massage and fomentturpentine and friction with mustard oil, perhaps it was somewhat heroic in the face as
to the
ation with
of the conditions which were present in the bowel with pain and tenderness ; but had peritonitis actually set in, the patient's natural decubitus would have been very different to what it was, aud the knees would have been instinctively drawn up to relieve pressure of the abdominal muscles. Moreover, there would surely have been a high temperature and a quick wiry pulse. Massage doubtless helped to a great degree in supporting the peristaltic action of the bowels in the normal direction and driving the scybalous mass to the termination of the large intestine. The modus operandi of the large doses of glycerine so rapidly effectual in its results, might be explained in the usual manner, viz., abstracting fluid rapidly from the bowels and also from the (cecal mass itself which it perhaps percolates through and softens and breaks down in the process ot abstracting water and softeuing, and so its triumph in this particular case.
This
will also illustrate the fact that you patient and not the disease only. It will al^o illustrate to the physician and surgeon the necessity of trying the simpler methods first before hastening into the graver ones, and it will also impress one with the fact that one large glycetine enema is not surrounded with the dangers of aperients and enemas which are so much deprecated in works by standard authors. case
must treat your
of the poor
sufferer,
as
powerful
muscular contractions of the voluntary or involuntary muscular tissues. We see it exemplified in cases of tetanus and hydrophobia, cholera, colic and bowel obstruc-
welcome to continuance of intense agony. I was called to see a patient one morning during my rounds by a gentleman who stated that the poor sufferer had been in agonies for fifteen hours at a stretch,?that the Hospital Assistants and Assistant Surgeon's treatment had been tried without avail. On arriving at his bedside, the following was the history of the case:? General history.?The patient was a tall, thin, spare individual, about 50 years of age, had always had a fair measure of health, his occupation being that of a cook.
tion,?death being
Family history.?Nothing noteworthy.
Past state of health.?Fair, except that he had had occasionally attacks of colicky paiu, which were soon relieved with a purgative. Present illness.?Came on suddenly after a meal of kitcherry. A dose of castor oil was administered by the master, but soon rejected by patient. The Hospital Assistant and Assistant Surgeon had given enemas of castor oil, but without any good effect, and that the patient was now suffering for fifteen hours from severe pain which was exhausting him rapidly, requiring a careful examination of his condition. Present state.?A thin, spare and tall individual, decubitus dorsal, with an expression of great pain and auxiety on his countenance, rather a woe-begone appearauce, with limbs out-
AN OBSTINATE CASE OF OBSTRUCTION OF THE BOWEL?TREATMENT?RECOVERY. By Surgeon-Captain G. H. Fink, i.m.s., Civil Surgeon, Bijnor District, N.-W. P. and Oudh.
The various-
causes
of bowel obstruction
stretched.
are
Shin.?Cold, and clammy on surface. Pulse.?Feeble, quick, regular and becoming
too well known to the physician and surgeon to need any description of an elaborate kiud; value to be able to rapidly but that it is of
imperceptible. Tongue.?Dirty yellow-brown tip, small and very dry. Temperature.?Sub-normal.
somewhat
great
and correctly diagnose your patients condition, and to adopt surgical or medical measures for the relief of the wretched sufferer, every practical surgeon or physician must in the course of his experience have come to fully recognise the deep importance of. Delay in diagnosis of your patient's state is not only dangerous, but it shakes the confidence of the patient's friends and others, although in bowel obstruction it is always necessary to wait for some urgent symptom to justify surgical interference even in these days of antiseptic abdominal surgery. The surgeon who has fully considered his case, and has given his patient all the opportunities which medicinal treatment can accomplish, must make up his mind, however, to operate ere the sufferer has reached that lowered stage when surgical interference would give him very little hope of recovery. There is no complaint which the human body js subject to, which gives rise to such intense Buffering and anxiety aa is depicted iu
at
Physical
on
dorsum, red
examination.
Inspection.?Muscular tension
of abdominal
muscles.
Palpation.?Hardness of a board over surface of abdomen generally,?tenderness in the right lumbar and iliac regions, with hardness and resistance
on
pressure.
Percussion.?Dulness of abdomen generally. On lifting the thighs and flexing thenTou abdo-
men> he complained of pain on movement; he felt relief in the position assumed, so was maintained to relief.
position
The bowels
vomit, although
,
the^l
were a
keep
up
constipated,
little
food of any kind
was
the attack ; thirst
was
no
but this
desire
to
present. No nor taken since
nausea was
desired
great. Diagnosis.?Obstruction of the bowel. Nature?doubtful, but in favour of scybalous mass impacted in the intestine.
INDIAN MEDICAL GAZETTE.
136
Prognosis.?Somewhat unfavourable, owing rapid exhaustion.
to
Treatment.?Rest in bed with the thighs flexed on abdomen and maintained in this position by pillows. Strong beef tea with a little rum to be given every quarter of an hour in small quantities to maintain the strength and overcome rapid #
o
%
exhaustion. Solid opium
pill gr. i to relieve pain and give the bowels rest and to cause sleep to overcome exhaustion and pain after fifteen hours of unrest and agony. Hot fomentations and turpentine over belly every hour with massage in downward direction towards the pelvic outlet, with a little mustard oil to be rubbed over the abdomen with friction. but not
Result.?Relief,
following
Patient
permanent.
seemed better in every way,
so
I ordered the
enema:?
Rj Castor oil
Turpentine
Warm water
...
...
...
...
...
...
...
...
...
Mix.?Sg. Inject gently
3 iss. m. 40 O iss.
into the bowel per
rectum.
about the size of This indicated that there was a scybalous mass present; and if it could not be brought away by inducing action of the bowels, it would have to be broken down by mechanical means to remove the obstruction early, since perityphlitis or peritonitis might set iu from the severe pressure exercised by such a hard mass.
Result.?One small
goat's dung
ecybala
and very hard.
I next ordered another enema, with
no
result
this time. I then injected glycerine jiv into the bowel straight away, and in less than half an hour a huge motion occurred with scybalous masses in The injection of glycerine was repeated in it. two hours with
a like result. Geutle massage the belly with mustard oil and hot fomentations with turpentine were continued, and the patient made au excellent recovery and is now
over
happy. Remarks.?It is worthy
of note in this
case
that,
required to pain, it was also necessary to husband his strength which had been so very lowered through the long continualthough very prompt measures were relieve the patient from his agonising
of his troubles which had lasted fifteen hours I arrived at his bedside, since, whatever might be the cause of the obstruction, au operation under chloroform would have eventually been the only means of saving the patient's life, " has he got the ftnd the question would arise, to endure a severe operation or mechangtrength down of the scybalous mass in ical breaking " ? bowel the ance
ere
Nausea case
was
looked
as
present, if it
be it
were
remembered,
going
on
and the
towards actuaj
[Ar*it
1894.
vomiting, if relief did not come very soon, and then operative interference would surely be called for if the patient could bear the operation which might have been a protracted one or otherwise, depending of course on the nature of the obstruction. The passage of the scybala was some reason for supposing it to be one of foecal impaction ; but the triumph was not due to enemas of castor oil and turpentine, but to glycerine injections in large doses of 3iv twice per rectum; the results were astonishingly rapid and effectual. feel also that the administration of solid in pill, together with the careful nourishment and small doses of stimulant at frequent iutervals, gave strength to the patient's whole system, and enabled the bowel after rest to evacuate its contents, by the restoration of the nervous system which controls bowel action. This was only a commonsense method of reasoning out the probabilities of the case. I
opium
I feel that perhaps I would have acted more if I had administered morphia instead of solid opium, for reasons which need no explanation ; but as a rule natives indulge in opium as a prophylactic against various diseases ; and had I failed in my wished-for-effect of the opium pill, I would certainly have given morphia, hypodermieally, a fair trial.
wisely
Now
question of massage and fomentturpentine and friction with mustard oil, perhaps it was somewhat heroic in the face as
to the
ation with
of the conditions which were present in the bowel with pain and tenderness ; but had peritonitis actually set in, the patient's natural decubitus would have been very different to what it was, aud the knees would have been instinctively drawn up to relieve pressure of the abdominal muscles. Moreover, there would surely have been a high temperature and a quick wiry pulse. Massage doubtless helped to a great degree in supporting the peristaltic action of the bowels in the normal direction and driving the scybalous mass to the termination of the large intestine. The modus operandi of the large doses of glycerine so rapidly effectual in its results, might be explained in the usual manner, viz., abstracting fluid rapidly from the bowels and also from the (cecal mass itself which it perhaps percolates through and softens and breaks down in the process ot abstracting water and softeuing, and so its triumph in this particular case.
This
will also illustrate the fact that you patient and not the disease only. It will al^o illustrate to the physician and surgeon the necessity of trying the simpler methods first before hastening into the graver ones, and it will also impress one with the fact that one large glycetine enema is not surrounded with the dangers of aperients and enemas which are so much deprecated in works by standard authors. case
must treat your
