VOL. XXI.

No. 7.

cations.

REPORT OF A CASE OF OBSTRUCTION OF THE BOWELS.*

BY L. H. DUNNING, M. D., OF INDIANAPOLIS, Professor of Diseases of Women in the Medical College of Indiana.

Mrs. A. B. was operated upon October 16, 1902, at the Deaconess Hospital. The operation consisted of the removal of a large pedunculated fibroid tumor of the uterus by myomectomy and double salpingo-oophorectomy for cystic degeneration. In two of the stumps the raw surfaces were covered with peritoneum and the third stump in which the raw surface was slight, was dropped without the peritoneal covering. All went well with this patient for two days when she began vomiting. In response to enemas there was a slight movement of the bowels and some gas was ejected. The vomiting was for a few hours bilious, then became grumous. The second day a large amount of dark, decomposed blood was vomited, after which there was less vomiting and less pain in the stomach. From the beginning of the vomiting, all pain was complained of as located in the stomach. This organ was very perceptibly distended before each act of vomiting.

The temperature was not elevated more than one or one and a half degrees but the patient was greatly distressed and the countenance showed marked signs of prostration.

On Tuesday, October 21st, the third day of the vomiting, the patient threw up a large quantity of fecal matter. I did not see her this day until late in the evening and her condition seemed somewhat re

*Presented on Case Night, December 2, 1902. to the Marion County Medical Society and read by the author.

had been a watery movement from the intestines which was of a dark color and had a slight fecal odor.

Wednesday morning I found her suffering with the stomach again. It was distended and painful. The patient was much distressed. Pulse 90, full and not weak, temperature normal. There had been another watery discharge from the bowels which was chocolate colored but not odorous. No gas.

I decided to operate upon her at once. In the afternoon, October 22d, four days after the onset of the vomiting, the abdomen was reopened by cutting the stitches and separating the edges of the incision. Many coils of distended dark colored small intestines appeared in the

wound. There was not much fluid in the abdominal cavity. The lowest coil was drawn up into the incision and gradually withdrawn while the assistant returned the intestine above.

In a moment or two we reached the part of the intestines that resisted our traction and by slipping the finger into the pelvic cavity the gut was traced to the stump and found adherent in such a manner as to make an acute flexure. By further slight traction the adhesion of the intestines to the stump gave way and the intestine came out of the wound acutely bent upon itself and held by soft adhesions. The adhesions were loosened by traction when to our delight, the gas rushed into the ribbon of the collapsed intestines and we were able to see them fill all the way along to the ileocecal valve and could hear the gas rush on into the colon.

It was surprising to see how the distension of the loops above the intestines diminished in size and how quickly their color changed from a dark to a light chocolate color. The gas was so lively and

the gloss upon the intestines so distinct that I was very hopeful of a speedy recovery, and our hopes were fully realized.

The whole operation including the sewing of the wound required but eighteen minutes. The patient did not seem much shocked from the operation but vomited fecal matter every few minutes in small quantities for four hours, when we gave her a Watkin's enema and the bowels moved copiously. From this time on the recovery was uneventful though the patient regained her strength slowly. She left the hospital five weeks after the second operation.

This was a very instructive case to me. I learned much from it. It is often difficult to correctly diagnose obstruction at the beginning. I did not believe there was complete obstruction until there was stercoraceous vomiting. There was the coffee ground vomiting the second day, but there was also passed a little gas and on the third day it was reported she had a movement containing fecal matter. I' Low believe these feces were only washings from the colon and cecum. I waited twenty-eight hours after fecal vomiting before operating. If she had died, I should have felt culpable. I waited because of the dark watery passages having a fecal odor. These were further washngs from the colon together with a little fluid that had been poured out into this tract with probably a slight hemorrhage.

At the beginning in this case, only the stomach was distended and this led to my deception for I have many times seen patients two or three days after an abdominal section vomit grumous fluid and yet recover; indeed I have seen a few patients recover after fecal vomiting. It is highly dangerous to wait after such vomiting for such vomiting should be taken as an evidence of obstruction and speedy operation should be instituted.

My final decision to operate was reached on seeing increasing meteorism which must in such cases denote developing peritonitis.

This is my first case of obstruction of the bowels I have seen recover when operated upon as long as four days after the onset of the seizure. Altogether I can recollect that I have operated upon eighteen cases with seven recoveries.

In

six of the cases recovering from the obstruction, the operation was done previous to three and a half days.

This experience has had a marked influence upon my course when called to the bedside of one suffering from obstruction. If the patient has been suffering obstruction five, six or seven days and is prostrated, I have been inclined to discourage operation, yet have sometimes proceeded at the urgent solicitation of the physician and friends. Probably I have attempted to do too much, in some of the cases, viz., have persisted in the search for the obstruction when the establishment of an artificial anus would have been the best procedure. The importance of this subject is worthy of the most careful study and thought of the general practitioner and specialist alike.

THE USES OF MYDRIATICS.

BY EUGENE DAVIS, A. M., M. D., OF INDIANAPOLIS, Assistant to the Chair of Diseases of the Eye, Medical College of Indiana.

As about seventy-five per cent. of all patients that come to the oculist for treatment are suffering from the result of errors of refraction the problem of proper correction and relief of these symptoms is an important one.

American oculists have the reputation for more careful refractive work and closer fitting of lenses than foreign workers in ophthalmology.

Since the classical investigations of Donders on the physiological action of atropin and the uses to which it may be applied for the accurate study of the refraction of the eye, the alkaloidal derivatives of the solanaceæ have become the most important drugs for the specialist in eye diseases.

Belladonna or atropin as a mydriatic or drug for dilating the pupil was known long before Donders' time but for our knowledge of its action as a cycloplegic, or a drug that temporarily spends the action of the ciliary muscle we are chiefly indebted to the investigations of Donders and his pupils.

Atropin being the first reliable cvcloplegic and the one whose action has been most studied, it has become the standard of comparison for all its associate drugs.

In private practice, on account of its toxic. effects in many cases and its prolonged suspension of the accommodative effort, it has been superseded as an aid to refraction by some of the weaker cycloplegics, except where a prolonged and powerful action on the ciliary muscle is desired. In clinical practice atropin, on account of its cheapness, surety of action and simplicity of application, still holds the most important place.

Atropin and its associate drugs act both by paralyzing the branches of the oculomotor nerve distributed to the iris and ciliary muscle and by stimulation of the sympathetic nerve filaments supplied to these parts. With the addition of cocaine which contracts the vessels of the iris the dilatation of the pupil is increased.

When dropped in the conjunctival sac, they are absorbed into the anterior chamber and act locally on the nerve supply of the iris and ciliary body.

The various mydriatics in common use are atropin, hyoscyamin, hyoscin, duboisin, daturin, scopolamin and homatropin. Cocaine which is not derived from the solanaceæ is valuable as a mydriatic but is only cycloplegic in very strong solutions.

It is the purpose of this paper to take up briefly the uses of mydriatics for examination and to dwell more fully on their cycloplegic action as an aid in the fitting of lenses and in overcoming the ill effects caused by errors of refraction.

A thorough examination of the eye in many cases can only be made with the aid of a dilated pupil. If a complete record of the case is made at this time it gives one data that may be of great importance both to the physician and patient at some subsequent time. This is especially true of lens and fundus changes that have to be observed from time to time. While it would seem possible that the cornea could be thoroughly examined without the use of a mydriatic, I have seen cases where irregularities of the cornea due to old inflammatory troubles in childhood and leaving no visible opacity, could be diagnosed only with the retinoscopic mirror under mydriasis. Then it is easily explained to your own satisfaction and the enlightenment of your patient why a vision of 20-20 is not obtained with any correcting glass.

In many communities some physicians and especially the laity are very much opposed to the administration of mydriatics and insist upon refraction without their use. In some of the New York clinics they do a great deal of refraction of a certain kind without cycloplegia.

As one of the younger men of this city and one who believes in the use of cycloplegies for refraction, we have much to thank the previous work and teaching in this line by the older oculists.

There are necessarily certain dangers and unpleasant symptoms that are liable to follow the administration of such powerful drugs. The only ill results I have had thus far have been erythematous rashes and mild delirum from a susceptability to atropin. The greatest danger probably is in patients predisposed to or having glaucoma and a suspicion of a tendency to this disease does not warrant their use in solutions strong enough for refractive purposes. However, if a careful history of the case is taken and an examination made of the pupil reflex, tension of the eveball and as to the condition of the retinal vessels as they pass over the edges of the optic discs, the accident of an acute attack of glaucoma following the administration of a mydriatic will probably seldom occur. Some authors, especially Fuchs, Snellen and Shoen, claim hypermetropia with want of proper glasses as and that if they were prescribed at the time when irritation of the eyes began the chief predisposing cause of glaucoma there would be few cases of this disease.

I believe that accurate refraction can only be done with the aid of a cycloplegic and that one should be used in almost every case where there is no direct contra indication. If the eyes are giving sufficient trouble to require the fitting of a pair of glasses the patient should be required, if necessary, to give his oculist the three or four days to get his eyes in proper condition again.

Then also no oculist is sufficiently expert as a diagnostician with the opthalmoscope without a dilated pupil, to eliminate all other conditions of the lens vitreous or fundus that might cause irritation of the eves and be mistaken for refractive errors.

In the nervous asthenopia often found