The Question of Early Catharsis 
after Coeliotomy. 
BY 
JOSEPH BRETTAUEli, M. D., 
Assistant Gynaecologist to Mount Sinai 
and New York Cancer Hospitals. 
Reprint from The New York Journal of Gynaecology 
and Obstetrics. [Reprinted from the New York Journal of Gynaecology and Obstetrics 
for February, 1894. 
THE QUESTION OF EARLY CATHARSIS AFTER 
C CELIOTOMY.* 
Joseph Brettauer, M .D, 
Assistant Gynaecologist to Mount Sinai and New York Cancer Hospitals. 
A glance at our latest text-books makes it sufficiently evident that 
the question of catharsis after coeliotomy is by no means settled. 
Though the older method of one week’s artificial constipation is now- 
adays scarcely practiced, nevertheless there are still important differ- 
ences between the two methods of treatment in vogue : in the one, 
the bowels are not moved till about the fourth day; in the other, 
catharsis is induced at the earliest possible moment, even within 
twelve hours after operation. The undoubtedly excellent results at- 
tained by either method seem to indicate that it is not the time at 
which catharsis is induced, but rather a wholly different factor, recog- 
nized by every one as the conditio sine qua non—namely, perfect asepsis 
—to which the good results must be ascribed. 
Though I can not agree with those who attribute to this question 
a role of the first magnitude, I venture to bring this subject before 
you because a few cases do occur in which the question is of great, 
perhaps even vital, importance, and because several considerations 
present themselves to me in this connection to which I should like to 
call your attention. 
The great majority of our cases are uncomplicated, and do not 
demand immediate operation. We have sufficient time to prepare 
the patient and secure thorough evacuation of the bowels. Thus 
prepared, with empty stomach and quiet intestines, our patients are 
operated for ovarian cysts, fibroids, and some diseases of the annexa. 
The operation is simple, requires but little time, and the patient is 
brought to bed in good condition. The first few hours the patient 
may be disturbed by some after-effects of the anaesthetic, but, as a 
rule, after twenty-four hours we find the following condition: Tem- 
perature normal, or perhaps slightly raised; pulse, 80 to 100 ; abdo- 
men flat and painless on palpation ; tongue clear and moist; urine 
* Read at a meeting of the New York Obstetrical Society, held December 19, 1893 2 
/oseph Brettauer, M. D. 
normal in quantity or possibly a little concentrated; subjective symp- 
toms on the whole good. The nourishment taken during this time 
almost nil; gases have not yet escaped. 
Does there exist at this moment any indication whatever for inter- 
ference with the natural course by starting peristaltic action ? I 
should say, Certainly not. 
In the normal course of these cases we notice after forty-eight 
hours, exceptionally somewhat sooner, the escape of gas per anum—a 
welcome sign of intestinal permeability and beginning peristalsis. If, 
now, at this time, any untoward symptoms, such as a feeling of full- 
ness or tympanites, develop, an enema of soapsuds or olive oil suf- 
fices in the vast majority of cases to bring on thorough evacuation 
and to relieve the patient. 
This is the course I look for after uncomplicated operations, and 
in them I follow the golden rule : “ Let well enough alone.” 
Sometimes we find on the second day an elevation of temperature 
from one to three degrees, accompanied by slight tympanites and an 
acceleration of the pulse. These symptoms are regarded by many 
operators as an urgent signal for immediate catharsis, on the ground 
that thorough evacuation of the bowels may prevent septic infection 
or abort the process already started. Are we justified in considering 
the symptoms I have referred to as necessarily the signs of septic in- 
fection, or can we not find another more probable explanation for 
them? Most of us, unhappily, have not yet attained the lofty stand- 
point of a recent writer, who says : “ Of peritonitis following an opera- 
tion I know nothing, except, in a general way, that it is treated by 
salines.” Nevertheless, our results sufficiently prove that acute septic 
infection is extremely rare, except in those cases in which the field of 
operation is infected beforehand. 
We have in some cases a considerable exudation of fluid from 
blood-vessels and cut lymphatics, caused by the irritation of our 
operative procedures. The exuded fluid necessarily undergoes some 
chemical changes, and it appears to me far more reasonable, in the 
light of our present knowledge, to attribute the symptoms in question 
to the absorption of chemical products in this aseptic lymph. That 
in the majority of these cases we are not confronted by a septic in- 
fection is perfectly clear from the further course they take when left 
without any treatment whatever ; within twenty-four or forty-eight 
hours after the development of the suspicious symptoms the tempera- 
ture has fallen, the pulse-rate is reduced, and the tympanites is re- 
lieved by a simple enema. The Question of Early Catharsis after Ceeliotomy. 
3 
There is another possible explanation for these symptoms—a factor 
on which some surgeons base their advocacy of the use of purgatives. 
All of us have met with cases in which an elevation of temperature 
was due to constipation, and disappeared after evacuation had taken 
place. It is probable that in such cases the temperature is caused by 
absorption of products of decomposition of the intestinal contents, 
the so-called “auto-infection." Certainly, there are some abnormal 
or diseased conditions of the intestinal mucous membrane in which 
this is possible, but, as we are at present considering only cases with 
normal digestive organs, we are justified in not regarding this as a 
likely source for these symptoms. 
But, granted that septic infection has taken place, how are we to 
explain the action claimed for the purgatives ? None of the writers 
on the subject, so far as I know, have entered to any extent into a 
theory of this alleged action of salines, except Dr. Boise, of Michigan, 
who says * (page 6) that they relieve the congestion of mesenteric 
vessels, “causing them to replenish themselves from the fluids in the 
peritoneal cavity, thus promoting absorption and drainage ” ; and, 
again (page 7), the introduction of salines will “establish the flow of 
fluid toward the intestinal canal. . . . Thus, good intestinal drainage 
is established, the effusion of serum into the cavity is checked, the 
culture medium of pyogenic germs is removed, and septic peritonitis 
is prevented.’’ 
Now, in the first place, exudation is not necessarily present in 
cases of septic infection. Secondly, if the vessels are made to absorb 
an infected exudation, in accordance with this theory, they are doing 
just what it is desirable that they should r.o.t do. The danger in septic 
infection depends solely on the absorption of the toxines produced by 
the germs in the peritonaeum, and if we were able to prevent this ab- 
sorption absolutely, the infection would be harmless. Thirdly, even 
though the fluids may be taken up by the vessels or transuded into 
the intestinal canal, the source of the danger, the germs—the manu- 
facturers of the poison—would remain behind, and therefore no per- 
manent advantage would be attained. 
It seems to me clear, for the reasons which I have given, that the 
prevalent faith in the beneficial action of early catharsis in cases of 
supposed or threatening peritonitis is not justified. On the contrary, 
I believe that by this treatment the great advantage of keeping a pos- 
* The After-treatment of Cceliotomy. Ann. of Gynacol. and Pcediat., October, 
1893, vol. vii. 4 
Joseph Brettauer, M. D. 
sible peritonitis circumscribed within its limits is sacrificed, and thus 
more harm than good may be done. 
The second, and not less important, reason for which early ca- 
tharsis is advocated is that by this means the formation of peritoneal 
adhesions is prevented. A final explanation of the cause of peri- 
toneal adhesions has not yet been formulated, and a definite con- 
clusion will be arrived at only as the result of experimental studies. 
The many experiments which have already been made (by Sanger, 
Dembrowsky, Kelterborn, Kiistner, Thomson, and others) have yield- 
ed the most diverse results. One fact is certain : that adhesions 
occur not less when the intestines are in active motion than when 
they are at rest. In this matter I share the opinion of Reichel,* who 
regards the various measures taken for the prevention of adhesions 
as useless refinements, which, missing the real cause of the formation 
of adhesions, may even be harmful. The observation of Reichel that 
normal peristalsis suffices to overcome newly formed adhesions, and 
of Kiistner,! who, on reopening the abdomen fourteen months after 
an operation, found no trace of adhesions which he had previously 
seen, rather indicate that we attach far too much importance to this 
subject. 
I have thus far attempted to show that the advantages claimed for 
early catharsis rest on no scientific foundation, without entering into 
a consideration of the positive harm which the unqualified and in- 
variable employment of early purgation may accomplish. 
In the great majority of cases it is a matter of no consequence 
whether the bowels are moved a little sooner or later. But in those 
cases in which early catharsis has been unsuccessfully attempted, in 
which symptoms develop, analogous to those which occur more com- 
monly after severe and complicated operations—incessant vomiting, 
intense distention, etc.—in those cases the further exhibition of 
purgatives is, in my opinion, decidedly harmful. It is to this point 
that I should like to see the discussion of the society especially 
directed. 
Permit me to present the following illustrative cases : 
Case I.J—Mrs. K., abdominal hysterectomy, performed by Dr. 
Cleveland at the New York Cancer Hospital ; vaginal opening into 
the peritoneal cavity tamponed with iodoform gauze ; thirty-six hours 
* Paul Reichel, Zur Pathologie des Ileus und Pseudoileus. Deutsche Zeitschnft 
fiir Chirurgie, 1893. 
f Ctrlbl. fiir Gyn., 1890, No. 24. 
\ Transactions of the N. Y. Obst. Soc., 1S93, page 300. The Question of Early Catharsis after Cceliotomy. 
5 
after operation routine treatment was followed and several doses of 
salt were given without effect other than to produce vomiting. 
Enemata of soapsuds, olive oil, turpentine, and high rectal tube were 
then employed and calomel given, but no evacuation was produced, 
not even gases being passed. The condition of the patient grew 
steadily worse, vomiting became more frequent, meteorism increased, 
and the patient died twelve hours later with the signs of intestinal 
obstruction. Post-mortem examination revealed no sign of septic 
peritonitis ; the entire intestinal canal was enormously distended ; 
the sigmoid flexure was empty and adherent to the gauze tampon, but 
no obstruction was apparent ; all other organs somewhat anaemic but 
apparently normal. 
Case II.*—Coeliotomy by Dr. Cleveland at the New York Cancer 
Hospital. Extra-uterine pregnacy. Extirpation of the sac difficult 
and tedious; the large cavity packed with gauze. Although during 
the first three days the temperature rose to 101.50 to 102°, the pulse 
was 120, and slight abdominal distention present, no attempt was 
made to move the bowels, but morphine was given quite freely. On 
the fourth day, when the temperature showed a tendency to decline, 
a dose of calomel followed by Epsom salts produced several copious 
evacuations. Patient recovered with an abdominal sinus. 
Case III.f—Operation by Dr. Boise for inflammatory disease of 
the appendages. The case seems to me of such importance that I 
take the liberty of quoting it to some extent, at least, in the words of 
the author. Pus was found in the right tube. The operation was a 
difficult and tedious one ; no drainage was used. “ The patient 
rallied well but was troubled very much with vomiting and severe 
abdominal pain. The bowels gradually became distended with gas, 
and the stomach refused to be quieted. Although the temperature 
was not high and the character of the pulse good, I feared peritonitis, 
and attempted to move the bowels by means of sulphate of magnesia 
in repeated doses, but with no effect except aggravation of the 
stomach symptoms. Enemata were then resorted to—turpentine and 
castor oil, oxgall, large quantities of water administered through the 
long tube, concentrated solution of salt, etc.—but with no result. 
There was, however, constant regurgitation from the stomach, with 
some abdominal pain and increasing tympanites. The patient was 
seen by Dr. Etheridge, of Chicago, who concurred in the diagnosis of 
* Transactions of the N. Y. Obst. Soc., 1893, page 103. 
f N. Y. Jour, of Gyn. and Obst1893, No. 2, page 118. 6 
Joseph Brettauer, M. D. 
intestinal paralysis and predicted death within twenty-four hours. 
All active measures were stopped and a quarter of a grain of mor- 
phine administered hypodermically. This was followed by cessation 
of pain and vomiting, with rest to the patient. The administration 
of another enema after the lapse of several hours was followed by 
copious free and offensive discharges—-so free and frequent as to 
be entirely involuntary. From this time the patient recovered, but 
developed a pelvic abscess on the left side, which was opened through 
the abdominal wall ” 
Case IV.—Mrs. G. Dilatation of the cervix by a practitioner in 
this city was followed by pelvic peritonitis, in which condition she came 
under my care at the Mount Sinai Hospital. After the general symp- 
toms had nearly subsided I removed with considerable difficulty the 
diseased appendages, and packed the cavity with gauze on account of 
the presence of very offensive pus in the left tube. The patient did well 
until the end of the second day, when she began to vomit and showed 
some tympanites. Temperature, 102°; pulse, 125. In the habit of 
inducing catharsis at this period, especially in the presence of such 
alarming symptoms, the acting house surgeon ordered the bowels to 
be moved by salts, or, if they were not well taken, by enema. These 
measures were without effect other than to aggravate the condition of 
the patient; meteorism became intense, and vomiting of greenish fluid 
incessant. In this condition I found the patient forty-eight hours 
after operation. I at once stopped all attempts at moving the bowels, 
and ordered an ice-coil to the abdomen and a third of a grain of mor- 
phine hypodermically. Nourishment and stimulants were given by 
rectum in very small but repeated doses. Twenty-four hours later 
the alarming symptoms had in great part subsided. Vomiting had 
nearly ceased, the distention was reduced, the abdomen was softer 
and nearly painless on palpation. During the following day improve- 
ment was steady, gases passed spontaneously, and an enema of castor 
oil and glycerin produced a good movement. The patient recovered 
with an abdominal sinus, for which she was recently operated by Dr. 
Munde. 
It is clear that all of these cases present more or less marked de- 
grees of intestinal paralysis, or, as some call it, “ pseudo-ileus,” mani- 
fested, to use the words of Dr. Boise, as a refusal of the muscular 
fibers of the intestines to act under the ordinary stimuli. 
To enter into a complete account of the physiology of peristalsis 
would carry me beyond the limits of this paper. I wish, however, 
briefly to mention a few points. The intestines are at rest when I he Question of Farly Catharsis after Cceliotomy. 
7 
they are empty ; peristaltic action is ordinarily started by the presence 
of chyme or faecal matter. There are, of course, a number of minor 
causes, which act as stimuli. Brunton has shown experimentally that 
excess of venous blood stimulates peristalsis, whereas excess in the 
arterial flow inhibits intestinal movements. 
The fact that irritation of the sympathetic fibers in the peritonaeum 
is followed by contraction of the arterioles, and therefore by diminu- 
tion in the arterial supply in the mesenterium, affords one explanation 
for the paralysis; on the other hand, the circumstance that all long 
and difficult operations in the peritoneal cavity necessitate severe 
manipulation of the intestines, separation of adhesions, and long ex- 
posure to the atmosphere, affords us another ready explanation for 
the occurrence of overstimulation with consequent exhaustion of the 
ganglia, and paralysis of the muscles supplied by them. 
Of course, for our purpose it is a matter of indifference whether 
the ganglia in the intestinal walls themselves or the more central 
sympathetic fibers are responsible for this condition. 
If what I have just said is correct—if, as is generally assumed, the 
intestinal paralysis is caused by overstimulation of the nerve mechan- 
ism of the intestinal muscles, can there be any scientific justification 
for the persistence in the attempts to move the bowels—that is to 
further stimulate the already exhausted nerve centers ? It seems to 
me far more rational to stimulate the inhibitory centers by means of 
srnad doses of opium in those cases in which the conditions described 
are favorable for the development of intestinal paralysis ; and later, if 
paralysis has occurred, to paralyze these centers by large doses of 
opium. This action of opium, analogous to the action of small and 
large doses of digitalis on the heart, has been demonstrated by Noth- 
nagel.* 
Reasonable as this mechanical theory of the origin of intestinal 
paralysis appears, I can not give it my unqualified support, but prefer 
another explanation, at least for the majority of cases. If the mechan- 
ical insults sufficed, we should expect to meet with intestinal paralysis 
far more frequently than it occurs—to meet it, in fact, after every case 
involving severe manipulations of the intestines. As a matter of fact, 
intestinal paralysis is, on the whole, a rare occurrence. I am inclined 
to think that it always depends on an infection with germs whose 
identity has as yet perhaps escaped us, but whose metabolic products 
exercise a paralytic action on the intestinal muscle fibers. 
* Nothnagel, Beitrage zur Physiologie und Pathologie des Darmes, Berlin, 1884. 8 
Joseph Brettauer, M. D. 
We all know that it is frequently impossible to differentiate acute 
septic peritonitis from mere intestinal paralysis, which, indeed, is 
always a symptom of the infectious process. 
In the second place, in my experience, we encounter intestinal 
paralysis most frequently in those cases in which the conditions for 
septic infection are present before operation. Dr. Coe,* for instance, 
has expressed the opinion that iodoform-gauze packing, which some 
of us use in these cases, favors the development of paralysis. I would 
rather suggest the view that it is just in those cases in which we have 
reason to fear an infection that we make use of Mikulicz’s method; 
in other words, that it is not the gauze packing that we use in septic 
cases, but the sepsis itself which is responsible for the paralysis. 
In the third place, in the cases which I have cited, and I am sure 
they are fairly typical of this class of cases, there was the most posi- 
tive evidence of infection—pelvic abscess and abdominal sinus—ex- 
cept in Case I, in which the evidence was negative so far as the gross 
appearances were concerned ; but we know from experiments, espe- 
cially Reichel’s,f that a septic process in the peritonaeum does not 
necessarily produce macroscopic lesions. 
Permit me, in conclusion, to sum up briefly the points which I 
have endeavored to establish in this paper : 
1. In the vast majority of our cases of coeliotomy it is a matter of 
absolutely no consequence if the bowels are moved early or not. Our 
good results depend solely upon perfection in the operative technique 
and asepsis. 
2. In those cases in which early attempts to move the bowels have 
failed, persistent efforts to produce catharsis should not be made, but, 
on the contrary, a dose of opium (morphine) is indicated. 
3. In those cases in which we have employed iodoform gauze to 
exclude the field of operation from the general peritoneal cavity, to 
prevent infection, it is, in my opinion, decidedly bad practice to at- 
tempt early catharsis ; but we should rather wait until the sign of the 
restitution of normal peristalsis has been given—that is, the spontane- 
ous escape of gases per rectum. 
45 East Sixty-fourth Street. 
* Dr. H. C. Coe, The Etiology and Pathology of Pelvic Adhesions. New York 
Journal of Gyncecology, 1893, p. 387. 
f Reichel, loc. cit.