[Reprinted from the American Gynaecological .and Obstetrical Journal 
for November, 1895.] 
INTRAPERITONEAL ADHESIONS.* 
By Ernest T. Tappey, A. M., M. D., 
Professor of Surgery, Detroit College of Medicine, and Surgeon to the Harper Hospital, etc. 
Abdominal surgery as it has been so extensively practiced in the 
last few years has established, among other things, that many of the 
pains, vague, uncomfortable feelings, and so-called dyspepsias, are 
caused by adhesions of various organs in the abdominal and pelvic 
cavities. The organs in these cavities are particularly liable to be- 
come adherent to one another because they all have, as one part of 
their peripheral structure, the peritonaeum, a membrane very vascular 
and prone to adhesions and fibrinous exudations ; and when we say 
that organs in these cavities are adherent we mean that the perito- 
naeum covering them is adherent. But though it is the peritonaeum 
in each instance that is adherent, still the symptoms caused are 
those that pertain to the organ covered by the adherent peritonaeum. 
In operating, for instance, to relieve ovarian pain, we not infre- 
quently find the ovaries themselves not much changed but bound 
firmly by more or less extensive adhesions ; the adhesions being 
broken up, the pain is relieved. Of course there was an inflamma- 
tory process at some time to cause these adhesions, but in the course 
of time the adhesions seem to be the principal if not the entire cause 
of pain. I have in mind a case I operated upon several years ago ex- 
pecting to find gallstones. There were attacks of pain at intervals 
of two or three weeks, at which times there was jaundice, and there 
was every reason to suspect gallstone. I found the gall bladder of 
normal size, and, though I could not feel stones through the walls, I 
incised it and explored its interior carefully. There were no stones. 
I found, however, extensive adhesions binding the duodenum and 
* Read before the American Association of Obstetricians and Gynaecologists, 
September 24, 1895. 
Copyright, i8qs- by J D. Emmet, M. D. 2 
Ernest T. Tappey, M. D. 
stomach to the posterior abdominal wall; then passing a probe into 
the duct, I found it patulous to within a short distance from the in- 
testine, the duodenum was bound fast in such a way as to bend the 
duct and obstruct it, the adhesions were broken up, the wound in the 
gall bladder was closed, and the patient recovered, and has been quite 
free from pain since. Operation was done November 25, 1892. I 
presume there had been gallstones in this case and that the adhesions 
had been caused by their presence, but when I operated it was the 
adhesion which caused the trouble. After narrating this case to a 
well-known surgeon, whose name I shall not mention, he said “ the 
stone had ulcerated through the walls of the duct or bladder and was 
somewhere there, else how could the adhesions be there?” I think, 
however, that the frequent passage of gallstones, or even their pres- 
ence, with the congestion they may cause, would be sufficient expla- 
nation of the adhesions. Another frequent location of adhesions is 
the neighborhood of the appendix. They may be caused by in- 
flammation of the appendix or as the result of an operation for ap- 
pendicitis. Every case of laparotomy is probably followed by some 
adhesion of peritoneal surfaces. For example, in a recent case the 
operation of oophorectomy was followed by a very severe and persist- 
ent form of cystitis and great pain in the region of the stump of the 
left broad ligament. Two years after the first operation the abdo- 
men was opened again March 22, 1895, and the colon found adherent 
to the bladder wall and to the stump of the broad ligament, 
the first adhesion accounting for the persistent nature of the cys- 
titis, it having been caused and kept up, in all probability, by the 
transmigration of the colon bacillus through the walls of the intestine 
and bladder ; the pain was caused by the tension at the point of adhe- 
sion to the stump of the broad ligament. The adhesions, formed 
from whatever cause, may be the occasion of pain and functional dis- 
turbance, not only by tension, as mentioned above, but by the forma- 
tion of internal hernia, which may become strangulated—two loops 
of intestine may be joined by adhesions so as to cause obstruction or 
in such a manner as to favor volvulus. Pain in the female pelvis 
is not infrequently caused by adhesions alone, so far as we can judge 
by the look of the organs. It is frequently the experience of the 
surgeon that he opens the pelvis to see what may be the cause of 
pain in the region of the ovaries—for he has not been able to make 
a diagnosis otherwise—and he finds apparently healthy ovaries, ex- 
cept that they are adherent. He either removes the organs or breaks 
up the adhesions and relieves the pain. The uterus is fixed in some Intraperitoneal Adhesions. 
abnormal position by adhesions ; they are severed and the symptoms 
relieved. 
Riedel, of Jena, in the forty-seventh volume of Archiv fur klin- 
ische Chirurgie, presents an exhaustive paper on this subject. He has 
evidently, from the number of cases he cites, had an extensive expe- 
rience, and he treats the subject in a most interesting manner. He 
begins by stating that during the past year a great number of laparot- 
omies have been performed on account of adhesions of the viscera, 
the existence of inflammatory bands in the abdominal cavity, and the 
kinking and narrowing of the intestines due to them. He states that 
most of the operations undertaken to remedy these conditions have 
been successful, and that the good results have remained for months 
and years in a number of instances. In considering this subject, one 
of the most obvious objections to operation would be the likelihood 
of a formation of new adhesions. Riedel admits that new adhesions 
are sure to be formed, but maintains that the symptoms caused by the 
original adhesions are almost invariably relieved, and my own experi- 
ence is the same, though it is quite limited as far as those cases are 
concerned in which only adhesions have been divided and no tissue 
or organ has been removed. The question of diagnosis is often per- 
plexing, and in some instances impossible without abdominal section. 
Riedel mentions the following causes of adhesion in the abdomi- 
nal cavity. They suggest at once the approximate locality in which 
they exist, except in the instances of contusion of the abdomen and 
of detached lipomata : 
a. Contusion of the abdomen. 
b. Ulcer of the stomach. 
c. Inflammation about the gall bladder. 
d. Inflammations about the gall bladder and ascending colon. 
e. Inflammations of the gall bladder and vermiform appendix to- 
gether. 
f. Inflammations of the vermiform appendix alone. 
g. Inflammatory processes in the colon. 
h. Lipomata that have become detached from their pedicles in- 
side the peritoneal cavity. 
Besides these there are adhesions found in the pelvic cavity 
caused by— 
i. Inflammation of the ovaries or tubes, or both. 
2. Inflammation of the uterus. 
3. Inflammations of and about the rectum. 
4. Inflammation of the bladder. Ernest 7\ i appey, M. D. 
The question of diagnosis is often perplexing and in many in- 
stances impossible without abdominal section, but there are consid- 
erations which will aid materially. Wherever there is pain, and pal- 
pation does not reveal any tumor or other enlargement, adhesions is 
one of the probable causes. In obstruction of the intestines, for 
instance, if the cause be intussusception or the pressure of a tumor or 
of a faecal mass, it will be possible, very likely, to feel a mass. If, 
then, no mass be felt, the cause may be paralysis of the bowel, stric- 
ture, or adhesions. If paralysis be the cause, no peristaltic action of 
the bowels can be seen through the abdominal walls, and it can be in 
the case of stricture or adhesions. It would probably be impossible 
to distinguish between these two conditions, though there might be a 
sensation of greater resistance on palpation in the case of adhesion. 
The localization of the adhesions is of course just as difficult as and 
no more so than that of stricture, and will often have to be done after 
the abdomen is open. I believe it to be eminently proper to subject 
cases of chronic dyspepsia, chronic and obstinate constipation, and 
cases of persistent pain which is caused by accumulation of flatus, to 
exploratory opening of the abdomen to determine whether there be 
adhesions and for the purpose of severing them.