[Reprinted from the New York Journal of Gynecology and Obstetrics 
for May, 1894. 
THE MANAGEMENT OF THE INTESTINE AFTER 
ABDOMINAL SECTION. 
By Skene Keith, F. R. C. S. E., and George E. Keith, M. B., C. M. 
The treatment of the intestine after abdominal operations is in 
itself a special study and, while considering this, reference must be 
made to the food and drink which the patient is to have. 
Until gas has passed from the anus the quantity of fluid must be 
limited, and no solid food is allowed for about a week. For the first 
five or six hours after the operation a teaspoonful of cold water is to 
be given at long intervals, but only if the patient ask for it. Then 
hot water, as nearly boiling as it can be taken, is what allays thirst 
best. 
During the first night the average quantity of hot water given will 
be about five or six ounces, and the exact amount will depend on the 
condition of the patient. If the skin be dry, less must be given than 
when there is free perspiration ; and if the patient be inclined to 
vomit, nothing whatever must be given by the mouth, thirst being re- 
lieved if necessary by an injection of eight or ten ounces of weak milk 
and water. After the gas has passed the quantity may be increased. 
Ice should never be allowed ; it is deliciously cooling at the moment, 
but it is difficult to regulate the quantity of fluid, and the patient 
continually asks for one little piece more. Besides, much cold water 
does not assist the downward passage of the gas. 
A little stimulant is of service in almost every case, a teaspoonful 
or so of brandy or whisky occasionally makes the patient feel better 
and prevents the weary hours seeming so long. One or two ounces 
may be given in the twenty-four hours, but when the patient is very 
weak the spirit may be drunk like water. As much as an ounce and 2 
Skene Keith, F. R. C. S. E., and George E. Keith, M. B., C. M. 
a half in the hour has been known to do good and not make the pa- 
tient intoxicated. 
When the patient is weak, rectal injections must be commenced 
immediately after the operation and continued every two, three, or 
four hours until the stomach can retain nourishment. As soon as the 
gas begins to pass through the rectal tube, a little weak tea will be 
much appreciated, even by those who do not care for it as a rule. 
Then a small cupful of well-boiled gruel may be given and repeated 
in six or eight hour's. This with the tea and stimulants is sufficient 
for the day following the first passage of the gas. The next day a 
larger quantity of the gruel may be given three times or may be varied 
with some clear, thin soup. Toward the end of the week a little 
bread and butter may be added to the diet and, after che bowels have 
been thoroughly moved, fish, pounded chicken, sweetbread, etc., may 
be given. 
When a patient is very weak, and especially if she has been ac- 
customed to take food often, it may be necessary to give something 
every two hours and to continue the injections as long as they are re- 
tained. In these feeble people do not spare the stimulant. It may 
be well to fix a minimum quantity and give instructions that the pa- 
tient may have it as often as she wishes in addition, so long as the 
smell of alcohol does not remain constantly in the breath. 
In the majority of cases what is most difficult to learn is that Na- 
ture will see the patient through her troubles if we do not interfere 
but, when Nature threatens to fail, we must be prepared to assist with- 
out delay. As it is impossible to say that progress will be satisfactory 
even after the most simple abdominal operation, it is necessary that 
the patient be seen at least three times in the twenty-four hours for 
the first three days, na matter how well the case is progressing. 
The one important sign of satisfactory progress which must always 
be looked for is the passage of gas from the rectum. When it has 
passed freely the chief danger is over. It is often difficult to wait 
and watch, to have faith in Nature and to hold one’s hand, when it 
appears that she is likely to fail. The passage of flatus commences 
from fifteen to thirty hours after the operation ; sometimes, but not 
very often, it may pass sooner and at other times this sign may not be 
noticed for fifty, sixty, or even one hundred hours. In the very large 
majority of cases all that is required is to avoid straining by opening 
the sphincter ani and thus prevent pressure on the tender wound. For 
this purpose a hollow glass, not thicker than one of Dr. Keith’s drain- 
age tubes, is to be used, and it may be incidentally mentioned that Management of the Intestine after Abdominal Section. 
3 
the extreme diameter of these tubes is three eighths of an inch. The 
tube is passed into the rectum for about four inches whenever there 
are colicky pains in the left side of the abdomen. It may be left for 
hours in this position so long as it does not cause irritation, and when 
there are piles or the rectum is sensitive a little cocaine ointment 
may be used as a lubricant. Treatment, except by thus opening the 
sphincter, is to be avoided at first; all that is necessary is to prevent 
undue irritation of the stomach by not giving too much food or drink. 
When treatment becomes necessary it must be prompt, there is not 
any time to lose, for a few hours of inactivity at the wrong time may 
easily result in the death of the patient. The symptoms which call 
for interference are vomiting, distention of the abdomen, either when 
accompanied by colicky pains or not, and especially when long-con- 
tinued windy pains have been followed by intestinal paresis. This 
brings us to the cause of distention, excluding mechanical obstruction. 
Two theories have been advanced : the one is, that the distention is 
due to commencing peritonitis ; the other, that it is due to a paresis 
or paralysis of the intestine itself. As a variety of the latter must be 
included the so-called septic peritonitis, as this may be a septicaemia 
without any definite inflammation of the peritonaeum. There is truth 
in both of these hypotheses, though it is probable that distention is 
comparatively seldom caused by peritonitis. We do not have oppor- 
tunities of examining the peritonaeum at the time when distention be- 
gins, and it is thus impossible to say with absolute certainty what is 
the exact pathological condition. A careful clinical study leads one 
to the conclusion that the sympathetic nervous system has much to 
do with this condition. This conclusion is strengthened by the post- 
mortem examination of cases of so-called acute septic peritonitis, but 
which are described more correctly by the single word septicaemia. 
At such examination no sign of inflammation may be seen except in 
the neighborhood of the wound ; but some, perhaps very little, red 
serum will be found. The symptom of distention is common both to 
these cases of septicaemia or septic peritonitis and to those of what is 
usually called simple peritonitis ; and it is possible that, as there is 
little inflammation in the one case, there may also be little in the 
other. Still there can not be any doubt that cases of simple traumatic 
peritonitis are met with. Distention ought never to be treated by any 
routine method. When it is accompanied by increased peristalsis, it 
would be folly to treat it in the same way as when it is due to cessation 
of this peristaltic action. In the former case, when there are frequent 
colicky pains and no appearance of flatus passing downward, it must 4 
Skene Keith, K. R. C. S. E., ami George E. Keith, M. E., C. M. 
be evident that it would be a mistake to increase this useless peristal- 
tic action, and treatment must be directed to quieting it. When 
there is a want of intestinal movement, and when there has been no 
previous condition of increased peristalsis and consequent exhaustion 
of the ganglia of the sympathetic nervous system, it is necessary to 
stimulate these ganglia and thus set up movement of the intestine. If 
the abdomen begins to distend when there has not been much or any 
peristaltic action, and when the sympathetic nervous system is there- 
fore not exhausted, a stimulant to the nerve ganglia is required. 
Some veiy hot water or bicarbonate of soda and hot water is to be given, 
or a drachm of the sulphate of magnesia with ten grains of the car- 
bonate in peppermint water, and repeated every two hours until the 
bowels move. If there be vomiting with derangement of the stom- 
ach itself it is better to give the stimulant by the rectum. For this 
purpose six grains of quinine are to be dissolved in a couple of ounces 
of weak whisky and water and injected into the bowel. Three such 
doses are to be given at intervals of two hours, the rectal tube being 
put in for fifteen or twenty minutes before each. 
No drug has been more abused in the after treatment of abdominal 
operations than morphine, and there is no drug which can serve a 
more useful purpose; but it must be given with discrimination and 
with a clear understanding of what will be obtained by its adminis- 
tration. If the choice lay between so much opium so many times a 
day and its entire exclusion from the lists of abdominal remedies, 
preference would be given to its exclusion. Formerly, opium was 
used too much and in too large doses, and now the other extreme 
seems to have been reached and many decline to give it under any 
circumstances. The hypodermic method of administration must al- 
ways be employed ; to give the drug by the mouth is in some cases 
absolutely useless, as no absorption may be going on from the whole 
alimentary canal. The dose must never exceed one quarter of a 
grain of the tartrate and will vary down to one twelfth; the more 
common amount being from a sixth to a ninth of a grain. When 
there are frequent colicky pains and no gas is passing from the anus, 
one sixth of a grain will soothe the excited intestine, and wind will 
often pass easily and within half an hour. 
A more anxious condition of the intestine is that of paresis follow- 
ing great peristaltic effort. This means that there is some obstruction 
to the passage downward of the flatus, which the muscular action of 
the intestine has failed to overcome. A rest must be given to the 
tired-out muscular fibers before an effort is made to stimulate them Management of the Intestine after Abdominal Section. 
5 
to renewed action. Give one sixth of a grain of morphine, or even 
in exceptional cases a larger dose, and stop all fluid by the mouth. 
After this dose allow a rest of three or four hours, then give the 
quinine by the rectum ; if the first dose does not set up windy pains 
let the patient have from one to two tablespoonfuls of castor oil by 
the mouth and continue the quinine until the three doses have been 
given. Should this fail, give a large enema with turpentine, turn the 
patient on the side and, if necessary, repeat the turpentine injection 
several times. If there be no septicaemia nor any mechanical block 
wind can always be got down, if the proper treatment for the case be 
used. 
When there is vomiting, one must discover if possible its exact 
cause. Is it due to the anaesthetic, to some derangement of the 
stomach, to the mechanical pressure of a distended colon or to the 
condition of the intestinal secretions ? When the vomited matter is 
either sweet or sour, a teaspoonful of bicarbonate of soda is to be 
given in eight or ten ounces of warm water. This either acts as an 
emetic or neutralizes and dilutes the acidity. Some attach great im- 
portance to washing out the stomach, but this is more fatiguing and dis- 
tressing than the soda. Mechanical pressure on the stomach may be 
relieved by rubbing the back, or by raising it on a small firm pillow, 
so as to give more room. When the vomiting is part of the general 
state of relaxation and distention quinine by the rectum will be found 
invaluable, especially if the stomach reject everything. 
So far we have dealt with cases where there was not supposed 
to be any evidence of septicaemia. The first symptoms of this dread 
condition are noticed about eighteen hours after the operation ; there 
is some difference in the expression and in the manner of the patient. 
At the very commencement it is difficult to say exactly what is no- 
ticed ; there is something not quite natural, and a few hours later this 
shows itself in the eyes and mouth. There is an appearance of fixa- 
tion about the face, the eyes have a wild look and the upper lip is 
beginning to be drawn up. The manner too has changed ; the patient 
may be elaborately polite, talks in a rapid jerky fashion and, if given 
a drink, will clutch the cup and put it to the lips quickly and abruptly. 
There is a look impossible to describe, that makes one’s heart sink on 
first seeing the patient. In the commencement it may be passed over, 
but any one who has seen one well-marked case is not likely ever to 
forget the appearance. To have the slightest hope of success in the 
combat with this disease we must throw overboard the good plan of 
waiting on the natural efforts, for this will lead to but one result. By 6 
Skene Keith, F. R. C. S. E., and George E. Keith, M. B., C. M. 
the time that the first appearance of septicaemia is noticed there may 
be some, perhaps slight, distention ; and all our efforts must be 
directed to the elimination of the poison by, if possible, free move- 
ment of the bowels and by the action of the skin. The administration 
of the saline mixture must be begun immediately and the quinine 
added to the nutritive enemata. A small dose of morphine will not 
interfere with the action of the laxative and will perhaps cause the 
skin to act. If taken early enough it is possible to believe that an 
undoubted case of septicaemia might be cured, provided that the 
absorption of the poison has stopped and the patient has sufficient 
vitality to overcome what has been taken into the system. If absorp- 
tion be allowed to go on, the patient must inevitably die. As soon as 
we find that the bowels will not move nor the skin act, and we feel 
certain that we are dealing with a case of septicaemia, the treatment 
ought to be to open up the lower angle of the wound, to put in a 
drainage tube to the bottom of the pelvis if there be not one already 
there—being quite sure that it does reach to the bottom of the 
cul-de-sac—and to wash out with a large quantity of warm water. It 
is useless to attempt to wash out by the tube unless an exit be pro- 
vided lor the escape of the fluid. This can hardly be done too soon 
in a case of septicaemia, but we must be very sure of the diagnosis ; 
for, if the patient be not relieved by the removal of septic matter, the 
simple opening up of the wound may be enough to turn the balance 
against her. 
In conclusion we may lay down very shortly a few general 
rules: 
(a) When the general condition of the patient is fairly good and 
the abdomen is not distending, and when there is not much colic, let 
things take their natural course. This advice holds for the great 
majority of cases. 
(l>) W’hen the abdomen is distending without a previous state of 
peristaltic action shown by much colic, and when there is a tendency 
to vomiting, give the mixture of magnesia until the bowels move. 
(c) Treat distention without colic or vomiting by the quinine 
injections. 
(d) Quiet excessive peristaltic action by small doses of morphine 
given hypodermically. 
(<?) For distention following excessive peristalsis give a small dose 
of morphine followed in a few hours by castor oil or magnesia. 
(f) When there is septicaemia, wash out the abdomen as soon as 
the condition is evident and treat as above. Management of the Intestine after Abdominal Section. 
7 
(g) Do not get into the habit of calling septicaemia shock, ex- 
haustion or any such term. Be content to believe that some mistake 
has been made in the antiseptic precautions and that additional care 
must be taken in future. 
42, Charles Street, London, W.