In considering the therapeutic value of vomiting in intestinal obstruction one goes back to the 1880s, when cases of strangulated hernia of four or five days’ duration came into hospital, and when, even by leading surgeons, operation was delayed until too late, and was then only undertaken as a last resort.

Happily, there were a few surgeons who, convinced that herniotomy carried little risk, advocated immediate operation. Notably amongst these were those who had adopted Lister’s antiseptic methods. The necessity of immediate operation was not a new, but rather a forgotten, practice, for in 1806 Astley Cooper, in commenting on three fatal cases of femoral hernia, expressed the opinion that the patients died, not because of the operation but because it had been undertaken too late. Both the profession and the public now believe in early operation for all acute abdominal conditions, including strangulated hernia. Late cases are now the exception, but they still occur.

I have observed that when vomiting had been persistent and vigorous from the first, recovery after release of the obstruction was more likely to occur than when it had been arrested either from lack of intestinal irritability or as a result of treatment.

When vomiting had been absent, the stomach, at operation, was  found to be filled with brown, acrid fluid, which was sometimes rejected under the anaesthetic, occasionally fatally entering the lungs. The small intestine was dark and loaded with the same fluid material. In advanced cases the wall was oedematous. Under such conditions the infection of the peritoneum through the intestinal wall can easily be understood. When vomiting had been continuous and unchecked, the bowel wall was normal in colour, free from oedema, and the contents of a lighter colour.

Two cases, one in which recovery followed and the other ending fatally illustrate the therapeutic value of uncontrolled vomiting.

A vigorous and restless man

A vigorous and very restless man had been seized, more than three days before I saw him, with acute pain and vomiting. The vomiting was copious and persistent. I was shown several basins and pots, some in one room some in another, all containing the usual brown fluid. This man had walked from one room to the other, so that practically he had never been at rest.

One might be inclined to criticize the action of his medical adviser in allowing the patient to have so much of his own way; in this, to my thinking, lay his wisdom. The doctor was a man with a sense of humour, and realizing that only the use of sedatives would keep his patient quiet, he instead wisely let him have his way, while keeping a close watch on the symptoms. There were no symptoms either before or during the attack even to suggest the cause of the obstruction. After practically withdrawing the whole of the small intestine into a towel, a biliary calculus was found impacted in the lower end of the ileum. The surrounding bowel was in good condition, and the impaction not so tight as to prevent the calculus being moved upwards into a healthy part and removed. Through the opening made for the removal, the fluid contents of the intestine were evacuated.

This patient continued to vomit copiously for another three days, and recovered. During these days vomiting was encouraged by the free administration of fluids, of which he consumed many pints a day, much to his own satisfaction and to those of his nurse, for he was very thirsty.

A lady with an impacted gallstone

In contrast with this case was that of a lady who, also with antecedent symptoms, was found to have a gallstone impacted in the lower end of the ileum.

Instead of the alert mentality exhibited by the previous case, she had all the signs of a profound toxaemia, and it was a question whether any operation could be borne. The bowel round the calculus was thickened and dark, while above it was oedematous and filled with evil-smelling brown fluid. Death ensued within 24 hours. The patient had been treated on orthodox lines, sips of water, complete rest, and some sedative.

The contrast between the two cases could not be greater; the one owed his life to free vomiting, whilst the other died because this most important symptom was checked. Free vomiting and the movement it entails does no harm, in the absence of perforation.