INTESTINAL OBSTRUCTION.
BY HUNTER MCGUIRE, M.D.
When a mechanical impediment to the passage of the contents of the bowel along the intestinal canal exists, the condition is known as intestinal obstruction. The causes of this occurrence are numerous, the symptoms urgent, the diagnosis difficult, the treatment uncertain, and the termination, unless relieved by nature or art, speedily fatal. There is no class of cases to which the practitioner is called more important, or which demands on his part greater skill and judgment.
It is customary to divide the causes of obstruction of the bowels into two great classes—acute and chronic.
In acute cases the attack is sudden, the symptoms violent, and, unless the cause is speedily removed, life ends in a few hours or at most in a few days. In chronic cases the causes act comparatively more slowly, the symptoms are chronic and less urgent, and danger of death less imminent. In this class the cause is not uncommonly spontaneously relieved, and the individual restored to perfect health without the aid of medicine or the surgeon's art. This result may happen in apparently the most desperate cases.
This classification of acute and chronic obstruction is necessary for a proper clinical study of the subject, but it should be remembered that in practice there will be found some cases which partake of many of the symptoms of both acute and chronic obstruction, making it difficult to determine to which division the cases properly belong. It will also be seen that some, at first, well-marked acute cases subside and become chronic in character, and that (old) chronic cases of obstruction sometimes suddenly change their nature and become acute. Again, some of the causes mentioned as giving rise to acute obstruction of the bowel in rare instances produce symptoms of chronic obstruction, and some of the causes referred to as giving rise to symptoms of chronic obstruction in rare instances provoke signs of acute obstruction. These cases are exceptional. As a rule, the following list embraces conditions which produce symptoms of acute obstruction:
1. Congenital malformations.
2. Impaction of foreign bodies, gall-stones, enteroliths, etc.
3. Twisting of the bowel—volvulus.
4. Internal strangulation by loops, bands, false membranes, diverticula, mesenteric pouches, slipping of a portion of bowel into natural or unnatural openings, diaphragmatic hernia, etc.
As a rule, the following causes produce symptoms of chronic intestinal obstruction:
1. Constipation and fecal accumulation.
2. Stricture of the bowel, sometimes cancerous.
3. Compression of the bowel from abdominal tumors.
4. Contraction of the bowel from inflammatory changes, often tuberculous.
A consideration of external hernia is, of course, not included in this paper, but the possibility of the symptoms of intestinal obstruction being due to this cause should never be overlooked.
Congenital Strictures and Malformations.
Cases of congenital strictures and malformations are confined almost wholly to the rectum and anus, and come more properly under the province of the surgeon. Some of the cases, however, belong to the physician, the obstruction being so slight as not to require surgical assistance. With all of them, however, the physician should be familiar, that he may be able to distinguish between congenital malformation giving rise to immediate obstruction and other forms of intestinal occlusion. He should know, too, when to seek the aid of the surgeon. For these reasons, as well as to make the history of the causes of intestinal obstruction as complete as possible, it has been thought proper to include in the list congenital occlusion and malformation of the intestine. They will be treated, however, in the briefest possible way, and the reader is referred to works on surgery for a more detailed account of the pathology, symptoms, and treatment.
When congenital occlusion of the colon occurs, it is almost invariably found in the sigmoid flexure, and is due, as most congenital atresia of the intestine, to foetal peritonitis. Congenital occlusion may be found in any portion of the small bowel, but a frequent site is the lower part of the ileum and the ileo-cæcal opening. The following case1 gives an example of a form of stricture of the duodenum in infants, with the symptoms and pathological changes. The septum is supposed to be an unnaturally developed valve, or two valvulæ conniventes united: "A child when born presented no unusual symptoms for the first twenty-four hours. Vomiting then came on, and continued with short intermissions until death, which took place some thirty-eight hours after birth. The bowels were never relieved during life. The only disease found was stricture of the duodenum close to the entrance of the gall-duct, so that a probe passed down the latter entered the duodenum immediately below the constriction. There was nothing to indicate in what manner the constriction had occurred. On the gastric side of the latter the duodenum was immensely distended—so much so that at first sight it appeared like the pyloric end of the stomach itself, and only by a more careful examination was the distinction between the stomach and intestine detected by a ridge running around their place of junction."
1 Quoted by Mr. Pollock in Holmes's System of Surgery, from Pathological Transactions, vol. xii. p. 101.
Cases like this, a number of which are on record, are instructive and of pathological interest; when, however, congenital occlusion exists in the small intestines, no treatment can be suggested. If the sigmoid flexure is the part involved and diagnosis can be made, opening the intestine in the right groin and establishing an artificial anus should be attempted.
In the development of the foetus the anal part of the bowel, beginning below, develops upward, and the intestinal portion, commencing above, grows downward; both portions, advancing, finally unite, making one continuous tube. When, however, there is some interruption in the foetal development of the intestine, and the two portions of bowel fail to unite, we have malformation of the rectum and anus and intestinal obstruction; or the two portions of bowel may have been united and continuity of the intestinal track established, and subsequent intra-uterine inflammation may obliterate the canal. Under these circumstances a ligamentous cord represents the original tube. The cord descends from the cul-de-sac in which the upper part of the bowel ends to the skin about the anus, or is lost in the tissues about the neck of the bladder. In congenital malformations the following conditions may be found: 1st. The anal orifice may be so minute as not to allow the feces to escape; or the aperture may be occluded by a membrane, through which the meconium may be seen; or the anus may be entirely absent. 2d. The rectum may be occluded by a membranous septum, the presence of which is not suspected until symptoms of intestinal obstruction arise, and then it is discovered by introducing the finger or a probe; or the rectum may be entirely absent, the colon terminating in the iliac fossa in a dilated pouch, or ending at the top of the sacrum or stopping at any point between this and the normal anus, the place being determined by the period of arrest of foetal development; or, the anus being absent, the rectum may open into the vagina, bladder, urethra, and other places. These cases belong exclusively to the surgeon.
Impaction of Foreign Bodies.
Intestinal obstruction may arise from the introduction, accidental or otherwise, of foreign bodies into the stomach and bowels. Coins, marbles, bullets, fruit-seeds, etc. are often swallowed by children, sometimes intentionally, and if the object is round and small it rarely gives rise to any serious trouble. The foreign body, however, if small, may drop into the appendix vermiformis or some other diverticulum and end in serious mischief, or if the individual has stricture of the bowel the foreign body may be arrested by it.
Foreign bodies which are pointed or irregular in shape, swallowed by accident or design, may give rise to dangerous and fatal symptoms, but not unfrequently they escape per vias naturales. Thus, pins, needles, pieces of bone, artificial plate and teeth, small pen-knives, and other pointed or irregular-shaped bodies, have passed in this way. Sharp-pointed bodies, as needles, sometimes make their way through the walls of the stomach and present themselves at other and more distant parts of the body. I have removed a needle from the calf of the leg which the patient had a month before accidentally swallowed. Jugglers accidentally, in practising their calling, and insane people, not unfrequently intentionally, introduce into the stomach all sorts of foreign bodies, such as buckles, forks, spoons, knives, pieces of wood, iron, bone, etc. Gross2 records the case of a juggler who let a bar of lead ten inches long and weighing a pound slip into his stomach. Bell of Iowa removed it by gastrotomy, and the man recovered. Agnew3 reports a post-mortem of an insane woman in whose intestinal canal he found three spools of cotton, two roller bandages, a number of skeins of thread, and a pair of suspenders.
2 System of Surgery, by S. D. Gross, 6th ed., vol. ii. p. 616.
3 Agnew's Surgery, vol. i. p. 393.
The morbid appetite of some people, particularly girls and pregnant women, sometimes induces them to swallow powdered chalk, magnesia, and other substances, and when this practice is continued for a long time the insoluble powder is deposited in the bowel and forms hard masses which more or less completely obstruct the intestines.
Stony concretions or enteroliths are found generally in the cæcum or in the sacculi of the colon, very rarely in the small intestines. They are round or oval, and when two or more are found together they have facets. They consist usually of carbonate of lime or magnesia or sesquioxide of iron. Other concretions are sometimes seen composed of starch or the felted husks of oats, called oat-stones (avenoliths), found particularly among the poorer classes of people in Scotland. Other vegetable remains of husks, fibres, etc. may produce the same thing. Young and middle-aged people more frequently suffer with these concretions than the old. Foreign bodies made up by the gradual accumulation of hair, string, and other substances are not unfrequently found in the stomach and intestines. The mass produced in this way is often very large. Sometimes the foreign body is arrested in the oesophagus. In a post-mortem reported to the writer by Fairfax a large copper coin, accidentally swallowed a few days before, was found lodged in the gullet. Ulceration followed, a neighboring artery was opened, and the patient died from hemorrhage.
Impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. Small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. If, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. A very large single stone or a number of stones forming a coherent mass may collect in the gall-bladder, slowly distend the dilatable biliary passages, and escape into the bowel; or—and this is more common—an opening made by ulceration between the distended gall-bladder and the duodenum allows the concretion to escape into the small intestine. These stones or aggregation of stones are sometimes three, four, or five inches in circumference and from one to four inches long. They occur, as a rule, in people over fifty years of age, and more commonly in women. Brinton, in his excellent book on Intestinal Obstruction, makes the average age in these cases fifty-three and a half years, and from the statistics he has gathered it will be seen that their occurrence is four times as often in females as in males. In 41 cases collected by Leichtenstern, 32 were women and 9 men. The site of the impaction is always in the small intestines. In 32 cases observed by Leichtenstern, 17 were found in the lower part of the ileum, 10 occupied the duodenum and jejunum, and 5 the middle part of the ileum.
SYMPTOMS.—Foreign substances introduced into the stomach do not always immediately give rise to serious symptoms. It is wonderful sometimes to see how tolerant the stomach is of their presence. Many instances are recorded of foreign bodies remaining in the stomach for months without producing dangerous symptoms. The mass may be discharged by vomiting, or it may escape through the pyloric opening into the intestine, and ultimately be discharged through the rectum, or, lodging in the bowel, give rise to symptoms of inflammation and obstruction. If, however, the foreign mass remains in the stomach, and is not removed by the surgeon's art or spontaneously discharged by ulceration, as in several rare instances has been the case, it uniformly proves fatal.
Before the foreign body is discharged by ulceration through the walls of the abdomen, adhesive inflammation unites that portion of the alimentary canal, gastric or intestinal, in which the mass is lodged with some part of the abdominal wall. By this union the cavity of the peritoneum is protected, just as we see the peritoneal sac protected by an effusion of lymph in hepatic abscess opening into the small intestine. If the adhesion between the canal and abdominal wall is imperfect, or by an undue amount of inflammation is disunited, the foreign body or inflammatory products which surround it may escape into the peritoneal sac and produce fatal peritonitis. Instead of passing through the abdominal wall, the foreign substance may escape into the bladder or vagina, or from the small intestine into the colon or rectum. Dangerous peritonitis may follow the simple presence of the foreign body in the alimentary canal from the obstruction it produces when no attempt at discharge by ulceration has been made. If the size and shape of the body permit its passage into the small intestine, it makes its way very slowly along this tube, giving rise to occasional attacks of colicky pains and symptoms of partial impermeability of the bowel.
At any moment the foreign body may lodge, become impacted in the canal, and all the grave symptoms of enteritis and general peritonitis present themselves. Symptoms of inflammation may appear, and after a longer or shorter time suddenly disappear, as if the foreign body had glided over some point of obstruction and again begun its descent through the tube. Its course is always irregular, passing quite rapidly over a portion of the intestine, then going more slowly, then lodging for a time at some point where it is obstructed by a fold or the contents of the bowel or by spasmodic contraction of the muscular coat of the intestines. As the calibre of the small intestine gradually diminishes as it approaches the cæcum, the passage of the foreign body becomes more and more difficult as it is propelled onward toward the ileo-cæcal valve. After a time it may reach the cæcum, where, of all places, it is most apt to lodge; but it may continue its course to the rectum, where it gives rise to tenesmus and a constant desire to go to stool. Finally, spontaneously or aided by the finger of the physician or some instrument, it is evacuated per anum. Not unfrequently, the foreign body can be felt through the abdominal walls, and its course traced day after day as it makes its way along the canal.
It is a common practice with uninformed persons to give castor oil or some purgative medicine when a pin, needle, coin, or other foreign substance has accidentally passed from the mouth into the stomach. Such practice is irrational and hurtful. Experience has shown that the larger and more solid the alvine discharges, the more likely the foreign body is to escape by the natural outlet; and the physician should order such a regimen and diet as will probably secure this condition of the contents of the bowel.
Long residence of a foreign mass at any point in the intestinal canal is certain to produce some chronic enteritis and effusion of lymph and subsequent stricture of the bowel, or the presence of the foreign body may produce an ulcer; and when this is healed the resulting cicatrix may end in serious obstruction from the natural tendency of the new material to contract. Signs of constriction of the bowel may not be noticed for some time after the escape of the foreign body.
Obstruction from the presence of intestinal stones and concretions is almost invariably preceded by impaired health, emaciation, or cachectic appearance, signs of partial impermeability of the bowels, and repeated attacks of inflammation, especially in the region of the cæcum. It terminates sometimes by the concretion becoming encysted, by its spontaneous evacuation, or by ulceration and perforation, or sometimes by complete occlusion of the bowel, and death.
As occlusion of the bowel by the presence of gall-stones always occurs in the small intestines, the symptoms are at once of the most urgent and violent character. The signs are those of internal strangulation, and the termination is often rapid in the extreme. Colicky, griping pains are soon succeeded by violent agony; vomiting begins at once, and is constant; at first bile is thrown up, and afterward feculent matter; the pulse is small, wiry, and frequent; the belly is retracted; the features are pinched, the extremities cold, and prostration soon comes on, succeeded by collapse.
Evidences of disorder of the liver, symptoms of inflammation of the peritoneum in that region, or attacks of hepatic colic sometimes precede obstruction of the bowel by gall-stones; unfortunately, however, for the purposes of diagnosis, these premonitory symptoms are not invariably present.
Acute Internal Strangulation, Twisting, etc.
When a portion of bowel within the abdomen is constricted, its circulation interfered with, and the passage of the contents of the bowel interrupted, it gives rise to acute internal strangulation. This condition is very similar to that of external strangulated hernia. The difference is, that one is inside and the other outside of the cavity of the abdomen.
Twisting of the gut upon its mesenteric axis, the passage of the bowel through some natural or unnatural opening, the encircling of one portion of bowel by another or by bands, false membranes, etc., may cause internal strangulation. It may happen at any age, and involves generally the small intestine or the more movable parts of the large bowel—viz. the sigmoid flexure and cæcum.
Twisting, or torsion, is not an unfrequent cause of intestinal obstruction, and may involve almost any portion of the intestinal tube. Its most common site is the sigmoid flexure, and next in point of frequency the cæcum. It sometimes, but rarely, involves the small intestines, and may occur as a simple twisting of one loop of intestines upon another. Several conditions are necessary for its production. First, the mesentery must be elongated. This change in the mesenteric root may have been caused by the dragging of an old and large hernia, or the mesentery may have been lengthened by relaxation of the abdominal walls from childbearing or by the disappearance of fat. However caused, before torsion of the gut takes place the mesentery is elongated, so that the two ends are approximated and something like a pedicle formed. Second, the portion of bowel attached to the lengthened mesentery may become filled with an enormous quantity of fecal matter and paralyzed by the great distension. In this paretic condition it may be displaced by the living, moving parts around it, and become bent and twisted, or the length of bowel belonging to the elongated portion of the mesentery may be the seat of inflammation, and, paralysis following, it becomes without resistance subject to the pressure and movements of the active vital parts surrounding it. A portion of bowel with its accumulated contents having a redundant mesentery and paralyzed by enormous distension or by inflammation, or by both, may readily be twisted more or less completely, and in some cases several times upon itself.
The weight of the bowel and its contents, along with the rapid distension of the intestine above, fixes the gut in this state of torsion and effectually prevents it from untwisting. A semi-rotation of the paretic and distended bowel about the mesenteric axis is sufficient to interfere with the supply and return of blood and provoke enteritis. Indeed, the rotation is rarely sufficiently great to produce complete obstruction, and the symptoms are frequently rather those of inflammation than of internal strangulation. For weeks before the final attack the patient usually has symptoms of intestinal disorder, such as flatulence, constipation, and spells of colic, due no doubt to the changes provoked by the elongated mesentery and bent or curved intestine. When torsion takes place the attack is sudden and the symptoms violent and urgent. Vomiting, meteorism, insuperable constipation, and frequently tenesmus, are soon followed by collapse and speedy death. The patient may die in twenty-four hours; he rarely lives beyond the fourth day. In some cases excessive tenesmus and bloody stools are seen in the early stages of torsion of the bowel. The condition may be mistaken for intussusception, but can usually be distinguished by the premonitory symptoms of twisting and by the more rapid course, the sudden meteorism, and quick collapse of the latter.
Still another way by which displacement of intestine may occasion obstruction to the passage of its contents is when a portion of the intestine has a long and narrow mesentery, and around this mesentery, which is like a pedicle, another portion of the bowel is thrown, encircling and compressing it. The accompanying figure, taken from Ziemssen's Cyclopædia, gives a good idea of this condition (Fig. 23). It represents a loop of the small intestine placed around the mesenteric pedicle of the sigmoid flexure. Leichtenstern calls this "intertwining or knotting of two intestinal loops."
| FIG. 23. | FIG. 24. |
| Anterior view of the strangulated intestine and stricture. a, gastric extremity; b, rectal extremity. | Posterior view of the strangulated intestine and stricture. a, gastric extremity; b, rectal extremity. |
In consequence of inflammation of the peritoneum and effusion of lymph, peritoneal surfaces are joined together, and before the lymph is fully organized these surfaces are separated by the constant movements of the organs and the change in the relationship of the parts, and strings and bands of various shapes and sizes are formed in which a portion of the intestine may become entangled and constricted. Sometimes the bowel accidentally becomes engaged in a loop or noose of false membrane, or becomes bound down under a band of fibrin; or, the peritoneal surfaces of some of the organs having been joined together or to the wall of the abdomen or pelvis, a loop of bowel may escape into a slit or opening and become incarcerated; or a fold of bowel may fall into a fissure in the omentum or mesentery or broad ligament of the uterus or suspensory ligament of the liver, and become constricted; or the appendix vermiformis may be twisted around the intestine in such a way as to cause ligation of the tube, or, by becoming attached to some neighboring part, it may form a loop through which the intestine may pass and become obstructed. In the same way the bowel may be constricted by a diverticulum. (This is well shown in Figs. 23, 24, and 25.) Bands entangling the bowel and causing strangulation may be attached to the fimbriated process of the Fallopian tube or the ovary or uterus. Indeed, it is impossible to describe in a limited space the almost infinite ways in which these bands and strings may engage and incarcerate the intestinal tube (Figs. 24, 25).
| FIG. 25. |
| An appearance of the natural relations of the diverticulum to the intestine. a, gastric extremity; b, rectal extremity. |
Internal strangulated hernia may result from the bowel falling into a pouch of the peritoneum and becoming ligated by the orifice of the pouch, or passing into the foramen of Winslow, of which there are three cases of strangulation recorded; or a retro-peritoneal hernia may be formed; or, more common still, a hernia of the intestine through the diaphragm.
In diaphragmatic hernia an opening is more frequently found in the posterior part of this muscle. Two hundred and fifty-two cases of this form of internal hernia have been collected by Leichtenstern, in which the diagnosis was made in only five cases. He found the oesophageal opening, a spot just behind the sternum, and a gap between the lumbar and costal parts of the muscle, the weakest points in the diaphragm.
Diaphragmatic and other forms of internal hernia may exist and not produce symptoms of strangulation either at the time of formation or subsequently, just as we so commonly see in cases of external hernia. When the bowel is constricted, however, and its circulation interfered with, symptoms of internal strangulation come on, and are exactly like the symptoms of external strangulated hernia. The attack is sudden, the symptoms acute and urgent, and the course and termination very rapid. Unless the constriction is relieved death may take place in twenty-four hours; life is rarely protracted beyond three or four days.
The patient has first eructations, soon succeeded by nausea and vomiting. The matter vomited consists of the contents of the stomach, then of gastric fluid, bile, and the contents of the intestines. When the last is ejected the vomiting is called fecal or stercoraceous. The patient complains of a sense of constriction about the abdomen, griping pains about the umbilicus, flatulence, tenesmus, and insuperable constipation. One or two free stools from the large intestine below the site of strangulation may be passed, but this should not deceive the practitioner. As a rule, peritonitis soon follows strangulation. The belly becomes tympanitic and tender, the pulse small and wiry, and the face anxious. When gangrene supervenes the pain subsides, the pulse becomes weak and intermittent, the surface cold and clammy, and the patient soon dies in a state of collapse. Slight delirium may precede death, or the mind remain unimpaired to the end. Very often, when gangrene sets in and pain disappears, the patient has a grateful sense of relief and is hopeful of recovery.
Intussusception, Invagination.
One of the most frequent and important causes of intestinal obstruction is intussusception or invagination of the bowel; by which term is meant the protrusion or slipping of one portion of bowel into a portion immediately adjoining.
This condition is sometimes found after death in persons old or young, but particularly the latter, in whom during life there were no symptoms of intestinal obstruction or intestinal trouble of any kind. The displaced intestine in these subjects is easily reduced, is unattended by any signs of inflammation, and is evidently the result of spasmodic contraction of the transverse muscular fibres of the bowel at one part, with distension and relaxation at another part, by which, just before death, one piece of the bowel is pushed into an adjacent piece. Not unfrequently two or more invaginations are seen in the same subject. Flint4 counted as many as fifteen in a child who died of typhoid fever. This invagination of the death-struggle almost invariably involves the small intestine, and may be the protrusion of a piece of the bowel above into a piece immediately below, or the reverse, a portion of bowel below being pushed into a portion above. It has been suggested that this slight and temporary intussusception may occur during life and give rise to temporary symptoms of intestinal obstruction, which disappear when reduction of the displacement spontaneously takes place.
4 Practice of Medicine.
| FIG. 26. | FIG. 27. |
It will be seen by the diagrams that three successive portions of intestine enter into the formation of an intussusception—an entering, returning, and receiving portion. Two mucous surfaces and two serous surfaces are thus brought into apposition. The mesentery attached to the included lengths of bowel—viz. the entering and returning lengths—is necessarily pulled down with the bowel in its descent, and is also embraced by the receiving portion of the intestinal tube. The traction excited by this portion of mesentery, thus wedged in between the middle and inner layers of the bowel, materially alters what would otherwise be the relationship of the parts. Fig. 26 shows simple invagination of the ileum like the finger of a glove, in consequence of the traction exerted. The entering or invaginated portion does not always lie in the axis of the enveloping tube, but is more or less curved, until very often its lower orifice is in contact with the wall of the outer layer. The concavity of this curve looks toward the mesenteric edge of the invaginated portion of bowel, and the convexity toward the opposite side of the receiving portion. The convex side of the middle cylinder is often thrown into transverse folds or convolutions. Intussusception, which gives rise to symptoms characteristic of intestinal obstruction during life, is invariably from above downward. It is doubtful whether there is on record a single well-authenticated case of inflammatory invagination where the lower segment of bowel protruded into the upper.
Reference to the diagrams will show that the lumen of the bowel is diminished, and that more or less intestinal obstruction must follow invagination. This obstruction is increased by the inflammation which necessarily follows this condition. The large and numerous blood-vessels of that portion of the mesentery involved in the invagination are compressed and stretched; arterial supply, and especially venous return, are interfered with; congestion quickly follows, with copious inflammatory exudation; the layers of intestine become swollen, and blood, sometimes in abundance, is poured out from the mucous membrane. Peritonitis, limited sometimes to the invaginated part, more often spreading to the peritoneum covering neighboring structures, soon begins, and the contiguous serous surfaces are agglutinated and the intussusception rendered irreducible. Lymph and other inflammatory products are poured out freely; the coats of the intestine become distended and thicker, and the inner and middle layers of the invagination are separated by the deposit; the invaginated part becomes more and more curved toward the mesenteric border of the outer layer; and occlusion of the bowel, begun by the invagination, is made more or less complete by the changes wrought by inflammation (Fig. 27). That intestinal obstruction is not always complete in intussusception is shown by the fact that fecal matter, often in considerable quantity, is passed through the bent and narrowed tube, the intestine retaining, at least for a time, its contractile power. The changes produced by inflammation are chiefly seen in the inner and middle layers of intestine, the receiving or outer layer of the invagination often escaping any serious damage. These changes vary with the character and duration of the inflammation. Sometimes they are limited to an agglutination of the opposed serous membranes, an effusion of blood and serum from the mucous surfaces, and an enormous distension and swelling of all the invaginated parts; or the inflammation may end in mortification of the middle or both the inner and middle cylinders, the dead part coming away in shreds or in large fragments, or, if the patient lives long enough, the entire invaginated tube being discharged through the anus. If the inflammation involves the invaginated parts unequally, strips and shreds of the bowel are detached by ulceration and sloughing, and may escape in the discharge from the bowels in pieces so small as to be unnoticed; but if the intussuscepted part dies en masse, a circular line of demarcation is formed by ulceration, and the dead segment is detached and drops into the cavity of the bowel below, and escapes through the rectum. It is often so complete that the inner and middle cylinders can be recognized, and the part of the intestinal tube to which the expelled bowel belonged can be determined. In favorable cases the blood-vessels of the healthy bowel above and below the dead segment pour out a circular mass of coagulable lymph, which, becoming organized, closes the breach and completes the intestinal tube. To accomplish this it is necessary that the ends of the two portions of bowel should be accurately coaptated: if they are not, some opening may be left through which the contents of the gut may escape into the peritoneal cavity, producing fatal peritonitis; or the new formation may be imperfectly organized, and burst during some peristaltic movement of the bowel or from the pressure of gas accumulating in the gut; or the supply of lymph may be so redundant as to obstruct the calibre of the bowel, or end in cicatricial contraction, stricture, and obstruction. Aitken5 records four instances where the curved end of the invaginated portion of bowel by prolonged pressure caused ulceration and perforation of the coats of the enclosing bowel, the invaginated portion passing through the side of the enclosing segment and projecting into the cavity of the peritoneum.
5 Science and Practice of Medicine.
Gangrene and ulceration, however, do not always follow intussusception. The mesenteric injuries may be sufficient to produce congestion and exudation, and the patient survive the invagination for weeks, and death eventually occur without sloughing or ulceration; or spontaneous reduction of the invagination may take place and recovery of the patient follow. The last termination must be rare, and impossible when firm adhesion between the serous surfaces has taken place; but that it does exceptionally occur is proved by cases where the diagnosis of intussusception was undoubted, the invagination being felt in the rectum or seen prolapsed through the anus. The most common termination, if the patient survives, is mortification of the invaginated part and separation in mass or by shreds or fragments.
Intussusception may occur in any portion of the intestinal canal, but some points are more liable to it than others. 56 per cent. of the cases collected by Brinton were ileo-cæcal; in 32 per cent. the small intestine alone was involved; 28 iliac and 4 jejunal; in 12 per cent. the colon, including its sigmoid flexure, was the part implicated.
When the rectum is involved, it usually forms the outer layer of the invagination, the middle and inner layers being formed by the bowel which has passed from above into it; when prolapse of the rectum itself occurs, the mucous membrane is generally alone involved, but along with this the muscular coat may also descend and a true invagination of the rectum be found.
The most common variety of intussusception is the ileo-cæcal. It is in this form that we find the greatest length of bowel involved. This invagination begins generally at the ileo-cæcal valve, the lips of which at first turn toward, and descend into, the cavity of the cæcum, drawing with them the end of the ileum; in this case the valve forms the lowest point of the invagination. If the invagination continues, the end of the cæcum is next inverted; and if the process still goes on, more and more of the colon is invaginated, until in some rare cases it traverses the whole of the large intestine, appearing just above or even protruding through the anus. In this variety the vermiform appendix lies between the middle and inner layers of the intussusception, and its opening, usually stretched and enlarged by the inverted cæcum and inflammatory effusion, is found close to the ileo-cæcal orifice. In this intussusception the cæcum and colon are large and roomy, and the invaginated portion not so liable, as it is when the small intestine is alone implicated, to strangulation and sloughing; nor is there seen in ileo-cæcal intussusception, unless the portion of bowel involved is very short, the marked curvature of the invaginated portion so commonly found in the small intestine. In the ileo-cæcal form it is twisted or much convoluted rather than bent.
Another variety of ileo-cæcal invagination—very rare, however—is where the ileo-cæcal orifice does not descend into the cavity of the cæcum, but the lower end of the ileum passes through the valve into the large intestine. In this instance the invaginated portion is tightly compressed by the valve, and strangulation is speedy and complete. An invagination may occur in the lower part of the ileum, and the inner and middle layers pass on to the ileo-cæcal valve, and be arrested at that point, and afterward, in consequence of violent peristaltic action, the whole intussusception, inner, middle, and outer layers, be invaginated into the colon. In this way the invagination becomes doubled.
While intussusception may occur in either sex and at all periods of life, it happens nearly twice as often in males as in females, and is most frequently seen in childhood. Leichtenstern6 found in his statistics of 473 cases that one-half were seen in children under ten years old, and one-fourth of all intussusceptions occurred in children from four to twelve months old. Invagination of the small intestine is found almost exclusively in adults. Brinton from his records gives the mean age of its occurrence 34.6 years. According to the same author, the average age of ileo-cæcal invaginations is 18.57 years, and one-half of all cases of this form of intussusception observed by him were in children under seven years of age. Leichtenstern states that the lower part of the ileum is the most frequent site of invagination in the small intestine, and the descending colon and sigmoid flexure the most common portion involved in intussusception occurring in the large intestine.
6 Op. cit.
The mechanism of intussusception is probably not always the same. The following is thought to be the most frequent process: A segment of bowel becomes paralyzed by local peritonitis, some injury, diarrhoea, or colic, and while in this state a segment of bowel above is subjected to violent peristaltic action, and is forced into the unresisting portion below. In this case the paretic segment forms the outer or receiving layer of the intussusception. Leichtenstern believes that the paretic portion is turned in and invaginated into the normal bowel below, and that the clinical course of intussusception and post-mortem appearance correspond with this explanation. If such is the case, the paralyzed portion forms the inner layer, and the active bowel below the receiving layer. Another theory, which applies with much force to the most common of all invaginations—viz. the ileo-cæcal—is, that as violent anal tenesmus produces prolapse of the rectum, so prolonged and powerful tenesmus at the ileo-cæcal opening may cause prolapse of the lips of this orifice, and, eventually, invagination of the ileum, or of both this and the cæcum, into the colon. When we remember that the ileo-cæcal valve is furnished with a sphincter muscle, the analogy is complete. The idea so long entertained that intestinal worms may occasion invagination of the bowel has generally been abandoned. A polypoid tumor, by dragging down the portion of bowel to which it is attached, may produce invagination; and Brinton's statistics give 5 per cent. of cases of intussusception from this source. An examination of a larger number of cases would probably show a much smaller percentage due to this cause.
A majority of cases of intussusception, however, take place suddenly, without previous diarrhoea, colic, traumatism, or ill-health of any kind, and probably occur without any tenesmus or paresis of a portion of bowel. It may be that the longitudinal fibres of a segment of gut contract, dilating and shortening a portion of the bowel; while this part is distended a portion immediately above may be lengthened and narrowed by contraction of the circular fibres, and violent peristalsis going on at this moment, aided, possibly, by contraction of the muscular wall of the abdomen, forces the upper and narrow segment into the lower and dilated one.
At first the invagination involves a small portion of the bowel, but, active peristaltic action continuing, it rapidly increases in size. This increase is made at the expense of the sheath or outer layer, which turns in to form the middle layer. The length of the invagination varies from two or three inches to three, four, or five feet.
The symptoms of intussusception generally come on suddenly, and indicate both intestinal obstruction and inflammation. Pain resembling violent colic, and referred to the site of the invagination, is a prominent symptom. The pain is intense, paroxysmal in character, but after a time it becomes continuous. At first pressure gives relief, but in a few hours tenderness, denoting peritonitis, appears, limited to the invagination or spreading gradually over the whole abdomen. Vomiting soon follows, and, with rare exceptions, is persistent. After two or three days occasionally blood and sometimes fecal matter are ejected from the stomach. Diarrhoea, with bloody, mucoid stools, is rarely ever absent, and is characteristic of invagination. The patient has from fifteen to twenty passages a day. If the large intestine is involved, the diarrhoea is accompanied with tenesmus. Above the obstruction gas and ingesta accumulate, and produce abdominal distension, sometimes well marked. Generally the tumor formed by the invagination can be felt through the abdominal wall, and is a symptom of great importance. Meteorism and peritonitis may render the existence of the tumor obscure or altogether prevent its recognition, but in intussusception of the colon and at the ileo-cæcal valve the solid cylindrical mass can usually be found, and frequently, when the small bowel alone is implicated, a very careful and patient examination will enable the observer to detect it. Sometimes it changes its site, size, and shape; occasionally it can be felt in the rectum or is seen protruding through the anus.
The urgency of the symptoms of invagination depends upon the portion of bowel involved and the degree of constriction of the gut and its attached mesentery. When the bowel is tightly constricted the symptoms are acute, and the patient may die in a day or two; when the bowel is not constricted the symptoms are chronic in character, and in the early stages not urgent. The difference here is like that between strangulated and incarcerated hernia.
In acute cases the attack is sudden, obstruction complete, and the symptoms those of internal strangulation of the bowel, often followed by collapse, which may destroy life in a few hours. These cases are chiefly jejunal and iliac invaginations, and the higher up in the small intestine the seat of obstruction the more violent and urgent the symptoms. Constriction, being great, is followed by engorgement and inflammation of the invaginated bowel, and if the patient lives long enough gangrene ensues, by which the obstructing mass is separated and discharged en masse or in fragments through the anus. Not unfrequently life is saved in this way. That gangrene has taken place and separation of the invaginated segments is in progress are often known by the very fetid character of the evacuations and by their admixture with blood and shreds of necrosed bowel. When the sequestrum has been detached entire, it is often passed with difficulty. Frequently it lodges at some point in the bowel, producing temporary obstruction and giving rise to tenesmus and pain as it passes along the large intestine. There is no doubt that the continuity of the intestine above and below the neck of the invagination has been established, and complete cures effected in the way already mentioned. Usually, however, the patient dies from collapse, peritonitis, or perforation of the bowel before the obstructing mass can be removed by gangrene. Children almost invariably die before this can take place, and adults live from the seventh to the fourteenth day, according to the greater or less violence and acuteness of the symptoms. When the slough has been discharged and the continuity of intestine established, recovery is still uncertain, and death very often happens for reasons referred to in speaking of the separation of the sequestrum.
Separation of the invaginated portion and its expulsion, according to Leichtenstern, in the majority of cases takes place from the eleventh to the twenty-first day, but in chronic cases it is often delayed for months. According to Brinton, separation of the sequestrum occurs between the eighth and fifteenth in intussuscepted small intestine, and between the fifteenth and twenty-second days in acute cases of ileo-cæcal and colic invaginations.
In chronic cases of intussusception, which usually embrace the ileo-cæcal and colic varieties, strangulation is not common and the course of the disease is protracted. These cases often last for several months, and the symptoms are not always well defined. At first the pain is paroxysmal, with long intervals of ease. Vomiting succeeds, but is not persistent; discharge of the contents of the bowel below the seat of lesion takes place and afterward fecal matter from above this point, because the permeability of the bowel is not usually lost in chronic cases. Eventually the alvine discharges become bloody, mucoid, and characteristic of intussusception; the severity of the symptoms may gradually increase, the pain becoming greater, more constant, the vomiting more incessant, the discharges from the bowels more frequent, and in one, two, or three months the patient dies from asthenia. Several authentic cases are related where the disease lasted one or two years before terminating fatally. Very often some days before death the pain and tenderness cease, and the operations become free from blood and normal in character.
Constipation.
Constipation is a prominent symptom in all of the conditions which give rise to intestinal obstruction, and habitual constipation or loss of the powers provided for the advance of the contents of the intestines not unfrequently leads to permanent occlusion of the canal. It is impossible to fix any definite rule as a standard of health for the number and quantity of alvine evacuations. Some individuals have a passage from the bowels once every day; others, in the enjoyment of as good general health, suffer from the ordinary inconveniences of constipation if they have less than two or three daily fecal discharges; others, again, apparently equally as well, have a movement from their bowels once in two or three days or once a week, or even once in two weeks. Habershon7 records the case of a "woman sixty years old who from youth upward had had a passage from the bowels only every six or eight days, and whose health had been perfect." A lady under my own observation, for twenty years never had an alvine discharge oftener than once in two weeks, and three times in her life had passed two months without a movement of her bowels. This lady was the mother of several children, and, although not in perfect health, was able to attend to her ordinary household duties. Such cases are not very uncommon, and occur, as far as I have been able to ascertain, more frequently in women than in men.
7 On Diseases of the Abdomen, quoted by Leichtenstern in Ziemssen's Cyc. P. of Med., vol. vii. p. 588.
The number of fecal evacuations and the quantity discharged have been shown by Bischoff and Voit to depend, to some extent, upon the character of the food ingested, vegetable diet producing abundant, and animal diet scanty, stools. Doubtless, the quality of the food partly explains the quantity of the alvine evacuation, although, to some extent, this must depend upon the time that the feces remain in the colon, a long residence there taking away a greater part of the watery constituents and making the fecal mass thicker and harder; but the variations in the number of stools in persons living on the same diet can only be explained by the variations in the activity of the peristaltic action in different individuals, or in the same individual at different periods and under different surroundings.
The causes of habitual constipation are of the most varied and diversified character, and it is not always possible in an individual case to point out the original or primary one. Not unfrequently several causes are in operation at the same time to produce sluggishness of the intestinal canal and constipation. Very often it begins with change of scene and habits, by which the daily visit to the water-closet is interfered with, or after confinement to bed with some temporary indisposition. It is more likely to occur in men and women whose habits are sedentary and who are constitutionally lazy and indolent. The feces are allowed to remain in the rectum and colon, and every hour after the ordinary time for going to stool diminishes the watery parts of the fecal mass and makes it harder and more consistent. Many cases of chronic constipation, begun in this way, have ended in dilatation and thickening of the intestine, ulceration of the mucous membrane, and, eventually, perforation of the coats and escape of the contents of the gut into the peritoneal cavity. Rapid excretion of water by the kidneys, lungs, and skin produces constipation by withdrawing a large proportion of the water from the fecal mass, rendering it unnaturally dry and of diminished bulk. In diabetes, constipation arises from this cause unless the patient makes up the loss by drinking an unusually large quantity of water. Constipation in nursing-women is explained by the loss of water in the secretion of milk. The profuse sweating which attends malarial fever, phthisis, and other diseases readily accounts for the constipation which often accompanies these disorders.
Certain articles of food not necessary to mention here produce constipation. They fail to excite peristaltic action; or articles of diet which at first act as a stimulus to the bowels, and even provoke temporary diarrhoea, lose their power if kept up too long—just as certain purgative medicines lose their force if continued for too long a period. Gradually they cease to increase the peristaltic action, and rather add than otherwise to the inactivity of the intestines. Eating the same kind of food day after day is very apt, sooner or later, to result in diminished sensibility of the intestinal canal, a reduction of the peristaltic force, and deficiency in the secretion of the digestive juices, which in itself is a common cause of constipation. Frequent change of diet is generally needed to supply the stimulus necessary for that intestinal motion which relieves the bowels.
Bile is looked upon as one of the most powerful agents in stimulating peristaltic action, and when, from any cause, mechanical or otherwise, it is not poured into the bowel, constipation ensues. Unnatural flexures, congenital or acquired, of the large intestine are not unfrequently the source of chronic constipation. These flexures, normal or factitious, favor accumulation of feces, especially in subjects who have diminished sensibility of the bowel and a paretic state of the muscular coat. Certain injuries and diseases of the brain and spinal cord reduce, and sometimes altogether prevent, intestinal activity. Hysteria, if it exist for any length of time, is generally attended by sluggishness of the bowels, and great mental depression (melancholia) is sometimes preceded and sometimes followed by habitual constipation. In treating such a case it is important to make the distinction.
Temporary paralysis of the muscular coat of the bowel, followed by symptoms of intestinal constriction, with insuperable constipation, sometimes attends violent contusion of the abdomen. In some cases prolonged functional weakness of the muscular coat follows the injury. Many chronic diseases leave the bowel in a sluggish condition by the pathological changes produced in the intestine. The function of the muscular coat is frequently injured by the infiltration which accompanies peritonitis. The fibres are separated by the serous effusion which attends this inflammation; they become overstretched, and, losing their contractility, end in paralysis and obstinate constipation. Occlusion of the canal from this cause may last for days, and be accompanied with tympanitis, stercoraceous vomiting, and all the signs of internal strangulation, ending in death. Post-mortem examinations in such cases show no stricture or unnatural diminution in the size of the canal, but that the fatal occlusion was due to paralysis of the muscular coat of the bowel and arrest of its power.
The normal advance of the contents of the bowel is interfered with by any cause which lessens the contractility of the muscular coat. Chronic diseases which debilitate the general muscular system affect at the same time the contractile power of the muscular coat of the canal, and the debility and degeneration of old age are felt here, and sometimes occasion the constipation which often accompanies this period of life. Leichtenstern8 says that chronic intestinal catarrh is a common factor of constipation—that when this catarrh is of long standing it produces relaxation of the muscular coat and diminishes the elasticity of the intestinal walls. He believes that this pathological condition exists in a large proportion of the cases of habitual constipation attended with mental depression, that the hypochondriasis makes its appearance after the constipation has become chronic, and that it is a secondary symptom. This affection is located chiefly in the small intestine, and does not usually involve the colon.
8 Op. cit.
Probably the most common form of chronic constipation is that which accompanies loss of sensibility and muscular inactivity of the colon and rectum. The large bowel becomes sometimes so distended by the accumulated fecal masses that it has been found after death to measure ten or fifteen inches in circumference and to contain an astonishing quantity of feces. Any part of the canal, except the last two inches of the rectum, which is kept empty by the contraction of the sphincters, may be occupied by the mass, but the accumulation is greatest in the rectum, cæcum, and sigmoid flexure. At the last-named location the distension is so great that the mass can be readily felt through the abdominal walls. The tumor may be as large as a foetal head, and may be mistaken for a simple or malignant tumor of the omentum, stomach, or other organ, or for pregnancy or ovarian growth. The dilatation may be so enormous as to push the small intestines into the back part of the abdominal cavity and to interfere with the function of any organ upon which it encroaches. It may press upon the concave surface of the liver, and, arresting the flow of bile, produce jaundice or mechanically interfere with some portion of the track of the urinary organs and cripple their functions. When situated in a portion of the canal not tightly attached to the abdominal walls it is slightly movable, more or less hard and consistent, according to its duration, for it remains often for months unchanged, sometimes giving to the fingers the impression of a rather soft, easily-indented swelling with a uniform smooth surface—more often feeling like a hard, irregular, elongated, and corrugated mass of fecal balls. Contraction here and there of bundles of the circular muscular fibres of the gut produces the irregular, corrugated impression imparted to the fingers. Their shape and position may sometimes be changed by pressure through the abdominal wall. If the accumulation occurs in the rectum, the introduction of a tube or bougie is prevented by the impacted mass, which can be gotten away only by the fingers or by some instrument. The colon and rectum may be dilated to their utmost capacity with an enormous amount of feces, enough to fill a common-sized pail, and both the patient and medical attendant be deceived as to the sufferer's condition by the fact that he has his daily number of stools. The semi-fluid contents of the small intestines find their way through this mass by some irregular and uncertain track, undermining and breaking down sometimes a lump of the old fecal accumulation, which, if small in size or broken up, may pass on and escape by the anus, but if large and hard may drop into the irregular and uncertain passage and permanently close it; then sudden and complete intestinal occlusion takes place, with all of its fearful consequences. If this, however, should not occur, and the accumulation is not recognized and removed, the enormous dilatation may go on until complete paralysis of the muscular coat is produced, and entire stoppage of the current of feces, with permanent occlusion of the bowel; or before this takes place ulceration may set in, partly because of the great pressure of the fecal mass upon the mucous membrane, and partly from the irritating character of the contents of the bowel. Ulceration begins, most likely, at some point where resistance is greatest, and perforation of the bowel may ensue.
SYMPTOMS.—If the accumulation occupies only a portion of the colon, as the cæcum or sigmoid flexure, the distended part may become displaced and twisted on its long axis. This condition scarcely ever happens in the large intestines except at the parts mentioned. Torsion of the cæcum rarely takes place except in persons of from forty-five to sixty years of age, while twisting of the sigmoid flexure may happen at any period of life. When distended and very heavy from the weight of feces, with probably some congenital defect about its mesenteric attachment, the sigmoid flexure may become twisted and drop into the pelvis, producing at once symptoms of internal strangulation.
Individuals accustomed to having one or more alvine evacuations a day are made uncomfortable by two or three days of constipation. A feeling of distension about the abdomen, with flatulence and heat, follows this condition, and soon afterward headache, loss of appetite, and symptoms of indigestion supervene. If this state of the bowels continues unrelieved, pressure upon the hemorrhoidal veins takes place and interference with venous return, producing congestion in the lower end of the rectum. This is attended by straining, diarrhoea, evolution of gaseous matter, colicky pains, and possibly sympathetic disturbance of the genito-urinary organs. When at last the hardened and enlarged mass is discharged, it produces some pain and burning about the anus, with possibly rupture of the mucous membrane in that region. Fissure of the anus may thus originate. In the case of a lad aged about nine years under my care fissure of the anus began in this way, and after its formation the pain of defecation was so intense that he resisted for ten days every attempt of his bowels to move. After this time he passed every day or two one or more hardened fecal balls, but always with such atrocious pain that he looked forward to the next attempt with terror. This case ended in fecal impaction, which nearly proved fatal.
Not unfrequently persons who habitually go two or three days without having a passage from the bowels are not apparently inconvenienced, and after a time any of the discomforts ordinarily felt from constipation are not noticed, if indeed any exist.
Generally, however, chronic constipation leads to a host of troubles of the most varied character. There is not an organ in the body that is not more or less influenced by it. The generation of gas in the intestines produces a sense of fulness of the abdomen and elevation of the diaphragm which interferes with the action of the lungs and heart. The sufferer is oppressed, sighs, and has difficult respiration and attacks of palpitation of the heart. The influence of the abdominal pressure is conducted by the sympathetic nerves to the brain, and the patient frequently has vertigo, headache, ringing in the ears, faintness, etc., and in consequence of the pressure upon other nerves or of hyperæmia of the spinal cord and its membranes he has dull aching pains in his back, groins, genitals, or extremities. I have seen in several instances pain in the legs, coming on after the patient has retired and lasting until morning, violent enough to prevent sleep, at once permanently relieved by an active cathartic after antiperiodics, alteratives, and anodynes had failed to do any good.
A patient suffering from habitual constipation usually obtains temporary relief by the bowels acting either spontaneously or after a dose of medicine; but, the causes of constipation continuing, the physical discomforts and suffering continue, varied in every conceivable way. His digestion being disturbed, appetite poor, and assimilation imperfect, he gradually loses flesh and his complexion becomes sallow and unhealthy. In addition to this, he soon grows irritable and fretful, trifling affairs trouble him, he has fits of great mental depression, and soon settles down into hypochondriasis, his life becoming a burden to himself and a nuisance to his friends.
If the constipation ends in fecal accumulation, the worst symptoms of mechanical obstruction may present themselves at any time, and death of the individual follow. The practitioner should always keep this fact in mind in treating every case of intestinal obstruction, and search for fecal impaction by examining the rectum and the whole length of the large intestine through the anterior abdominal wall. Very often symptoms of impaction come on gradually in one who has been ailing for some weeks or months, but sometimes the onset is as sudden as in a case of acute occlusion of the intestines. The patient is seized with pain like that of colic and an urgent desire to empty his bowels, but all attempts to do this are futile, and the straining is followed by great exhaustion; borborygmus, nausea, vomiting, and possibly hiccough, soon come on, with tympanitic distension of the belly. If the impaction is not overcome, death by collapse or from peritonitis follows. Post-mortem examination shows enormous fecal accumulation, peritonitis as a consequence of the obstruction, perforating ulcer in some part of the large bowel, more often the sigmoid flexure, or, in some cases, absolute rupture of the cæcum itself, and escape of its contents into the peritoneal cavity.
Stricture of the Bowel.
In a report by George Pollock9 of 127 cases of intestinal obstruction, 77 belonged to the above class; and Brinton, in his analysis of the whole group of cases collected by him, says stricture constitutes about 73 per cent. In 124 cases of intestinal obstruction reported by Mr. Bryant10 from the post-mortem records of Guy's Hospital, 47 were found to be stricture of the bowel. The above statements show that stricture, or diminution of the calibre of the bowel, is the most frequent cause of intestinal obstruction, and the subject is worthy of our earnest consideration.
9 Medico-Chirurgical Review, 1853.
10 Practice of Surgery.
While stricture of the bowel may be found in any portion of the intestinal canal, it occurs most frequently in the sigmoid flexure and rectum. Brinton found in 100 fatal cases of stricture 30 in the rectum and 30 in the sigmoid flexure; only 8 cases in 100 were in the small intestine. Brinton's statistics correspond very nearly with those of other writers. The affection is more common in men than women, and the average age at death is about forty-four years.
The most common cause of stricture is contraction following cicatrization of ulcers of the mucous and submucous coats of the intestine. The ulcer may involve the circumference of the bowel, and the resulting cicatrix terminate in uniform constriction of its lumen, or the ulceration may extend several inches along the side of the intestine, ultimately causing contraction in the direction of its longitudinal axis, marked stenosis, and kinking of the gut. When ulceration, continuous or in patches, involves a large extent of bowel, it may reduce the gut to a mass of indistinguishable cicatricial tissue. Bristowe11 says he has seen the whole cæcum thus contracted "into a channel barely capable of admitting a goose's quill."
11 Reynolds's System of Medicine.
Stricture of the intestine often follows dysentery or tubercular and syphilitic ulceration of the bowel. Follicular or hemorrhoidal ulceration is sometimes the beginning of a stenosis which ends in stricture of the rectum. Stercoral ulcers of the colon are not unfrequently the starting-point of cicatricial contraction of the calibre of the bowel. Sometimes, but rarely, ulcers of typhoid fever end in constriction of the intestinal tube. The diameter of the gut is also contracted by the effects of caustic substances, by ulceration following the lodgment of foreign bodies, and by effusion of lymph or thickening attendant upon long-standing hernia. Very often after death it is impossible to determine what particular kind of inflammation and ulceration caused the stricture. Generally, the cause which provokes the ulceration sets up chronic peritonitis, which materially aids in producing the obstruction. Spasm of the circular muscular fibres usually accompanies these lesions, and materially contributes in many cases to fatal intestinal obstruction. Some authors assert that spasm without organic change can produce acute obstruction: such an occurrence, except possibly in the rectum, must be very rare, if indeed it ever happens.
The most common cause of stricture is cancer. This disease may originate in the bowel itself, or, beginning in some neighboring organ or tissue, gradually spreads and involves the gut. It may extend around the bowel or be infiltrated along the sides of the canal for several inches, and may be scirrhous, medullary, or epithelial in character. Eighty per cent. of the cases of cancer of the bowel are situated in the rectum. Usually, but not invariably, cancerous deposits are found in persons who have passed middle age.
An impediment to the passage of fecal matter is invariably produced in constriction of the intestine from the above causes, and it frequently continues until fatal occlusion occurs. The contents of the bowel accumulate above the block, producing distension of the gut and thickening of the muscular coats above the stricture, with contraction and atrophy of the portion of intestine below. Dilatation of the bowel above the seat of lesion is sometimes great enough to cause rupture and peritoneal extravasation, or distension and stretching of the coats of the canal may be sufficient to interfere with its circulation, and ulceration ensue.
Occasionally cases of stricture or well-marked circumscribed contraction of the bowel are seen which give rise to no marked symptoms of constriction during life. Such was the case in the instance related by Bristowe and referred to above. These instances are, however, exceptional in the large intestine.
Symptoms of stricture vary according to the site, cause, and extent of the lesion. They are gradually developed, and in this respect are unlike the symptoms of internal strangulation or of intussusception, which are generally acute and rapid in their course. When the obstruction in stricture is complete, progress toward death is comparatively slow. If the stricture is seated in the small intestine, the symptoms are often so obscure that for a long time the presence of the contraction may not be suspected; the contents of the small bowel are usually fluid, and in this state readily pass through the constricted part. The more solid the contents of the bowel, the greater the difficulty in passing a contracted and narrow orifice, and the more conclusive and characteristic the assemblage of symptoms of obstruction from stricture.
The history of a case of intestinal obstruction from stricture is often instructive. For weeks or months there have been colicky pains and intestinal disorder; possibly, in the early stages, diarrhoea, but later marked constipation, and probably previous attacks where constipation was for a time insuperable and death from obstruction imminent. Hemorrhage, except in cancer or when complicated with piles, is rare. The attack may come on suddenly, or constipation become more and more difficult to overcome; violent peristalsis presents itself, accompanied by pain and abdominal distension, and followed by nausea and vomiting, the latter often being stercoraceous. During the throes of pain—for it is paroxysmal—the outline of the distended gut can be felt and seen through the abdominal walls if they are thin and free from fat. Unless the stricture is relieved the patient gradually dies from asthenia. Inflammation is often absent throughout, but enteritis or peritonitis may come on, or perforation and peritoneal extravasation ensue and hasten the fatal termination.
When the obstruction is in the rectum it can be felt with the finger; if in the sigmoid flexure, it may be felt with a gum bougie or probe, but the use of the former is unreliable, and the latter, unless carefully employed, dangerous. Obstruction at this point, however, is attended with marked distension of the descending and transverse colon. If seated in the small bowel, the large intestine is flaccid and collapsed. Careful manual exploration often enables the practitioner to determine the site of the contraction. Weight, pain, dulness, and fulness are usually found about the stricture, but these signs may be of little value when the abdominal wall is thick and unyielding, or peritonitis or tumor is present, or the contracted portion of bowel is compressed or drawn out of its proper site. Brinton suggests that the site of stricture may be determined by the quantity of water which can be injected through the anus into the bowel. Such an estimation must often be erroneous, as stricture is rarely ever complete and fluid may be forced through the constricted part. Indeed, Battey of Georgia has demonstrated upon dead and living subjects that fluid may be made to pass through the entire canal from the anus to the stomach.
Obstruction due to cancer of the rectum can be determined by digital examination. When seated in the small intestine or higher up in the large bowel, the presence of a painful tumor, preceded for weeks by evidences of impaired nutrition, emaciation, and followed by lancinating pain, cancerous cachexia, etc., will indicate the character of the trouble.
Compression and Contraction of the Bowel.
Obstruction of the bowel is sometimes occasioned by compression or traction exerted on the intestine by abdominal tumors or cysts. Fibrous tumors of the uterus, ovarian cysts, hydatid growths, or indeed any form of abdominal tumor, may by pressure on some part of the intestinal track produce fatal obstruction. Several inches of bowel may thus be compressed and rendered impervious, or if traction is exerted by the tumor, which is often adherent to the bowel, the tube may be sharply bent or twisted and its action interfered with. A case is reported of compression of the bowel from a great accumulation of fat about the colon. Adhesions of intestinal coils from chronic peritoneal inflammatory changes constitute a large and important class of cases of intestinal obstruction. This condition is known as contraction of the bowels: 23 of the 124 cases reported by Bryant were of this character.
The usual site of stricture is the large bowel: contraction is far more frequently seen in the small intestine, and is caused by an effusion of lymph following simple peritonitis or the inflammation attending the formation of cancer or tubercle of the peritoneum. Coils of intestine are matted together or to neighboring parts in this way by bands of lymph or false membranes, and the action of the bowel interfered with or obstructed. Constriction of a length of bowel may be found after death, or a sharp, angular bend by which complete obstruction has been produced.
Circumscribed peritonitis may produce adhesion of a portion of bowel by bands of lymph to the uterus or its appendages, or to some part of the large intestine, or to the abdominal wall, and the action of the bowel become embarrassed by traction, constriction, or bending. In consequence of the irritation following this condition, spasmodic contraction may follow and add to the difficulty, or enteritis may ensue; and this will especially be the case if the circulation of the part is interfered with, and render complete what before was a partial obstruction. Distension and fulness of the bowel above the obstruction, with contraction and emptiness of the portion of the gut below, are found after death in cases of contraction, just as we see in fatal cases of stricture. The history of the case and presence of a tumor will generally enable the practitioner to determine when obstruction is due to the presence of some adventitious growth. When contraction is complicated with the presence of tubercle or cancer, symptoms attending these conditions will be present.
Obstruction of the intestines from contraction generally comes on insidiously. The patient may date the beginning of his trouble from an old attack of circumscribed peritonitis which probably took place weeks or months before. He has attacks of colicky pains, indigestion, and constipation. The last is difficult to overcome, continuing for hours before it is relieved by medicine or the efforts of nature. During the attack of almost insurmountable constipation violent peristaltic movement of the bowel above the impediment may be noticed. The patient may gradually become more and more feeble from suffering and interference with nutrition, and die from exhaustion, or fits of obstinate constipation may continue to recur, until finally one of them becomes insuperable and fatal.
The symptoms of contraction closely resemble those of stricture, but it is important to distinguish one from the other, as the treatment, especially if surgical interference is demanded, is very different. A rigid analysis of all of the signs will usually, but not invariably, enable the practitioner to make the distinction.
There is an important difference between the constipation of stricture and that of contraction. In the former the difficulty is in defecation, emptying the large bowel, the usual site of stricture; in the latter the difficulty is in the passage of the contents of the gut along the narrowed and contracted small intestine, the common site of contraction. In stricture the calibre of the bowel is diminished by some sharply-defined mechanical impediment seated in the cavity or in the walls of the tube; in contraction the bowel is bent or kinked by adhesions, or coils of intestine are matted and glued together and peristalsis interfered with. In stricture defecation is difficult and painful; in contraction the alvine discharges are painless. In the former blood and mucus are not unfrequently seen in the feces; in the latter the motions are healthy. In stricture constipation alternates with diarrhoea; in contraction looseness of the bowels is rarely seen. In stricture distension of the abdomen is lumbar and epigastric; in contraction the distension is less and is central and hypogastric. In both conditions violent distinct peristaltic action is seen during a fit of constipation, and in both the bowel above the constriction is distended and hypertrophied. In contraction the powerful, writhing peristalsis involves the small intestine above the impediment, and in stricture the large bowel above the obstruction. In both stricture and contraction inflammation of the bowel and peritoneum may supervene. In contraction, when inflammation sets in or when enteritis and peritonitis are absent and the attack of constipation is insurmountable, I have noticed that the symptoms are more urgent and rapid in their course, and danger of death from collapse greater, than when these conditions exist in stricture.
DIFFERENTIAL DIAGNOSIS.—In every case of intestinal obstruction a careful examination should be made for external strangulated hernia. All of the regions of the abdomen in which hernia may occur should be thoroughly inspected, as the symptoms of the two conditions are identical. A small or incomplete external strangulated hernia may easily be overlooked. An individual with an old hernia may suddenly have symptoms of intestinal obstruction, and it may be doubtful whether the obstruction is due to internal constriction or to the external hernia. Diagnosis is especially difficult when the chronic hernia is irreducible in character. If the cause of the impermeability is internal and below the external hernia, that portion of intestine in the hernial tumor becomes swollen, tense, and hard, and closely resembles the local symptoms of strangulated hernia. If the external hernia is reducible, reduction en masse may take place and a retro-peritoneal hernia be formed. When the case is doubtful and urgent, an operation for strangulated hernia should be performed.
Functional obstruction of the bowel is sometimes seen, closely simulating obstruction from one of the structural changes mentioned. Cases of functional obstruction are seen usually in hysterical or nervous women, and are generally recognized by the history, course, and termination of the malady. The fact that local enteritis, peritonitis, or typhlitis, by paralyzing a portion of the bowel, may produce all the signs of acute and complete obstruction, should not be lost sight of.
In cases of congenital stricture or malformation, or the presence of foreign bodies in the intestine, or acute internal strangulation, or twisting of a length of bowel, and generally in intussusception, symptoms of acute obstruction are present. The individual may have been in perfect health, and suddenly symptoms of the gravest character set in. Intense pain, referred to some special part of the belly, is the first sign of trouble. Nausea soon follows, and with it great prostration; the depression of vital power approaches, and sometimes reaches, syncope; the patient rolls and tosses in agony; his mental distress is equally great, and if old enough he is conscious of his danger and is anxious and despondent. Vomiting succeeds the nausea: at first the contents of the stomach, and then those of the small intestines, are thrown up; after a time the vomiting is stercoraceous. The belly becomes swollen, tympanitic, and exquisitely tender; the weight of the bed-clothes or the slightest touch of the finger upon his abdomen is intolerable; he keeps his head and shoulders raised and his lower limbs retracted to avoid pressure of the abdominal muscles. Constipation is complete and insuperable. If the abdominal wall is thin, the violent motion of the intestines can be seen and felt through it. These painful peristaltic movements of the bowel are paroxysmal and attended by loud rumbling or gurgling noises. The pain gradually increases; the patient is very restless and complains of great thirst; his pulse is small, hard, and frequent, his extremities cool and features pinched. If not soon relieved, exhaustion comes on; he has muttering delirium, cold clammy perspiration, hiccough, twitching of the tendons, and death soon follows from collapse or from peritonitis or gangrene, or from both. The average period of death is from six to eight days. It may occur in thirty-six or forty-eight hours, or the patient may last for two weeks.
In congenital occlusion and malformation the history of the case, the age of the patient, and the fact that the deformity in such cases is almost always confined to the anus and rectum, usually render the diagnosis sufficiently easy.
Obstruction caused by foreign bodies impacted in the intestines can generally be diagnosed. The history of the case may show that foreign bodies have been swallowed or that the patient has been subjected to some of the conditions which cause the formation of enteroliths. These stony concretions are usually found in the cæcum or colon, and frequently give rise for days and weeks to symptoms of indigestion, emaciation, constipation, and other evidences of bad health before complete occlusion of the intestine takes place. Not unfrequently, before the sudden attack of impermeability of the bowel the patient has had repeated attacks of typhlitis, and has been conscious for a long time of the presence of a tumor in the region of the cæcum or colon. Possibly he has passed on some former occasion pieces of the stony concretion.
Diagnosis of obstruction by gall-stones is often aided by the fact that the patient has recently suffered characteristic pains of hepatic colic and by the icterous condition of the skin. Possibly the individual has suffered repeated attacks of hepatic trouble and has previously passed a gall-stone. Obstruction from this cause is seen four times as often in women as in men, and always after the middle period of life.
In obstruction occasioned by internal hernia or the presence of membranous bands, loops, mesenteric pouches, the symptoms are often such as to baffle all attempts at accurate and certain diagnosis. The onset of the symptoms is sudden and the course of the disease rapid; prostration of vital power is extreme, sometimes amounting to syncope; vomiting incessant and persistent; pain constant and fixed. The most characteristic symptom of internal strangulation is the very great and prolonged depression of vital power; it occurs generally in early adult life.
Erichsen states that in twisting of the bowel the abdomen is unevenly distended, it being tympanitic on one side and flattened on the other. This condition of the bowel is usually seen after middle age. In intussusception the principal signs are, usually, the early age of the patient—obstruction from other causes in children being rare—the suddenness of the onset of symptoms, the frequent desire to go to stool, the tenesmus, and the characteristic bloody mucus discharges. By abdominal palpation frequently the sausage-like tumor can be recognized, and very often the intussuscepted part can be felt in the rectum or seen protruding through the anus. When invagination involves the upper part of the small intestine, diagnosis of the cause of occlusion is almost impracticable.
In obstruction of the bowel from fecal accumulation, inflamed and thickened intestine, stricture, compression and traction, and contraction of the gut from cancerous deposit, the symptoms are gradually presented and chronic in character. They are unlike the signs of acute obstruction, which occur in persons apparently in perfect health and are sudden and violent from the beginning. In chronic obstruction of the intestine the patient has probably been complaining for some time, with symptoms of abdominal trouble. He has been unwell for weeks, his appetite poor, digestion disordered, strength diminished, and bowels constipated. The last symptom is the most distressing of all. Purgatives do not give the relief ordinarily obtained, but add to the griping, colicky pains, nausea, and general depression. When his bowels do act, the stool is sometimes liquid, sometimes very hard (scybalous), or the form of the matter passed is tape-like or pipe-like. Sometimes, in his frequent attempts at stool, the only discharge is blood and mucus or pus. Attacks of eructation and vomiting often take place during the progress of the disease. Stercoraceous vomiting is, however, rare, and only seen in the later period of the attack. Abdominal distension is slow in making its appearance, but after a time is well marked, and due more to tympanitis than to constipation; the tympanitic distension is accompanied by loud rumbling and gurgling noises in the bowels. After a period which varies much in different cases, inflammation, suddenly or gradually, is set up, and all the symptoms of acute obstruction are presented, grafted on signs of chronic occlusion. We have pain, nausea, vomiting, great distension and tenderness of the abdomen, peristalsis plainly seen and felt if the abdominal wall is thin, the small, frequent, wiry pulse, clammy perspiration, prostration with hiccough, tendinous twitchings, and death, very like that following a case of external strangulated hernia.
Obstruction due to fecal accumulation generally happens in persons who have passed middle age, and can often be diagnosed by digital rectal examination and palpation of the abdomen, by the presence of fecal tumors, and the history of long-existing constipation with its manifold consequences; previous attacks of impermeability, and relief by discharge of enormous masses of feces.
Obstruction caused by the presence of some abdominal tumor is generally known by the history of the case, the fact of the existence of the tumor being known to the patient or discovered by the physician by an examination through the abdominal walls or through the vagina or rectum. The progress of such cases is essentially chronic, but acute symptoms may at any time come on. Diagnosis of obstruction due to stricture is frequently made by examination of the rectum and sigmoid flexure, the usual sites of constriction from this cause. Complete occlusion from stricture is almost always preceded by well-marked premonitory symptoms.
When the obstruction is situated in the lower part of the colon and rectum, its precise seat can be determined by digital or manual examination or the use of a bougie or tube. When the site of obstruction is above the sigmoid flexure, it is difficult, and occasionally impossible, to determine its exact locality. As a rule, when the constriction is in the small intestine the symptoms are acute and urgent; pain is intense, vomiting comes on soon, and prostration is early and extreme. When the large intestine is involved, except in volvulus, the symptoms are generally chronic. In twisting of the gut the symptoms are rapid and uncommonly severe. The higher up the obstruction, the earlier stercoraceous vomiting begins. Above the constriction the bowel is distended and tympanitic; below the constriction it is generally collapsed. In obstruction of the large intestine the outline of the tympanitic and distended gut may be traced with the eye and hand. In constriction of the small intestine the secretion of urine, as has been shown by Hilton, G. Bird, and Barlow, is less than where obstruction is seated in the large bowel. Besides rectal and vaginal examinations, which should never be neglected in any case of intestinal obstruction, abdominal palpation may also aid in determining the site of constriction. It should not be forgotten, however, when a tumor is found—as, for instance, in invagination—that the bowel may be displaced; a distended cæcum may be pushed into and occupy the left side of the belly. Cases are not uncommon where the symptoms are so combined and uncertain as to render accurate diagnosis of the site of obstruction impracticable.
Very little light is thrown upon the diagnosis by pain, constipation, or vomiting when these symptoms are considered separately. Pain is common to many diseases of the abdomen; obstinate constipation, lasting for days and weeks, is often seen where there is no mechanical obstruction; and vomiting attends many morbid conditions of the body. But when these symptoms are combined and examined along with the history of the case and mode of invasion, they are often characteristic of constriction of the intestine. Pain in acute obstruction is fixed, umbilical, and intermittent; in chronic cases it is more diffused and increases with the distension. In acute cases constipation is complete and insuperable; in chronic cases this symptom gradually increases; in intussusception we have frequent discharges of a dysenteric character, and hemorrhage, sometimes copious, when the small bowel is involved. The bowel below the seat of complete constriction may be full of fecal matter, and the discharge of this spontaneously or by the aid of enemata may induce the attendant not to regard the case as one of occlusion. Stercoraceous vomiting, as a rule, comes on early in acute and late in chronic cases of complete occlusion of the gut; in spasmodic ileus or impermeability not due to mechanical occlusion feculent vomiting is only occasionally seen.
The duration of life in acute intestinal obstruction varies very much in different cases: death may ensue in a few hours or not for ten or twelve days; the average period is six days. The duration depends upon the site of the constriction and the mechanical injury to the bowel; the nearer to the pylorus the constriction, the more rapid the progress. In volvulus involving the sigmoid flexure, when injury to the bowel is great, the symptoms are acute in the extreme. After peritonitis or enteritis begins, progress toward a fatal issue is very rapid, the patient rarely living more than three or four days. In occlusion from stricture, compression, fecal impaction, and chronic intussusception the patient may live for weeks or even months.
The statistics of Leichtenstern show that from 5 to 10 fatal cases of intestinal obstruction occur every year among every 100,000 inhabitants; and according to the mortuary records of England an average of 1 death from this cause is seen in every 260 deaths. Brinton reports 1 death from intestinal obstruction in every 280 deaths; his statement is based upon 12,000 promiscuous autopsies. The first author states that the statistical reports of the general hospital of Vienna inform us that out of 60 cases of ileus, 6 or 10 per cent. recovered. This report, however, is too meagre to be of much value. From Brinton's statistics of 500 deaths from obstruction we find that out of 100 cases, 43 are intussusception, 17 stricture, 4.8 impaction of gall-stones, 27.2 internal strangulation, and 8 torsion.
TREATMENT.—There are few conditions of the body which cause the practitioner more anxiety and embarrassment than cases of intestinal obstruction, and when the precise seat and nature of the occlusion are not known the treatment is almost entirely empirical. The distinction, however, between acute and chronic cases of obstruction of the bowels, or of acute supervening upon chronic symptoms, can almost always be made, and a patient investigation of the history of the case, the mode of invasion, and a rigid analysis of all the symptoms presented will generally enable the attendant to come to some positive conclusion as to the cause and site of the occlusion. One fact in the treatment which cannot be too strongly impressed upon the mind, especially of the young practitioner, is not to use purgatives and irritating enemata, formerly so much in vogue, in the hope of forcing a passage through the occluded bowel. The patient is urgently solicitous for medicine which will open his bowels, but the use of purgatives to overcome internal strangulation is as senseless and hurtful as when used to overcome the constipation of external strangulated hernia. These agents only add to the nausea, vomiting, pain, and peristalsis. The latter is violent enough already to render coils of intestine visible, and with every paroxysm is adding to the entanglement and impermeability. It is said that cathartics in some instances have unlocked the bowel in intestinal obstruction: these cases are exceptional, and many of them were probably functional and not structural in character. The only exception to the rule of avoiding purgatives is as stated by Jonathan Hutchinson: "In certain cases when impaction of feces is suspected, and in cases of stricture when fluidity of feces is desirable."
Formerly, some of the best practitioners resorted to the exhibition of one or two pounds of quicksilver, in the hope of overcoming intestinal obstruction by the weight of the metal. This plan has properly been almost if not quite abandoned. Crude mercury is very slow to reach the obstruction, is divided into small portions by the peristalsis, which its presence increases, and if it should finally arrive at the point of constriction in any considerable quantity, it is more liable to add to than overcome the difficulty.
The great remedy in intestinal constriction is opium, in large or small and repeated doses. Its use arrests the vomiting, stops the pain, and quiets the violent movements of the bowel. Very often by it the intestine is preserved and the life of the individual saved. No special dose can be prescribed: it should be administered until slight narcosis is obtained and pain and vomiting cease. Small doses of morphine, given hypodermically and quickly repeated, is the best plan of exhibiting it. It may be given by the stomach, but under such circumstances it is apt to be rejected, or if retained absorption goes on slowly, or possibly not at all. If for any reason its hypodermic use is impracticable, it had better be given by the rectum. Opium lessens the danger of death from collapse: it gives nature an opportunity to untwist the gut in volvulus, or to unroll it in intussusception, or to cut off the invaginated part by gangrene; and in internal hernia, morbid adhesions, strangulation by bands of lymph, stricture, and other forms of obstruction, it diminishes violent peristaltic action, postpones inflammatory infiltration, fixation of the strangulated portion, and keeps the parts in better condition for operative interference, which in many cases offers the only hope of relief. To carry it farther than slight narcosis and arrest of the most painful symptoms of obstruction is an abuse of the remedy. By such abuse the symptoms will be masked and both patient and practitioner deceived.
When obstruction is due to fecal impaction or spasm, the opium treatment is still often indicated. Not unfrequently, after pain and vomiting are relieved and slight narcosis kept up for some hours, the bowels relax and spontaneous evacuation takes place. If not, discharge of the contents of the bowel should be assisted by the administration of castor oil, calomel, or repeated enemata of warm water. These agents should not be used, however, as long as there is pain, tenderness of the belly, or any evidence of peritonitis, but the opium treatment continued until all signs of inflammation have disappeared. It has been proposed to give belladonna in place of opium; in small doses and carefully watched it may be added to the opium, but should not be substituted for it.
The local application of ice-water or pounded ice to the abdomen has been recommended; and it is asserted that the danger of general peritonitis is lessened, and that the strangulation itself has disappeared, under the influence of cold. If, however, cold increases pain and peristalsis, it should be abandoned. The local application of moist heat or fomentations will more probably do good and give a grateful sense of relief to the sufferer. General bleeding should never be resorted to, and the use of leeches, except to ward off or subdue some local inflammation, is of doubtful expediency. Blisters, ointments, and cups are useless in such an emergency. Cracked ice, strong coffee, and carbonated water in small quantities are valuable in allaying thirst and nausea.
Cases are reported where obstruction of the bowels has been overcome by the use of electricity; both the continuous and induced currents, but chiefly the former, have been used; its value in such cases is improbable.
Abdominal taxis or massage has been earnestly recommended and frequently practised in cases of constriction. Successful results from this procedure have been reported. It has been attempted while the patient was in a warm bath or under chloroform or while taking large enemata of warm water. Abdominal traction by the use of large cups to the belly has also been advised. We can only hope for success from these measures in the early stages of obstruction, before inflammatory action or fixation of the strangulation has taken place, and any attempt of this kind should be made with tact and gentleness. Inversion of the body has also been suggested.
The injection of large quantities of warm water into the bowels to overcome obstruction should never be omitted before resorting to operative interference. The author has seen this plan in five or six instances succeed after all other means had failed. Simple warm water should be used, introduced by means of the common Davidson or a fountain syringe. The injection should be made slowly, with occasional intervals of rest, to allow the fluid time to pass through the intestinal coils. During the operation the patient should be in the knee-elbow or Sims's left lateral position, and under the influence of an anæsthetic. One or two gallons of water may be used. In place of water, the bowel may be inflated with air, introduced by a pair of common bellows to the nozzle of which a piece of India-rubber tubing is attached. The addition of castor oil, turpentine, carbonic acid gas, and other irritants will more likely detract from than add to the efficacy of these measures. In chronic intussusception, or in acute cases when fixation of invagination is believed to have taken place, and especially when inflammation is great, gangrene threatening or in existence, injections of air or water should not, of course, be attempted.
In invagination, when the intussuscepted part is low down in the rectum or protruding from the anus, replacement by fingers or sound should be tried; reduction begun in this way may be completed by injections of air or water. The propriety of introducing the whole hand into the rectum is very questionable. In occlusion of the gut by compression and traction the cause should be found, and, if possible, removed. An abdominal or pelvic tumor may be pushed out of the way of the compressed bowel, a cyst punctured, a displaced womb replaced.
Great care should be taken to support the strength of the patient by concentrated and nutritious food, and in the later stages by stimulants. When the bowels are distended by gas an injection into the rectum of ten grains of sulphate of quinia will often give marked relief.
It has been proposed to tap the distended gut with a fine trocar when accumulation of gas is enormous, causing dyspnoea and great general distress; temporary relief is often obtained by this plan, which is an imitation of a common practice among veterinary surgeons. Something more than temporary relief may, however, follow the tapping. In twisting of the bowel, in internal strangulation by band or loop or ring, and in some cases of invagination, the constriction is kept up by the enormous gaseous distension. The obstruction is continued as much by causes within as without the intestine. When tapped and the gas drawn off, the bowel collapses, and may escape from its constriction and return to its natural condition. Tapping is not always certain or safe. The trocar or aspirating tube may pass between the convolutions and no escape of gas take place, or it may be followed by fecal extravasation into the peritoneal cavity. Notwithstanding the risk, the plan is a valuable one, and in suitable cases should be resorted to.
SURGICAL TREATMENT.—In cases of acute obstruction of the bowel from bands of lymph, diverticula, internal hernia, slipping of a portion of gut into some opening, or twisting, when the treatment suggested has been tried and fails, laparotomy should be performed; that is, the abdomen should be laid open, the cause of the obstruction searched for, and, if possible, removed. In acute cases a few hours, at most one day, may be spent in trying the medical means recommended. After that time, if the patient is not relieved, the sooner laparotomy is resorted to the better the chance to save life. Acute internal strangulation of the bowel from these causes has the same symptoms, course, and termination that acute external strangulated hernia has. It demands the same treatment—removal of the cause of the constriction. Delay in performing the operation in the former is as certain to be followed by peritonitis, gangrene, and death as it is in the latter; and the surgeon who hesitates to open the abdomen and attempt to remove the constriction in a case of acute obstruction after a fair trial and failure of medical measures, is as culpable as the one who delays the operation of herniotomy for unrelieved strangulated hernia.
In rare instances spontaneous self-reduction of external strangulated hernia takes place; the cases are exceptional, and the fact is no apology for postponing herniotomy. So in occasional instances acute internal strangulation is spontaneously relieved; here too the cases are exceptional, and the occurrence should be no excuse for delay in laparotomy. To justify the operation it is not necessary that the precise site and nature of the mechanical impediment should be determined, although this can usually be done. It is only necessary to know that the cause of the acute obstruction is not enteritis or peritonitis, but a constriction mechanical in character, which no medicine or manipulation or expectant treatment can relieve. When diagnosis is clear and laparotomy is indicated to save or prolong life in intestinal obstruction, the aid of the surgeon should at once be invoked. Delay is fatal. Peritonitis beginning or in actual existence makes abdominal section more dangerous and lessens materially the chances of recovery. To make the operation absolutely the last resort when the bowel is injured beyond repair, when peritonitis is in full progress, gangrene threatening, or the patient on the verge of collapse, is a useless cruelty to the sufferer and his friends, and only serves to bring surgery into disrepute. If the truth were known, many of the cases of death following laparotomy should be ascribed not to the fact that the knife was used, but to the fact that it was used too late.
In intussusception not relieved by medical means the propriety of abdominal section is questionable. The subjects of this condition are usually children. Dislodging the invaginated bowel is not always practicable, and the opium or expectant treatment may end in spontaneous cure by the bowel righting itself or by sloughing of the intussuscepted part. It is doubtless true that many of the so-called cures from the latter process subsequently die from contraction of the cicatrix at the site of the separation of the slough. In 43 cases collected by Ashhurst of laparotomy for invagination, 13 recovered and 30 died. The record is bad, and to some extent the heavy mortality is due to the fact that the operation was put off too long—delayed in acute cases until sloughing had taken place, and in chronic cases until adhesion of the invaginated parts had occurred. Indeed, some of the cases reported were moribund when the operation was undertaken. Recently many successful cases have been reported, and it is fair to presume that the percentage of recoveries in the future will be greater than they have been in the past.
In acute intestinal obstruction due to bands, internal hernia, volvulus, or the presence of foreign bodies, as gall-stones, there is no question that laparotomy should be performed after other measures for relief have been employed and failed. Death in such cases is inevitable and imminent, and operative interference should not be postponed until peritonitis has set in. After the abdominal cavity has been opened the distended gut can easily be found and the fingers of the operator carried on down until the site of the constriction is reached and the cause of the obstruction discovered. If the constriction is due to the presence of bands or adhesions, they should be cut or broken up and the gut relieved. If an internal hernia is found or a portion of bowel has slipped into some fissure or pocket, it should be withdrawn and the parts restored to their natural position. If the cause of the obstruction is a volvulus, the bowel should be untwisted. If a foreign body is felt impacted in the bowel and closing it, unless it can be readily and without danger of lacerating the coats of the gut pushed on by the fingers of the operator until it has passed the ileo-cæcal valve, the foreign body should be removed from the bowel by an incision and the wound in the bowel afterward closed by sutures. If the case is one of intussusception, the invaginated parts should be pulled out: this is practicable where adhesions are absent or slight, but if the adhesions are very firm, and it is impossible to restore the parts to their natural position, the gut should be laid open above the occlusion, the edges of the opening should be attached to the margin of the external wound, and a fecal fistula established. If the case of acute obstruction be due to stricture of the small intestine, which is exceedingly rare, the gut may be laid open, and the patient recover with fecal fistula, or entorectomy or resection of the diseased part of the gut be resorted to. The operation of entorectomy has been recommended by many surgeons, and a large proportion of the cases reported recovered. In one case by Koeberle six and a half feet of the gut were successfully excised.
The following table by Ashhurst12 shows the results of laparotomy. It will be seen that in 230 cases 68 recovered:
| Operations for— | Cases. | Result not ascertained. | Recovered. | Died. |
| Volvulus | 14 | 1 | 4 | 9 |
| Strangulation continuing after herniotomy or taxis | 18 | ... | 6 | 12 |
| Invagination | 43 | ... | 13 | 30 |
| Foreign bodies, impacted feces, gall-stones, etc. | 18 | 1 | 7 | 10 |
| Strangulation by bands, adhesions, or diverticula | 76 | 1 | 20 | 55 |
| Obstructions from tumors, strictures, ulcers, etc. | 28 | 2 | 7 | 19 |
| Internal hernia and ileus | 20 | 1 | 7 | 12 |
| Obstructions from other causes | 4 | ... | 1 | 3 |
| Causes of obstruction not ascertained | 9 | 1 | 3 | 5 |
| Aggregate | 230 | 7 | 68 | 155 |
12 Surgery, p. 835.
Enterotomy is an operation originally performed by Nélaton. It is done by making an incision, preferably in the right groin, above the crest of the ileum and parallel with Poupart's ligament. When the abdomen is opened a coil of intestine is found and carefully stitched to the walls of the incision. A very small opening is then made into the bowel, and a fecal fistula established. Enterotomy is less dangerous than laparotomy, as by it there is less interference with the peritoneum; but no relief could be afforded by this procedure in cases of intussusception or acute obstruction from bands, hernia, or volvulus. It is applicable to cases of intestinal constriction when the obstruction is about the lower part of the small or upper part of the large intestine. It may be resorted to as a palliative measure when exact diagnosis as to the character and site of the obstruction is not clear, the case being otherwise hopeless, or in cases of obstruction where severe symptoms persist and death is near, and yet for any reason laparotomy or colotomy is inapplicable; or it may be performed in cases of contractions after failure of patient and persistent medical treatment. Many successful cases of enterotomy have lately been reported, and the operation has been earnestly advocated by Trousseau, Maunders, Wagstaffe, Bryant, and others. In chronic constriction due to stricture or other mechanical obstructions, malignant or otherwise, not remediable by any medical measures, colotomy should be performed. By this operation the colon is opened and an artificial anus established. The sigmoid flexure in the left lumbar region is the part selected for the colotomy if the obstruction is situated in the gut below that point. When the obstruction is higher up in the colon or its exact site cannot be determined, the cæcum in the right lumbar region is the part chosen. In cases of obstruction from the mechanical pressure of tumors, the possibility of relieving the compressed bowel by treating the tumors should of course be considered before resorting to colotomy.