Course. The disease may last six to twelve hours, or even as many days before it ends in recovery or death. The colicy symptoms usually increase, with the complication of dyspnœa when tympany becomes well marked, hyperthermia in case of the supervention of enteritis, and signs of general peritonitis and collapse in case of rupture of the bowel. A sudden increase of the pain may otherwise indicate the occurrence of invagination.
As indicating a favorable termination there may be restoration of the rumbling, the passage of fæces at first perhaps in the form of solid cylindroid masses, and later as a mixture of broken up ingesta, liquid and gas, the tension of the abdomen disappears, the pains lessen and cease, and there is a gradual restoration to health.
Lesions. The abdominal walls are tense and more or less drumlike, and when these are cut through the large intestines protrude strongly. When punctured there is a free discharge of gas. The most common seat of obstruction is the pelvic flexure, but it may occur in the floating colon, or rectum, in the double colon even at other parts than its pelvic flexure, in the cæcum or in the ilio-cæcal opening. The impacted mass is firm, rather dry, covered with mucus and sometimes blood, and manifestly only partially digested. Its size and form vary greatly as it is moulded into the affected viscus. The mucosa in contact with the impacted mass is covered with a thick layer of viscid mucus sometimes streaked with blood. The mucosa itself is congested, thickened, friable, and marked with spots or patches of various colors (white, gray, green,) indicating commencing necrosis. In old standing cases this may extend to the other coats of the bowel determining perforation or laceration.
The portion of the bowel immediately in front of the obstruction is filled with liquid which has been forced down upon the barrier by the active peristaltic movements, and the distension by liquid and gas may have increased until rupture has ensued with the escape of the contents into the peritoneal cavity. Invagination, volvulus and peritonitis are common.
Treatment. This will vary according to the stage and degree of the illness. In slight cases with transient colics only after meals, a more laxative diet may suffice. Boiled flaxseed, roots, potatoes, apples, green cornstalks, silage, or even sloppy bran mashes, with an abundance of good water and active exercise may prove efficient. Copious injections of warm water, soapsuds, or linseed oil emulsion may be added.
In the more violent cases we must resort to more active measures and yet drastic purgatives are full of danger. The free secretion from the vascular small intestines and the active vermicular movements, lead to the speedy overdistension of the bowel just in front of the obstruction, the current being strong and active all around the contracting gut in contact with the mucosa, while a weaker return current sets in in the centre, but is effectually checked and arrested at no great distance in front of the impaction by the strong backward peripheral stream. If therefore the impaction is not broken up, it is inevitable that the gut above must be more and more distended until a rupture ensues.
Yet in a certain number of cases a moderate dose of aloes or castor oil supplemented by frequent enemata and other measures, succeeds in safely overcoming the obstruction. The solid impacted mass is gradually softened and removed, and finally after perhaps three or four days of complete obstruction the fæces begin to pass and recovery ensues.
With or without the aloes, the hypodermic use of pilocarpin or eserine or both will often succeed in obtaining successful peristalsis. Barium chloride while inducing more active peristalsis is, on that account, somewhat more dangerous.
Pain may be moderated and fermentation checked by chloral hydrate (½ oz.), or, an anodyne, morphia (2–4 grs.), may be given hypodermically. In the absence of these, extract of hyoscyamus or belladonna (2 drs.) may be given by the mouth, and repeated as may be necessary. If tympany is dangerous use the trochar and cannula. Enemata and other accessory measures must not be neglected.
W. Williams has resorted to rectal injections of 2 oz. aloes forced into the rectum by a syringe furnished with a long elastic tube, and repeated when expelled. Brusasco has used copious liquid injections poured into a rectal tube the end of which is raised at least ten feet above the croup, so as to gain the requisite force. Schadrin uses injections of cold water to stimulate the bowels to contractions. Injections of oils or mucilaginous matters when they can be carried far enough lubricate the walls and favor the passage of solid matters. Castor oil which acts to a large extent locally is especially applicable.