It is not always easy to decide as to the condition of the bowel. Certain points must be observed:—
(1.) Colour.—There may be very great alteration in the colour of the bowel from congestion, and yet no gangrene. It may be dark red, claret, purple, or even have a brownish tint, and yet recover; where it is black, or a deep brown, the prognosis is unfavourable.
(2.) Glistening.—So long as the proper glistening appearance of the bowel remains, there is hope for it, even when the colour is bad; if it has lost it, and especially if, instead of being tense and shining, it is dull and flaccid and in wrinkles, the bowel is almost certainly gangrenous.
(3.) Thickness.—If much thickened, and especially if rough on the surface, the bowel has probably been forming adhesions to the sac, or to contiguous coils, and the prognosis is less favourable.
(4.) Smell.—The peculiar gangrenous odour on opening the sac is very characteristic. In cases where ulceration and perforation have occurred, the odour is fæcal.
1. If, then, the bowel is tolerably healthy-looking, though discoloured, it should be returned gradually, not en masse, into the abdomen, the wound sewed up, and a pad of lint put on, with a bandage.
2. If there are adhesions of bowel to sac or to a neighbouring coil, or of omentum to sac, the stricture should be freely divided, the protruding coils of intestine should be emptied of their contents, but no rash attempt made to force their return. Especially is this rule to be observed with protruded, swollen, or adherent omentum, for considerable risks attend any attempt at excision of the protruded portion—risks of hæmorrhage, peritonitis, and ulceration of the contiguous bowel.
If the bowel be returned, or even the continuity of the canal restored by the cutting of the stricture, though the bowel be not returned, no great risks accrue from the retention of a piece of omentum in the sac, in a position which it may possibly have already occupied for years.
3. If the bowel is absolutely gangrenous, even in a very small portion of its length, no reduction should be attempted, but the gangrenous portion should be kept outside, with the hope that adhesive inflammation may be set up, so as to glue the bowel to the abdominal wall, prevent fæcal extravasation, and form a temporary artificial anus. If the gangrenous portion be very full of fæces or flatus, incisions may be made into it. This should be avoided in cases where the patient is already much prostrated, as I have seen cases in which the opening of the bowel seemed to inflict a fatal shock.
Enterectomy or excision of the gangrenous portion has recently been recommended and performed by some surgeons. The very high authority of the late Professor Spence is against such procedure.[143]