—In the small intestines by far the most common type of malignant tumor is the round-cell carcinoma, epithelioma rarely appearing except in the lower part of the rectum, where flat epithelium is met. Adenocarcinoma, then, is common, and sarcoma relatively rare, the latter arising, of course, from mesoblastic elements. A diagnosis is made by first noting symptoms of intestinal obstruction plus certain added features of cachexia, lymph involvement and possibly of metastasis, for which a benign stricture would not account. Sometimes a tumor is easily felt within the abdominal wall; at other times one simply makes the general diagnosis of intestinal obstruction, presumably cancerous, because of age and cachexia, and leaves the rest to be determined by operation. Cancer of the bowel will naturally spread in the direction of the lymphatics at the root of the mesentery, and these will nearly always be found involved. It is fortunate if a case may come to operation before this invasion has occurred.
Treatment.
—Cancer of the bowel permits of but two methods of treatment, one excision of the entire infected area, both of bowel and of mesentery, in cases not too excessive, the other an anastomosis, by which temporary relief at least may be afforded. In all cases I am strongly inclined to advise the use of the x-rays, for a long time after operation; in favorable cases because it exerts a prophylactic influence, in the unfavorable cases because it nearly always relieves pain and retards growth, seeming sometimes even to disperse it. Such treatment should always be tempered by the best of judgment, lest x-ray dermatitis complicate or prevent it.
ACUTE INTESTINAL OBSTRUCTION; ILEUS.
The somewhat badly derived and indefinite term “ileus,” in common use abroad, is coming into more fashionable use in the English-speaking profession, which is rather unfortunate, for it has not always meant exactly the same thing in the writings of different authors. It will be used, however, in this chapter as practically synonymous with acute obstruction or strangulation.
Acute obstruction may be classified in two ways, as to types and as to causes. For the first purpose the best classification is perhaps the simplest, and, as recently rehearsed by Murphy, is as follows:
- 1. Adynamic, including those conditions which are due to absence of power of propulsion.
- 2. Dynamic, where obstruction is due to excessive power or excessive contraction of the muscular wall.
- 3. Mechanical, including all of those conditions of strangulation or obturation which, in a mechanical way, impede the advance of intestinal contents.
Conditions which permit the adynamic type may include those of spinal origin, those interfering with mesenteric nerve supply or that of the walls of the intestines (for instance, in cases of fracture of the spine), or, again, where extensive operations have been performed on the mesentery, or where there have been extensive wounds. Thus in removal of mesenteric tumors, unless care is exercised in separating the mesentery from the tumor and in ligating bloodvessels without including nerves, a paralytic ileus may promptly result. Gunshot wounds of the chest or of the spine may also include injuries to nerves, by which paralysis of the bowel ensues. So, too, adynamic ileus sometimes results through the paralyzing reflexes which follow strangulation of the omentum—as, for instance, in a hernial sac—or it may be due to biliary calculus acting in the same way.
The dynamic forms, as well as the mechanical, are much more likely to be characterized by pain and violent symptoms than are the paralytic. Gastric tetany is a condition to be differentiated from reflex ileus. Enormous distention of the stomach immediately after operation leads perhaps to a belief that a patient has acute obstruction of the intestine, when the fact is that such a case may be relieved by vomiting or passage of a stomach tube. Local peritonitis of septic type, as well as peritoneal traumatism, tends to weaken if not to paralyze peristalsis. In general peritonitis the entire intestinal tract is involved, partly from reflex paralysis, partly from inflammation of the intestinal wall. The embolic type of paralytic ileus may be due either to interference with nerve supply or with blood supply. In thrombophlebitis symptoms develop more slowly, especially when this follows abscess of the liver or spleen. Here there is not so much meteorism, and the bowel may be even nearly empty, while we have the other symptoms of pain, nausea, and vomiting. Borborygmus is one of the most pronounced manifestations of mechanical ileus and the stethoscope will then give much assistance. In fact auscultation of the abdomen, with a recognition either of active motion within or of absence of peristalsis, should not be neglected; when one can hear intestinal waves the condition is much more likely to be one of purely mechanical obstruction.
Classified by causes, we may make out the following well-marked groups: