8. Gallstones.
—In the section devoted to the biliary passages the accidents which may occur during gallstone disease have been summarized, and it has there been related how large ones may ulcerate through and drop into the small or even into the large intestine. Enteroliths may be thus produced, which were originally small gallstones that have lodged and grown by accretion until they have reached considerable size, or by gallstones which have suddenly entered the intestine by ulceration above, or by other material which may have collected in some sacculation or diverticulum, where it has received more or less calcareous deposit and has grown by accretion until it produces obstruction, either by occlusion or by causing the intestine to kink. Other foreign bodies may also produce obstruction. Although it has been generally held that whatever may escape through the pylorus may be evacuated from the rectum, nevertheless peculiarly shaped objects become entangled in such a way as to be checked in progress and serve as impacted bodies upon which an accumulation may take place. (See [Plate L].)
9. Peritonitis.
—While coprostasis is a feature of almost every case of acute peritonitis the obstruction referred to in this paragraph comes rather from the adhesion and fixation of bowel from outpour of lymph than from paralysis and ileus in consequence. It may be doubted whether acute peritonitis is ever idiopathic. As seen by the surgeon, at least, it has some point of origin which furnishes ample excuse for its existence. The most common cause in the male is the appendix, and in the female the appendix or the tube. At least one-half of the cases occurring in general practice originate in one or the other of these ways. Infection may also easily spread from the mesenteric nodes, beginning locally and resulting in adhesions, the disease spreading by a natural process until perhaps the whole abdomen is finally involved. While healthy bowel is ordinarily impervious to germs, when it becomes diseased germs may easily travel from its interior to its exterior and thus set up peritonitis. In this way a purely mechanical original condition may bring about a fatal septic peritonitis. It is known also that intestinal diverticula are subject to exactly the same lesions as is that one in particular which is called the appendix, and the symptoms and sequences of the diverticulitis may simulate those of an acute appendicitis. In acute appendicitis coprostasis and even apparently fatal obstruction are frequently met with. Their occurrence is to be explained not alone by toxemic paralysis (i. e., toxemic ileus), but by the actual mechanical impediments offered by loops of bowel strongly bound together around the appendix in the actual protective effort.
10. Bands.
—Bands of tissue which may cause obstruction of the bowel are neither necessarily long nor large, and one will frequently be astonished to see how trifling a tissue cord may produce intense disturbance. The bands which may be found within the abdominal cavity under these circumstances include those produced by peritoneal adhesions, where the cohering lymph has organized and at the same time stretched, such bands being found to arise from and connect with the bowels alone, to arise from the omentum from any other causes, particularly traumatic, or to occur at any point within the peritoneal cavity. They may be single or multiple. When speaking of Meckel’s diverticulum it was stated how it might be mistaken for a band extending to the region of the umbilicus, and acting as one cause of obstruction. (See [Fig. 559].) An adherent appendix or tube tightly attached at its free extremity may also act as a band, and the former is known to very frequently produce at least a mild form of intestinal obstruction, which may at any time assume acute proportions. The pedicle of an ovarian or other tumor may also, if long, by becoming twisted, include an intestinal loop and thus produce obstruction.
11. Slits and Apertures.
—The mesentery is the occasional site of fenestra which apparently are of congenital origin. Through such openings or slits a loop of bowel may easily pass and become strangulated. The same is true of the omentum. Openings in either of these structures are perhaps more frequently the result of traumatisms. Similar conditions result where omental or mesenteric surfaces have united over small areas, leaving pockets or openings in which bowel might be caught. Quite a similar condition results in so-called hernia of bowel into and through the foramen of Winslow.
12. Intestinal Loops and their Traction Effects.
—These causes are not perhaps independent of some of those above mentioned, yet presuppose a certain looping or abnormal festooning of intestine, with the further stretching that occurs as the result of greater loading and the final entanglement of such loops, or their adhesion, in such a way as to become completely occluded. To this result some local inflammatory process may contribute. The condition is often met in connection with pelvic disease of females. Much that may happen to a loop of bowel which has become attached to a growing tumor during its migration, as it gradually changes its shape and position, may be imagined.