Fig. 562
Strangulation of bowel by a long diverticulum. (Lejars.)
13. Congenital Defects.
—Certain congenital defects predispose to acute obstruction. Among these are diverticula, as already mentioned, which may produce trouble, either by incomplete obliteration and separation from the umbilicus, in which event they act as bands or cords, or by becoming acutely inflamed, then attaching themselves and indirectly producing the same effects ([Figs. 559] and [562]). Even the smaller diverticula or sacculations which extend between the folds of the mesentery may, when infected and inflamed, thicken and cause angular bending of the intestine, with consequent partial obstruction, which later is made complete by the consequences of local peritonitis, with its dense inevitable adhesions. Statistics show that acquired diverticula occur twice as often as Meckel’s, and nearly as frequently in the small as in the large intestine. They are mostly of the traction variety and occur at the mesenteric border, where they have close relation to the bloodvessels, thus increasing the dangers of operative measures because of possible gangrene from shutting off circulation. Porter has recently collected 188 cases of violent and even fatal trouble thus produced within the abdominal cavity, returning an exceedingly high death-rate after operation, which unfortunately was almost always done late. In nearly all of these cases the diverticula were found within the lower four feet of the ileum. In one case of my own an unobliterated hypogastric artery caused acute obstruction.
14. Postoperative Obstruction.
—Finally cases of postoperative obstruction are met with in a way to bring disappointment and disaster when everything else has seemed favorable, and constitute a clinical type without any distinct pathological foundation. Most of them are due either to some form of paralytic ileus, or else to local or general peritonitis with its combined sequels of paralysis and adhesion by the gluing of portions covered with exudate. Some of these cases will justify reopening the abdomen, while in others the condition is absolutely helpless because of the septic element present.
General Symptoms of Acute Intestinal Obstruction.
—Certain symptoms and signs characterize all cases of acute intestinal obstruction and may be, therefore, included as common to each; consequently they may be considered collectively. The cardinal indications are pain, vomiting, constipation, distention, and collapse.
Pain may be the first indication, and usually is so in invagination, volvulus, and mechanical obstructions generally. It is usually of violent paroxysmal character, continuing at least during the earlier stages, rapidly wearing away the patient’s strength, diminishing as distention increases and nerve endings become paralyzed.