The principles and practice of modern surgery

by Roswell Park

Vomiting is an early or late feature, according to the portion of the alimentary canal obstructed. The more prompt its occurrence presumably the higher in the small bowel the defect. In consequence of the remedies usually administered it will be found that when nothing but stomach contents are ejected it is easier to produce fecal evacuation from below, while the greater the difficulty in securing a return from the lower bowel the lower the obstruction and the more likely the vomited material to become fecal in character. Vomiting once begun is usually continuous until relief is afforded or the patient utterly exhausted.

Constipation or obstipation sooner or later characterize these cases. The tenesmus of intussusception, with the passage of bloody mucus, which may occur in this form, or in volvulus, for instance, does not imply that the bowel itself is not obstructed, nor does the emptying of the larger bowel of an accumulated load necessarily imply that the fecal stream is in motion. Even the passage of flatus usually is promptly shut off, and it is the gas which forms and cannot escape that produces the distention.

Distention gradually becomes excessive, the abdomen becoming ballooned and extremely tympanitic on percussion, while its surface becomes shiny because so stretched. This meteorism is in large degree due to the formation of gas within the bowel proper, but is permitted by the additional features of paralysis of intestinal muscle and weakening of that of the abdominal wall. As it increases the diaphragm is pressed upward and respiration is much impeded, while even the bladder may be compressed below. It affords another reason why fluid which is taken into the stomach is quickly ejected.

Characteristic collapse comes on more or less promptly, according to the nature of the exciting cause, and the date of its occurrence is in some degree an index of its violence.

In dealing with obstructive cases any history that may bear upon the conditions, as of previous peritonitis, appendicitis, of so-called dyspepsia which might indicate gallstone disease or gastric ulcer, or of pelvic conditions which might indicate pyosalpinx or the like, should be obtained. The manner of onset should be learned, whether acute or gradual, with the relative date of the occurrence of pain, vomiting, and stools, along with their character, if there be anything distinctive therein. Past and present history being secured, the most methodical examination of the body should be made, including the physiognomy and general conditions, the attitude (e. g., whether the knees are drawn up, whether the patient is able easily to turn), the type of respiration, and the amount of restlessness. The character of the abdominal movements during respiration should also be noted, as well as the presence of any prominence or the indications of violent peristalsis. By palpation the degree and location of greatest tenderness, the presence of muscle spasm or of tumor may be learned. Careful examination of all the ordinary hernial outlets should be made and the rectum and vagina explored. Revelations thus obtained may also prompt a careful physical examination of the chest. Percussion will show the presence of free or localized fluid or gas, while localized dulness may denote a loop of intestine distended with fluid or impacted feces. Auscultation will enable the surgeon to hear the sounds produced by violent peristalsis or to note the absence of movement within the bowel. A study of the temperature and the pulse may reveal much in certain cases, especially the inflammatory, and particularly in appendicitis, while the urine may be examined for indican, and a differential blood count made.

Meteorism, constipation, and fecal vomiting of themselves indicate acute obstruction, but furnish no aid as to the nature of the exciting cause. They are, however, sufficient to indicate the wisdom of immediate intervention.

Pathologically every case of intestinal obstruction has an interest of its own. Surgically, however, they are readily grouped as a class of cases in which operation should always be performed early, inasmuch as it offers the better prospect of relief and in which death is the inevitable spontaneous termination. It can scarcely be imagined how a more distressing case than an acute strangulation can be allowed to go to its fatal termination without being offered the prospect of a judicious operation, if only performed early. The disfavor with which operation is received by the general physician, as well as by laymen, is due to the fact that too much time is wasted with futile drug treatment, and that the golden hours when surgical intervention might save are allowed to pass unutilized. Of most of these cases it may be said that dying after operation they have died in spite of it rather than in consequence of it.

This is particularly true with intussusception and volvulus in young children or infants. Within six hours, in such cases, the harm which may be done is necessarily fatal, and to keep them for a day or more, dosing them with cathartics or making strenuous efforts to relax invagination, is to deprive them of the only measure which offers them any chance. The disrepute into which operative treatment of these cases has fallen in certain quarters is due, then, solely to the fact that the physician does not call the surgeon early, because there is a time in the history of nearly every one of them when it could be saved were mechanical relief afforded.

Treatment.

—There are certain cases of obstruction by fecal impaction or lodgement of enteroliths which may be successfully treated by internal or non-operative means. Could these always be diagnosticated it would be known when not to operate. But to wait until paralysis of the bowel has occurred, or gangrene due to stasis, or perforation have taken place, or septic peritonitis has set in, is to wait far longer than circumstances justify and reflects on those responsible for the delay rather than on the operator or the operation. In general terms, acute intestinal obstruction is always a surgical disease.