It is not necessary to wait for accurate diagnosis—recognition of the existence of obstruction alone is all that is required. Conditions rapidly aggravate themselves, and strength is rapidly lost, if we wait for more than distinctive symptoms. There is no palliative treatment save operation, and the drugs and other harsh measures which are often prescribed serve to intensify and aggravate rather than to relieve. Anodynes given, though administered with the most humane intent, serve only to mask conditions and lead to delay.
Exploration once resolved upon, careful judgment must decide as to where to place the incision. If local indications be present they may be followed. If there be good reason to believe that the original cause was an acute appendicitis, then the incision may be placed upon the right side. In the absence of all indications the surgeon operates most safely in the middle line by an incision below, above, or around the umbilicus, as circumstances may indicate. Edema of the subserous tissue or of the abdominal muscles indicates the presence of pus beneath. Peritoneum should be sought and opened with care, as in the presence of much distended bowel injury to the same may easily occur. The opening once made the operator will be embarrassed from that time until the conclusion of the operation by the distention of the bowels—at least those above the obstruction, and by their being constantly in the way. If a mechanical cause for obstruction be found it will be noted that the intestine above is more distended than that below, which latter may be collapsed and apparently smaller than natural. Thus if a constricting band be found, or an internal hernia, the removal of the obstructing cause will permit of prompt restoration of equal gaseous pressure between the parts above and below.
Scarcely any surgical emergency requires wiser discretion than do cases of this kind. Bands may be double ligated and divided, kinks straightened out, twists untwisted, invaginations withdrawn, if this be possible by reasonable effort. On the other hand the surgeon should be prepared to find bowel which has apparently lost its vitality or is actually necrotic, either for a few inches or for several feet, and he will soon realize that to leave such gangrenous masses within the abdomen is to accomplish naught, while to remove them is to subject the patient to a procedure longer and more severe than he can bear. He must, then, decide whether to close the abdomen for form’s sake and let the patient die a natural death, or whether to undertake the risk of resection, or perhaps to leave a considerable portion of the intestinal canal upon the outside of the body, opening it and establishing an artificial anus in the hope that the sloughing portion may be cast off, and that the artificial anus, having served its purpose, may be subsequently closed by another operation. Such cases live, though not very often. Here, perhaps as often as anywhere, can be seen the most desperate expedient succeed and the most trifling measure fail.
Another question is what to do with distended and paralyzed intestine, especially when it appears impossible to restore it to the abdominal cavity. Paralyzed as it is, it is almost too much to hope that it may recover its tone, and distended as it is, it is practically unmanageable. To open it at one point would be to empty several loops, at least of gas and probably of fluid fecal matter, all of which will help. One cannot but reflect on the toxic nature of all fecal matter so retained and feel that could it all be evacuated the patient would, other things being equal, be in vastly better condition. And so operators have often made openings, taking all possible precautions to prevent contamination, and have not only evacuated a considerable length of the intestinal canal, but, as suggested by Mixter and others, have washed it out.
A more perfect method, however, of accomplishing this purpose has been suggested by Monks, of Boston, in the use of a large glass tube, from twenty to twenty-four inches in length, strong and with smooth ends. He has shown how, an opening having been made, say just above the obstruction, it is possible by manipulating the bowel with gauze pads to draw it over the tube (as shown in [Fig. 563]), to an extent of several feet, and to thus more completely evacuate it than could be accomplished in any other way. Monks is undoubtedly entitled to priority for this suggestion over Moynihan, who has elaborately figured and described it. All in all this permits better management and more complete effect than any other method. The bowel having been emptied, the opening is closed by the usual double row of sutures and is then easily dropped back into the abdominal cavity. Cases occur where this procedure might be carried out at two different points, say above and below the obstruction.
Fig. 563
Method of inserting a tube (through an enterostomy opening) a considerable distance into the intestine by drawing the intestine around it with the help of a piece of dry gauze. The tube used in this case has a curved extremity, the opening being on the concavity of the curve. It is shown entire at the lower left corner of the illustration. The longer the abdominal incision and the longer the tube the greater the length of intestine which may be drawn upon it and emptied of its contents. (Monks.)
What may be done with the obstruction produced by local and septic peritonitis, such as is especially seen in acute cases of cholecystitis, appendicitis, and pyosalpinx? Here the surgeon deals not only with twisted, kinked, and obstructed bowel, tensely distended, but with much infected lymph and perhaps a collection of pus and a gangrenous appendix. Such a condition becomes appalling and every such case should be dealt with upon its merits. Any collection of pus should be evacuated and drained, and it must then be decided whether to endeavor to withdraw entangled loops, disengage and straighten them out, or to be content with an artificial anus for temporary purposes, the latter often being the safer course, even though it may lead to a tedious convalescence and the necessity for subsequent operation. It might even be advisable to evacuate pus and remove a sloughing appendix, if it were easily found, and then make an enterostomy, opening at some other point, in order to keep the two procedures and fields of activity quite distinct.
A case may occasionally be seen where the question of affording some relief is paramount to every other consideration, and where, at the same time, the patient’s condition is such as to make anything extra-hazardous. I have saved life under conditions of this kind by making a simple enterostomy under cocaine, the intent being only to attach a loop of distended bowel to the parietal peritoneum and to open it then or a little later, thus establishing an artificial anus. This may be done with local cocaine anesthesia. I have even seen the fecal fistula thus produced close spontaneously in the course of time, and, while the exact character of the lesion was never known, have had the satisfaction of thus saving a life which I believe would otherwise have been lost.