One of the most unfortunate accidents that can occur during operation for acute obstruction is to have the patient practically drown in his own fecal vomit. This may occur either on the operating table or soon after leaving it. The term implies simply this—that there is regurgitation of fecal matter into the stomach, and that as this is ejected by a patient in his unconscious condition he is not able to prevent its aspiration into the trachea, with the occurrence of all that essentially constitutes drowning. Even a few ounces of fluid material drawn into the lungs, under these circumstances, would be sufficient to cause asphyxia and death.
The accident is to be prevented not alone by lavage, both before and at the conclusion of the operation, but by placing the patient upon his side in such a way that any gush of fluid into the mouth may escape from it and not be sucked into the lung. The amount of fluid that may arise is sometimes astonishing. The introduction of harmless fluid, under these circumstances, would be sufficient, but the entrance into the lungs of a viscid, offensive, and septic fluid, even in small quantity, would quickly serve to induce a septic pneumonia if nothing else. The accident once having occurred, resuscitation is almost impossible. Under the relaxation of anesthesia it may occur without outcry and almost unsuspected, and with the patient on his back, death may be determined even before the attendant has noticed anything particularly wrong. To prevent this accident tubes have been devised having balloons around them which can be inflated with air, to the desired degree, and the esophagus thus be plugged.
Hence it will be seen that the surgeon should temper his measures to the condition of the case, its exigencies and its surroundings. Operation, therefore, may be exceedingly mild or exceedingly severe, taxing the resources of the best-equipped clinic.
Strangulations recognized from surface indications are usually dealt with according to standard indications. Those discovered only after abdominal section are to be dealt with each on its merits.
CHRONIC OBSTRUCTION OF THE BOWEL.
The expressions of chronic obstruction are essentially those of acute, in which they usually terminate, occurring meantime in milder degree. Their causes are nowise different from those tabulated above.
Symptoms.
—The symptoms of chronic obstruction are those of intermittent colic, constipation, perhaps with local tenderness, with change in shape of the abdomen due to the primary cause or to intestinal distention, and in many instances with some characteristic appearance or shape of the feces. Thus the stools are often loose, or scybalous masses when removed by cathartics, and these are followed by diarrheal stools containing many gaseous bubbles. Obstruction of the lower bowel will frequently cause the hardened fecal masses to assume a tape-like shape. With increasing obstruction there is increasing severity of symptoms, until finally they become acute.
Treatment.
—The treatment of chronic obstruction is also operative, either radical or palliative. When the exciting cause can not only be detected on exploration but removed, it should be radical. If, however, this be not possible then enterostomy or entero-anastomosis only can be practised. Thus in cancer of the rectum or sigmoid, colostomy is the last resort. In cancer of the bowel above the sigmoid anastomosis may relieve the obstruction and permit the patient to linger until he dies of the natural progress of the disease.