Intestinal obstruction may arise from the introduction, accidental or otherwise, of foreign bodies into the stomach and bowels. Coins, marbles, bullets, fruit-seeds, etc. are often swallowed by children, sometimes intentionally, and if the object is round and small it rarely gives rise to any serious trouble. The foreign body, however, if small, may drop into the appendix vermiformis or some other diverticulum and end in serious mischief, or if the individual has stricture of the bowel the foreign body may be arrested by it.
Foreign bodies which are pointed or irregular in shape, swallowed by accident or design, may give rise to dangerous and fatal symptoms, but not unfrequently they escape per vias naturales. Thus, pins, needles, pieces of bone, artificial plate and teeth, small pen-knives, and other pointed or irregular-shaped bodies, have passed in this way. Sharp-pointed bodies, as needles, sometimes make their way through the walls of the stomach and present themselves at other and more distant parts of the body. I have removed a needle from the calf of the leg which the patient had a month before accidentally swallowed. Jugglers accidentally, in practising their calling, and insane people, not unfrequently intentionally, introduce into the stomach all sorts of foreign bodies, such as buckles, forks, spoons, knives, pieces of wood, iron, bone, etc. Gross2 records the case of a juggler who let a bar of lead ten inches long and weighing a pound slip into his stomach. Bell of Iowa removed it by gastrotomy, and the man recovered. Agnew3 reports a post-mortem of an insane woman in whose intestinal canal he found three spools of cotton, two roller bandages, a number of skeins of thread, and a pair of suspenders.
2 System of Surgery, by S. D. Gross, 6th ed., vol. ii. p. 616.
3 Agnew's Surgery, vol. i. p. 393.
The morbid appetite of some people, particularly girls and pregnant women, sometimes induces them to swallow powdered chalk, magnesia, and other substances, and when this practice is continued for a long time the insoluble powder is deposited in the bowel and forms hard masses which more or less completely obstruct the intestines.
Stony concretions or enteroliths are found generally in the cæcum or in the sacculi of the colon, very rarely in the small intestines. They are round or oval, and when two or more are found together they have facets. They consist usually of carbonate of lime or magnesia or sesquioxide of iron. Other concretions are sometimes seen composed of starch or the felted husks of oats, called oat-stones (avenoliths), found particularly among the poorer classes of people in Scotland. Other vegetable remains of husks, fibres, etc. may produce the same thing. Young and middle-aged people more frequently suffer with these concretions than the old. Foreign bodies made up by the gradual accumulation of hair, string, and other substances are not unfrequently found in the stomach and intestines. The mass produced in this way is often very large. Sometimes the foreign body is arrested in the oesophagus. In a post-mortem reported to the writer by Fairfax a large copper coin, accidentally swallowed a few days before, was found lodged in the gullet. Ulceration followed, a neighboring artery was opened, and the patient died from hemorrhage.
Impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. Small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. If, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. A very large single stone or a number of stones forming a coherent mass may collect in the gall-bladder, slowly distend the dilatable biliary passages, and escape into the bowel; or—and this is more common—an opening made by ulceration between the distended gall-bladder and the duodenum allows the concretion to escape into the small intestine. These stones or aggregation of stones are sometimes three, four, or five inches in circumference and from one to four inches long. They occur, as a rule, in people over fifty years of age, and more commonly in women. Brinton, in his excellent book on Intestinal Obstruction, makes the average age in these cases fifty-three and a half years, and from the statistics he has gathered it will be seen that their occurrence is four times as often in females as in males. In 41 cases collected by Leichtenstern, 32 were women and 9 men. The site of the impaction is always in the small intestines. In 32 cases observed by Leichtenstern, 17 were found in the lower part of the ileum, 10 occupied the duodenum and jejunum, and 5 the middle part of the ileum.
SYMPTOMS.—Foreign substances introduced into the stomach do not always immediately give rise to serious symptoms. It is wonderful sometimes to see how tolerant the stomach is of their presence. Many instances are recorded of foreign bodies remaining in the stomach for months without producing dangerous symptoms. The mass may be discharged by vomiting, or it may escape through the pyloric opening into the intestine, and ultimately be discharged through the rectum, or, lodging in the bowel, give rise to symptoms of inflammation and obstruction. If, however, the foreign mass remains in the stomach, and is not removed by the surgeon's art or spontaneously discharged by ulceration, as in several rare instances has been the case, it uniformly proves fatal.
Before the foreign body is discharged by ulceration through the walls of the abdomen, adhesive inflammation unites that portion of the alimentary canal, gastric or intestinal, in which the mass is lodged with some part of the abdominal wall. By this union the cavity of the peritoneum is protected, just as we see the peritoneal sac protected by an effusion of lymph in hepatic abscess opening into the small intestine. If the adhesion between the canal and abdominal wall is imperfect, or by an undue amount of inflammation is disunited, the foreign body or inflammatory products which surround it may escape into the peritoneal sac and produce fatal peritonitis. Instead of passing through the abdominal wall, the foreign substance may escape into the bladder or vagina, or from the small intestine into the colon or rectum. Dangerous peritonitis may follow the simple presence of the foreign body in the alimentary canal from the obstruction it produces when no attempt at discharge by ulceration has been made. If the size and shape of the body permit its passage into the small intestine, it makes its way very slowly along this tube, giving rise to occasional attacks of colicky pains and symptoms of partial impermeability of the bowel.
At any moment the foreign body may lodge, become impacted in the canal, and all the grave symptoms of enteritis and general peritonitis present themselves. Symptoms of inflammation may appear, and after a longer or shorter time suddenly disappear, as if the foreign body had glided over some point of obstruction and again begun its descent through the tube. Its course is always irregular, passing quite rapidly over a portion of the intestine, then going more slowly, then lodging for a time at some point where it is obstructed by a fold or the contents of the bowel or by spasmodic contraction of the muscular coat of the intestines. As the calibre of the small intestine gradually diminishes as it approaches the cæcum, the passage of the foreign body becomes more and more difficult as it is propelled onward toward the ileo-cæcal valve. After a time it may reach the cæcum, where, of all places, it is most apt to lodge; but it may continue its course to the rectum, where it gives rise to tenesmus and a constant desire to go to stool. Finally, spontaneously or aided by the finger of the physician or some instrument, it is evacuated per anum. Not unfrequently, the foreign body can be felt through the abdominal walls, and its course traced day after day as it makes its way along the canal.