A system of practical medicine. By American authors. Vol. 2

by Unknown

The statistics of Leichtenstern show that from 5 to 10 fatal cases of intestinal obstruction occur every year among every 100,000 inhabitants; and according to the mortuary records of England an average of 1 death from this cause is seen in every 260 deaths. Brinton reports 1 death from intestinal obstruction in every 280 deaths; his statement is based upon 12,000 promiscuous autopsies. The first author states that the statistical reports of the general hospital of Vienna inform us that out of 60 cases of ileus, 6 or 10 per cent. recovered. This report, however, is too meagre to be of much value. From Brinton's statistics of 500 deaths from obstruction we find that out of 100 cases, 43 are intussusception, 17 stricture, 4.8 impaction of gall-stones, 27.2 internal strangulation, and 8 torsion.

TREATMENT.—There are few conditions of the body which cause the practitioner more anxiety and embarrassment than cases of intestinal obstruction, and when the precise seat and nature of the occlusion are not known the treatment is almost entirely empirical. The distinction, however, between acute and chronic cases of obstruction of the bowels, or of acute supervening upon chronic symptoms, can almost always be made, and a patient investigation of the history of the case, the mode of invasion, and a rigid analysis of all the symptoms presented will generally enable the attendant to come to some positive conclusion as to the cause and site of the occlusion. One fact in the treatment which cannot be too strongly impressed upon the mind, especially of the young practitioner, is not to use purgatives and irritating enemata, formerly so much in vogue, in the hope of forcing a passage through the occluded bowel. The patient is urgently solicitous for medicine which will open his bowels, but the use of purgatives to overcome internal strangulation is as senseless and hurtful as when used to overcome the constipation of external strangulated hernia. These agents only add to the nausea, vomiting, pain, and peristalsis. The latter is violent enough already to render coils of intestine visible, and with every paroxysm is adding to the entanglement and impermeability. It is said that cathartics in some instances have unlocked the bowel in intestinal obstruction: these cases are exceptional, and many of them were probably functional and not structural in character. The only exception to the rule of avoiding purgatives is as stated by Jonathan Hutchinson: "In certain cases when impaction of feces is suspected, and in cases of stricture when fluidity of feces is desirable."

Formerly, some of the best practitioners resorted to the exhibition of one or two pounds of quicksilver, in the hope of overcoming intestinal obstruction by the weight of the metal. This plan has properly been almost if not quite abandoned. Crude mercury is very slow to reach the obstruction, is divided into small portions by the peristalsis, which its presence increases, and if it should finally arrive at the point of constriction in any considerable quantity, it is more liable to add to than overcome the difficulty.

The great remedy in intestinal constriction is opium, in large or small and repeated doses. Its use arrests the vomiting, stops the pain, and quiets the violent movements of the bowel. Very often by it the intestine is preserved and the life of the individual saved. No special dose can be prescribed: it should be administered until slight narcosis is obtained and pain and vomiting cease. Small doses of morphine, given hypodermically and quickly repeated, is the best plan of exhibiting it. It may be given by the stomach, but under such circumstances it is apt to be rejected, or if retained absorption goes on slowly, or possibly not at all. If for any reason its hypodermic use is impracticable, it had better be given by the rectum. Opium lessens the danger of death from collapse: it gives nature an opportunity to untwist the gut in volvulus, or to unroll it in intussusception, or to cut off the invaginated part by gangrene; and in internal hernia, morbid adhesions, strangulation by bands of lymph, stricture, and other forms of obstruction, it diminishes violent peristaltic action, postpones inflammatory infiltration, fixation of the strangulated portion, and keeps the parts in better condition for operative interference, which in many cases offers the only hope of relief. To carry it farther than slight narcosis and arrest of the most painful symptoms of obstruction is an abuse of the remedy. By such abuse the symptoms will be masked and both patient and practitioner deceived.

When obstruction is due to fecal impaction or spasm, the opium treatment is still often indicated. Not unfrequently, after pain and vomiting are relieved and slight narcosis kept up for some hours, the bowels relax and spontaneous evacuation takes place. If not, discharge of the contents of the bowel should be assisted by the administration of castor oil, calomel, or repeated enemata of warm water. These agents should not be used, however, as long as there is pain, tenderness of the belly, or any evidence of peritonitis, but the opium treatment continued until all signs of inflammation have disappeared. It has been proposed to give belladonna in place of opium; in small doses and carefully watched it may be added to the opium, but should not be substituted for it.

The local application of ice-water or pounded ice to the abdomen has been recommended; and it is asserted that the danger of general peritonitis is lessened, and that the strangulation itself has disappeared, under the influence of cold. If, however, cold increases pain and peristalsis, it should be abandoned. The local application of moist heat or fomentations will more probably do good and give a grateful sense of relief to the sufferer. General bleeding should never be resorted to, and the use of leeches, except to ward off or subdue some local inflammation, is of doubtful expediency. Blisters, ointments, and cups are useless in such an emergency. Cracked ice, strong coffee, and carbonated water in small quantities are valuable in allaying thirst and nausea.

Cases are reported where obstruction of the bowels has been overcome by the use of electricity; both the continuous and induced currents, but chiefly the former, have been used; its value in such cases is improbable.

Abdominal taxis or massage has been earnestly recommended and frequently practised in cases of constriction. Successful results from this procedure have been reported. It has been attempted while the patient was in a warm bath or under chloroform or while taking large enemata of warm water. Abdominal traction by the use of large cups to the belly has also been advised. We can only hope for success from these measures in the early stages of obstruction, before inflammatory action or fixation of the strangulation has taken place, and any attempt of this kind should be made with tact and gentleness. Inversion of the body has also been suggested.

The injection of large quantities of warm water into the bowels to overcome obstruction should never be omitted before resorting to operative interference. The author has seen this plan in five or six instances succeed after all other means had failed. Simple warm water should be used, introduced by means of the common Davidson or a fountain syringe. The injection should be made slowly, with occasional intervals of rest, to allow the fluid time to pass through the intestinal coils. During the operation the patient should be in the knee-elbow or Sims's left lateral position, and under the influence of an anæsthetic. One or two gallons of water may be used. In place of water, the bowel may be inflated with air, introduced by a pair of common bellows to the nozzle of which a piece of India-rubber tubing is attached. The addition of castor oil, turpentine, carbonic acid gas, and other irritants will more likely detract from than add to the efficacy of these measures. In chronic intussusception, or in acute cases when fixation of invagination is believed to have taken place, and especially when inflammation is great, gangrene threatening or in existence, injections of air or water should not, of course, be attempted.

In invagination, when the intussuscepted part is low down in the rectum or protruding from the anus, replacement by fingers or sound should be tried; reduction begun in this way may be completed by injections of air or water. The propriety of introducing the whole hand into the rectum is very questionable. In occlusion of the gut by compression and traction the cause should be found, and, if possible, removed. An abdominal or pelvic tumor may be pushed out of the way of the compressed bowel, a cyst punctured, a displaced womb replaced.