Congenital Malformations of the Intestines.—Cases have been recorded in which the small intestine ended in a blind pouch. Imperforate anus is a fairly frequent occurrence in young infants, but attention is usually called to the condition. Partial strictures of the intestine, if the stricture be not too narrow, may pass unnoticed for years, and final complete obstruction may result from a blockage of the stricture by some foreign substance such as a plug of hard faecal matter or a fruit stone.
Treatment of Acute Intestinal Obstruction.—Early diagnosis and early laparotomy are essential, and it is important to operate before the patient is poisoned by the absorption of toxins from the bowel. To administer purgatives is worse than useless. Of massage and abdominal taxis Sir F. Treves says: “These are to be condemned, as they may rupture the already moribund bowel and make effective a threatened perforation. These measures are for the most part feeble excuses for avoiding or delaying the operation.” The operation may be undertaken in one or two stages, and includes the opening and evacuation of the distended intestines and the search for and reduction or removal of the obstruction.
Chronic Intestinal Obstruction.—The causes of chronic obstruction are very numerous, and may be divided into the following groups: (1) intra-intestinal conditions, i.e. the impaction of foreign bodies and impaction of faeces; (2) affections of the intestinal wall such as stricture, new growths in the intestine, particularly those of a malignant type, adhesions or matting together of the intestines from peritonitis or kinking of the gut from disease of the mesenteric glands; (3) chronic intussusception; (4) compression of the bowel by a tumour or bands developing outside the intestine. Of these the commonest are malignant growths and faecal impaction.
The general symptoms of chronic obstruction are more or less alike. The patient is attacked with gradually increasing constipation, which may alternate with diarrhoea which is generally set up by the irritation of the retained faeces. In obstruction due to malignant growths the character of the motions is changed, they become scybalous, pipe-like or flattened. The abdomen becomes distended, and at intervals severe symptoms may supervene, consisting of pain and vomiting with complete constipation owing to some temporary complete obstruction. The attacks usually pass off, and relief may be obtained naturally or by the administration of a purgative, but they have a tendency to recur and in malignant disease to increase to complete obstruction. Finally a seizure may persist and take on all the characters of an acute attack, and death may supervene from exhaustion, perforation or peritonitis, unless immediately treated. When it arises from simple stricture no tumour is to be felt, but in malignant disease the tumour may be frequently palpated, unless during an acute attack when the abdomen is much distended with gas.
Faecal Impaction is not uncommon in adult females who have suffered from chronic constipation. The common seat of the blockage is in the colon, chiefly in the sigmoid flexure and in the rectum, but it may occur in the caecum. The accumulation may form a doughy tumour which in parts may be nodular and intensely hard. The causes are due to the state of the contents of the bowel itself, to congenital or acquired weakness and diminished expulsive power of the bowel, or to painful affections of the anus, fissures, piles and painful bladder affections. The acute symptoms are always preceded by a prolonged period of malaise; the breath is offensive and the tongue foul, and the temperature may be raised from the absorption of toxins. Faecal impaction requires the regular and repeated administration of large enemata, given through a long tube, together with the administration of calomel and belladonna. Large impacted masses in the rectum may be broken up and removed by a scoop.
Strictures of the Intestinal Wall.—Simple strictures are infrequent, and are dealt with by the operation of lateral anastomosis. They follow dysenteric or tuberculous ulceration or the passage of gall-stones. Stricture due to carcinoma of the intestinal wall occurs usually in the old or middle-aged, and the symptoms come on insidiously. As soon as the condition is diagnosed an attempt should be made to remove the tumour if freely movable, or if this is not possible to afford relief by short-circuiting the intestine or by colotomy.
Chronic Intussusception has been frequently mistaken in the diagnosis for rectal polypus, cancer, tuberculous peritonitis, &c. (Treves). If diagnosed it may be reduced by inflation with air, but frequently too many adhesions are present for this to be possible, and laparotomy with excision of the mass should be undertaken; the results are said to be very encouraging.
Compression of the bowel due to a tumour or bands external to the bowel may occasionally give rise to obstruction. An exploratory operation should be undertaken for the excision of the tumour, or the separation of adhesions and release of the bowel, or if the intestines are much matted together by peritonitis an intestinal anastomosis may give relief. Obstruction due to paralysis of the muscular coat of the intestine has been described (adynamic obstruction), but its existence is a subject of dispute.
(H. L. H.)