that mostly cause embarrassment in differential diagnosis. Hemorrhage
from the lungs, nose, or stomach is usually readily excluded by the
absence of any evidence of disease of these organs, and the presence of
the other symptoms of any general disease attended with enterorrhagia
makes a diagnosis in most cases easy enough. Alterations in the
contents of the {834} bowel, the presence of foreign bodies, are
recognized by the history of the case and by careful local examination,
while a diagnosis of anomalies in the walls of the bowel is usually
reached by exclusion. In no doubtful case should local inspection or
digital examination of the anus and rectum be omitted.
TREATMENT.--As in all cases of hemorrhage, the first requisite is
absolute rest. The patient should be at once put to bed and kept
perfectly quiet. Many a case of hemorrhage in typhoid fever is produced
by arising from bed to go to stool. The bed-pan is an absolute
necessity in the management of a case of typhoid fever after the second
week of the disease. Rest is the chief agent in prophylaxis as well as
therapy.
The most effective styptic in enterorrhagia is cold. An ice-bladder
should be laid upon or suspended immediately above the abdomen during
the whole duration of the flow. The injection of ice-water into the
bowel should be practised only in cases where the hemorrhage is
believed to come from the colon. Otherwise, the peristalsis it awakens
may only aggravate the danger. Should rest and cold fail to quickly
check the hemorrhage, resort should be had at once to ergot. This
remedy, in the form of ergotin, is most effective when introduced
beneath the skin. In cases of less imminent danger the practitioner may
be content to give the remedy by the mouth.
Small doses of the simple or camphorated tincture of opium frequently
repeated speedily arrest contractions of the bowel, and at the same
time feed the brain in threatening syncope. The astringents
proper--tannic acid or its preparations, acetate of lead, alum, the
perchloride of iron--are seldom necessary or advisable, but may be
called for in obstinate or protracted cases.
To turpentine has been ascribed, from time immemorial, specific virtues
in relief of hemorrhage of the bowels, and its administration is still
a routine system with many older practitioners. It is most effective in
large doses--one drachm, with milk or in emulsion, every hour or two
until the hemorrhage ceases.
In relief of collapse, alcohol, ether, and musk are imperatively
indicated, with the external application of heat; and in the treatment
of the anæmia and hydræmia the preparations of iron, including, later,
the mineral waters which contain it. In the worst cases of sudden
alarming hemorrhage the physician should not fail to practise the
transfusion of blood or solutions of salt or soda.
Milk is the best food and drink during the attack, and after it for
some days or weeks. Chopped or scraped raw beef may substitute it
later, while all farinaceous foods are to be strictly avoided for some
time.
{835}
INTESTINAL OBSTRUCTION.
BY HUNTER MCGUIRE, M.D.
When a mechanical impediment to the passage of the contents of the
bowel along the intestinal canal exists, the condition is known as
intestinal obstruction. The causes of this occurrence are numerous, the
symptoms urgent, the diagnosis difficult, the treatment uncertain, and
the termination, unless relieved by nature or art, speedily fatal.
There is no class of cases to which the practitioner is called more
important, or which demands on his part greater skill and judgment.
It is customary to divide the causes of obstruction of the bowels into
two great classes--acute and chronic.
In acute cases the attack is sudden, the symptoms violent, and, unless
the cause is speedily removed, life ends in a few hours or at most in a
few days. In chronic cases the causes act comparatively more slowly,
the symptoms are chronic and less urgent, and danger of death less
imminent. In this class the cause is not uncommonly spontaneously
relieved, and the individual restored to perfect health without the aid
of medicine or the surgeon's art. This result may happen in apparently
the most desperate cases.
This classification of acute and chronic obstruction is necessary for a
proper clinical study of the subject, but it should be remembered that
in practice there will be found some cases which partake of many of the
symptoms of both acute and chronic obstruction, making it difficult to
determine to which division the cases properly belong. It will also be
seen that some, at first, well-marked acute cases subside and become
chronic in character, and that (old) chronic cases of obstruction
sometimes suddenly change their nature and become acute. Again, some of
the causes mentioned as giving rise to acute obstruction of the bowel
in rare instances produce symptoms of chronic obstruction, and some of
the causes referred to as giving rise to symptoms of chronic
obstruction in rare instances provoke signs of acute obstruction. These
cases are exceptional. As a rule, the following list embraces
conditions which produce symptoms of acute obstruction:
1. Congenital malformations.
2. Impaction of foreign bodies, gall-stones, enteroliths, etc.
3. Twisting of the bowel--volvulus.
4. Internal strangulation by loops, bands, false membranes,
diverticula, mesenteric pouches, slipping of a portion of bowel into
natural or unnatural openings, diaphragmatic hernia, etc.
{836} 5. Invagination.
As a rule, the following causes produce symptoms of chronic intestinal
obstruction:
1. Constipation and fecal accumulation.
2. Stricture of the bowel, sometimes cancerous.
3. Compression of the bowel from abdominal tumors.
4. Contraction of the bowel from inflammatory changes, often
tuberculous.
A consideration of external hernia is, of course, not included in this
paper, but the possibility of the symptoms of intestinal obstruction
being due to this cause should never be overlooked.
Congenital Strictures and Malformations.
Cases of congenital strictures and malformations are confined almost
wholly to the rectum and anus, and come more properly under the
province of the surgeon. Some of the cases, however, belong to the
physician, the obstruction being so slight as not to require surgical
assistance. With all of them, however, the physician should be
familiar, that he may be able to distinguish between congenital
malformation giving rise to immediate obstruction and other forms of
intestinal occlusion. He should know, too, when to seek the aid of the
surgeon. For these reasons, as well as to make the history of the
causes of intestinal obstruction as complete as possible, it has been
thought proper to include in the list congenital occlusion and
malformation of the intestine. They will be treated, however, in the
briefest possible way, and the reader is referred to works on surgery
for a more detailed account of the pathology, symptoms, and treatment.
When congenital occlusion of the colon occurs, it is almost invariably
found in the sigmoid flexure, and is due, as most congenital atresia of
the intestine, to foetal peritonitis. Congenital occlusion may be found
in any portion of the small bowel, but a frequent site is the lower
part of the ileum and the ileo-cæcal opening. The following case[1]
gives an example of a form of stricture of the duodenum in infants,
with the symptoms and pathological changes. The septum is supposed to
be an unnaturally developed valve, or two valvulæ conniventes united:
"A child when born presented no unusual symptoms for the first
twenty-four hours. Vomiting then came on, and continued with short
intermissions until death, which took place some thirty-eight hours
after birth. The bowels were never relieved during life. The only
disease found was stricture of the duodenum close to the entrance of
the gall-duct, so that a probe passed down the latter entered the
duodenum immediately below the constriction. There was nothing to
indicate in what manner the constriction had occurred. On the gastric
side of the latter the duodenum was immensely distended--so much so
that at first sight it appeared like the pyloric end of the stomach
itself, and only by a more careful examination was the distinction
between the stomach and intestine detected by a ridge running around
their place of junction."
[Footnote 1: Quoted by Mr. Pollock in Holmes's _System of Surgery_,
from _Pathological Transactions_, vol. xii. p. 101.]
{837} Cases like this, a number of which are on record, are instructive
and of pathological interest; when, however, congenital occlusion
exists in the small intestines, no treatment can be suggested. If the
sigmoid flexure is the part involved and diagnosis can be made, opening
the intestine in the right groin and establishing an artificial anus
should be attempted.
In the development of the foetus the anal part of the bowel, beginning
below, develops upward, and the intestinal portion, commencing above,
grows downward; both portions, advancing, finally unite, making one
continuous tube. When, however, there is some interruption in the
foetal development of the intestine, and the two portions of bowel fail
to unite, we have malformation of the rectum and anus and intestinal
obstruction; or the two portions of bowel may have been united and
continuity of the intestinal track established, and subsequent
intra-uterine inflammation may obliterate the canal. Under these
circumstances a ligamentous cord represents the original tube. The cord
descends from the cul-de-sac in which the upper part of the bowel ends
to the skin about the anus, or is lost in the tissues about the neck of
the bladder. In congenital malformations the following conditions may
be found: 1st. The anal orifice may be so minute as not to allow the
feces to escape; or the aperture may be occluded by a membrane, through
which the meconium may be seen; or the anus may be entirely absent. 2d.
The rectum may be occluded by a membranous septum, the presence of
which is not suspected until symptoms of intestinal obstruction arise,
and then it is discovered by introducing the finger or a probe; or the
rectum may be entirely absent, the colon terminating in the iliac fossa
in a dilated pouch, or ending at the top of the sacrum or stopping at
any point between this and the normal anus, the place being determined
by the period of arrest of foetal development; or, the anus being
absent, the rectum may open into the vagina, bladder, urethra, and
other places. These cases belong exclusively to the surgeon.
Impaction of Foreign Bodies.
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 {838} 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. Gross[2] 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. Agnew[3]
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.
[Footnote 2: _System of Surgery_, by S. D. Gross, 6th ed., vol. ii. p.
616.]
[Footnote 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 {839} 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 {840} 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.
It is a common practice with uninformed persons to give castor oil or
some purgative medicine when a pin, needle, coin, or other foreign
substance has accidentally passed from the mouth into the stomach. Such
practice is irrational and hurtful. Experience has shown that the
larger and more solid the alvine discharges, the more likely the
foreign body is to escape by the natural outlet; and the physician
should order such a regimen and diet as will probably secure this
condition of the contents of the bowel.
Long residence of a foreign mass at any point in the intestinal canal
is certain to produce some chronic enteritis and effusion of lymph and
subsequent stricture of the bowel, or the presence of the foreign body
may produce an ulcer; and when this is healed the resulting cicatrix
may end in serious obstruction from the natural tendency of the new
material to contract. Signs of constriction of the bowel may not be
noticed for some time after the escape of the foreign body.
Obstruction from the presence of intestinal stones and concretions is
almost invariably preceded by impaired health, emaciation, or cachectic
appearance, signs of partial impermeability of the bowels, and repeated
attacks of inflammation, especially in the region of the cæcum. It
terminates sometimes by the concretion becoming encysted, by its
spontaneous evacuation, or by ulceration and perforation, or sometimes
by complete occlusion of the bowel, and death.
As occlusion of the bowel by the presence of gall-stones always occurs
in the small intestines, the symptoms are at once of the most urgent
and violent character. The signs are those of internal strangulation,
and the termination is often rapid in the extreme. Colicky, griping
pains are soon succeeded by violent agony; vomiting begins at once, and
is constant; at first bile is thrown up, and afterward feculent matter;
the pulse is small, wiry, and frequent; the belly is retracted; the
features are pinched, the extremities cold, and prostration soon comes
on, succeeded by collapse.
Evidences of disorder of the liver, symptoms of inflammation of the
peritoneum in that region, or attacks of hepatic colic sometimes
precede obstruction of the bowel by gall-stones; unfortunately,
however, for the purposes of diagnosis, these premonitory symptoms are
not invariably present.
Acute Internal Strangulation, Twisting, etc.
When a portion of bowel within the abdomen is constricted, its
circulation interfered with, and the passage of the contents of the
bowel interrupted, it gives rise to acute internal strangulation. This
condition is very similar to that of external strangulated hernia. The
difference is, that one is inside and the other outside of the cavity
of the abdomen.
Twisting of the gut upon its mesenteric axis, the passage of the bowel
through some natural or unnatural opening, the encircling of one
portion of bowel by another or by bands, false membranes, etc., may
cause {841} internal strangulation. It may happen at any age, and
involves generally the small intestine or the more movable parts of the
large bowel--viz. the sigmoid flexure and cæcum.
Twisting, or torsion, is not an unfrequent cause of intestinal
obstruction, and may involve almost any portion of the intestinal tube.
Its most common site is the sigmoid flexure, and next in point of
frequency the cæcum. It sometimes, but rarely, involves the small
intestines, and may occur as a simple twisting of one loop of
intestines upon another. Several conditions are necessary for its
production. First, the mesentery must be elongated. This change in the
mesenteric root may have been caused by the dragging of an old and
large hernia, or the mesentery may have been lengthened by relaxation
of the abdominal walls from childbearing or by the disappearance of
fat. However caused, before torsion of the gut takes place the
mesentery is elongated, so that the two ends are approximated and
something like a pedicle formed. Second, the portion of bowel attached
to the lengthened mesentery may become filled with an enormous quantity
of fecal matter and paralyzed by the great distension. In this paretic
condition it may be displaced by the living, moving parts around it,
and become bent and twisted, or the length of bowel belonging to the
elongated portion of the mesentery may be the seat of inflammation,
and, paralysis following, it becomes without resistance subject to the
pressure and movements of the active vital parts surrounding it. A
portion of bowel with its accumulated contents having a redundant
mesentery and paralyzed by enormous distension or by inflammation, or
by both, may readily be twisted more or less completely, and in some
cases several times upon itself.