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, {863} 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 {864} 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.
{865} Great care should be taken to support the strength of the patient
by concentrated and nutritious food, and in the later stages by
stimulants. When the bowels are distended by gas an injection into the
rectum of ten grains of sulphate of quinia will often give marked
relief.
It has been proposed to tap the distended gut with a fine trocar when
accumulation of gas is enormous, causing dyspnoea and great general
distress; temporary relief is often obtained by this plan, which is an
imitation of a common practice among veterinary surgeons. Something
more than temporary relief may, however, follow the tapping. In
twisting of the bowel, in internal strangulation by band or loop or
ring, and in some cases of invagination, the constriction is kept up by
the enormous gaseous distension. The obstruction is continued as much
by causes within as without the intestine. When tapped and the gas
drawn off, the bowel collapses, and may escape from its constriction
and return to its natural condition. Tapping is not always certain or
safe. The trocar or aspirating tube may pass between the convolutions
and no escape of gas take place, or it may be followed by fecal
extravasation into the peritoneal cavity. Notwithstanding the risk, the
plan is a valuable one, and in suitable cases should be resorted to.
SURGICAL TREATMENT.--In cases of acute obstruction of the bowel from
bands of lymph, diverticula, internal hernia, slipping of a portion of
gut into some opening, or twisting, when the treatment suggested has
been tried and fails, laparotomy should be performed; that is, the
abdomen should be laid open, the cause of the obstruction searched for,
and, if possible, removed. In acute cases a few hours, at most one day,
may be spent in trying the medical means recommended. After that time,
if the patient is not relieved, the sooner laparotomy is resorted to
the better the chance to save life. Acute internal strangulation of the
bowel from these causes has the same symptoms, course, and termination
that acute external strangulated hernia has. It demands the same
treatment--removal of the cause of the constriction. Delay in
performing the operation in the former is as certain to be followed by
peritonitis, gangrene, and death as it is in the latter; and the
surgeon who hesitates to open the abdomen and attempt to remove the
constriction in a case of acute obstruction after a fair trial and
failure of medical measures, is as culpable as the one who delays the
operation of herniotomy for unrelieved strangulated hernia.
In rare instances spontaneous self-reduction of external strangulated
hernia takes place; the cases are exceptional, and the fact is no
apology for postponing herniotomy. So in occasional instances acute
internal strangulation is spontaneously relieved; here too the cases
are exceptional, and the occurrence should be no excuse for delay in
laparotomy. To justify the operation it is not necessary that the
precise site and nature of the mechanical impediment should be
determined, although this can usually be done. It is only necessary to
know that the cause of the acute obstruction is not enteritis or
peritonitis, but a constriction mechanical in character, which no
medicine or manipulation or expectant treatment can relieve. When
diagnosis is clear and laparotomy is indicated to save or prolong life
in intestinal obstruction, the aid of the surgeon should at once be
invoked. Delay is fatal. Peritonitis beginning or in actual existence
makes abdominal section more dangerous and {866} lessens materially the
chances of recovery. To make the operation absolutely the last resort
when the bowel is injured beyond repair, when peritonitis is in full
progress, gangrene threatening, or the patient on the verge of
collapse, is a useless cruelty to the sufferer and his friends, and
only serves to bring surgery into disrepute. If the truth were known,
many of the cases of death following laparotomy should be ascribed not
to the fact that the knife was used, but to the fact that it was used
too late.
In intussusception not relieved by medical means the propriety of
abdominal section is questionable. The subjects of this condition are
usually children. Dislodging the invaginated bowel is not always
practicable, and the opium or expectant treatment may end in
spontaneous cure by the bowel righting itself or by sloughing of the
intussuscepted part. It is doubtless true that many of the so-called
cures from the latter process subsequently die from contraction of the
cicatrix at the site of the separation of the slough. In 43 cases
collected by Ashhurst of laparotomy for invagination, 13 recovered and
30 died. The record is bad, and to some extent the heavy mortality is
due to the fact that the operation was put off too long--delayed in
acute cases until sloughing had taken place, and in chronic cases until
adhesion of the invaginated parts had occurred. Indeed, some of the
cases reported were moribund when the operation was undertaken.
Recently many successful cases have been reported, and it is fair to
presume that the percentage of recoveries in the future will be greater
than they have been in the past.
In acute intestinal obstruction due to bands, internal hernia,
volvulus, or the presence of foreign bodies, as gall-stones, there is
no question that laparotomy should be performed after other measures
for relief have been employed and failed. Death in such cases is
inevitable and imminent, and operative interference should not be
postponed until peritonitis has set in. After the abdominal cavity has
been opened the distended gut can easily be found and the fingers of
the operator carried on down until the site of the constriction is
reached and the cause of the obstruction discovered. If the
constriction is due to the presence of bands or adhesions, they should
be cut or broken up and the gut relieved. If an internal hernia is
found or a portion of bowel has slipped into some fissure or pocket, it
should be withdrawn and the parts restored to their natural position.
If the cause of the obstruction is a volvulus, the bowel should be
untwisted. If a foreign body is felt impacted in the bowel and closing
it, unless it can be readily and without danger of lacerating the coats
of the gut pushed on by the fingers of the operator until it has passed
the ileo-cæcal valve, the foreign body should be removed from the bowel
by an incision and the wound in the bowel afterward closed by sutures.
If the case is one of intussusception, the invaginated parts should be
pulled out: this is practicable where adhesions are absent or slight,
but if the adhesions are very firm, and it is impossible to restore the
parts to their natural position, the gut should be laid open above the
occlusion, the edges of the opening should be attached to the margin of
the external wound, and a fecal fistula established. If the case of
acute obstruction be due to stricture of the small intestine, which is
exceedingly rare, the gut may be laid open, and the patient recover
with fecal fistula, or entorectomy or resection of the diseased part of
the gut be resorted to. The operation of entorectomy has been
recommended by many {867} surgeons, and a large proportion of the cases
reported recovered. In one case by Koeberle six and a half feet of the
gut were successfully excised.
The following table by Ashhurst[12] shows the results of laparotomy. It
will be seen that in 230 cases 68 recovered:
| | Result | |
| | not | |
| | ascer- | Recov- |
| Cases. | tained. | ered. | Died.
---------------------------------+--------+---------+--------+------
Operations for-- | | | |
Volvulus | 14 | 1 | 4 | 9
Strangulation continuing after | | | |
herniotomy or taxis | 18 | ... | 6 | 12
Invagination | 43 | ... | 13 | 30
Foreign bodies, impacted | | | |
feces, gall-stones, etc. | 18 | 1 | 7 | 10
Strangulation by bands, | | | |
adhesions, or diverticula | 76 | 1 | 20 | 55
Obstructions from tumors, | | | |
strictures, ulcers, etc. | 28 | 2 | 7 | 19
Internal hernia and ileus | 20 | 1 | 7 | 12
Obstructions from other causes | 4 | ... | 1 | 3
Causes of obstruction not | | | |
ascertained | 9 | 1 | 3 | 5
---------------------------------+--------+---------+--------+------
Aggregate | 230 | 7 | 68 | 155
---------------------------------+--------+---------+--------+------
[Footnote 12: _Surgery_, p. 835.]
Enterotomy is an operation originally performed by Nélaton. It is done
by making an incision, preferably in the right groin, above the crest
of the ileum and parallel with Poupart's ligament. When the abdomen is
opened a coil of intestine is found and carefully stitched to the walls
of the incision. A very small opening is then made into the bowel, and
a fecal fistula established. Enterotomy is less dangerous than
laparotomy, as by it there is less interference with the peritoneum;
but no relief could be afforded by this procedure in cases of
intussusception or acute obstruction from bands, hernia, or volvulus.
It is applicable to cases of intestinal constriction when the
obstruction is about the lower part of the small or upper part of the
large intestine. It may be resorted to as a palliative measure when
exact diagnosis as to the character and site of the obstruction is not
clear, the case being otherwise hopeless, or in cases of obstruction
where severe symptoms persist and death is near, and yet for any reason
laparotomy or colotomy is inapplicable; or it may be performed in cases
of contractions after failure of patient and persistent medical
treatment. Many successful cases of enterotomy have lately been
reported, and the operation has been earnestly advocated by Trousseau,
Maunders, Wagstaffe, Bryant, and others. In chronic constriction due to
stricture or other mechanical obstructions, malignant or otherwise, not
remediable by any medical measures, colotomy should be performed. By
this operation the colon is opened and an artificial anus established.
The sigmoid flexure in the left lumbar region is the part selected for
the colotomy if the obstruction is situated in the gut below that
point. When the obstruction is higher up in the colon or its exact site
cannot be determined, the cæcum in the right lumbar region is the part
chosen. In cases of obstruction from the mechanical pressure of tumors,
the possibility of relieving the compressed bowel by treating the
tumors should of course be considered before resorting to colotomy.
{868}
CANCER AND LARDACEOUS DEGENERATION OF THE INTESTINES.
BY I. E. ATKINSON, M.D.
The term cancer of the intestines is used here in a clinical sense to
designate new formations in the intestinal tract the tendency of which
is to destroy life, and has no reference to the histological characters
of the tumors, inasmuch as these are, during life, for the most part,
concealed from the eye of the pathologist. It so happens, however, that
in a histological as well as in a clinical sense the term is
appropriately applied to all but a very few of the malignant new
growths that develop in the parts under consideration, if we adopt, as
seems proper, the opinion of most modern pathologists, that cancer or
carcinoma should only include those tumors "consisting of cells of an
epithelial type, without any intercellular substance, grouped together
irregularly without the alveoli of a more or less dense fibroid
stroma."
Carcinoma of the intestines appears either as cylindrical-cell cancer,
as scirrhus, or as gelatinous or colloid cancer. Scirrhous cancer of
the intestines may resemble in appearance and texture the ordinary
medullary cancer, degrees of hardness or of softness depending upon the
predominance of the stroma or of the cellular elements in the
constitution of the tumor. Rarely, and in a purely clinical sense,
cancer of the bowels may exist as a lympho-sarcoma in the small
intestine, and then through progression from the glands of the
mesentery or elsewhere. Primary intestinal sarcoma has, however, been
observed. Similarly, melano-sarcoma has been detected in the intestine
as secondary to this form of sarcoma, originating in the skin or in the
eye.
Of the forms of carcinoma, cylinder-cell cancer is the most frequent.
Carcinoma gelatinosum or colloid cancer is of great relative frequency,
but it is altogether probable that here, as elsewhere, this represents
a degenerative form of ordinary carcinoma. At all events, it is certain
that it may be detected in many cases where the essential changes
reveal the ordinary glandular or cylinder-cell variety. These forms of
cancer may affect the bowel primarily or secondarily by extension from
adjacent organs and textures, or by metastasis. Primary cancer occurs
most frequently, metastatic cancer with great rarity. The relative
frequency of the different forms of cancer is not definitely known. In
the article on carcinoma in the _Dictionnaire Encyclopédique des
Sciences médicales_ (xii. pp. 576, 577) cancer of the bowels is said to
constitute about 8 per centum of all carcinomatous new growths.
Sibley[1] found that primary {869} carcinoma occurred in the alimentary
canal (exclusive of the mouth, tongue, and the annexed organs) in 6 per
centum of the cases collated by him. Tauchou's compilations of nine
thousand fatal cases of carcinoma show that intestinal cancer was
present in 4 per centum.[2] These computations include cancer of the
rectum. If statistics of cancer of the bowels exclusive of rectal
cancer were available, they would show, doubtless, a much smaller
proportion.
[Footnote 1: _Medico-Chir. Transact._, xlii., 1859.]
[Footnote 2: Leube, _Ziemssen's Cyclop._, vii. p. 432.]
Any portion of the intestinal tract is liable to be attacked by cancer,
though undoubtedly some parts of it with much greater frequency than
others. Köhler[3] reported that in thirty-four cases the cancer was
situated twenty-two times in the large intestine (the rectum excluded)
and twelve times in the small intestine (nine times in the duodenum).
It is not unlikely that in the cases of duodenal cancer the new growth
extended from the pylorus. At all events, primary cancer is seated with
far greater frequency in the large intestine, and, not including the
rectum, usually in either the sigmoid flexure or the cæcum. Grisolle[4]
declares the large intestine to be four times more often affected with
cancer than the small intestine; that the sigmoid flexure is attacked
as often as all the rest of the colon taken together; and that the
cæcum is still more often affected. Where the intestinal new growth is
secondary to carcinoma elsewhere, it is usually so by extension from
neighboring parts; thus, the ileum may become implicated by contact
with uterine cancer, etc., and cancer of the stomach, liver, kidney,
etc. may invade the colon.
[Footnote 3: _Ibid._, vii. p. 431.]
[Footnote 4: _Pathologie int._, 1865, ii.]
Cancer of the intestines usually begins after the middle period of
life, and apparently irrespective of sex. Nevertheless, young persons
are occasionally affected, and children sometimes develop malignant new
growths of the bowels (usually sarcomatous), either primarily, which is
rare, or secondarily, by extension from other parts. The influence of
heredity seems not to be well established. There can be no doubt that
chronic irritation may act as an exciting cause of cancer of the
bowels, as it may in cancer of other parts. It has been impossible to
recognize any specific influence from especial forms of irritation, and
it is not likely that such exist. Indeed, the etiological relations of
intestinal cancer remain exceedingly obscure.