ILEUS CAUSED BY NEOPLASMS.
My clinical experience with ileus due to neoplasms has been most unsatisfactory, from the fact that I have had a mor tality of nearly 5o per cent. of all cases of this kind that I have operated, either from shock or sepsis, or continued obstruction of the intestines, and because of the fact that of all the cases that lived there were but two whose recovery I have not re gretted. In other words, my efforts in giving these patients surgical relief have been successful ( with two exceptions) only in the cases that did not recover. The same experience is found in the reports of a number of other surgeons,—Kroenlein, Madelung, and others.
From a scientific stand-point, however, the subject is inter esting, but the limited time given to this paper will make it necessary to simply touch upon the important points.
Pathology. The following varieties of neoplasms have given rise to ileus : carcinoma, sarcoma, myosarcoma, myoma, fibroma, lipoma, adenoma. Their frequency corresponds to the order in which they are given here.
The neoplasm has its origin in the intestine itself, or it originates in any one of the other intra-abdominal organs, and causes the obstruction by involving the intestine. I have oper ated upon patients suffering from ileus in whom the tumor originated in the ovary, the stomach, the pancreas, the omen turn, the liver, and the mesenteric lymph glands.
Carcinoma of the intestine causing ileus is most common in the rectum ; next in the sigmoid flexure of the colon ; next the splenic ; next the hepatic flexure; next in the ileoccal valve, and next to this in the duodenum.
Most of the cases of primary sarcoma, myoma, and myo sarcoma that I have encountered in the literature occurred in the small intestine; while lipoma, adenoma, and fibroma are more commonly found in the colon.
Primary carcinoma gives rise to ileus only when annular, the obstruction being due both to contraction and to accumu lation of carcinomatous tissue within the lumen of the intes tine. Not infrequently the exciting cause of the ileus is the impaction of some undigested portion of food. In a case of carcinoma of the splenic flexure of the colon, I found an orange seed impacted ; in a case of carcinoma of the sigmoid, an en terolith.
Ileus due to the other primary neoplasms of the intestines usually results from acute bending of the tube or intussuscep tion or valve formation, because these tumors are usually spherical or pear-shaped, and cause obstruction by dragging upon the walls of the intestine.
Ileus due to secondary involvement of the intestine by car cinoma or sarcoma occurs most frequently through the inclu sion of the sigmoid flexure in a sarcoma or papilloma of the ovary ; but, as stated before, the invasion may occur from any one of the other intra-abdominal organs. In each of course, the origin determines the pathological structure of the neoplasm. In primary tumors the carcinoma is always of the glandular type ; the sarcoma is most commonly of the spindle celled variety.
Diagnosis.Although the conditions which ultimately re sult in ileus due to neoplasm develop very slowly, the onset of the obstruction is usually quite sudden. The symptoms con sist in the obstruction to the passage of gas, nausea, and, later, vomiting, the latter becoming more and more severe until it may become stercoraceous. Pain usually follows the adminis tration of cathartics. Upon inspection of the abdomen, peri galsis of the small intestines will be observed, and it is this symptom which is of the greatest value. Percussion may demonstrate an area of dulness corresponding to the location of the neoplasm. Early in the attack, before the abdomen has become severely distended with gas, it is often much easier to recognize this dulness than later on.
If the abdominal walls are thin, the growth can some times be palpated ; although its most common locations—the upper end of the rectum, the sigmoid, the splenic and hepatic flexure—make this a very difficult task. If in the rectum, the tumor can be located with the proctoscope or by digital exami nation. Auscultation has been recommended because it is claimed that it is possible to follow the sound caused by the gas and fluid in the intestines to the point of obstruction, thus locating the neoplasm. I have succeeded several times in fol lowing this sound, but in each case the obstruction was at a dif ferent point from the one located by this method.
In a general way one may state that if the vomiting is severe directly after the beginning of the obstruction, the neoplasm is high up in the alimentary canal, and vice versa. The neoplasm can frequently be located by the history of pain in the region of the neoplasm for some time previous to the occurrence of the obstruction. This may be due to the irrita tion of ulcers which usually exist in the intestine above the loca tion of the tumor. This fact has been of great value in a num ber of my cases.
History.There is usually a history of chronic constipa tion. In some cases this is intermittent with attacks of diar rhcea. There are usually several acute attacks of obstruction, occurring especially when indigestible food has been taken, which pass away in a short time, before there is a severe at tack. Quantities of mucus accumulate above the stricture, and this is evacuated from time to time, or may be evacuated daily for a long period of time. Many of these cases give a history of repeated evacuations of blood. It is rare to find portions of the tumor which have been torn loose and evacuated with the faces. In one however, in a patient fifty-one years of age, with a carcinoma of the lower end of the sigmoid flexure, I was able to make a positive diagnosis in this way.