ILEUS DUE TO MECHANICAL OBSTRUCTION TO THE FAECAL CURRENT.
In the present paper I have limited my remarks to me chanical ileus or enterostenosis, or acute intestinal obstruction in which faecal movement is mechanically impeded or pre vented, a condition that is accompanied by pretty uniform and definite symptoms, and almost invariably terminates in the death of the patient within a comparatively few days, unless the mechanical obstruction to the faecal current is removed by a surgical intervention. This limitation, of course, excludes a large number of cases of ileus that have an inherent tendency to recover under expectant or medicinal treatment, such, for example, as adynamic or paralytic ileus, dynamic, postopera tive, septic, reflex, vascular, and ileus due to neoplasms. The latter varieties, however, require prompt surgical intervention to save life. We exclude also congenital impermeability of the intestinal canal. For a clearer understanding of the pathology of mechanical ileus, we may classify the various forms of acute intestinal obstruction as based upon an anatomical cause : First, from compression ; second, from obstruction ; third, from constriction.
Obstruction to the intestine by compression from without includes all forms of internal strangulation of the bowel, and is accompanied by symptoms identical with those of external strangulated hernia. The division adopted by Treves is gener ally followed, to wit : ( 1 ) Strangulation by peritoneal false bands, or omental cords.
(2) Strangulation from diverticula.
(3) Strangulation by normal structures abnormally at tached.
(4) Strangulation through slits or apertures on the mes entery, omentum, or peritoneal bands.
( ) Whenever we have an aseptic or plastic peritonitis, we are likely to have the formation of adhesions between ad jacent coats of intestines by reason of the lymph exudate, which in time gradually becomes elongated and stretched out until it forms bands or false ligaments of considerable length, at tached at one end to the intestine, at the other to a neighboring loop of intestine, to the abdominal wall, to the omentum, or mesentery, or to the bladder, uterus, ovary, tube, appendix, or some viscus, so that it becomes a source of danger to the patient and a frequent cause of ileus by permitting a loop of intestine to slip under or over them, or to be looped about them in a noose. Such adhesions and bands may be the result of pelvic peritonitis, or a local peritonitis around a hernia, or the vermi form appendix, or the gall-bladder; and they are frequently postoperative, due to a stump improperly sutured, or an intra peritoneal lesion left denuded of peritoneum, to septic infec tion, to foreign bodies, as ligatures, sutures, sponges, gauze, drainage tubes, etc., or too long exposure of the peritoneal sur face to dry air or too much handling, or by the use of antiseptic solutions in the abdomen, or anything that will abrade or infect the endothelial covering of the bowel. I have operated on a considerable number of cases of acute intestinal obstruction due to one or more of the different causes here enumerated.
(2) Strangulation from diverticula is usually met with in the ileum within three feet of the ileocmcal valve.
(3) Strangulation by normal structures abnormally at tached.
Under this head the vermiform appendix may become fixed by its free end to the cxcum, ileum, ovary, or Fallopian tube. A Fallopian tube, or the mesentery and omentum, may form similar attachments and cause strangulation.
(4) Strangulation through slits or apertures takes place through normal openings, as the foramen of Winslow, and also in accidental or traumatic slits, as in the mesentery, omen tum, or broad ligament, the bowel becoming bent or kinked upon itself, and by compression, peritonitis, adhesions, and strangulation soon follow. This form of obstruction is almost invariably met with in the small intestine. Volvulus or twist ing of the bowel is usually met with in the sigmoid flexure, and is caused by a long mesentery, with a narrow attachment, per mitting rotation of a loop upon its own axis or upon its mesen teric attachment, or around an adjacent coil of small intestine.
Intussusception or invagination of the bowel wall into the lumen of an adjacent part constitutes nearly one-third of all cases of acute intestinal obstruction. Nearly all cases of ob struction in children are due to this cause. There are four varieties,—the ileocaecal, the colic, the iliac, and the ileocolic. The first variety is the commonest. Intussusception is due to active peristalsis—obstruction of the intestinal canal by foreign bodies. Gall-stones, enteroliths, fruit-pits, worms, and other foreign bodies cause obstruction in the ileum near the ileoczecal valve. Obstruction of the bowels from constriction due to cica trization of ulcers, new growths, tumors, etc., will be excluded, as they all usually give a history of chronic obstruction for a considerable period before acute obstructive symptoms develop ; neither do we include reflex ileus due to the impaction of a gall stone in the cystic duct, or a calculus in the ureter, or the press ure of a tumor on an ovary, although each of these conditions may give rise to symptoms closely analogous to that of me chanical ileus.
Symptoms. Mechanical ileus or acute intestinal obstruc tion is marked by a group of symptoms that are remarkably uniform if studied before they are masked by the administra tion of opium. These classical symptoms of acute obstruction of the bowels are pain due to rupture or tearing of the peri toneum by the constricting or compressing force, pain that is sudden and sharp in its onset, and distinctly paroxysmal in character, colicky pain due to the intermittent muscular con traction of the bowel wall, as each peristaltic wave beats against the obstruction seeking to overcome it. These waves can be seen and felt and heard upon the proximal side of the obstruc tion in all cases where the abdominal walls are thin. They terminate at the point of obstruction, and are a guide to its loca tion. The pain is usually referred to the region of the umbili cus at first, but soon becomes diffuse, and is relieved by pressure or compression. The abdomen is not tender at this stage. Eructation and vomiting soon begin; at first the contents of the stomach, then of the small intestine, and, if the obstruction is low down in the ileum or colon, stercoraceous vomiting fol lows in twenty-four to forty-eight hours. Distention of the abdomen is rapid and progressive, and its extent depends upon the location of the obstruction. The higher up it is, the less the distention, and in colonic or sigmoid obstruction the dis tention is sometimes enormous. Constipation is complete from the moment of the acute obstruction, although enemas may bring away a small amount of faecal fragments and gas con tained in the bowel below the seat of obstruction. Symptoms of shock or collapse are usually present. The countenance is indicative of pain and anxiety, and soon becomes drawn and haggard ; the extremities cold ; the fingers blue ; respiration shallow, and diaphragm stationary. Temperature is station ary, or may be subnormal ; the pulse is small and rapid ; urine is either diminished or suppressed.
Diagnosis. We must differentiate mechanical ileus from ileus due to paralysis of the afferent nerve, vascular ileus, dy namic ileus, postoperative ileus, lead-colic ileus, adynamic ileus. septic ileus, paralytic ileus, reflex ileus, strangulated hernia. irritant poisoning, and perforative peritonitis. A careful con sideration of the antecedent history enables us frequently to make an accurate diagnosis of the special variety of ileus in a given but too often the differential diagnosis is made by the aid of a laparotomy or a post-mortem section.
In ileus due to bands or adhesions there is usually a his tory of plastic peritonitis due to a hernia, a salpingitis, an ap pendicitis, or gall-stones, an ovariotomy, or some intra-ab dominal operation that was followed by an abrasion of the endothelial coat of the intestine, and adhesions to an adjacent loop, or to an uncovered stump or pedicle that directs our atten tion to compression from without. Postoperative dynamic ileus cannot be differentiated. In ileus due to compression of the bowel in a slit or opening, there may be a history of ab dominal traumatism also.
In volvulus we have the age of the patient,—forty to sixty, —chronic constipation, and the enormous early distention of the abdomen, to guide us as to the location and probable cause of obstruction.
In intussusception we have the sudden onset of symptoms during infancy, childhood most frequently,—the characteristic tenesmus and desire to evacuate the bowels, the faces consist ing of simply mucus and then mucosanguinolent, with the marked exacerbations of peristalsis and pain, and the history of previous diarrhoea and excessive peristalsis. A lozenge shaped tumor can be felt ; obstruction from foreign bodies usually gives a fairly clear history of gall-stones, or the swal lowing of fruit-pits, or the imbibition of magnesia and chalk for a long time, or obstipation.
Treatment.Lavage of the stomach and rectal or colonic enemata are usually only palliative procedures in mechanical intestinal obstruction, although in intussusception cases are sometimes cured by large enemata of soapsuds or water when the patient is inverted, or the hips greatly elevated. Gaseous enemata also occasionally unfold the invagination, and both these methods should be resorted to in all cases of invagination seen during the first twelve hours before resorting to lapa rotomy. They may succeed in dynamic ileus also, but are usually useless in ileus due to compression of the bowel in a slit or opening, and are harmful in all cases of volvulus. Opium should never be administered. General practitioners, however, continue to use it, notwithstanding the warnings of surgeons as to its inutility and danger in masking the early symptoms that enable us to make an accurate diagnosis, and advise prompt surgical intervention as the only rational treatment in the vast majority of cases of mechanical ileus. The earlier a diagnosis is made, and the earlier a laparotomy is done, the lower the mortality from resection or anastomosis. An artifi cial anus is rarely indicated in acute obstruction. In obstruc tion from neoplasms it is often a valuable preliminary opera tion to conserve the strength and nutrition of a patient before undergoing an enterectomy.
With earlier diagnosis, earlier surgical intervention, and better operative technique, the mortality has been steadily low ered, and will continue to be lowered still more. In pre-anti septic operations the mortality of intestinal resection was 78 per cent., under antiseptic methods 53 per cent., and the sta tistics of 'goo, 47 per cent.
As to the method of operating, the majority of surgeons prefer a median incision, although in cases where there is great meteorism and the obstruction is located at the cxcum, or in the right side of the abdomen, my preference is for an oblique inci sion extending to the right of the rectus muscle, as it brings more directly into view the seat of the obstruction ; there is less handling of the bowels, and, if eventration does become necessary, the intestines are much more easily replaced. When the abdomen is opened, the distended and congested coils im mediately appear in the wound, and, as our search must be made methodically and thoroughly, I usually push them aside and examine the cmcum ; if it is greatly distended and dilated, I know that the obstruction is in the colon, and I make a sys tematic search along the ascending transverse and descending colon until I come to the seat of the obstruction. If I find the urcum collapsed and a coil of collapsed small intestine lying in the pelvis, I know that the obstruction is higher up in the small intestine, and continue my search upward until I come to the point of obstruction. When found, the point of obstruction should always be brought outside of the abdomen, when pos sible, where a resection is necessary. When bands are found to be the cause of obstruction, we must not return the intestines and close the wound when the first point of compression has been relieved, for frequently there are more than one, and, if all are not relieved, the operation is a failure. In the case of obstruction from foreign bodies, the obstructing mass is pushed along the bowel to a healthy point, and either crushed or the bowel is surrounded by moist gauze pads and incised, the foreign body removed, and the incision closed by a Czerny Lembert suture.
In volvulus the bowel is untwisted, and the mesentery shortened in a transverse fold, care being exercised that the angulation does not interfere with the vascular supply of the intestines. Where there is kinking of the bowel and strong adhesions, sometimes the most practical procedure is lateral or anastomosis rather than resection. If in doubt about the via bility .1 of the strangulated loop, it may be brought outside the .4abdomen and treated with hot compresses, and watched for a day or two, after Hahn's method. 4 N. In laparotomy for intussusception, the invagination may N.
be relieved by dragging the intussusceptum out of the in- f f tussuscipiens when the operation is done during the first ;P A twenty-four hours before the bowel wall is permanently dam aged. Small necrotic areas of bowel, or lacerations of small 0, extent, may be infolded by a Lembert suture. In some cases f t complete eventration is the quickest method of finding the ob- h struction, although much manipulation of the intestines is likely .: to be followed by adynamic ileus. i He summarizes that the most frequent causes of intestinal obstruction are intussusceptions and bands. The mortality is 47 per cent.; the mortality of resection is 74 per cent.; the mortality of artificial anus is 77 per cent.
Prognosis depends upon (I) duration of obstruction ; (2) extent and severity of changes in the bowel wall ; (3 ) the nature of the obstruction and the ease or difficulty of the relief; (4) the promptness, judgment, and skill of the surgeon ; (5) the patient's general condition.