Part 142

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 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."

{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 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 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.

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.

The weight of the bowel and its contents, along with the rapid distension of the intestine above, fixes the gut in this state of torsion and effectually prevents it from untwisting. A semi-rotation of the paretic and distended bowel about the mesenteric axis is sufficient to interfere with the supply and return of blood and provoke enteritis. Indeed, the rotation is rarely sufficiently great to produce complete obstruction, and the symptoms are frequently rather those of inflammation than of internal strangulation. For weeks before the final attack the patient usually has symptoms of intestinal disorder, such as flatulence, constipation, and spells of colic, due no doubt to the changes provoked by the elongated mesentery and bent or curved intestine. When torsion takes place the attack is sudden and the symptoms violent and urgent. Vomiting, meteorism, insuperable constipation, and frequently tenesmus, are soon followed by collapse and speedy death. The patient may die in twenty-four hours; he rarely lives beyond the fourth day. In some cases excessive tenesmus and bloody stools are seen in the early stages of torsion of the bowel. The condition may be mistaken for intussusception, but can usually be distinguished by the premonitory symptoms of twisting and by the more rapid course, the sudden meteorism, and quick collapse of the latter.

Still another way by which displacement of intestine may occasion obstruction to the passage of its contents is when a portion of the intestine has a long and narrow mesentery, and around this mesentery, which is like a pedicle, another portion of the bowel is thrown, encircling and compressing it. The accompanying figure, taken from Ziemssen's Cyclopædia, gives a good idea of this condition (Fig. 23). It represents a {842} loop of the small intestine placed around the mesenteric pedicle of the sigmoid flexure. Leichtenstern calls this "intertwining or knotting of two intestinal loops."

In consequence of inflammation of the peritoneum and effusion of lymph, peritoneal surfaces are joined together, and before the lymph is fully organized these surfaces are separated by the constant movements of the organs and the change in the relationship of the parts, and strings and bands of various shapes and sizes are formed in which a portion of the intestine may become entangled and constricted. Sometimes the bowel accidentally becomes engaged in a loop or noose of false membrane, or becomes bound down under a band of fibrin; or, the peritoneal surfaces of some of the organs having been joined together or to the wall of the abdomen or pelvis, a loop of bowel may escape into a slit or opening and become incarcerated; or a fold of bowel may fall into a fissure in the omentum or mesentery or broad ligament of the uterus or suspensory ligament of the liver, and become constricted; or the appendix vermiformis may be twisted around the intestine in such a way as to cause ligation of the tube, or, by becoming attached to some neighboring part, it may form a loop through which the intestine may pass and become obstructed. In the same way the bowel may be constricted by a diverticulum. (This is well shown in Figs. 23, 24, and 25.) Bands entangling the bowel and causing strangulation may be attached to the fimbriated process of the Fallopian tube or the ovary or uterus. Indeed, it is impossible to describe in a limited space the almost infinite ways in which these bands and strings may engage and incarcerate the intestinal tube (Figs. 24, 25).