Intestinal obstruction

“ Partial strictures of the intestine, if the stricture be not too narrow, may pass unnoticed for years, and final complete obstruction may result from a blockage of the stricture by some foreign substance such as a plug of hard faecal matter or a fruit stone.
Treatment of Acute Intestinal Obstruction.—Early diagnosis and early laparotomy are essential, and it is important to operate before the patient is poisoned by the absorption of toxins from the bowel. To administer purgatives is worse than useless. ”

“ If the constipation ends in fecal accumulation, the worst symptoms of mechanical obstruction may present themselves at any time, and death of the individual follow. The practitioner should always keep this fact in mind in treating every case of intestinal obstruction, and search for fecal impaction by examining the rectum and the whole length of the large intestine through the anterior abdominal wall. ”

“ Chronic Intestinal Obstruction.—The causes of chronic obstruction are very numerous, and may be divided into the following groups: (1) intra-intestinal conditions, i.e. the impaction of foreign bodies and impaction of faeces; (2) affections of the intestinal wall such as stricture, new growths in the intestine, particularly those of a malignant type, adhesions or matting together of the intestines from peritonitis or kinking of the gut from disease of the mesenteric glands; (3) chronic intussusception; (4) compression of the bowel by a tumour or bands developing outside the intestine. ”

“ The chronic ulceration, the scarring, thickening, and contractions of the gut are irremediable conditions which too often, after months or years of suffering, lead to intestinal obstruction or, very frequently, to atrophy of the glandular and absorbent system of the entire alimentary tract, general wasting, and fatal asthenia. Such patients hardly ever pass a healthy motion; they are troubled with chronic indigestion; at times they pass their food unaltered; they have recurring attacks of diarrhœa ”

“ 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 malformation is of such a character that the fecal matter can find no exit, a train of symptoms ensues analogous to those seen in the adult affected with intestinal obstruction: the infant cries and is constantly restless, refuses food, vomits, the abdomen distends, and death speedily ensues. A remarkable exception to this rule was the case mentioned by Bodenhamer of a child with absence of the rectum who was not operated on until three months after birth, and who was apparently in perfect health. ”

“ Acute symptoms of a violent nature are sometimes developed in persons who have been constipated a long or short time, in consequence of attempts at purgation or from the accumulation of indigestible food. Violent paroxysmal pains in the abdomen and efforts at stool are soon followed by symptoms of intestinal obstruction and serious collapse. Quick relief follows a free movement from the bowels obtained by an enema, or if not so relieved the case may terminate fatally. ”

“ The convex side of the middle cylinder is often thrown into transverse folds or convolutions. Intussusception, which gives rise to symptoms characteristic of intestinal obstruction during life, is invariably from above downward. It is doubtful whether there is on record a single well-authenticated case of inflammatory invagination where the lower segment of bowel protruded into the upper. ”

“ Should the disease be arrested these ulcers may heal entirely, but occasionally they remain, causing more or less disorganization of the coats of the intestines, as is often found in chronic dysentery. Sometimes, though rarely, the ulcers perforate the intestines, causing rapidly fatal inflammation of the peritoneum, or they may erode a blood vessel and produce violent haemorrhage. Even where they undergo healing they may cause such a stricture of the calibre of the intestinal canal as to give rise to the symptoms of obstruction which ultimately prove fatal. ”

“ This condition is sometimes found after death in persons old or young, but particularly the latter, in whom during life there were no symptoms of intestinal obstruction or intestinal trouble of any kind. The displaced intestine in these subjects is easily reduced, is unattended by any signs of inflammation, and is evidently the result of spasmodic contraction of the transverse muscular fibres of the bowel at one part, with distension and relaxation at another part, by which, just before death, one piece of the bowel is pushed into an adjacent piece. ”

“ In volvulus involving the sigmoid flexure, when injury to the bowel is great, the symptoms are acute in the extreme. After peritonitis or enteritis begins, progress toward a fatal issue is very rapid, the patient rarely living more than three or four days. In occlusion from stricture, compression, fecal impaction, and chronic intussusception the patient may live for weeks or even months.
The statistics of Leichtenstern show that from 5 to 10 fatal cases of intestinal obstruction occur every year among every 100,000 inhabitants ”

“ The bowel below the seat of complete constriction may be full of fecal matter, and the discharge of this spontaneously or by the aid of enemata may induce the attendant not to regard the case as one of occlusion. Stercoraceous vomiting, as a rule, comes on early in acute and late in chronic cases of complete occlusion of the gut; in spasmodic ileus or impermeability not due to mechanical occlusion feculent vomiting is only occasionally seen.
The duration of life in acute intestinal obstruction varies very much in different cases: death may ensue in a few hours or not for ten or twelve days ”

“ If the stone happily finds its way into the intestine the distress suddenly ceases. In the meanwhile relief may be afforded by fomentations, and by morphia or chloroform, but if no prospect of the stone escaping into the intestine appears likely, the surgeon will be called upon to remove it by an incision through the gall-bladder, or the bile-duct, or through the intestine at the spot where it is trying to make its escape. Sometimes a gall-stone which has found its way into the intestine is large enough to block the bowel and give rise to intestinal obstruction which demands abdominal section. ”

“ A continuous stream of carbonic acid or of hydrogen directed against muscular tissue will cause paralysis of the part.
Physicians admit that in certain portions of the alimentary canal extensive dilatation may occur, independent of any permanent obstruction, in the lumen, or bore, of the gut. As a rule, however, victims of proctitis and colitis suffer from more or less occlusion of the lumen in the region invaded by the ulcerative inflammatory process. ”

“ Collapse often follows upon shock--for example, in intestinal perforations, or after abdominal operations complicated by peritonitis, especially if there is vomiting, as in cases of obstruction high up in the intestine. The symptoms of collapse are aggravated if toxin absorption is superadded to the loss of fluid. ”

“ This condition may be caused by foreign bodies introduced into the anus, by indigestible substances swallowed, by impaction of feces, by pressure of tumors external to the rectum, and by intestinal concretions. Any condition which causes loss of muscular and nervous tone in the large intestine favors its obstruction; thus, it is not uncommon in the aged of both sexes, but especially is this the case in women, and in them it often follows parturition. Hysterical, nervous, and debilitated persons are particularly prone to it. ”

“ Sometimes a sudden disappearance of the symptoms of obstruction—a result due to the softening and breaking down of the cancerous mass, restoring temporarily the integrity of the intestinal tube—may give an unjustifiable hope to the patient; or the same effect may follow the establishment of a communication, by ulceration, between the bowel above the tumor and some portion nearer to the anal orifice. The progress of the new growth soon annuls the benefits thus gained. ”

“ The abdomen is soft and flaccid and the affected coil is rarely to be felt. The symptoms vary with the situation of the obstruction and are generally more urgent the nearer to the duodenum. Foreign bodies that have been swallowed by accident or otherwise may give rise to obstruction, though extraordinary objects, as knives, coins, pipes, flints, &c. swallowed by jugglers, are known to have passed by rectum without injury. In cases where the foreign body lodges in the intestine the caecum and duodenum are favourite situations for obstruction. ”

“ When the obstruction is situated in the lower part of the colon and rectum, its precise seat can be determined by digital or manual examination or the use of a bougie or tube. When the site of obstruction is above the sigmoid flexure, it is difficult, and occasionally impossible, to determine its exact locality. As a rule, when the constriction is in the small intestine the symptoms are acute and urgent; pain is intense, vomiting comes on soon, and prostration is early and extreme. When the large intestine is involved, except in volvulus, the symptoms are generally chronic. ”

“ In obstruction of the bowel from fecal accumulation, inflamed and thickened intestine, stricture, compression and traction, and contraction of the gut from cancerous deposit, the symptoms are gradually presented and chronic in character. They are unlike the signs of acute obstruction, which occur in persons apparently in perfect health and are sudden and violent from the beginning. In chronic obstruction of the intestine the patient has probably been complaining for some time, with symptoms of abdominal trouble. ”

“ The lesions are those of acute gastro-enteritis—congestion of the mucous membrane, abomasum, and intestine, submucous infiltration, shedding of the epithelium, which sometimes attains the stage of ulceration, suffusion and intestinal or superficial hæmorrhage, dilatation of the capillaries, etc.
The symptoms of poisoning are produced by the absorption of toxic products, which pass from the intestine into the blood current.
Poisoning is frequently complicated by infection produced in a similar manner. ”

“ Gradually these will lose their efficacy, and finally complete obstruction of the lumen of the gut is effected; in which event the symptoms of ileus will develop, with cramps and vomiting, finally of a fecal character, and the fatal issue quickly follow. Not unfrequently peritonitis is developed, and may be of a chronic character or may destroy life within a day or two, or the patient may die from exhaustion before the obstruction becomes complete. ”

“ 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. ”

“ I have met with some violent and untractable cases which proved fatal in the acute state; but, in general, this disease draws out to a chronic form in this climate, and does not prove mortal for many weeks. The usual cause of death appears, from the inspection of the bodies, to be an ulceration of the great intestines, particularly of the descending colon and the rectum. This part of the intestinal tube is most affected from its being the receptacle of all the acrid secretions from the rest of the canal ”

“ Proctitis, the most widespread disease of civilized man, originates very early in life, and develops in after years numerous painful symptoms—such as piles or hemorrhoids, con­sti­pa­tion, etc.
Now, what is the most common exciter of proctitis, which, as has been said, is an inflammation of the mucous membrane of the anus and rectum? In my earlier work, Intestinal Ills, I have shown that inattention to the soiled diaper is generally the original cause of this most grievous of ills, with its train of malign consequences continuing throughout the victim’s life on earth. ”

“ The usual site of stricture is the large bowel: contraction is far more frequently seen in the small intestine, and is caused by an effusion of lymph following simple peritonitis or the inflammation attending the formation of cancer or tubercle of the peritoneum. Coils of intestine are matted together or to neighboring parts in this way by bands of lymph or false membranes, and the action of the bowel interfered with or obstructed. Constriction of a length of bowel may be found after death, or a sharp, angular bend by which complete obstruction has been produced. ”

“ As has been pointed out, inflammation, septic poisoning, intestinal foulness, or retained feces, act as irritants on the mucous membranes, thereby drawing the blood to the colon where it is excreted and exhaustion follows. The great danger in diarrhea, therefore, is the rapid depletion of the vital force. But when the small intestines are affected the consequences may be still more deplorable. Then the unassimilated food is hurried along too quickly for absorption and the body receives but little nourishment to restore its powers. ”