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COMPOUND

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ACUTE OBSTRUCTION OF THE BOWEL, DUE TO
MECHANICAL CAUSES.*

BY DR. M. C. MCGANNON, OF NASHVILLE, TENN.

THIS is a subject of paramount importance to both the physician and surgeon: one upon which neither can afford to err, either in diagnosis or treatment, because a mistake in either means death to the patient. The further fact that the disease is, in the great majority of instances, amenable to successful treatment, places it in the list of those that should be familiar to all practitioners of the healing art.

By intestinal obstruction we mean that condition of the bowel

Read at regular meeting of the Nashville Academy of Medicine, Tuesday, Jan. 16, 1906.

by which its contents are prevented from onward passage, because of a closure of the lumen of the gut.

The causes producing this condition, of occlusion of the lumen of the bowel and obstruction of the onward flow of its contents, are either: (1) Within the gut, or, (2) external to it.

The most usual causes operating within the intestine are: (1) Inspissated fecal matter, or fecal impaction. The mass of hardened fecal matter collects in the large intestines, and seldom causes a complete blocking of that viscus.

(2) Fecal stones. Of these there are several varieties: (a) Coproliths, which develop in the large intestine, from inspissated fecal matter. They may attain a large size and great firmness, and completely occlude the lumen of the bowel. It is rare, however, that complete obstruction is produced by these masses, since there is usually sufficient space between them and the wall of the gut to permit of the passage of liquid feces and of gas.

(b) Enteroliths. These are smaller stones that arise in the intestines. They vary much in weight and consistency, depending upon the material entering into their formation. The harder ones are made up of phosphates of calcium, or magnesium, deposited about some foreign body which serves as a nucleus. The lighter and softer enteroliths are made up of vegetable, indigestible material, having incorporated with it salts of lime, magnesium, or sodium.

(3) Gall stones. These gain an entrance to the intestine usually by a fistulous opening between the gall bladder and the duodenum, though cases have not been wanting in which the stone has ulcerated its way into the duodenum from the common bile duct. The stone having reached the intestine, may cause obstruction at any point between that of entrance and the ileo-cecal valve. It is however, much more common to have the lumen of the gut closed where it is smallest and where the intestinal mesentery is shortest; viz., in the lower part of the ileum.

(4) Cases of absolute obstruction by parasites. Authorities are not agreed as to whether complete obstruction ever arises from this cause. The writer has no personal knowledge of an au

thentic case of absolute obstruction due to blocking of the intestinal channel by parasites.

(5) Tumors. Neoplasms growing within the intestinal canal may fill it, and prevent the passage of both gas and feces.

Of the causes acting on the outside of the intestine to narrow its calibre and cause complete obstruction, we may preferably consider :

(1) Volvulus. By this we mean a twisting of coils of intestine upon each other, or rotation of a single coil upon itself, so that the lumen of the gut is closed. The closure is not necessarily always complete. It occurs most commonly at the sigmoid flexure of the colon; rarely at the ileo-cecal junction or other parts of the large intestine. It occurs, though not frequently, in the small intestines. The actual twist is, as a rule, about the mesentery as an axis; but it is quite possible, and cases are reported in proof of it, for the gut to twist upon itself. Coils of small intestine may become knotted together, or the ileum may become tied up with the sigmoid flexure of the colon. The twisting may vary in degree. When the volvulvus is not complete, spontaneous recovery may take place; but when the torsion is complete, the changes that speedily follow in the parts involved make untwisting impossible.

The etiological factors entering into the cause of volvulus

are numerous.

Fecal impaction stands first upon the list. The waste material fills the fecal reservoir, causes the upper part of the filled portion to prolapse upon the lower part, thus bringing the two ends near together, when peristaltic movements twist them upon each other. Of other causes for volvulus, the most active are undue intestinal peristalsis, a long mesentery, contracting exudate in the mesentery, tumors, and bulky, indigestible food stuffs.

The changes that follow a complete closure of a portion of the intestines by a twisting about the mesenteric axis are:-congestion due to interference with the venous return, edematous thickening of all the bowel coats, decomposition of the intestinal contents with formation of gas; and necrosis of the strangulated part.

At first there is violent peristalsis without much abdominal distension; but this is soon followed by paresis of the intestinal wall and gaseous distension of the abdomen, and a collection into the peritoneal cavity of a quantity of bloody fluid.

(2) Intussusception or invagination. This term is used to express a condition in which one part or portion of intestine is rolled into the lumen of the adjacent portion; that is, the one part is swallowed by the other. The intussusceptum, or entering part, forms two layers, the entering and the returning layers; while the intussuscipiens or receiving part forms a third layer. So that in every case of complete invagination there is in the mass or tumor at least three distinct intestinal layers, and also the mesentery of the invaginated part. There may however, be more than three coats. In what is known as the double form, five coats may enter into the mass, and in the triple form, seven are found. Partial invagination arises when a part of the intestinal wall is dragged into the adjoining portion of the gut. This is usually due to the existence of a tumor, attached by a pedicle to the wall, and hanging within the intestinal lumen.

Intussusception may occur in any portion of the intestines, small or large; but it is more frequent in some parts than in others. Invagination of the small into the large intestine forms more than fifty per cent. of all cases for all ages, though in childhood the percentage is much higher. About thirty per cent. of cases in childhood occur in the ileum, and twenty per cent. in the colon; while these two situations furnish about an equal number in adult life.

The disease may almost be said to be one of childhood, since at least half of all cases occur during the first few years of life. The actual cause producing intussusception of the bowel is as yet not positively determined; though certain etiological factors have been recognized and tabulated. Some of these are: Age. Fifty per cent. occurring in youth. Sex. The majority of cases occur in females. Foreign growths in the intestines. Abdominal injuries, pregnancy, diarrhea, and other intestinal disorders.

Three theories of the actual cause of this trouble may be mentioned; all have ardent and enthusiastic advocates:

(1) The spastic theory. According to this theory, it is contended that a portion of the intestines undergoes tetanic contraction, and then the adjacent relaxed portion is drawn over it.

(2) The paralytic theory. This is the reverse of the spastic contention. According to it, there is no undue contraction, but a portion of the intestine relaxes, because of the paralysis due to diarrhea, traumatism, or other diseased conditions, and the adjacent normally contracting portion slips into it.

(3) Disproportion in the width of the ileum and the cecum. This is stated to be responsible for many, if not for all, of the cases of ileo-cecal invagination.

Pathological Changes Following Intussusception. A welldefined line between the agonal and the vital forms of intussusception should be drawn. The former is physiological, and occurs just before death; the latter is pathological and has no causative relationship, in time, with dissolution.

The pathological variety differs in being usually single, occurring at any age, the invagination is descending in 90 per cent. of the cases, and the mesentery accompanies the invaginated part. This variety is the only one that concerns us as practitioners of medicine; but from a medico-legal standpoint, we must not forget the characteristics of the other.

In pathological intussusception, the invagination in nearly all cases is from above downward, and the mesentery is carried in with the intussusceptum. The venous return is interfered with in the invaginated portion, congestion, edema, inflammatory exudate, and necrosis soon supervene. At first there may be some relief to the congestion from rupture of the blood vessels in the mucous membrane of the congested portion; but as the swelling increases this relief ceases, and the intussusceptum dies. A local peritonitis will unite the peritoneum at the neck of the invaginated portion, and if the patient lives long enough for the intussusceptum to slough away, the general peritoneal cavity will be protected and the patient may recover.