ACUTE INTESTINAL OBSTRUCTION. H. J. O'BRIEN, ST. PAUL. Traditions, usages and even lines of thought of pioneers are hard to get away from, even though they may be proven erroneous with the lapse of time or not applicable because of changed conditions or environment. In no walk of life is this more true than in medicine and surgery, and while in some branches we have advanced, not by strides, but by leaps and bounds, yet there is much room for improvement, careful observation and investigation. Abdominal surgery is really only in its infancy, and as the child is to the man, so is abdominal surgery of to-day to that of thirty, forty or fifty years hence. Within our own generation we have seen the cycle of oöphorectomy, salpingectomy, hysterectomy, appendicectomy, colocystectomy and many other operations for the relief of abdominal diseases, together with minute and at times accurate observation and description of symptoms by which disease of the abdominal viscera may be recognized and properly treated. In reviewing the literature of diseased abdominal viscera for the past fifteen years one is struck with the sometimes sudden, but more often gradual, change in the symptomatology of disease of all the viscera except the pathologic condition known as acute intestinal obstruction. It would be unfair, even though permissible, to ask you to listen to a detailed proof of this statement, and it will suffice for the object of this paper, and doubtless at the same time surfeit you, if I take the liberty of citing a few extracts from some of our bestknown writers on the subject of intestinal obstruction. Sands says: The symptoms of invagination are somewhat different from those of other obstructions. They ordinarily supervene rapidly, the patients being, usually, children who have suffered some days from diarrhea. The symptoms are chiefly severe localized pain; the development of a tender, rather soft abdominal tumor, which yields a dull note on percussion, may change its form or position, and is most frequently found in the right iliac fossa; emesis, sometimes stercoraceous and diarrheal, or sanguinolent evacuations which may contain gangrenous shreds or masses. The leading symptoms of the other varieties of obstruction are constipation; vomiting, which appears early, is bilious at first and may remain so if the obstruction be high up in the small intestine, but which comes later and becomes stercoraceous if the small bowel be occluded low down, or the colon at any part of its course; the formation of a sensitive, painful tumor, dull on percussion, if the obstruction be not too high in the small intestine; increasing tympanites above the tumor, singultus, lowered temperature, and finally, collapse. Ross says: In cases of acute obstruction the onset is sudden; the symptoms from the beginning are urgent; and the result, after a rapid course, is almost uniformly fatal. Spontaneous recovery after volvulus is unknown; a very small proportion of intussusception get well; and genuine examples of recovery after strangulation by bands or through apertures must be less common than in ordinary hernia, where the chance of recovery is practically considered as nil. In the case of the last, recovery takes place from gangrene of the gut, with the formation of false anus; in internal obstruction gangrene is certain death. The symptoms are those of strangulated hernia aggravated. Severe abdominal pain, collapse, vomiting, constipation and abdominal distension are the leading symptoms. The pain is always severe and often agonizing. Parks says: Pain, vomiting, distension and collapse appear early. Richardson and Cobb say: Pain, the first and most important symptom of acute obstruction, comes on suddenly in violent paroxysms. Vomiting begins early. At first the vomitus consists of the contents of the stomach only; later, if unrelieved, it contains bile and the regurgitated contents of the small intestine; finally, if the obstruction is in the large intestine, the vomiting may become distinctly fecal. The dark fluid so often vomited in acute obstruction, as well as in general peritonitis, is not necessarily stercoraceous, though often so described. Distension of the abdomen begins soon after the onset of pain and vomiting, and is at times excessive. Tenderness is usually present-at first local, and later general.. Obstipation is complete, though flatus and feces may pass from the bowel below the stricture in the early hours of an acute obstruction, and thus give rise to error. After one or two evacuations of this kind nothing whatever will be passed by rectum. With the onset of the acute symptom collapse out of all proportion to the severity of the lesion may take place, making in a few hours surgical interference practically hopeless. Warren says: The general appearance of a patient in this condition is quite characteristic. The "facies" is usually well marked. The face is pale and the eyes are sunken. There is more or less cyanosis, due to the impeded respiration or, earlier, to the shock attending the obstruction. The nose is pinched and the skin clammy. The extremities are cold and the body temperature is often subnormal. Even the tone of the voice is altered. The pulse is small, weak and rapid. The cardinal symptoms of obstruction are pain, vomiting, tympany and tumor. These may vary according to the nature and acuteness of the obstruction. Pain is not always present, and is not always referred to the seat of the constriction. It is due largely to the increased peristaltic action caused by the efforts of the intestine to break through the obstructed point. Visible outlines of coils of intestine are seen, often arranged in horizontal rows one above another. Increased peristaltic action is indeed a characteristic symptom of obstruction. Vomiting is an almost constant symptom. The vomitus consists, first, of the contents of the stomach; later, either a watery or greenish fluid, and finally the characteristic odor of fecal vomiting is observed. This peculiar odor is due to the chemical changes taking place in the proximal portion of the canal. Actual vomiting of fecal matter is exceedingly rare, and occurs only when the obstruction is low down in the large intestine. Tympany varies largely according to the seat of obstruction. After the lower bowel has been emptied of its contents there is a persistent constipation. In certain forms of obstruction there may be stools of blood or mucus. No fecal matter is found in them. I have quoted these well-known men at length to show that the symptoms of acute intestinal obstruction as given in textbooks have varied little if any in the last quarter of a century, yet many of us are as slow to open the abdomen in a case of possible obstruction to-day unless all the cardinal symptoms are present, as were the surgeons of a quarter of a century ago. This, I believe, to be a mistake, and while I do not think a revision of the symptomatology of intestinal obstruction is required, I do believe a revision of treatment would be advisable, and we are to look for this revision rather from the operating room than from the bedside and postmortem room. I think too much stress is laid on differential diagnosis; not only as to other diseased abdominal conditions, but as to what particular form of intestinal obstruction we have to deal with. It is like splitting hairs to spend valuable time trying to make a differential diagnosis between invagination and other forms of obstruction. If we have reasonably good grounds to believe we are dealing with an obstruction of the intestinal canal, we are not only justified in operating, but are direlict if we do not operate. An exploratory incision may or may not be of grave moment, depending largely on the condition found or sought for, while it may be regarded as heresy, I believe the truthful man will admit that the more abdomens he opens the less sure he is of all the conditions he will find on opening the next abdomen. I make this statement, not only on observation of other men, but on an experience of some two thousand of my own. The three following cases will perhaps better demonstrate what I mean than would a lengthy dissertation on the subject. CASE 1.-Miss K., aged 19, seen with Dr. Doran Nov. 4, 1902. Patient gave a history of several attacks of abdominal colic. She had been ill some days before I saw her; the night previous she had severe abdominal pain. When I saw her there was localized tenderness in right iliac fossa; no abdominal distension, slightly elevated temperature, pulse and respiration, urinalysis normal. We determined to wait, send her to St. Joseph's Hospital and operate when the acuteness of the attack had somewhat abated. We operated on her November 6, and found a grossly diseased appendix surrounded by partially organized lymph exudate. I noticed at the time of operation and called attention to the somewhat collapsed condition of the ileum, but as there had been no constipation or distension before operating I did not explore the ileum. A small drain was left in the wound and the patient returned to her room. She complained of much pain that night and vomited frequently. The next morning her temperature was 99.6, pulse 72, respiration 18. A glycerin and warm-water enema was followed by two good bowel evacuations together with the expulsion of flatus, and patient passed a very comfortable day, followed, however, by a sleepless night with a good deal of pain, temperature 98, pulse 80, respiration 20, no abdominal distension. Vomiting returned, was persistent, becoming greenish in color. No further bowel movement could be obtained; temperature 100, pulse 120, respiration 24, no abdominal distension; patient died the morning of November 9, three days after operation. Dr. Ferguson kindly made an examination for me, and found the last eighteen inches of the ileum collapsed and constricted by an inflammatory, wellorganized band, apparently antedating the appendicectomy. Had I made a careful examination of the lower part of the ileum at the time of operation, instead of contenting myself with remarking on the unusual condition of the gut, or failing in this, had I reopened the abdomen, the girl would be alive to-day and I would have one less sin of omission charged against me by the recording angel. CASE 2.-Mr. C., aged 47, was seen at St. Joseph's Hospital on the afternoon of Jan. 17, 1903. While smoking an afterlunch cigar he was seized with a violent pain in the left lumbar region. When I first saw him his face was white, drawn, and whole body covered with cold perspiration. He was given a hypodermic of morphin and atropin and put to bed. Pa |