ACUTE OBSTRUCTION OF BOWEL.

J. B. BOUCHER, M. D.,

HARTFORD.

Few diseases or conditions at the present time require more care and skill both in the diagnosis and treatment than intestinal obstruction.

The limits of this paper will not permit me to go into detail, neither can I take up each of the forms and conditions that may produce obstruction, but I will endeavor to bring out some of the most important points regarding the more frequent forms which we are liable to encoun ter in our daily practice.

The acute obstructions are caused by mechanical lesions not associated with disease. Simple mechanical closure may be congenital. It may be caused by intussusception, volvulus, internal and external strangulation, kinks and flexures and the impaction of foreign bodies. The passive obstructions met with in peritonitis, in mesenteric embolism and thrombosis are due to intes tinal paresis.

The commonest form of mechanical obstruction is that due to the various forms of external hernia which time will not allow me to discuss in this paper.

The next in frequency is intussusception, which represents about 35% of all forms of obstruction. The major ity of cases occur in children.

Dr. L. Emmet Holt collected 385 cases of intussuscep tion under three years of age. Three-fourths of all these cases occurred in the first two years of life, and one-half between the fourth and ninth months. In children it is nearly twice as common in males as in females, but in adults it is more frequent in women.

The most frequent seat of intussusception is at the

ileocaecal valve, where the small intestine is invaginated into the large, but it may be confined to the small intestine proper. In rare cases a double invagination may occur.

It is caused by irregular action of the muscular walls of the intestine. One part of the tube, by reason of irritation, becomes stiff and small by contraction of the circular muscular fibres, while the part immediately below is relaxed and into this the smaller and stiffened part telescopes. The mesentery is drawn in with the bowel. Gangrene may occur due to strangulation of the mesentery as it becomes crowded in with the invaginated gut. In some instances parts of the gangrenous intestine are passed by the rectum. It may be produced by anything that causes vigorous peristaltic action, such as a powerful cathartic, by constipation or diarrhea, or even sudden and severe jolting of the body.

The main symptoms are sudden and severe pain and vomiting, with indications of abdominal shock, tenesmus, especially when the tumor is low down toward the rectum, and bloody and mucus evacuations. A tumor may usually be felt on the left side along the sigmoid flexure or by rectal examination. The abdomen is not distended in the early stages of the disease, but when obstruction becomes established tympanitis is well marked. The pain is usually intermittent, colicky and excruciating during the attacks. The most marked symptom is the passing of blood and bloody mucus. The temperature may be normal or subnormal in the early stages of the attack, but usually rises in the first twentyfour to forty-eight hours.

Volvulus or twisting of a loop of the intestine occurs usually in the sigmoid flexure of the colon, although any portion of the intestine may be occluded by this accident.

An intestinal coil heavily loaded with feces, hanging by a long mesentery presents the most favorable condition for a twist. It is not uncommon to find an enor

mously lengethened coil in the form of a huge S stretching from the sigmoid flexure to the liver, thence into the pelvis.

The symptoms of volvulus are those of acute intestinal obstruction. Pain similar to colic is present from the start. Constipation is the rule and indicates the sig. moid colon as the seat of the lesion. If tenesmus is present it is an additional evidence that the colon is involved. Extreme distention of the abdomen occurs in a large proportion of cases. Vomiting is rarely present until late in the history of the case. When it appears early it suggests obstruction in the small intestine. The urine is diminished in a certain number of cases.

The course of the disease is violent and fatal if relief is not afforded by early operation. The diagnosis of volvulus cannot be made with certainty, as the symptoms may be confounded with intussusception. If the symptoms of acute obstruction develop suddenly, late in life, in a patient habitually constipated together with the detection of an ill-defined tumor of a distended and resistent intestinal coil and the absence of bloody stools volvulus may be suspected, but an absolute diagnosis can only be made by exploration.

Constriction by bands of cicatricial tissue resulting from acute and chronic peritonitis causes intestinal ob struction in a certain number of cases. This accident occurs chiefly in adults about equally in both sexes. They are frequently due to pelvic inflammations in women and to appendicitis and traumatic peritonitis in men. The bands vary in length and points of attachment, the lower jejunum and ileum are involved in most cases.

The symptoms are in general those of acute obstruction of the small intestine. Pain is violent in the beginning and is usually referred to the part involved. Vomiting is an early and persistent symptom and is common in obstruction above the ileocaecal valve, is apt to be stercaraceous. Shock is more prominent in this form of oc

clusion. The abdomen is not tympanitic as a rule, although the constricted loop may be greatly distended and may be recognized as a distinct tumor by palpation, percussion or by vaginal or rectal exploration. The diagnosis must be made from the presence of the symptoms above given together with the history of a former peritonitis.

These three conditions which I have described comprise the most frequent forms of obstruction.

Among other causes may be enumerated internal strangulation, which may be caused by constriction of the bowel through slits in the omentum and mesentery. The ileum is most frequently involved and the mesentery in the lower part of the organ is usually the point of constriction.

The symptoms are those of hernia of the small intestine with strangulation. Early operation is the only hope of relief.

Meckel's diverticulum, when it exists, represents the vitalline duct of the embryo in which the normal process of closure and obliteration has not taken place. When present it is attached to the last two or three feet of the ileum and may remain patulous and open at the umbilicus or more frequently it ends in a blind extremity which may be continued as a cord to the umbilicus.

There are no symptoms peculiar to this form of obstruction. The nature of the lesion can only be discovered by abnormal section, which is always indicated.

Acute obstructions result occasionally from the impaction of foreign bodies-gall-stones, enteroliths and from masses of round worms, the latter found usually in children. When a partial obstruction is present, a very small foreign body no larger than an orange seed may cause an acute obstruction.

Neoplasms, Sarcoma and Carcinoma, strictures both congenital and acquired, all may occasionally produce obstruction, but they are less common and cannot be