Acute intestinal obstruction

ACUTE

INTESTINAL

OBSTRUCTION

MONROE A. McIVER,

SEVENTH PART

M.D.,

F.A.C.S.

INSTALLMENT

II: DIAGNOSIS

AND TREATMENT

CONTENTS [This CHAPTER XVIII. Diagnosis: XIX. Diagnosis

VOL.XXI PAGE

Genera1 Considerations. (Cont.): SpeciaI Points [Contents

I. II. III. IV. V. VI. VII.

Number]

. . . . . . . . . . . . 145 & DifferentiaI Diagnosis . . 159

of Part I: The Disease)

Introduction . . . . . . . . . Genera1 Considerations . . Varieties of Obstruction . . . . Varieties of Obstruction (Continued): Varieties of Obstruction (Continued): Varieties of Obstruction (Continued): Varieties of Obstruction (Continued):

. . . . . . . . . .

.

.

.

. . .

.

Bands and Membranes VoIvuIus. . . . Intussusception InternaI Hernias .

Var. XIX . . I 63 . 172 ,

.

IgI

. 365 . 378 387 581

Var. xx VIII. Varieties of Obstruction (Continued): Neoplasms . . . . ITI IX. Varieties (Continued): StranguIated ExternaI Hernia 182 x. Varieties (Continued): OccIusion of the Mesenteric VesseIs rg4 XI. The CIinicaI and PathoIogicaI Picture: Morbid Anatomy . . 476 XII. CIinicaI PathoIogicaI Picture (Continued) : Genera1 Findings 483 Picture (Cont.): Changes in Body FIuids 489 XIII. CIinicaI PathoIogicaI Picture (Cont.) : Mechanism of CardinaI XIV. CIinicaI PathoIogicaI Symptoms . . . . . . jO0 Obstructions . . . 812 xv. Functiona Obstructions (Continued): Varieties. 823 XVI. Functiona Obstructions (Continued) : Preventive Measures. 833 XVII. Functiona

PART II: DIAGNOSIS AND TREATMENT CHAPTER XVI

II

DIAGNOSIS GENERAL CONSIDERATIONS In approaching the question of the diagnosis of acute intestina1 obstruction, it shouId be cIearIy borne in mind that if the Iife of the patient is to be saved, diagnosis must be made earIy in the disease. The terms “ earIy ” and “ Iate ” in the disease have a different significance according to their application to the fuIminating or miIder varieties of obstruction. Where stranguIation is present, the Iapse of tweIve hours or Iess may be sufficient for irreparabIe damage to the invoIved intestine and for the deveIopment of serious systemic effects; whiIe in simpIe obstruction of the coIon severa days may go by without the deveIopment of serious IocaI or genera1 effects. There are many variations between these two extremes. As even in strangmations there are pointed out by Eisberg,l considerabIe differences in the clinical course of the disease, depending on the Iength of Ioop InvoIved and on whether the bIood suppIy is suddenIy or graduaJIy occIuded. Diagnosis in the earIy stages of the disease is often diffkuIt. This is demonstrated by the fact that aIthough the symptom compIex and major features of the disease have been taught to five or six generations of medica students and have been stressed at medica and surgica1 meetings for the past two or three decades, the patients continue to be brought to operation Iate and the mortaIity continues high. Modern Iaboratory diagnostic methods in genera1 are not very heIpfu1 in arriving at a diagnosis of acute intestina1 obstruction. The diagnosis must, therefore, rest on the oJd cIinica1 basis of signs and symptoms; and yet the physica signs in the earIystages of the disease may not be very constant. MuscIe spasm and tenderness may be absent; visabIe peristaIsis can be seen

146

ACUTE INTESTINAL

OBSTRUCTION

onIy occasionaIIy ; abdomina1 distention may be absent or sIight; the temperature and white bIood count may be normaI; and whiIe the cardina1 symptoms of abdomina1 pain, vomiting and obstipation are usuaIIy a11 present, they vary in intensity and prominence and are, of course, aIso associated with other diseases which do not demand operative interference. As a practica1 matter the real difFicuIty may be, not in diagnosing the presence or absence of obstruction, but in distinguishing between organic and functiona obstruction. The two types may have many basic signs and symptoms in common, yet the former (organic) aIways demands operative interference, the Iatter onIy occasionaIIy. The distinction is of particuIar importance in obstruction occurring during the convalescence from an abdomina1 operation, especiaIIy when peritonitis compIicates the picture. STUDY OF THE PATIENT An intestina1 obstruction may come on suddenIy, with the patient in perfect health; or there may be a history of chronic obstruction before the acute attack. The symptoms are frequentIy severe from the beginning, aIthough sometimes the onset is insidious. Where the pain is very intense, the patient may show some signs of prostration earIy in the disease; but usuaIIy this is not the case; the presence of this symptom earIy in the disease points to stranguIation.2r3 If the pain is extreme, the puIse-rate may be eIevated; it usuaIIy, however, remains fairIy norma unti1 the Iate stages of the disease and then becomes rapid and thready.4 The temperature is usuaIIy normaI, or onIy sIightIy eIevated. The patient frequentIy has a rather characteristic facia1 expression that might be described as one of anxiety. If there has been much Ioss of fIuid by vomiting, the usua1 signs of dehydration (sunken eyes, dry tongue, depressed fontaneIIes in infants, and Ioose, ineIastic skin) are present. The amount of urine passed is IikeIy to be smaI1, its voIume furnishing some indication as to the extent of the dehydration. Book Page 204

DIAGNOSIS

147

In eIderIy patients, symptoms of abdomina1 distention, the peristaItic type of coIic, and vomiting, suggest the possibIe diagnosis of obstruction from neopIasm of the coIon. In these patients a past history can not infrequentIy be obtained of progressive constipation, bIoody mucus in the stooIs, or frequent smaI1 movements, which tends to confirm the first impression. In infancy and earIy chiIdhood, severe abdomina1 coIic associated with a Iack of bowe1 movements shouId suggest the possibiIity of intussusception; if bIoody mucus is passed, is greatly strengthened. Intussusception is the suspicion outstandingIy the chief cause of obstruction in infancy and earIy chiIdhood, as is shown by the figures from chiIdren’s cIinics: Ladd and CutIer5 reported 103 cases of obstruction in infants and chiIdren, of which 88 were caused by intussusception, and 17 by other conditions; Peterson” reported 33 cases of intestinal obstruction in the same age group, intussusception being responsibIe in 46 instances. The presence of an abdomina1 scar in a patient with symptoms consistent with an acute obstruction shouId at Ieast put the physician on his guard. Since abdomina1 Iaparotomies have become more common, postoperative intestina1 obstruction is more frequentIy encountered.i-g This increase is shown in the foIIowing figures from the Massachusetts Genera1 HospitaI : in the ten-year period 1898-1907 there were 37 cases of obstruction foIIowing earIy or Iate after abdomina1 operations ; in the period 1908-19 I 7, there were 57; in Igr8-1927, there were 82. (See TabIe XVIII.) In studying the patient suspected of having acute intestinal obstruction, particuIarIy detaiIed information is needed on certain points, which are summarized beIow. Since, however, the suspected “IntestinaI obstruction” may prove actuaIIy to be Iead coIic, an abdomina1 crisis of tabes, or some other condition equaIIy removed, a carefu1 history that is not Iimited to the presenting symptoms, and a thorough and compIete physica examination are required.

ACUTE

148

INTESTINAL

OBSTRUCTION

PRESENTILLNESS Abdominal pain: Location; duration; intensity; character (has it been cramp-like, “doubIing-up”?). Periods of partiaI or compIete remission? Diminishing or increasing in severity? Radiation? Vomiting: Time of onset; frequency; character (accompanied by nausea? projectiIe?). Amount; appearance of vomitus (coIor and odor). Bowel movements: Number since onset of ilIness; time of Iast movement; its character; did it contain bIood or mucus? Has gas been passed by rectum? How frequently? Have cathartics been given? What resuIt? Have enemata been given? How many? What resuIts? Urine: Amount passed; has it been highIy coIored? Distention: When first noticed? Has it been more severe than at present? Medication: What kind? Morphia? Cathartics? Diet: SoIid food? FIuids? Retained? PASTHISTORY Previous abdominal operations: Date on which they occurred; character; was wound drained? Question as to existence of any hernia. Has patient had any symptoms in the past suggesting partia1 or compIete obstruction, such as abdomina1 pain, vomiting, distention, excessive or unusua1 gurgIing peristaItic sounds, constipation or diarrhea? PHYSICALEXAMINATION General condition: Does patient appear acuteIy iII? Signs of coIIapse? Does he appear dehydrated (drawn features, sunken eyes, dryness of tongue)? Abdomen: Fiat? Distended? UniformIy so? Visible peristaIsis? Tenderareas of duIIness or ffatness, spasm or masses on paIpation ? Tympanitic; activity on auscuItation ness, or fluid wave on percussion ? PeristaItic normaI? Increased? Absent? Rectal examination: Masses? Tenderness? LABORATORY STUDIES Blood: Count of white blood ceIIs, incIuding differentia1 count; nonprotein nitrogen; bIood chIorides.* Urine: UsuaI examination. X-ray: Examination (if indicated).

the cIassica1 signs and symptoms are a11 present in any individua1 case; and acute obstruction forms no exception to this ruIe. Pain, vomiting and obstipation are, however, so commonIy encountered that they must receive specia1 consideration. * Not of much vaIue in differentia1 diagnosis; see page 154. There

Book

Page 206

are

few

diseases

in

which

DIAGNOSIS

149

ANALYSIS OF SYMPTOMS PAIN. Acute obstruction is usuaIIy ushered in by abdominaI pain. This cardina1 symptom is aImost aIways present, aIthough it varies considerabIy in character, severity and Iocation. With simpIe obstructions of the smaI1 intestine it is coIicky or cramp-Iike earIy in the disease and has a tendency to be intermittent, working up to a cIimax and then subsiding. After tweIve to twenty-four hours the patient insists that the pain is constant, not coinciding with the waves of peristaIsis which in some cases may be seen or heard at intervaIs. In obstructions of the Iarge intestine the coIicky character of the pain Iasts Ionger than it does in obstructions of the smaI1 gut. Where strangulation exists, the infiItrated, distended Ioop of intestine causes pain that is steady and agonizing from the beginning, rather than coIicky in character, and which may be of sufficient severity to bring on a state of coIIapse. In cases, where a chronic obstruction has been graduaIIy converted into an acute obstruction, however, the pain may not be severe; and in certain types of obstruction (notabIy postoperative obstructions foIIowing serious operative procedures, or where peritonitis compIicates the picture) pain may be absent, or if present may not be the most outstanding feature. The Iocation of the pain in obstructions of the smaI1 intestine is IikeIy to be the region of the umbiIicus or epigastrium. If the obstruction is situated in the coIon, the pain is IikeIy at first to extend across the Iower abdomen, aIthough in the earIy stages it may at times be referred to the epigastrium; when the obstruction has existed for some time, the pain is often IocaIized over the site of the obstruction, probably because of edema and infection. If there is a stranguIated Ioop of gut the pain may aIso be referred to the region overIying it. At times the patient is unabIe to IocaIize the pain, passing his hands a11 over the abdomen when asked to show where it is. Book

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ACUTE INTESTINAL

OBSTRUCTION

VOMITING. Vomiting is present with the rarest exception and usualIy occurs very promptIy after the onset of the obstruction. The amount of vomiting is IikeIy to vary with the IeveI of the obstruction and the stage of the disease. In genera1 the vomiting is more frequent and profuse in high obstructions, particuIarIy in the earIy stages of the disease; in the Iater stages it may take pIace frequentIy and in Iarge amounts regardIess of the IeveI of the obstruction. In the Iater stages it may be observed that the patient goes for a number of hours without vomiting, and then, suddenIy and with IittIe vomiting effort, regurgitates a Iarge amount of fouI-smeIIing fIuid from a diIated stomach. In these cases the stomach-tube is most usefu1 in determining the true state of affairs. The vomitus from obstruction presents no characteristic features in the earIy stages of the disease, consisting either of food recentIy eaten or of cIear or biIe-stained gastric juice. Later in the disease the vomitus does have characteristic and distinct quaIities : it is a thin, yeIIowish ffuid containing smaI1 whitish particIes that settIe out on standing; and the characteristic odor is fou1 in the extreme. This fluid represents the contents of the smal1 intestine, aIthough, of course, not the norma contents: it is a mixture of the secretions of the digestive gIands and of the intestina1 tract, which are poured out in great quantities under conditions of obstruction, and it is heaviIy infected with bacteria. It is this materia1 which is usuaIIy described as “feca1” or “stercoraceous,” receiving its name from the fecaI-Iike odor imparted by the action of the coIon baciIIus and other putrefactive bacteria; it does not contain any actua1 feces, since true vomiting of feces is found onIy where there is a fistuIous communication between the stomach and the coIon. Between the onset of the obstruction and the appearance of the characteristic vomitus, a time interva1 eIapses, which in certain types of obstruction may be as Iong as severa days; so that whiIe inspection of the vomitus may confirm the diagnosis, Book Page 208

DIAGNOSIS

IjI

it may aIso indicate that the most favorabIe time for operation has passed. OBSTIPATION. Since compIete intestina1 obstruction necessariIy stops the intestina1 stream, it might be supposed that cessation of bowe1 movements and faiIure to obtain them after appropriate stimuIation wouId be pathognomonic of the disease. The situation, however, is not quite so simpIe. If the patient is seen earIy after the onset of the attack, the fact that the boweIs have not moved even with the use of enemas may not be concIusive evidence of obstruction: obstinate constipation and reflex inhibition of intestinal motiIity are findings not at a11 uncommonIy associated with other conditions in which abdomina1 pain occurs, as, for exampIe, renaI coIic. On the other hand, even though the boweIs have moved after the onset of the pain, this is not concIusive evidence that obstruction does not exist. FaiIure to obtain even gas on the administration of subsequent enemas, however, is a finding that cannot be disregarded; and in conjunction with abdomina1 pain shouId suggest to the attending physician the necessity of at Ieast pIacing the patient under surgica1 observation.‘” In attempting to decide whether a partia1 obstruction has become compIete, the question as to whether or not flatus has been passed is particuIarIy important, since the patient with complete obstruction faiIs to expe1 even gas after the administration of an enema. If, however, vomiting and distention persist, and particuIarIy if the character of the vomitus suggests intestina1 contents, one shouId not be Ied into deIaying operation too Iong because a IittIe gas is being obtained on administration of an enema. PHYSICAL SIGNS The physica signs nounced in some cases, DISTENTION. The abdomina1 distention. time for fluid and gas

of intestina1 obstruction may be proin others absent, or sIight. most consistent physica finding is Since it takes an appreciabIe Iength of to accumuIate in sufhcient quantities Rook

Page

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ACUTE INTESTINAL

152

OBSTRUCTION

to produce a demonstrabIe distention of the abdomen, this is not an earIy symptom unIess there has been some chronic obstruction before the onset of the acute attack. Distention does not aIways occur; it may be absent, or sIight, when the obstruction is situated at a high IeveI in the smaI1 intestine; and in certain cases of interna stranguIation the whole course of the disease is so short and severe that there is not time for noticeabIe distention to occur. If, however, a case is seen Iate in the course of the disease, or if it has been improperIy treated, the distention may be very great. It is seen in its most extreme degree where the obstruction is in the Ieft side of the coIon,7 particuIarIy where an acute obstruction is superimposed upon a chronic obstruction; and is aIso IikeIy to be found in its severer forms where in addition to an organic obstruction there is a functiona eIement introduced by peritonitis. MUSCLE SPASM ANDTENDERNESS. The presence or absence of tenderness depends IargeIy upon the type and duration of the obstruction. In StranguIations, tenderness over the invoIved Ioop of bowe1 is frequentIy found early in the disease, particuIarIy if the Ioop Iies in contact with the abdomina1 waI1. In cases of simpie obstruction, tenderness and muscIe spasm (abdomina1 muscIes) are often absent earIy in the iIIness; usuaIIy, however, the abdomen is heId rather tightIy and some generaIized tenderness is often present.* Codman12 considers that the feehng of increased intra-abdomina1 tension obtained Later in the obstruction on paIpation is quite characteristic. tenderness is present over the edematous, infiItrated Ioop of obstructed gut. In obstruction of the coIon there is Iikely to be tenderness especiaIIy over the cecum. In a recent series of 188 cases of intestina1 obstruction13 (obstructions by stranguIated externa1 hernia excIuded) abdomina1 tenderness on paIpation was recorded in 72 instances, muscIe spasm in 41. * According to Dr. D. F. Jones 11 the degree of tenderness aIso depends much upon whether marked.

or not the bowe1 is in spasm;

Book Page 210

when it is contracted

the tenderness

over it is

I53

DIAGNOSIS

TUMORS. OccasionaIIy it may be possibIe by paIpation or percussion to detect a distended Ioop of gut (WahI’s sign); this finding, however, is infrequent. In cases of intussusception it is fairIy common in infants to be abIe to paIpate the characteristic “sausage-shaped” tumor in the region of the cecum or ascending coIon, or on the Ieft side in the region of the descending coIon or sigmoid. In the recent Massachusetts Genera1 HospitaI series, out of I I cases in infants, a mass couId be paIpated in 8 instances. This is in contrast with the group of oIder patients with intussusception, where a mass couId be paIpated in onIy one out of 6 cases. OccasionaIIy the tumor produced by an enteric intussusception may be feIt in other regions of the abdomen. On recta1 examination it may be possibIe to paIpate the apex of an intussusception. VISIBLE PERISTALSIS. VisibIe peristakis can occasionaIIy be made out above the point of obstruction. It was recorded in 27 of the 188 cases (obstructions from a11 causes except externa1 stranguIated hernia) recentIy reported by McIver.13 It occurred with the greatest frequency in the earIy and Iate postoperative obstructions. Some of the most extreme exampIes are encountered not in compIete but in partia1 obstructions. When the stranguration is present, peristaIsis is not often visibIe. AuscuItation of the abdomen may yieId evidence of increased peristaItic activity even when none is visible on In attempting to determine the existence of inspection. mechanica obstruction when peritonitis is present, the absence of any sounds of peristaItic activity is strongIy suggestive that the symptoms of obstruction may be due to a paraIytic distention of the intestines. CLINICAL INDICATIONS AS TO THE LEVEL OF THE OBSIYRUCTIOK One is abIe not infrequentIy to draw inferences as to the IeveI of the obstruction on the basis of the cIinicaJ picture presented. If there is no eIement of strangulation, the Iow obstructions run a miIder course than the high obstructions. Hook

Pagr. 2

I,

134

ACUTE INTESTINAL

OBSTRUCTION

In high bIockage, the profuse, characteristic vomitus of obstruction comes on quickIy and is an outstanding feature, so that these patients very rapidIy show evidence of considerabIe dehydration; distention takes Ionger to deveIop and, indeed, may be shght even when the disease is advanced; the course of the disease is rapid and unIess reIief is obtained death is a matter of a few days. SimpIe obstructions of the coIon, on the other hand, may require a number of days before the disease reaches its maximum intensity. Vomiting is not so profuse in the earIy stages, and evidences of dehydration appear more sIowIy. Distention usuaIIy assumes marked proportions. The cIinica1 picture presented by patients with obstruction of the iIeum usuaIIy lies somewhere between that presented by the high jejuna1 obstruction on the one hand, and obstructions of the coIon on the other. In genera1 it may be said that in simpIe obstructions the symptoms become Iess fuIminating as one approaches the iIeoceca1 sphincter. LABORATORY STUDIES As ah-eady stated, laboratory examinations do not usuaIIy furnish a great dea1 of aid in estabIishing the diagnosis of acute intestina1 obstruction. The bIood chemistry findings earIy in the disease may be compIeteIy normaI. So much has been written within the past decade on the Iow bIood chIorides found in obstruction, that the impression may exist that this is a heIpfu1 diagnostic point. As a matter of fact, such is rareIy the case. In the first pIace, since the Iow bIood chIorides are the resuIt of extensive vomiting, this finding is not present at the onset of the iIIness in any type of intestina1 obstruction; and in the most common and fulminating types, in which stranguIation is present, Iowered bIood chIorides may not be found at any stage of the disease. Furthermore, profuse vomiting occurs in connection with a number of diseases other than intestina1 obstruction, and if it has been of sufficient amount wiI1, of course, resuIt in a Iowering of the bIood Book

Page 312

DIAGNOSIS

15;

so that however heIpfu1 the Iaboratory finding chIorides*; of a Iowered bIood chIoride may be from the point of view of indicating the extent of the dehydration and the need for adequate administration of saIt soIution, it is onIy rarely that this finding is heIpfu1 in estabhshing the diagnosis. The same thing appIies, with even more force, to an eIevation of the non-protein nitrogen of the bIood: it is true that after intestina1 obstruction has become established the non-protein nitrogen is usuaIIy eIevated; but, obviousIy, this finding occurs in a number of other diseases aIso. The white bIood count is frequentIy normaI, especiaIIy in the earIy stages of simpIe obstruction. Where a stranguIation is present the white count is IikeIy to be high,14 emphasizing the need for prompt operation. X-RAY

EXAMINATION

Diagnosis by means of x-ray examination has a rather Iimited fieId in acute intestina1 obstruction. NevertheIess, in certain cases it may be heIpfu1. The administration of opaque substances by mouth for this purpose is highly dangerous, for it may convert a partia1 into a compIete obstructiont Roentgenograms folIowing the administration of barium by enema wiI1 often estabhsh or refute the diagnosis of obstruction of the coIon; and whiIe the barium enema may be a harmIess procedure, if the patient is not in good condition it may overtax his strength and prove a needIess waste of time. It has its greatest IieId of usefuIness in subacute obstructions of the colon. X-ray pIates of the abdomen taken without the administration of any opaque medium may furnish existence of an obstruction, and, at times, indication as to its IeveI.15-” (Fig. 49.)

evidence of the may give some

The diagnosis of obstruction of the smaII intestine by x-ray examination depends on noting coIIections of fluid and gas * The digestive secretions may aIso be lost as a result of a severe diarrhea, and, in chiIdren particuIarIy, a Iowering of the blood chIorides may resuIt from this condition. t See March instaIIment, p. 394. Book Page 2 I 3

156

ACUTE INTESTINAL

in 1the intestines In obstructions

OBSTRUCTION

and the characteristic of the smaI1 intestine

patterns they assu !Il le. the accumuIation: S of

in a child of three months. Barium enema, showing CI ITIG. 49. Intussusception of b
gas ; may give the outline described by Case16 as the “ her1 ‘II ‘8or, at times, a “Iadder” arrangemen 1t of bol ze” appearance; Book :

Page314.

FIG. 50. MultipIe

FIG. 5 I. MuItipIe

Auid IeveIs in acute

Ruid levels in acute

obstruction; and Granger.ls)

patient

obstruction; patient and Granger.15)

in upright

position.

(0~ :hsner

in IlorizontaI

position.

(0~ :hsner

(I WI! Book 1’2,gc 2Ij

ACUTE INTESTINAL

158

OBSTRUCTION

the diIated co&. The diameter of the diIated coiIs is aIso a point to note carefuIIy, according to Case. The presence of various fluid IeveIs in the obstructed bowe1 can at times be visuaIized. To bring this out, the roentgenograms must be taken with the patient in the upright position (either sitting or standing upright) or Iying on the side, the picture being taken antero-posteriorIy; or a IateraI view may be taken with the patient Iying on his back. Ochsner and Granger15 have found the detection of muItipIe fluid IeveIs a particuIarIy important point in the diagnosis of obstruction. (See Figs. 50 and 51.) REFERENCES I. EISBERG, H. B. On viabihty

TO CHAPTER

XVIII

of intestine in intestinal obstruction.

Ann. Surg., 81:

926-938, 1925. 2. TAYLOR, W., HANDLEY, W. S., and WILKIE, D. P. D. Discussion on acute intestina1 obstruction. &it. M. J., 2: gg3-Ioo4, Igz5. 3. TREVES, F. Intestinaf Obstruction; Its Varieties with Their PathoIogy, Diagnosis and Treatment. N. Y., CasselI, 1899, p. 293. 4. EISBERG, H. B. Diagnosis in acute mechanica intestinal obstruction. Am. J. Surg., 2: 147-153, 1927. 5. LADD, W. E., and CUTLER, G. D. IntestinaI obstruction s. J., 191: 141-144, 1924.

in chiIdren. Boston M. w

6. PETERSON, E. W. Acute intestina1 obstruction in infancy and chiIdhood; brief review of 55 cases. Surg. Gynec. Obst., 35: 436-439, Igzz. 7. MILLER, C. J. Study of 343 surgica1 cases of intestina1 obstruction. Ann. Surg., 89: 91-107, 1929. 8. FINNEY, J. M. T. Acute intestina1 obstruction. Surg. Gynec. Obst., 32: 402-408, 1921. g. DEAVER, J. B., and Ross, G. G. The mortaIity statistics of 276 cases of acute intestinal obstruction. Ann. Surg., 61: 198-203, IgI5. IO. RICHARDSON, E. P. Acute intestinal obstruction; study of second series of cases from Massachusetts Genera1 HospitaI. Boston M. CT+ S. J., 183: 288-298, Igzo. I I. JONES, D. F. Persona1 communication to author. 12. CODMAN, E. A. Intestinaf obstruction. Boston M. w S. J., 182: 420-424; 451-458, 1920. 13. MCIVER, M. A. Acute intestinal obstruction. Arch. Surg., 25: 1098-I 134, 1932. 14. MAYO, C. H. Cause and reIief of acute intestina1 obstruction. J. A. M. A., 79: 194-197, 1922. 15. OCHSNER, A., and GRANGER, A. Rijntgen diagnosis of iIeus. Ann. Surg., gz: 947-954, 1930. 16. CASE, J. T. RoentgenoIogicaI

aid in diagnosis of ifeus. Am. J. Roentgenol.,

Ig: 413-

425, 1928. 17. DAVIS, K. S. VaIuabIe roentgenographic aid in diagnosis of intestina1 obstruction. Am. J. Roentgenol., 17: 543-546, 1927.

Book Page zr6

CHAPTER XIX DIAGNOSIS

(Continued)

In the previous chapter we have considered the cardina1 signs and symptoms of acute intestina1 obstruction. The clinical picture may be briefly summarized as foIIows: The attack is IikeIy to be ushered in by abdomina1 pain, of a coIicky and cramp-Iike character at the onset, often becoming constant after the first tweIve to twenty-four hours; and by vomiting, which becomes more profuse and persistent as the disease progresses, taking on the characteristics of “feca1” vomiting in the Iate stages. While the Iower bowe1 may be emptied once after the onset of the attack, either voIuntariIy or by means of enemas, subsequent enemas usuahy fail to produce either feca1 materia1 or gas. AbdominaI distention usuaIIy deveIops, aIthough it may be negIigibIe in amount if the obstruction be situated high in the smaI1 intestine. VisibIe peristaIsis may occasionahy be seen and in the presence of the symptoms aIready referred to is characteristic of the disease; but it is not present as commonIy as one might suppose from the textbooks, and is rareIy seen where stranguIation exists. The temperature and puIse rate are usuaIIy normaI, aIthough not infrequentIy a subnorma temperature is encountered earIy in the disease. While the foregoing picture is in genera1 characteristic of acute intestina1 obstruction, certain varieties of the disease present specia1 cIinica1 features, which wiII now be briefly discussed; certain points in differentia1 diagnosis wiI1 aIso be considered. SPECIAL POINTS IN THE DIAGNOSISOF CERTAIN VARIETIES OF OBSTRUCTION EARLY POSTOPERATIVEOBSTRUCTION.The signs and symptoms of obstruction shown by the earIy postoperative group are in genera1 those of acute obstruction from any cause: ‘59 Book

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160

OBSTRUCTION

vomiting, pain, distention and obstipation; but owing to the fact that these obstructions come on during a convalescence from abdomina1 operation, the picture is often masked. When the cIassica1 symptoms come on suddenIy during a convaIescence that is proceeding normaIIy, the diagnosis is usuaIIy easy: the diffrcuIties arise when the obstructive symptoms come on somewhat graduaIIy during a stormy convaIescence. The question often to be decided is whether the symptoms are due simpIy to a disturbance of the motor function of the intestine by operative trauma or peritonitis; or whether an organic obstruction is present.* The presence of cramp-Iike or coIicky pains or visibIe peristaIsis, or the detection of hyperperistaIsis on auscuItation, indicates that there is an attempt to push intestina1 contents beyond some obstructed point, and suggests that some mechanica eIement is present. The character of the vomitus shouId be carefuIIy noted and any change to “feca1” vomiting shouId be detected at the earIiest possibIe moment. The amount of distention in these cases shows considerabIe variation: if the obstruction is high, it may be slight. OccasionaIIy, IocaIized distentions pointing to the presence of distended coiIs of bowe1 can be made out. A rising white count in the presence of obstructive symptoms is suggestive of strangulation. The cIinica1 variations shown by the obstructions that occur earIy after operation have been comprehensiveIy discussed by Richardson.4 VOLVULUS. VoIvuIus of the smaJ1 intestine cannot usuaIIy be distinguished from any of the other forms of interna StranguIation of the smaI1 intestine. * The use of spinal anesthesia has been suggested for the differential diagnosis between functional and mechanical obstruction. FoIIowing the administration of spina anesthesia in functional obstructions a movement of the boweIs and passage of Aatus may occur. The advocates of this procedure advise prompt operation if this favorabIe resuIt does not take pIace. The possibiIity that vioIent peristaItic movements set up by the spina anesthesia may produce rupture of a gut damaged by obstruction, shouId be borne in mind. In connection with the use of spinal anesthesia, Ochsner’s work on splanchnic anesthesia in the treatment of experimenta ileus is of interest; and numerous references to the literature on this subject will be found in his articles.*,3 Book

Page

218

DIAGNOSIS

161

VoIvuIus of the sigmoid at times has more distinctive features. In genera1 it occurs in middIe age or Iater. Not infrequentry there is a history of obstinate constipation preceding the attack; it is aIso not uncommon to have a history of attacks in the past that suggested obstruction but were milder in character and subsided after the administration of cnemas.5J The pain and tenderness are IikeIy to be IocaIized in the Ieft Iower portion of the abdomen; the pain may be intense and associated with considerabIe prostration.’ At times a mass can be made out, its outIine corresponding with the diIated Ioop of sigmoid. A barium enema may show the point of obstruction. In voIvuIus of the cecum aIso there may be a history of earher attack?; and at times a mass, representing the twisted cecum, can be made out in the right side of the abdomen. GALLSTONES. As wouId be expected from the etioIogy, this type of obstruction is a disease chiefly of Iater Iife.g It is one of the few types of obstruction that is more common in femaIes than in maIes. The obstruction may be compIete from the beginning; or there may be a subacute period before the intestine is compIeteIy bIocked. The severity of the symptoms varies, depending in part upon whether the gaIIstone has become impacted in the upper intestine, or, as more frequentIy happens, Iodges near the iIeoceca1 vaIve. In the earIy stages the pain is usuaIIy coIicky in character and referred to the umbilicus. Not infrequently a history that suggests galIbIadder pathoIogy can be obtained.10s1’ OccasionaIIy upper abdomina1 pain, nausea, vomiting and tenderness, corresponding with the discharge of a gaIIstone into the upper intestina1 tract, may have preceded the obstructive symptoms. At times an x-ray of the abdomen may show the presence of a galIstone; and, rareIy, the passage of galIstones by rectum may be reported. EssentiaIIy, the diagnosis of obstruction by gaIIstones shouId be suggested by obstructive symptoms deveIoping in an eIderIy individua1 whose past history indicates gaIIBook

Page

219

162

ACUTE INTESTINAL

OBSTRUCTION

bIadder disease. The common cause of obstruction in this age group is carcinoma of the coIon; but in this Iatter disease there is usuaIIy a history of increasing constipation, or of frequent smaI1 movements, at times containing blood and mucus, preceding the acute attack. The distention is IikeIy to be more marked than in obstruction by gaIlstones. MESENTERIC THROMBOSIS.The diagnosis of occIusion of the mesenteric circuIation by thrombosis or emboIism is difficuIt, and is often made onIy at operation or autopsy: in Trotter’s12 series of 360 cases, the diagnosis was made before operation or autopsy in onIy 13 instances. There are, however, certain points which may suggest the diagnosis. WhiIe the disease may occur at any age, even in chiIdhood, it is more commonIy a disease of Iater Iife. It is usuaIIy associated with some disease of the circuIatory system, such, as endocarditis, atheroma of the aorta or arterioscIerosis; and the patient may give a history of emboIic phenomena in other parts of the body before the onset of the abdomina1 symptoms or simuItaneousIy with it. There are aIso other diseases with which it is sometimes associated: Meyer13 reports that it occurred in 3 patients with poIycythemia. The cIassica1 signs and symptoms are severe abdomina1 pain,14 vomiting, meIena, distention of the abdomen with tympanites and at times a shifiing duIness in the Aanks. If the boweIs move after the onset of the attack, the feces may contain bIood. This finding was present in 41 per cent of the cases reported by Jackson et a1.15 When the process of infarction invoIves the upper intestine, the vomiting of bIood has been reported. The patient may show signs of coIIapse,16 with a faI1 in body temperature. A Iow puIse rate is sometimes found at the onset of the attack.17 The Ieucocyte count is IikeIy to be quite high: in the series of 92 cases coIIected by MeyerI the count in a11 but 3 instances was above 18,ooo, the highest being 45,000. OBSTRUCTION OF THECOLONBY NEOPLASM.The symptoms of obstruction of the coIon from neopIasm have a tendency to Book Page 120

DIAGNOSIS

163

be less fulminating than if the obstruction were Iocated in the smaI1 bowe1. Symptoms of subacute obstruction (usuaIIy increasing constipation, or in certain cases frequent smaI1 watery movements occasionally mixed with bIood or mucus, cramp-Iike pains radiating across the Iower abdomen, increasing gurglings of gas and ffuid and a sensation of inability to empty the boweIs,‘8~1g) are Iikely to antedate the acute attack. Since stranguIation is very rareIy present in these obstructions, the pain may not be particuIarIy severe. It is, however, In the earIy stages it is usuaIIy aImost constantIy present. Iocahzed across the Iower abdomen; when the obstruction has existed for some time, the pain and tenderness are often IocaIized over the site of the obstruction, probabIy because of edema and infection. In some instances acute discomfort from distention is the most outstanding compIaint. Vomiting comes on earIy with the onset of the acute attack, but is not IikeIy in the earIy stages to be so profuse or frequent as in obstructions of the smaI1 intestine; in the Iater stages, after the obstruction is we11 estabIished and as the smaII intestine becomes more and more invoIved in the obstructive process, the vomiting may be profuse and of the typical “ fecal” character. Distention is IikeIy to be a very marked feature. In the earIy stages, visibIe peristaIsis of the Iarge intestine above the point of obstruction is not infrequentIy seen. Recta1 examination is important and may discIose a mass, particuIarIy when the growth is situated near the rectosigmoid juncture.“” In an attempt to say whether or not an obstruction is compIete, the passage of ffatus either voIuntarily or on the administration of an enema is an important criterion. The vomitus shouId be carefuIIy observed; if it takes on the character of smal1 intestinal contents, prompt surgical intervention shouId be undertaken even though some ffatus is being passed by rectum. There is usuaIIy IittIe or no systemic reaction, the temperature

and

white

bIood

ceII

count

being

generaIIy

normal. Rook Page 32 I

164

ACUTE INTESTINAL

OBSTRUCTION

X-ray examination following the administration of a barium enema is often helpful. STRANGULATED EXTERNAL HERNIAS. The diagnosis in cases of strangulated external hernia is usually obvious. In typical cases, a hernia which has previousIy been reducibIe becomes irreducible. This condition is accompanied by severe, often intense, pain, which may not be confined to the hernia1 sac but may take the form of generaIized abdomina1 cramps. Vomiting is usuaIIy present, starting soon after the initiaI pain. Obstipation is usuaIIy present; although earIy in the iIIness the bowe1 beIow the point of obstruction may be emptied voIuntariIy or by means of an enema, and in types of hernia where a section of bowe1 waI1 aIone is stranguIated, without obstruction of the Iumen (Richter’s hernia), bowe1 movements may continue throughout the course of the disease. Under these conditions, diarrhea is not infrequent. The Iate manifestations are those usuaIIy found in acute intestina1 obstruction from any cause: distention, feca1 vomiting and prostration. Although the diagnosis is usually so easy, there are occasiona1 cases where it is not obvious. The patient may not be aware that he has a hernia, and a small, tense sac may be overIooked, particuIarIy if it occurs in the femora1 cana1. In the recent Massachusetts Genera1 HospitaI series of I 47’ cases of obstruction by strangulated external hernia, there were 3 instances in which the diagnosis was not made unti1 Iaparotomy had been performed and a knuckIe of gut found stranguIated in the femora1 cana1. In any patient with symptoms suggesting intestina1 obstruction, the usua1 sites of hernia shouId be carefuIIy examined to excIude the possibility of a smal1, strangulated hernia. INTUSSUSCEPTION. Most of the cases of intussusception occur in infants or young children, frequently at an age when the patient is unabIe to describe his symptoms. With the onset of the attack the infant is IikeIy to show unmistakabIe signs of abdomina1 pain, at times drawing up the Iegs and crying Book Page 122

DIAGNOSIS

165

as the cramp-Iike pain takes pIace. Vomiting frequently takes place at the onset of the obstruction and is IikeIy to be repeated; it may not be very profuse. Often the pain is considered to be one of the commoner varieties of intestina1 colic and there is deIay in caIIing the physician; or at times the physician prescribes for the infant over the telephone without a physical examination. After the onset of the attack there may be one norma bowe1 movement; after that, the passage of bIoody mucus occurs and is a very constant symptom in infants.21-23 The infant may Iie in a rather apathetic state, showing evidence of marked toxemia; other signs of prostration may occur reIativeIy early in the disease. On the other hand, even after a number of hours have elapsed he may not show a great deal of systemic reaction. On physica examination there is usuaIIy not a great dea1 of distention, and in the cIassica1 case a “sausage-shaped” tumor may be feIt in the right or Ieft side of the abdomen; at times, however, the intussusception is under the Iower border of the Iiver and no mass can be feIt. On recta1 examination it is often possibIe definitely to palpate the apex of the intussusception. The syndrome shown by infants with intussusception is usuaIIy so typica that it seems almost incredibIe that cases shouId so often come to the surgeon Iate. Among the 9 deaths from intussusception in the series recently reported from the Massachusetts Genera1 HospitaI there were onIy 2 patients who were received at the HospitaI in Iess than forty-eight hours a.fter the onset of symptoms. This group of obstructions seems to be outstandingly one in which the genera1 practitioner can contribute to a Iowering of the mortaIity by sending the patients to the surgeon earIier. WhiIe intussusceptions occurring in infants and young children are usuaIIy of the iIeoceca1 or iIeocoIic variety (invoIving both smaI1 and Iarge intestines). The rare cases of intussusception in adults are IikeIy to be of the enteric variety (invoIving the smaI1 intestine aIone) or the coIic (invoIving the Iarge intesBook

Page

zz 3

166

ACUTE INTESTINAL

OBSTRUCTION

tine onIy), and are usuaIIy caused by a benign or a mahgnant tumor24; this Iatter is usuaIIy encountered in eIderIy individuaIs. In aduIt patients the cIinica1 syndrome is not so typica as in chiIdren. There are frequentIy attacks of abdomina1 pain preceding the fina attack. With the acute attack, vomitis usuaIIy not marked; ing and pain are present; distention bIeeding from the rectum is infrequent; and an abdomina1 tumor is onIy occasionaIIy feIt. From the genera1 symptoms, however, in spite of features which are not typica of intussusception in infants, it shouId be easy to reaIize at Ieast that an acute obstruction is present and that operative interference is indicated. There is a reIativeIy rare disease, nameIy, purpura abdominaIis or Henoch’s purpura, which may be confused with intussusception because in this disease aIso there are frequentIy abdomina1 cramps associated with the passage of bIood by rectum. Other signs of purpura, such as the rash over the abdomen and the petechia1 hemorrhages that may foIIow after the appIication of a tourniquet (the “tourniquet test”), may cIarify the diagnosis. Even if it proves to be purpura, however, the question of intussusception may stiI1 be invoIved, for, as pointed out by BaiIey, 25the hemorrhagic infiItration of the waI1 of the smaI1 intestine often taking pIace in purpura may resuIt in intussusception. BaiIey reports 9 cases where this occurred, with 7 recoveries foIIowing operation. In cases of doubt an expIoratory Iaparotomy shouId be carried out. DIFFERENTIAL DIAGNOSIS Diseases that may be confused with acute intestina1 obstruction are in genera1 those that give abdomina1 pain and at the same time cause interference with intestina1 motiIity. The Iist of diseases having a symptom compIex which may, at Ieast in part, resembIe that of acute obstruction, is rather Iong and heterogeneous; a few outstanding exampIes of different types may be mentioned and briefIy commented upon. Book Page 224

DIAGNOSIS

IO7

Among the more genera1 constitutiona diseases that may have abdomina1 symptoms of sufficient prominence to be confused with intestina1 obstruction, shouId be mentioned Iead coIic, the gastric crises of tabes, and uremia. It shouId not be forgotten that pneumonia and cardiac thrombosis arc capable of causing severe upper abdominal pain which ma>. be accompanied by nausea and vomiting. Among the rare1 medica conditions that have been mistaken for obstruction, Treves2” mentions choIera and poisoning by arsenic. Angioneurotic edema may at times cause intense abdomina1 pain, nausea and vomiting; OsIer’s articIe2’ and Withington’s2” on this disease are very interesting. The differentia1 diagnosis depends upon finding in the course of the history and physica examination, cIear evidence that some disease other than intestina1 obstruction is responsibIe for the symptoms : for exampIe, the fixed pup& and absent knee-jerks of tabes, the Iead Iine on the teeth in Iead poisoning, and so forth. The pain associated with the passage of a caMus, either biIiary or renaI, may be mistaken for the coIic of intestina1 obstruction. UsuaIIy the characteristic Iocation and radiation of the pain in these conditions,* or associated findings such as bIood in the urine or at times sIight jaundice, wiI1 serve to estabhsh the correct diagnosis. The foIIowing case iIIustrates the symptoms of obstruction associated with the passage of a renaI caIcuIus: CASE XXXIII. No. 5317, MIBH. was sent to the hospital She gave a history cessation

FemaIe,

with a diagnosis

of four days of abdomina1

of bowel movements.

aged fifty-eight.

of acute intestinal pain, profuse

The pain was located

The patient obstruction. vomiting,

and

in the left Iower side

* The characteristic pain of gallstones is, of course, likely to be located in the right upper quadrant of the abdomen and frequently radiates through to the back, especially to the “shoulder blade.” The pain of renal coIic may be IocaIized IargeIy in the region of the costovertebral angIe, in which case it is not IikeIy to be mistaken for intra-abdomina1pathoIogy; where the pain is felt in the abdomen it is IikeIy to be Iocalized in one side of the abdomen or flank and radiate downward to the scrotum or penis in the maIe or the vagina in the femaIe; the pain may be referred down the thigh on the affected side. Contrast the pain in these conditions with the pain in intestina1 obstruction (see p. 149).

ACUTE

INTESTINAL

OBSTRUCTION

of the abdomen and flank, and radiated to the Ieft inguinal region; it had been very intense at times and paroxysmal in character. The vomitus had not been fou1 smeIIing at any time. The patient had been we11 and strong during her past life, “had never had a doctor.” A number of years before, she had had an attack of left-sided abdomina1 pain resembhng somewhat the present attack but shorter in duration and less severe in character. Physical examination showed an obese woman with some abdominal distention. She complained of pain in the left side of the abdomen, but stated that it was not as severe as it had been previous to entrance. There was no muscle spasm; definite tenderness over the left side of the abdomen and in the left costovertebral angle. It was noted on examination of the extremities that the patient held the fingers somewhat tense; the thumb was in the abducted position. On appIying the tourniquet to the arm (Trousseau’s test) the typica carpa spasm of tetany occurred. Temperature IOI.~“F., puIse 96, respirations 22; white blood count 6000, poIymorphonucIear Ieucocytes 81 per cent, smaI1 Iymphocytes 16 per cent, Iarge Iymphocytes 2 per cent, mononuclear Ieucocytes I per cent. Examination of the urine showed a faint trace of aIbumin, a few red ceIIs and a few white bIood ceIIs. The bIood chIorides were 495 mgs. per IOO C.C. The uniIatera1 nature of the pain, with the radiation to the Ieft inguina1 region, suggested the diagnosis of renal coIic. When the urine was found to contain red bIood ceIIs, this impression was strengthened. A roentgenogram of the abdomen showed a shadow in the course of the Ieft ureter that was characteristic of a caIcuIus. This was Iater confirmed by a cystoscopic examination. Within the course of a few days the patient passed the caIcuIus. Comment: The fact that the patient’s pain and tenderness were IargeIy confined to the Ieft side of the abdomen and flank, together with the characteristic radiation of the pain, was very suggestive of some Iesion of the kidney and ureter. As has already been pointed out, functiona disturbances of the gastrointestina1 tract are not uncommonIy associated with such pathoIogy. In this case they were marked, particuIarIy the vomiting. The gastric secretions had been lost to such an extent that gastric tetany occurred: this is not infrequent in organic obstruction at the pylorus; but it is rare that the vomiting in cases with no organic obstruction is sufficient in amount to produce this resuIt. The distention yieIded to the simpIe measures of ffaxseed poultices and recta1 tube. Large voIumes of normal saIt soIution were administered to the patient SubcutaneousIy. The vomiting subsided, as did Iikewise the signs of gastric tetany. No operative procedures (other than cystoscopic examination) were required. Book

Page

226

DIAGNOSIS

169

Various acute conditions arising in the abdomina1 cavit), cause a sudden onset of intense pain, nausea and vomiting, and may resembIe the picture of intestina1 obstruction with stranguIation. Among these may be mentioned the twist of an ovarian cyst or of a pedunculated fibroid, the perforation of an uIcer, acute pancreatitis, etc. RareIy, the intensive coIic accompanying the onset of a fulminating appendicitis might be confused with the pain from an obstruction, but usuaII>the IocaIized tenderness and other findings wiI1 cIear up the diagnosis. FrequentIy in this group it is not possibIe to make an accurate differentia1 diagnosis; but it is usuaIIy cIear that prompt surgica1 intervention is indicated, whatever the diagnosis, and operation shouId not be deIayed. In the foIIowing case certain symptoms of obstruction were associated with acute appendicitis and genera1 peritonitis : CASE XXXIV. No. 8124, sent to the HospitaI

MIBH.

Male,

with a diagnosis

aged forty-nine.

of intestinal

obstruction.

weeks before this he had had an attack

of abdominal

the

for about

lou-er abdomen,

pain was somewhat as “indigestion.”

which colicky

persisted in character,

severa

doses of cathartic

fecal

resuIt.

Two

days

before

without

was administered that

time

abdomen;

hyperdermicaIIy;

the patient

and nephritis PhysicaI

examination

of the abdomen; tenderness there The

respirations

hyaIine

bIood ceI1; diacetic

The

the patient

was caIIed and morphine

vomited

but

severa

marked

times. Since

distention

and enemas

of the

have produced

was known to have had diabetes

a moderately no pain.

obese man with distention

On paIpation

over the right Iower quadrant;

muscIe spasm.

was sweating

Ieucocytes.

with many

showed

on deep pressure

24, white

The

of years.

he was having

was definite patlent

nucIear

pain,

of gas. The patient

for a number

hours.

he woke from sIeep with a \rerj

a physician

there have been no bowe1 movements

onIy a smaI1 amount

two

across

by the patient

the pain recurred;

the patient

has had IittIe

tlycnty-four

rvas

reIief of the pain and with littlc

admission

severe pain across the Iower abdomen;

About

pain, extending

but was dismissed

Four days before admission

took

The patient

Rectal

profuseIy.

bIood count

14,000,

urine showed

and granuIar and acetone

sugar was 235 mgs. per 100 c.c.

examination Temperature traces

few white

were present

was sIight

over this region

was not remarkable. IOI.~‘F.,

with 90 per cent

heavy

casts,

there

pulse

I 16,

poIymorpho-

of albumin

and sugar,

bIood ceIIs, a rare rec1

in Iarge amounts;

the blood

ACUTE

INTESTINAL

OBSTRUCTION

AIthough this patient did have certain signs of intestina1 obstruction (cessation of bowe1 movements and essentialIy negative resuIts from enemas, together with abdomina1 pain and vomiting), it seemed reasonabIy certain that these signs were not primary, but were secondary to an inffammatory process within the peritonea1 cavity. The history, together with the eIevation of the temperature and the Ieucocytosis, abdomina1 tenderness and spasm, a11 pointed to this diagnosis. The patient was intensiveIy treated for a few hours by insuIin and intravenous administration of solutions of saIine and gIucose, by the medica department. Under this regime the bIood sugar was Iowered and the acetone and diacetic disappeared from the urine. The abdomen was then expIored under novocaine and gas anesthesia. A ruptured appendix and genera1 peritonitis were found. The appendix was removed and a drain inserted. The patient’s genera1 condition became progressively worse, and he died on the second postoperative day, with marked eIevation of puIse, temperature and respiration. There was no vomiting foIIowing the operation and the abdomina1 distention diminished somewhat. Comment: This case represents a functiona disturbance of intestina1 motiIity from peritonea1 sepsis. The diagnosis was reasonabIy clear. The functiona obstruction reaIIy pIayed no important roIe in the picture, the patient dying of a progressive peritonitis.

The distention and obstinate constipation shown by patients with Hirschsprung’s disease may at times suggest obstruction; in case of doubt, a barium enema wiII show the true state of affairs. FecaI impaction in the rectum in the aged may at times reach such proportions as to constitute a temporary obstruction. The obstruction, however, is rareIy compIete, and a recta1 examination and enema wiI1 usuaIIy settIe the question. REFERENCES

TO CHAPTER

XIX

I. GUTHRIE, D. Postoperative ileus; its early recognition and control. N. York State J. Med., 31: 1021-1024, 1931. 2. OCHSNER, A., GAGE, I. M., and CUTTING, R. A. Treatment of iIeus by spIanchnic anesthesia; preIiminary report of experimental study. J. A. M. A., go: 1847-1853, 1928. 3. OCHSNER, A., GAGE, I. M., and CUTTING, R. A. Comparative vaIue of spIanchnic and spinal anaIgesia in treatment of experimental ileus. Arch. Surg., 20: 802~831, 1930. 4. RICHARDSON, E. P. IIeostomy for postoperative Boston M. @ S. J., 182: 362-366, xgzo. Book Page 228

obstruction

folIowing appendectomy.

DIAGNOSIS 5. BLOODGOOD, .I. C. IntestinaI obstruction due to voIvulus or adhesions of sigmoid colon, with report of 5 cases, and study of etioIogica1 factors. One case of recurrent voIvuIus of sixteen years’ duration, thirty-two attacks, cured by resection; second, observation at operation, of acute voIvuIus seven hours after onset of symptoms. Ann. Surg., 49: 161-182, 1909. 6. %‘EEKS, C. VoIvuIus of sigmoid megacoIon. Ann. Surg., 94: ro5o_ro6(), 1931. 7. DEAVEK, J. B., and hlACOUN, J. A. VoIvuIus of sigmoid Aexurc. SW,<. Gynec. Obsr., 44: 101-104, 1927. 8. HOMANS, J. Torsion of cecum and ascending colon. Arch. Surg., 3: 395-404, 1921. 9. BAKNAKD, 1-I. L. IntestinaI obstruction due to gall-stones; report of 3 cases, with summary of 5 more cases from records of London IIospitaI, 1893-1901. Ann. Surg., 36: 161-182, 1902. IO. ABBOTT, C. R., and HOST, E. L. Intestinal obstruction by gaIIstones. Boston M. cd I I.

12.

13. 14. 15. 16.

17. 18. ‘9.

S. J., 188: 390-397, 1923. POWERS, J. II. Acute intestina1 obstruction due to impacted gal1 stows; cases. Surfi. Gym. Obst., 47: 416-420, 1928. TROTTEII, L. B. C. EmboIism and Thrombosis of Mesenteric Vessels.

report of 4 Cambridge

Univ. Press, 1913, p. 115. ~IEYER, J. L. hlesenteric vascular occhrsion. Ann. Surg., 94: 88-96, 1931. Ross, G. G. nlesenteric thrombosis with report of 6 cases. Ann. Surg., 72: 121-128, I 920. JACKSON, J. Xl., PORTER, C. A., and QUINUI., \V. C. nlesenteric embolism and thrombosis; study of 214 cases. J. A. kf. A., 43: 25-29; I IO--I 14; 183-187, 1904. I(I.EIN, E. EmboIism and thrombosis of superior mesenteric artery. Sure. G>-net. Obst., 33: 385-405, 1921. GHAKP~IIE, P. V. Diagnosis of gangrene of small intestine. Brit. M. J., I : 217, 1928. JONES, D. F. End resuIts of radical operations for carcinoma of rectum. Ann. Surg.. 00: 675-691, 1929. Joues, D. F. Carcinoma of rectum and coIon. New En,ziand J. .Ifed., 202: 162-164, 193”.

22.

11’. D. IntestinaI obstruction from carcinoma of colon. Ann. Surp.. 94: 717.-721, ,931. LADD, \I:. E., and CUTLER, G. D. Intestinal obstruction in children. Boston 121. pa S. J., 191: 131-144, 1924. PETEIXSOU, E. \\-.Acute intestinaf obstruction in infancy and childhood; brief rcvirw

23.

PERKIK,

20. HAGGAKD, 21.

of 55 cases. Surg. Gynec. Obst., 35: 436-439, 1922. \1’. S., and Lrn-~s.4~. E. C. Intussusception; monograph

Brit. J. Surz., 9: 46-71,

24. 25. 26. 27. 28.

based on 400 cases.

1921. RICIVER, XI. A. Intussusception of smaI1 intestine with special reference to hleckcl’s diverticuIum as causative factor. New England J. :Lled., 199: 453-456, 1928. BAILEY, 11.Purpura as acute abdominal emergency. Brit. J. Surg., 18: 234-240, 1930. TRE~ES, F. IntestinaI Obstruction; Its Varieties with Their Pathology, Diagnosis and Treatment. N. Y., CasseII, 1899, p. 444. OSLIXI~, 12.. On viscera1 manifestation of erythema group of skin diseases. Am. J. ~21.SC., n.s. 127: r-23, 1904. \VITHIKGTON, C. F. VisceraI purpura and nngioneurotic edema. Boston :\I. @” S. J., 166: 51 rp5r5,

1912.