CHAPTER XLVIII

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THE SMALL INTESTINES.

CONGENITAL ANOMALIES OF THE SMALL INTESTINES.

The entire intestinal canal is sometimes too short and sometimes fails to develop sufficiently in caliber, or sections of it may remain undeveloped. None of these changes have interest or importance for the surgeon as such, save those which produce acute or chronic obstruction or conduce to acute inflammatory affections.

_Intestinal diverticula_ are usually of that type described by Meckel and everywhere known by his name. Aside from these the others usually met are irregular sacculations or hernial protrusions which may be due to previous disease or to some congenital anomaly of structure. These are sometimes seen in multiple form, and in one case recently under my observation over one hundred of them were found scattered along the intestinal canal, but, inasmuch as the patient died practically of old age without a history of serious previous disease, it could not be ascertained whether the pouches were of congenital or acquired origin.

The genuine Meckel diverticulum is a relic of the tubular structure which leads from the primitive intestine to the vitelline or yolk sac, and which should persist until about the end of the second month of embryonic life. After this time it should be completely obliterated and disappear. When this does not happen there may result a fecal fistula at the navel, which is then usually referred to as _persistent omphalomesenteric duct_, and which implies a continuous passage-way between the skin and the interior of the bowel.

When the umbilical portion alone persists there results a small cyst on the posterior side of the navel.

When the intestinal end alone persists a protrusion or sacculation will remain to mark its site.

The duct may become obliterated and yet fail to disappear, thus leaving a fibrous cord which represents the original omphalomesenteric structures and vessels, which will be probably mistaken for an inflammatory band and may serve as a later cause of acute obstruction. If such bands lead to the umbilical region their identity may be easily established.

The presence of Meckel’s diverticulum may cause serious abdominal mischief. It may become involved in a localized process exactly as the appendix often does, which may then be referred to as a _diverticulitis_, where ulceration and perforation may occur. It may constitute the whole or a portion of the contents of a hernial sac. I have twice found it in inguinal hernia, once in umbilical hernia, and by others it has been reported in all the ordinary hernial locations. Porter has collected from literature 184 cases in which its presence caused serious abdominal crises. The condition itself is probably present in at least 1 per cent. of mankind, and is stated by Halsted to be the cause of intestinal obstruction in 6 per cent. of cases. In the 184 collected cases above mentioned it caused obstruction in 101. Out of 21 cases of the above collection it was not only found in the hernial sac, but in all but 1 was shown to be the actual cause of the trouble. In 5 of these cases the diverticulum was open at the umbilicus. In such a case if the opening be large the gut wall might prolapse and thus form a hernia.

Diverticulitis has been repeatedly mistaken for appendicitis, its symptomatology not being distinctive. Exact diagnosis is seldom possible before operation.

On general principles, considering their possible dangers, it would be well to remove all diverticula which are found in the course of ordinary abdominal operations, whether they appear to be causing trouble at the time or not.

While the average length of Meckel’s diverticulum is three inches it may exist as a mere nipple-like projection, or it may be a free tube attaining a length of several inches. Its attached end is usually larger than its distal portion and its diameter usually less than that of the gut from which it arises. It may be provided with a scanty mesentery or may hang independently. While ordinarily its distal end is free it may nevertheless be continued as a solid cord attached, as above mentioned, to the umbilicus. This cord frequently contracts secondary adhesions, and it is under these conditions that it most often constricts the bowel by forming a loop within which the intestine becomes entangled. Free diverticula of sufficient length are sometimes found tied in a genuine knot in a manner which is absolutely inexplicable. There are numerous ways by which such a diverticulum may produce strangulation of the normal bowel; thus, by formation of a ring in which its own free end projects, in which is later entangled a bowel loop, or by surrounding the pedicle of an intestinal loop as might a noose. Again bowel is sometimes tightly drawn over such a diverticular band, just as a shawl may be thrown over the arm, obstruction following in the displaced bowel. When much contraction is brought to bear the gut may be so acutely bent as to become occluded. Finally the bowel at the point of origin of the diverticulum may undergo gross structural changes, the result of long-continued traction, which may lead to cicatricial narrowing. More indirectly diverticula seem in some unknown way to predispose to intussusception at their point of origin, or they have been found inflated and hanging from the intestine after obstructing it (Fig. 559).

[Illustration: FIG. 559

Meckel’s diverticulum still attached at the umbilicus and producing obstruction. (Lejars.)]

ACQUIRED MALFORMATIONS OF THE SMALL INTESTINE.

Of acquired malformations of the small intestine we have mainly to deal with those which are produced by injury or disease. Among the former would be the results of violent contusions or of any of the lacerated, incised, or gunshot wounds to which the bowel is so often exposed. Should recovery ensue cicatricial contraction is likely to result. On the other hand, such previous disease conditions as ulcerations--tuberculous or typhoidal--or the so-called chronic catarrhal or malignant, may in one way or another occlude and thus finally obstruct the lumen of the bowel. Distention diverticula may also result, which correspond to the traction diverticula of the esophagus already described.

WOUNDS OF THE SMALL INTESTINE.

The small bowel, like the larger or the stomach, may be ruptured in consequence of abdominal contusions, the condition depending on the nature of the injury, the degree of fulness of the bowel itself, and other obvious causes. This character of injury has been already sufficiently considered in dealing with rupture of the stomach. Their symptoms are not essentially different, neither are the principles of ordinary surgical treatment. Of all gunshot wounds those of the abdomen constitute about 6 per cent., being more frequent than stab wounds.

=Gunshot Wounds.=--Gunshot wounds of the intestine would by themselves fill an interesting chapter in a work on surgery. In such an epitome as this they can be given but short consideration. The condition was for centuries hopeless, until the American surgeons Parkes, Bull, and Senn took up the subject and taught the profession how to more quickly recognize the injury as well as to treat it. The special dangers of all punctured wounds of the bowel, like those of the stomach, are hemorrhage and escape of fecal contents. The great length of the intestinal tube, and its coiled arrangement within the abdominal cavity, subject it to the possibility of multiple punctures, from a dozen to twenty having been inflicted by the passage of one bullet. The multiplicity of these injuries, therefore, gives a still more formidable character to their presence. Much will depend upon the size and velocity of the bullet and the distance from which it is fired. The perforated gunshot wounds of the abdomen which occur in civil life are usually inflicted by a smaller bullet than those occurring in actual warfare, while, at the same time, the distance is usually short.

Gunshot wounds are followed by an apparently disproportionate amount of collapse. There is no accurate method of recognizing from the exterior the amount of harm done by the passage of a bullet into or through the abdominal cavity. This constitutes one of the greatest arguments in favor of immediate exploration, an argument which is strengthened by the fact that almost every penetrating wound of the abdomen is complicated by injury of some abdominal organ. The greatest danger attaches to perforation of the transverse colon or of the small intestine, because these are the most movable parts of the intestinal canal. The dangerous wounds are those which lie in the frontal plane. Bullets which pass through the abdomen obliquely are perhaps less likely to produce fatal result. Astonishing differences prevail between the severity of those accidents received upon the field of battle and in civil life. In battle men are shot through the abdomen and not conspicuously disabled, recovering sometimes with no other treatment than antiseptic occlusion. It is impossible to assume that the bowels have not been injured, and yet they recover. The fact thus stated best indicates the reason for abstention from intervention on or near the firing-line in battle, and its most prompt and early performance when the patient is in a well-managed civil hospital.

=Symptoms.=--The symptoms of _intestinal perforation_ in these cases are not so prompt as when the stomach is wounded. Blood may occur in the vomitus or in the stools, but only ordinarily after the expiration of a few hours. Should fecal matter be found within the external wound evidence would be complete, but this is rarely the case. The probe may show whether the abdominal wall has been completely perforated or not; beyond this it will give little information. By far the best probe is the sterile finger, introduced through the opening enlarged for the purpose. With this more distinct information may be gained. Some years ago Senn proposed the method of inflating the colon and small intestine with hydrogen gas, on the expectation that it will escape through any intestinal perforation into the abdominal cavity, which it would distend, and that then by inserting a small glass tube in the abdominal wound it could be lighted and made to thus identify itself at the distal orifice of this tube; but this method requires special conveniences which are rarely at hand in emergency cases, and has been practically abandoned.

A study of the direction of the abdominal wound which may be sometimes made from an accurate account of the accident, and at other times by noting the location of the wounds of entrance and exit, will do much to determine whether intestines were probably in or out of harm’s way. If it can be established that the bullet has probably avoided them then some would wait for the inception of the first serious sign of mischief before exploring. On the other hand, if it should seem inevitable that such injury must have occurred, or, without such reasoning, if the patient present a serious condition, he should be promptly operated unless practically moribund.

The general principles of recognition and treatment of gunshot wounds have been considered in an earlier chapter and the subject will not be further considered here except as regards treatment.

=Treatment.=--The principles of surgical treatment for gunshot wound of the intestines include a free abdominal incision, an inspection of the entire length of the intestinal canal, which can only be made by passing it through the examining fingers while exposed to sight upon the abdominal surface, the accurate securement of all bleeding vessels, and the closure of all punctures. Any portion whose blood supply has been so completely cut off as to threaten or produce gangrene should be removed by resection, with end-to-end or a lateral anastomosis. The patient having been thus eviscerated and the intestinal viscera examined, the abdominal cavity should be further explored, not so much to find the missing bullet as to discover what further harm may have been done; while if such be found the indication should be met. Then after an exceedingly careful toilet of the peritoneum the intestines may be restored, it being of course assumed that every puncture has been fully recognized and properly sutured and secured. Nearly all of these cases will call for some abdominal drainage, which may or may not be posterior, as shall seem best.

_The location of the bullet is a matter of minor importance._ Should it lie where it can be easily identified and removed this should be done. Otherwise one should not waste valuable time in hunting for it, remembering that he is performing not an autopsy but an operation.

ULCERS OF THE SMALL INTESTINES.

There is no point of the intestinal tube between the pylorus and the anus which may not be involved in an ulcerative process, either acute, chronic, or malignant. Acute ulcers of the upper bowel are usually of typhoidal origin, while those of the lower bowel may be due to either typhoid, tuberculosis, or syphilis. At certain points ulcers assume somewhat distinctive character. Thus the acute catarrhal ulcer, so called, seems to have a more definite entity than a declared pathology, it being somewhat difficult to account for its existence. The peculiar duodenal ulcers which have been met with after operations or burns have been elsewhere discussed, and are to be regarded as of an acutely toxic origin. A special type of ulcer of the duodenum has also been noted opposite the anastomotic opening which is made in the ordinary gastro-enterostomy, for whatever purpose performed. This appears to be due to the outpour of the gastric juice upon a surface not normally prepared for it, upon which it acts as an irritant, in time producing more or less acute ulceration. This is the so-called _peptic ulcer of the duodenum_, an occasional complication of gastro-enterostomy.

=Duodenal Ulcer.=--Duodenal ulcer of a type corresponding to gastric ulcer has been recently determined to be a more frequent lesion than has been supposed. A series of over fifty operations for this condition, reported by Moynihan, in 1905, thus occurring in the practice of one surgeon, will dispose of the question as to its great rarity. Its symptoms are often so characteristic as to admit of reasonably easy diagnosis, and it has, therefore, become more and more a matter of greatest interest to the surgeon, since duodenal like gastric ulcer is essentially a surgical condition.

These ulcers are usually located in the first portion of the duodenum, _i. e._, in at least 90 per cent. of cases. They may be solitary or multiple, and may be associated with gastric ulcers. In the ordinary postoperative peptic ulcer the sequence of events is usually gastric ulcer, hyperchlorhydria, and duodenal lesion. It may occur at any age, and is the frequent cause of melena of the newborn or of the young.

=Symptoms.=--Symptoms of duodenal ulcer include pain, hematemesis, and melena. Pain may be a vague uneasiness or may be severe. It is usually described as of a burning character, felt mainly in the middle line or along the right costal margin. It becomes gradually more severe and may finally disable. It is sometimes described as cramp-like. When severe it is referred to the right of the middle line. In cases where there are adhesions to the liver or gall-bladder, pain radiates upward to the right breast, or even around the chest to the back. The pain is associated, by more or less marked time limit, with the ingestion of food, coming on from two to four hours after a meal, whereas that of gastric ulcer comes soon after eating. Sometimes it is even regarded as a “hunger pain,” and patients find that the taking of a little food will give relief. So soon, however, as this is digested pain returns, when they again call for more food. Hematemesis and melena may be present together or either may appear without the other. Small quantities of blood in the vomitus is more likely to attract attention than considerable quantities in the stools. It has been estimated that in from 25 to 30 per cent. of acute cases hemorrhage is frequent, and occurs in 40 per cent. of chronic cases. In the stools blood is found in perhaps one-half of the instances. The amount of blood may be considerable, even sufficient to produce faintness. In fact, the intestine has been found full of blood when the abdomen was opened, and Moynihan has seen even the colon distended with blood.

The more serious _complications of duodenal ulcer_, aside from hemorrhage, are those of _perforation_, cicatricial contractions or _stricture_ formation (obstructing the bowel or the common duct, or both), _local peritonitis_, cancer, and indirectly gall-bladder or pancreatic disease. Next to hemorrhage perforation is more likely to occur in a duodenal than in a gastric ulcer and with more disastrous consequences. Such perforation affords a peculiar mimicry of acute, gangrenous appendicitis which, as Moynihan has shown, is due to the direction taken by the extravasated fluid down along the right of the transverse mesocolon toward the iliac fossa. In fact, the condition is more likely to be mistaken for one of acute appendicitis than for anything else.

With a primary ulcerative lesion in the duodenum it is easy to realize that infection may readily travel up the common duct, involving both the pancreas and the biliary passages, while the resulting cholecystitis will intensify and spread the local peritonitis previously produced, and all combined will cement the viscera in this region into one common mass in which anatomical identity is easily lost. A good history, when obtainable, will help very much in diagnosis, especially when the absence of previous gastric symptoms can be established. This, with the symptoms already given above, and the tenderness over the duodenum, which is rarely absent, will afford good basis for diagnosis in the more chronic cases. Duodenal perforation may even be mistaken for rupture of an extra-uterine pregnancy, as well as for perforation of the stomach or of the gall-bladder, or, as mentioned above, of an appendix.

Quite recently attention has been called to a condition of the duodenum resembling that known as hour-glass stomach, and produced in much the same way. It seems to be the result of cicatricial contraction of an old ulcerated area, and may cause almost complete constriction. _Hour-glass duodenum_ is amenable to surgery only, and should be treated either by gastrojejunostomy or possibly by a resection with end-to-end suture.

=Treatment.=--For duodenal ulcer when recognized before perforation, there is but one treatment, _i. e._, _gastro-enterostomy_, preferably posterior, performed exactly as for gastric ulcer, for the same reason, and with the same prospect of relief, inasmuch as it affords physiological rest for the diseased area. In rare instances it may be possible to so expose the duodenum as to make it justifiable to attack the ulcer directly, but the simplest and, in general terms, the best procedure is that just mentioned.

_For perforated ulcer of the duodenum_ the indication is not alone for a gastro-anastomosis, but for exposure of the site of perforation, removal of all extravasated material, a most careful toilet of the peritoneum, and suture of the perforated area, this being the indication when possible. Provision should be made for drainage, while at the same time affording a direct outlet from the stomach into the first portion of the jejunum beyond. Should the surgeon operate apparently for appendicitis and discover that he has to deal with a perforated duodenum he should extend far upward the incision made for the former purpose, and, having thus widely opened the abdomen, should thus find himself perhaps better provided with space in which to work than had he opened at first directly over the duodenum.

=Typhoidal Ulcers.=--Typhoidal ulcers of the intestines have a tremendous surgical interest in that they not infrequently lead to perforation, and that this almost always is fatal if let alone. It may be possible, however, by prompt recognition of the occurrence of the perforation and by immediate intervention to cleanse the peritoneal cavity of extravasated feces and close the opening thus made.

=Symptoms.=--The symptoms of perforation are at first not unlike those of hemorrhage, in that shock is immediate and profound, and pain, usually intense, is produced. These are quickly followed by abdominal rigidity, while a blood count will show a rapidly increasing and high leukocytosis. To the expressions of local peritonitis are quickly added those of one which is generalized, with well-marked rigidity and great meteorism.

The condition having occurred admits of but one remedy--namely, operation. One of the latest collections of statistics includes 63 operations for typhoid perforation, with 11 recoveries, although probably today the percentage is somewhat better than in 1903. _Operations to be effective should be immediate._ Patients are usually too profoundly collapsed to justify general anesthesia, unless perhaps this may be secured with ethyl chloride or somnoform. Many of them have been operated under local anesthesia. This has its disadvantages, however, in that it is so difficult to make free opening and exploration or free toilet. Opening having been effected, the loops of intestine must be successively examined until the site of the perforation is discovered. Here sutures must be applied, if possible. Should the condition of the bowel render it absolutely unreliable, _i. e._, should it be too extensively gangrenous to retain sutures, it should be brought out and an artificial anus made, at least for temporary purposes. In addition to these measures the most careful toilet of the peritoneum is needed, perhaps including extensive irrigation, unless it can be shown that the area contaminated by extravasation is localized and shut off.

_Perforation of tuberculous, dysenteric, cancerous, or other ulcers_ will cause symptoms very much like those of typhoidal perforation, and the case will differ essentially only in this respect, that in most of the latter the general condition of the patient will not be so extreme, and the danger of administering an anesthetic or of operating not so great. Otherwise the indication, the necessity, and the method do not differ.

=Tuberculous Ulcers.=--Tuberculous lesions of the small intestines produce less destructive features than when situated in the colon. Tuberculous infection of the intestinal tract occurs more often through the swallowing of infected sputum, and, consequently, is a frequent condition among consumptives. Such lesions in the small intestines will lead to infection of the mesenteric nodes which, in time, may become serious or even fatal, or it may lead to tuberculous peritonitis with its finally disastrous consequences. As a rule, however, tuberculous ulcers are not so likely to perforate, this being in large measure due to the frequency with which they contract adhesions or affix diseased surfaces to others, thus rather guarding against such an accident.

=Symptoms.=--Tuberculosis may also appear throughout the intestinal tract in miliary form, or we may find _tuberculous gummas_, either in the folds of the peritoneum or subperitoneally in the wall of the bowel. Any of these lesions may lead to any of the others, and by the time the case has been diagnosticated or has come to operation or autopsy it is sometimes difficult to say what was the primary lesion. Diagnosis is made partly with the thermometer and partly by inspection and palpation, where one may be able to discover mesenteric enlargements or the presence of fluid, as it usually collects in tuberculous peritonitis; and perhaps partly by the general appearance of the stools, in which a careful search may possibly, although by no means with certainty, reveal the tubercle bacilli.

=Treatment.=--The treatment of such tuberculous lesions is largely constitutional. When the case assumes the aspect of tuberculous peritonitis much more can be accomplished by abdominal section and irrigation, at which time it may be possible to remove some localized focus without thereby doing more harm than good. The usual constitutional measures, including oxygen, are indicated; but there maybe difficulty in forcing hypernutrition because of the actual state of ulceration. In this case foods which are cared for by the stomach should be given in preference. Such intestinal antiseptics as creosote or other remedies of its class may also be pushed to the point of toleration.

The other _granulomas_ produced by either _syphilis_ or _actinomycosis_ may give rise to ulceration and its consequences and sequels, in a way resembling those of tuberculosis. While the lesions they produce may give rise to uncertain symptoms, a diagnosis can hardly be made without accurate history and without the co-existence of other lesions in more accessible parts of the body, by whose character they may be determined. Primary actinomycosis of the intestinal tract is more common than is generally realized. As it develops it tends to spread to adjoining viscera and form tumors which later may break down. The debris thus resulting will be indicative, especially when the characteristic calcareous particles are felt in it, or the characteristic ray fungus discovered with the microscope. (See

## Actinomycosis.)

STRICTURE OF THE INTESTINES.

Save in rare instances where stricture may be due to congenital defect the condition is never primary, but is secondary to some previous and active disease. Stricture proper should be distinguished from obstruction produced by compression from without and should usually be made to include those cases due to intrinsic disease of the intestinal wall. Here it is in the vast majority of cases either due to cicatricial contraction, following the healing of some previous lesion, or else to the infiltration and progress of malignant disease. In the former instances a great deal may be accomplished by operation. In the latter much will depend upon the relative period at which the case is seen by the surgeon.

=Symptoms.=--The symptoms of stricture are those of bowel obstruction. The tumor which produces it may be identified by palpation, or by the fecal impaction, at least accumulation, which is likely to occur above it, which may appear as a tumor and be mistaken for it until cleared away by suitable cathartic measures. Ordinarily the surgeon never recognizes stricture of the small intestines, then, save by its obstructive features.

=Treatment.=--The treatment consists in what can be done by radical surgical measures, and this can only be determined after exploratory abdominal section.

TUMORS OF THE SMALL INTESTINES.

Benign tumors of the small bowel are relatively infrequent, perhaps the most common being the lipomas which develop along the mesenteric border, usually as excessive epiploic appendages. But circumscribed and even pedunculated lipomas are seen occasionally in this location and are of surgical interest largely because, at points where they are located, intussusception is peculiarly liable to occur. In fact, the condition figures as one of the predisposing causes of invagination. Fibromas develop occasionally in the intestinal walls and adenomas grow from the glandular structures which abound therein. Other benign tumors are exceedingly rare.

Besides predisposing to intussusception these tumors are innocent, save that in time they constrict or obstruct the lumen and produce one form of stricture with obstruction, which will first be chronic and then terminate acutely and fatally unless promptly relieved.

All benign tumors of the bowel should be removed with the least harm possible to the bowel itself, but when a neat extirpation without reduction of intestinal caliber is not possible no hesitation should be felt about resecting a sufficient portion of the gut; or should this be impracticable in making an anastomosis, thus excluding that part of the bowel involved.

=Cancer of the Bowel.=--In the small intestines by far the most common type of malignant tumor is the round-cell carcinoma, epithelioma rarely appearing except in the lower part of the rectum, where flat epithelium is met. Adenocarcinoma, then, is common, and sarcoma relatively rare, the latter arising, of course, from mesoblastic elements. A diagnosis is made by first noting symptoms of intestinal obstruction plus certain added features of cachexia, lymph involvement and possibly of metastasis, for which a benign stricture would not account. Sometimes a tumor is easily felt within the abdominal wall; at other times one simply makes the general diagnosis of intestinal obstruction, presumably cancerous, because of age and cachexia, and leaves the rest to be determined by operation. Cancer of the bowel will naturally spread in the direction of the lymphatics at the root of the mesentery, and these will nearly always be found involved. It is fortunate if a case may come to operation before this invasion has occurred.

=Treatment.=--Cancer of the bowel permits of but two methods of treatment, one _excision_ of the entire infected area, both of bowel and of mesentery, in cases not too excessive, the other an _anastomosis_, by which temporary relief at least may be afforded. In all cases I am strongly inclined to advise the use of the _x_-rays, for a long time after operation; in favorable cases because it exerts a prophylactic influence, in the unfavorable cases because it nearly always relieves pain and retards growth, seeming sometimes even to disperse it. Such treatment should always be tempered by the best of judgment, lest _x_-ray dermatitis complicate or prevent it.

ACUTE INTESTINAL OBSTRUCTION; ILEUS.

The somewhat badly derived and indefinite term “_ileus_,” in common use abroad, is coming into more fashionable use in the English-speaking profession, which is rather unfortunate, for it has not always meant exactly the same thing in the writings of different authors. It will be used, however, in this chapter as practically synonymous with acute obstruction or strangulation.

Acute obstruction may be classified in two ways, as to types and as to causes. For the first purpose the best classification is perhaps the simplest, and, as recently rehearsed by Murphy, is as follows:

1. Adynamic, including those conditions which are due to absence of power of propulsion.

2. Dynamic, where obstruction is due to excessive power or excessive contraction of the muscular wall.

3. Mechanical, including all of those conditions of strangulation or obturation which, in a mechanical way, impede the advance of intestinal contents.

Conditions which permit the adynamic type may include those of _spinal origin_, those interfering with mesenteric _nerve supply_ or that of the walls of the intestines (for instance, in cases of fracture of the spine), or, again, where extensive operations have been performed on the mesentery, or where there have been extensive wounds. Thus in removal of mesenteric tumors, unless care is exercised in separating the mesentery from the tumor and in ligating bloodvessels without including nerves, a paralytic ileus may promptly result. Gunshot wounds of the chest or of the spine may also include _injuries to nerves_, by which paralysis of the bowel ensues. So, too, adynamic ileus sometimes results through the _paralyzing reflexes_ which follow strangulation of the omentum--as, for instance, in a hernial sac--or it may be due to biliary calculus acting in the same way.

The dynamic forms, as well as the mechanical, are much more likely to be characterized by pain and violent symptoms than are the paralytic. _Gastric tetany_ is a condition to be differentiated from reflex ileus. _Enormous distention of the stomach immediately after operation_ leads perhaps to a belief that a patient has acute obstruction of the intestine, when the fact is that such a case may be relieved by vomiting or passage of a stomach tube. _Local peritonitis_ of septic type, as well as peritoneal traumatism, tends to weaken if not to paralyze peristalsis. In general peritonitis the entire intestinal tract is involved, partly from reflex paralysis,

## partly from inflammation of the intestinal wall. The _embolic type of

paralytic ileus_ may be due either to interference with nerve supply or with blood supply. In thrombophlebitis symptoms develop more slowly, especially when this follows abscess of the liver or spleen. Here there is not so much meteorism, and the bowel may be even nearly empty, while we have the other symptoms of pain, nausea, and vomiting. Borborygmus is one of the most pronounced manifestations of mechanical ileus and the stethoscope will then give much assistance. In fact auscultation of the abdomen, with a recognition either of active motion within or of absence of peristalsis, should not be neglected; when one can hear intestinal waves the condition is much more likely to be one of purely mechanical obstruction.

Classified by causes, we may make out the following well-marked groups:

1. Strangulated hernia of all varieties, including diverticula.

2. Intussusception.

3. Volvulus.

4. Ileus from fecal impaction.

5. Stricture.

6. Intrinsic neoplasms.

7. Extrinsic neoplasms.

8. Gallstones and foreign bodies, enteroliths, etc.

9. Peritonitis, with paralytic ileus or kinking of bowel by adhesions, or both. This condition is seen in severe cases of appendicitis.

10. Bands, congenital and acquired, recent and old.

11. Slits and apertures in the mesentery or omentum.

12. Effects of contraction and intestinal looping.

13. Congenital causes, including diverticula, unobliterated omphalomesenteric and hypogastric remains, etc.

1. =Strangulated Hernias.=--By far the most common of all the causes of acute obstruction are strangulated hernias. These are, however, treated by themselves in a distinct chapter.

2. =Intussusception or Invagination.=--These terms imply a protrusion or prolapse of one part of the intestine into the lumen of an immediately adjoining portion. This is found to be the cause of perhaps one-third of the total number of cases. Enteric invaginations occur along any portion of the small intestine, being more common in the lower portion and rare in the uppermost. They seldom attain great length and are often very short. The ileocecal is the most common variety, since obviously it is the easiest of occurrence, the ileum protruding into the cecum or the ileum and cecum together passing into the ascending colon. Colic invagination may occur anywhere along the large bowel, being again more common near its distal termination. The colon may descend into the colon or the sigmoid into the rectum, even to such an extent as to present at the anus or possibly protrude. Statistics show that the ileocecal occurs in 44 per cent., the enteric in 30 per cent., the colic in 18 per cent., and the ileocolic in 8 per cent. of cases.

While the surgeon is concerned only with the obstructive form of intussusception it is of interest to know that the condition occurs occasionally shortly before death and is then spoken of as the _intussusception of the dying_, being usually due in these cases to irregularity and uncertainty of peristalsis during the concluding hours of life; paralysis occurring at one portion of the intestinal tube and abnormal activity just above it. These conditions are discovered at autopsy, and can be recognized as such by the absence of exudate or of any attempt either at repair or inflammation. They occur most commonly in the young and may also be multiple. In direction intussusception is practically always descending, although there may be a secondary and associated ascending movement, the latter being unimportant.

_Double_ intussusceptions are somewhat common, and triple or multiple have been described.

Cross-section of an invaginated bowel will show that on each side one must pass through three distinct layers of bowel wall. That portion which is intruded is spoken of as the _intussusceptum_, while that portion which receives the latter is known as the _intussuscipiens_ (Fig. 560). Obviously when invagination occurs the mesentery should be drawn in with the intussusceptum, while traction upon it should increase with advance of the included bowel. This is particularly often seen in ileocolic varieties where the ileum, with its mesentery, may travel the whole length of the colon and even present at the anus. Moreover, this may occur within a relatively astonishing short time, and the fact that the intussusceptum may be felt in the rectum within a few hours after the occurrence of the first symptoms is a fact not easily to be explained.

[Illustration: FIG. 560

Diagrammatic section of an intussusception: _A_, reflected tube; _B_, receiving tube or sheath; _C_, entering tube.]

=Causes.=--The causes of intussusception are obscure, postmortem findings or even the revelations of a laparotomy demonstrating conditions, but not often affording explanations. The presence of tumors, especially lipomas, which may even be pedunculated along the small intestine, has been demonstrated in a number of instances, and they have been supposed to be active factors in the first disturbance. Everything points to the association of disordered intestinal movements with the mechanical condition of obstruction, and the former are more frequently seen in the intestinal complaints of the young, along with the presence of masses of undigested food or impacted feces within the bowel, or the occurrence of intestinal polypi. The most complicated case of ileocecal invagination which ever came under my notice was associated with the presence of a polyp in the ileum. All of these conditions, save the presence of tumors, pertain more frequently to the young than to the aged. The influence of the ileocecal valve is also undeniable, and that at this region parts are more predisposed to invagination than elsewhere is quite obvious. In at least half of the cases that have been recorded no satisfactory cause could be shown. Any condition which causes severe intestinal colic may give rise to intussusception; the next most common causes are paralysis or weakening of some part of the bowel, such as may follow injury or disease, or the presence of tumors, while even the role which they play is not entirely explained (Fig. 561).

That invagination will produce mechanical obstruction is obvious, while the fact that such obstruction is not always nor necessarily complete incites surprise. The orifice of the intussusceptum is distorted, while the included portion may be greatly bent or curved upon itself, in addition to which the obstruction to the circulation leads to congestion, exudation, and swelling, and predisposes to

## active inflammation, all of which tend to still further narrow the

passage-way. If, in addition to this, some tumor or hardened fecal mass be included in the grasp of the bowel involved it may be seen how complete shutting off of the intestinal tube may occur within a few hours. Invagination having occurred tends quickly to become irreducible; most commonly by the formation of adhesions, as lymph quickly exudes and bowel surfaces are by it thus glued together. Such adhesions may persist throughout the whole involved length of bowel or may occur at various scattered spots. As pressure becomes greater circulation of the invaginated portion is impeded and finally shut off, gangrene of the intussusceptum thus resulting. Cases occasionally terminate favorably through this actual condition, the included portion being finally cast off as a slough and passing onward and outward. It is on record, for instance, that six feet of invaginated bowel have thus been obtruded from the rectum after having sloughed, the patient eventually recovering. While this possibility, then, is present it is never safe to wait for it, and it is to be regarded simply as a happy accident when it occurs. Unless, then, a case of intussusception be very early and promptly operated, the included portion of the bowel may be regarded as dangerous and unsafe, unless upon disengagement it prove to have been but very slightly affected. Even then there is danger of immediate recurrence of the previous condition because of distention of the bowel above, paralysis of the part disengaged, and stretching of the part below. In proportion as obstruction becomes more complete distention of the bowel above the lesion, from accumulation and gas formation, will cause more and more distress, until finally complete paralysis of the muscular coat and possibly eventual rupture may terminate the case.

[Illustration: FIG. 561

Invagination of ileum, cecum, and ascending colon into transverse colon. One probe is passed into the appendix, the other into the invaginated portion of the ileum. (Rafinesque.)]

In addition to the conditions above described, all of which are acute, there is known also a _chronic form of intussusception_, whose whole course is much slower and less severe, where symptoms of obstruction never become more than partial, but may involve any portion of the bowel, and with about the same relative frequency as the acute forms. Such a condition in the rectum, for instance, has been mistaken for cancer.

=Symptoms.=--The special symptoms by which intussusception may be recognized, or at least by which suspicion is aroused, are, in addition to those common to all forms of acute obstruction, the _abrupt onset_, which may even occur during sleep, the _late_ rather than the early occurrence of _vomiting_, complaint of _tenesmus_, the _wave-like or colicky character of the pain_, and the fact that along with the violent peristalsis of which this colicky pain is an indication _diarrhea_ is a common accompaniment, the actual local coprostasis being masked by this fact. As the lumen of the bowel becomes occluded and fecal matter fails to pass, the _evacuations become more bloody and contain little but mucus_. Finally, almost pure blood may be passed. _In no other form of obstruction is the passage of blood so distinctive as in this._ Urine elimination is but slightly influenced, and strangury is an exceedingly rare feature. Meteorism is also less pronounced. The discovery of a _tumor_ formed by the invagination will lend further aid in diagnosis. It may be felt either through the abdominal wall or by the rectum, and may be noted in about half of the cases. It is most frequently found in the ileocecal and colic varieties, and felt in the rectum with the lower colic forms. In children it is more distinct than in adults. The tumor may even take the outline of the involved bowel, is usually movable, but may be fixed. When such a tumor is felt within the rectum it may have to be distinguished from some intrinsic neoplasm of the lower bowel; but the history of the case should prove satisfying if the physical examination leaves one in doubt.

=Treatment.=--_Spontaneous cure of an intussusception_ by a sloughing process has been mentioned above. Cure may also occur by spontaneous reduction. It would seem possible also only in recent cases and in the enteric forms. Cure may also occur by formation of a fecal fistula, although this is most rare.

3. =Volvulus.=--The term “volvulus” implies some form of twisting or of revolution of a part of the bowel upon itself or its mesenteric axis, the result being knotting or intertwining of intestinal coils to an extent causing their partial and finally complete obstruction. A common site for volvulus is the sigmoid flexure. Still no part of the intestine which hangs loosely is exempt.

The most common causes of volvulus are chronic constipation and fecal impaction, with distention and ptosis. Intestine thus displaced and overloaded becomes more or less paralyzed, its circulation more or less impeded, and any twist which has once occurred is not likely to right itself. The twisted loop having been engorged becomes distended with gases, and thus tends to increase the difficulty. In these cases the bowel loop is closed at both ends. Unless relief be afforded by operation it is a question merely of how soon the loop will become gangrenous from aggravation of every one of the features above recounted. Bowel thus involved permits easy passage of bacteria, and thus to the other features are rapidly added a septic peritonitis. The resulting abdominal distention may appear early and will become more prominent.

4. =Ileus from Fecal Impaction.=--A condition of extreme coprostasis, or fecal impaction, to a degree producing actual obstruction, may occur without necessary volvulus or twisting of any portion of the bowel. As fecal impaction increases the overloaded bowel becomes more and more paralyzed until there may occur final and complete arrest of peristalsis, with gradual development of symptoms of obstruction. The longer the condition persists the less the prospect of restoration of peristaltic movement. Moreover the condition may be complicated by the development of ulcers above the obstructed segment, known as _stercoral ulcers_, due partly to gangrene from pressure and partly to the chemical effects of long-retained decomposing material. They may appear as sloughs of the mucous membrane and finally lead to perforation.

This form of ileus is more common in the large than in the small intestine, and especially so in the cecum. Here there is little chance of retrograde movement, while fecal matter coming down from above will continue to pack the colon, and thus the cecum may have to bear the brunt of great pressure. The amount of fecal matter which may be thus collected is sometimes astonishing, for the bowel may dilate to the diameter of six or even ten inches, and contain many pounds of impacted feces. Such masses of collected feces can usually be palpated through the abdominal wall, and will at least indicate the location of the principal disturbance, if not its actual character.

5. =Strictures.=--The most common causes of cicatricial stenosis in large or small intestine are the results of cicatricial contraction following recovery from local ulceration or repair of injury, as, for instance, after reduction of a strangulated hernia. The exact character of the ulcer does not matter. Any lesion which may granulate and heal will also contract, and the extent of the stricture will be proportionate to the area first involved. Should this extend well around the mucous membrane there may be a distinct annular stricture. Stricture may also result from infiltration and thickening in connection with a more active diseased process, and such a condition may be multiple. This is particularly true in cancerous involvement of the bowel.

Previous history of the case will shed much light on the probable existence of intestinal stricture. Thus a history of typhoid, of dysentery, of tuberculosis, or of syphilis will be most suggestive, for in any of these diseases there may be numerous intestinal ulcers. A history of hernia, reduced or operated, or of injury, is also of importance, as also is one of operation upon other viscera, especially within the pelvis, the lower bowel being often involved in a disease process within this cavity which may have left its marks.

[Illustration: PLATE L

Enterolith with Gallstone for a Nucleus; Removed by Enterotomy. (Richardson.)

This patient was a man of sixty-nine, with symptoms of complete intestinal obstruction. There was no previous history whatever of gallstone. The impaction was high up in the small intestine. The gallstone was removed by a small linear cut which was satisfactorily sutured. The patient died in the course of twenty-four hours.]

Stricture may be recognized by the gradual course of the case and by a history of increasing difficulty or of increasing constipation. A stricture as such is not formed within an hour, and in this sense is the result of a previous more or less active disease. This is true, also, of cancerous stricture.

6. =Intrinsic Neoplasms.=--The possibility of both innocent and malignant tumors occurring within the intestinal structures has already been considered. It is obvious that any such growth will cause gradual obstruction by the usual process, or may precipitate by its presence the occurrence of intussusception, of volvulus, or of some kinking by which obstruction is suddenly produced.

7. =Extrinsic Neoplasms.=--What has been said above applies equally well to growths not primarily involving the intestine, but encroaching upon it. Thus obstruction may gradually result from retroperitoneal growths, or from the impaction of a growing uterine myoma pressing upon the rectum and finally occluding it. Also cancers growing in various locations encroach upon and finally involve the bowel in conditions which nevertheless were originally quite external to it.

8. =Gallstones.=--In the section devoted to the biliary passages the accidents which may occur during gallstone disease have been summarized, and it has there been related how large ones may ulcerate through and drop into the small or even into the large intestine. Enteroliths may be thus produced, which were originally small gallstones that have lodged and grown by accretion until they have reached considerable size, or by gallstones which have suddenly entered the intestine by ulceration above, or by other material which may have collected in some sacculation or diverticulum, where it has received more or less calcareous deposit and has grown by accretion until it produces obstruction, either by occlusion or by causing the intestine to kink. Other foreign bodies may also produce obstruction. Although it has been generally held that whatever may escape through the pylorus may be evacuated from the rectum, nevertheless peculiarly shaped objects become entangled in such a way as to be checked in progress and serve as impacted bodies upon which an accumulation may take place. (See Plate L.)

9. =Peritonitis.=--While coprostasis is a feature of almost every case of acute peritonitis the obstruction referred to in this paragraph comes rather from the adhesion and fixation of bowel from outpour of lymph than from paralysis and ileus in consequence. It may be doubted whether acute peritonitis is ever idiopathic. As seen by the surgeon, at least, it has some point of origin which furnishes ample excuse for its existence. The most common cause in the male is the appendix, and in the female the appendix or the tube. At least one-half of the cases occurring in general practice originate in one or the other of these ways. Infection may also easily spread from the mesenteric nodes, beginning locally and resulting in adhesions, the disease spreading by a natural process until perhaps the whole abdomen is finally involved. While healthy bowel is ordinarily impervious to germs, when it becomes diseased germs may easily travel from its interior to its exterior and thus set up peritonitis. In this way a purely mechanical original condition may bring about a fatal septic peritonitis. It is known also that intestinal diverticula are subject to exactly the same lesions as is that one in particular which is called the appendix, and the symptoms and sequences of the diverticulitis may simulate those of an acute appendicitis. In acute appendicitis coprostasis and even apparently fatal obstruction are frequently met with. Their occurrence is to be explained not alone by toxemic paralysis (_i. e._, toxemic ileus), but by the actual mechanical impediments offered by loops of bowel strongly bound together around the appendix in the actual protective effort.

10. =Bands.=--Bands of tissue which may cause obstruction of the bowel are neither necessarily long nor large, and one will frequently be astonished to see how trifling a tissue cord may produce intense disturbance. The bands which may be found within the abdominal cavity under these circumstances include those produced by peritoneal adhesions, where the cohering lymph has organized and at the same time stretched, such bands being found to arise from and connect with the bowels alone, to arise from the omentum from any other causes, particularly traumatic, or to occur at any point within the peritoneal cavity. They may be single or multiple. When speaking of Meckel’s diverticulum it was stated how it might be mistaken for a band extending to the region of the umbilicus, and acting as one cause of obstruction. (See Fig. 559.) An adherent appendix or tube tightly attached at its free extremity may also act as a band, and the former is known to very frequently produce at least a mild form of intestinal obstruction, which may at any time assume acute proportions. The pedicle of an ovarian or other tumor may also, if long, by becoming twisted, include an intestinal loop and thus produce obstruction.

11. =Slits and Apertures.=--The mesentery is the occasional site of fenestra which apparently are of congenital origin. Through such openings or slits a loop of bowel may easily pass and become strangulated. The same is true of the omentum. Openings in either of these structures are perhaps more frequently the result of traumatisms. Similar conditions result where omental or mesenteric surfaces have united over small areas, leaving pockets or openings in which bowel might be caught. Quite a similar condition results in so-called hernia of bowel into and through the foramen of Winslow.

12. =Intestinal Loops and their Traction Effects.=--These causes are not perhaps independent of some of those above mentioned, yet presuppose a certain looping or abnormal festooning of intestine, with the further stretching that occurs as the result of greater loading and the final entanglement of such loops, or their adhesion, in such a way as to become completely occluded. To this result some local inflammatory process may contribute. The condition is often met in connection with pelvic disease of females. Much that may happen to a loop of bowel which has become attached to a growing tumor during its migration, as it gradually changes its shape and position, may be imagined.

[Illustration: FIG. 562

Strangulation of bowel by a long diverticulum. (Lejars.)]

13. =Congenital Defects.=--Certain congenital defects predispose to acute obstruction. Among these are diverticula, as already mentioned, which may produce trouble, either by incomplete obliteration and separation from the umbilicus, in which event they act as bands or cords, or by becoming acutely inflamed, then attaching themselves and indirectly producing the same effects (Figs. 559 and 562). Even the smaller diverticula or sacculations which extend between the folds of the mesentery may, when infected and inflamed, thicken and cause angular bending of the intestine, with consequent partial obstruction, which later is made complete by the consequences of local peritonitis, with its dense inevitable adhesions. Statistics show that acquired diverticula occur twice as often as Meckel’s, and nearly as frequently in the small as in the large intestine. They are mostly of the traction variety and occur at the mesenteric border, where they have close relation to the bloodvessels, thus increasing the dangers of operative measures because of possible gangrene from shutting off circulation. Porter has recently collected 188 cases of violent and even fatal trouble thus produced within the abdominal cavity, returning an exceedingly high death-rate after operation, which unfortunately was almost always done late. In nearly all of these cases the diverticula were found within the lower four feet of the ileum. In one case of my own an unobliterated hypogastric artery caused acute obstruction.

14. =Postoperative Obstruction.=--Finally cases of postoperative obstruction are met with in a way to bring disappointment and disaster when everything else has seemed favorable, and constitute a clinical type without any distinct pathological foundation. Most of them are due either to some form of paralytic ileus, or else to local or general peritonitis with its combined sequels of paralysis and adhesion by the gluing of portions covered with exudate. Some of these cases will justify reopening the abdomen, while in others the condition is absolutely helpless because of the septic element present.

=General Symptoms of Acute Intestinal Obstruction.=--Certain symptoms and signs characterize all cases of acute intestinal obstruction and may be, therefore, included as common to each; consequently they may be considered collectively. The cardinal indications are _pain_, _vomiting_, _constipation_, _distention_, and _collapse_.

_Pain_ may be the first indication, and usually is so in invagination, volvulus, and mechanical obstructions generally. It is usually of violent paroxysmal character, continuing at least during the earlier stages, rapidly wearing away the patient’s strength, diminishing as distention increases and nerve endings become paralyzed.

_Vomiting_ is an early or late feature, according to the portion of the alimentary canal obstructed. The more prompt its occurrence presumably the higher in the small bowel the defect. In consequence of the remedies usually administered it will be found that when nothing but stomach contents are ejected it is easier to produce fecal evacuation from below, while the greater the difficulty in securing a return from the lower bowel the lower the obstruction and the more likely the vomited material to become fecal in character. Vomiting once begun is usually continuous until relief is afforded or the patient utterly exhausted.

_Constipation_ or obstipation sooner or later characterize these cases. The tenesmus of intussusception, with the passage of bloody mucus, which may occur in this form, or in volvulus, for instance, does not imply that the bowel itself is not obstructed, nor does the emptying of the larger bowel of an accumulated load necessarily imply that the fecal stream is in motion. Even the passage of flatus usually is promptly shut off, and it is the gas which forms and cannot escape that produces the distention.

_Distention_ gradually becomes excessive, the abdomen becoming ballooned and extremely tympanitic on percussion, while its surface becomes shiny because so stretched. This _meteorism_ is in large degree due to the formation of gas within the bowel proper, but is permitted by the additional features of paralysis of intestinal muscle and weakening of that of the abdominal wall. As it increases the diaphragm is pressed upward and respiration is much impeded, while even the bladder may be compressed below. It affords another reason why fluid which is taken into the stomach is quickly ejected.

Characteristic _collapse_ comes on more or less promptly, according to the nature of the exciting cause, and the date of its occurrence is in some degree an index of its violence.

In dealing with obstructive cases any history that may bear upon the conditions, as of previous peritonitis, appendicitis, of so-called dyspepsia which might indicate gallstone disease or gastric ulcer, or of pelvic conditions which might indicate pyosalpinx or the like, should be obtained. The manner of onset should be learned, whether acute or gradual, with the relative date of the occurrence of pain, vomiting, and stools, along with their character, if there be anything distinctive therein. Past and present history being secured, the most methodical examination of the body should be made, including the physiognomy and general conditions, the attitude (_e. g._, whether the knees are drawn up, whether the patient is able easily to turn), the type of respiration, and the amount of restlessness. The character of the abdominal movements during respiration should also be noted, as well as the presence of any prominence or the indications of violent peristalsis. By palpation the degree and location of greatest tenderness, the presence of muscle spasm or of tumor may be learned. _Careful examination of all the ordinary hernial outlets_ should be made and the rectum and vagina explored. Revelations thus obtained may also prompt a careful physical examination of the chest. Percussion will show the presence of free or localized fluid or gas, while localized dulness may denote a loop of intestine distended with fluid or impacted feces. Auscultation will enable the surgeon to hear the sounds produced by violent peristalsis or to note the absence of movement within the bowel. A study of the temperature and the pulse may reveal much in certain cases, especially the inflammatory, and

## particularly in appendicitis, while the urine may be examined for

indican, and a differential blood count made.

_Meteorism, constipation, and fecal vomiting of themselves indicate acute obstruction_, but furnish no aid as to the nature of the exciting cause. They are, however, sufficient to indicate the wisdom of immediate intervention.

Pathologically every case of intestinal obstruction has an interest of its own. _Surgically, however_, they are readily grouped _as a class of cases in which operation should always be performed early_, inasmuch as it offers the better prospect of relief and in which death is the inevitable spontaneous termination. It can scarcely be imagined how a more distressing case than an acute strangulation can be allowed to go to its fatal termination without being offered the prospect of a judicious operation, if only performed early. The disfavor with which operation is received by the general physician, as well as by laymen, is due to the fact that too much time is wasted with futile drug treatment, and that the golden hours when surgical intervention might save are allowed to pass unutilized. Of most of these cases it may be said that dying after operation they have died _in spite of it rather than in consequence of it_.

This is particularly true with intussusception and volvulus in young children or infants. Within six hours, in such cases, the harm which may be done is necessarily fatal, and to keep them for a day or more, dosing them with cathartics or making strenuous efforts to relax invagination, is to deprive them of the only measure which offers them any chance. The disrepute into which operative treatment of these cases has fallen in certain quarters is due, then, solely to the fact that the physician does not call the surgeon early, because there is a time in the history of nearly every one of them when it could be saved were mechanical relief afforded.

=Treatment.=--There are certain cases of obstruction by fecal impaction or lodgement of enteroliths which may be successfully treated by internal or non-operative means. Could these always be diagnosticated it would be known when not to operate. But to wait until paralysis of the bowel has occurred, or gangrene due to stasis, or perforation have taken place, or septic peritonitis has set in, is to wait far longer than circumstances justify and reflects on those responsible for the delay rather than on the operator or the operation. In general terms, _acute intestinal obstruction is always a surgical disease_.

It is not necessary to wait for accurate diagnosis--_recognition of the existence of obstruction alone is all that is required_. Conditions rapidly aggravate themselves, and strength is rapidly lost, if we wait for more than distinctive symptoms. _There is no palliative treatment save operation, and the drugs and other harsh measures which are often prescribed serve to intensify and aggravate rather than to relieve._ Anodynes given, though administered with the most humane intent, serve only to mask conditions and lead to delay.

Exploration once resolved upon, careful judgment must decide as to where to place the incision. If local indications be present they may be followed. If there be good reason to believe that the original cause was an acute appendicitis, then the incision may be placed upon the right side. In the absence of all indications the surgeon operates most safely in the middle line by an incision below, above, or around the umbilicus, as circumstances may indicate. Edema of the subserous tissue or of the abdominal muscles indicates the presence of pus beneath. Peritoneum should be sought and opened with care, as in the presence of much distended bowel injury to the same may easily occur. The opening once made the operator will be embarrassed from that time until the conclusion of the operation by the distention of the bowels--at least those above the obstruction, and by their being constantly in the way. If a mechanical cause for obstruction be found it will be noted that the intestine above is more distended than that below, which latter may be collapsed and apparently smaller than natural. Thus if a constricting band be found, or an internal hernia, the removal of the obstructing cause will permit of prompt restoration of equal gaseous pressure between the parts above and below.

Scarcely any surgical emergency requires wiser discretion than do cases of this kind. Bands may be double ligated and divided, kinks straightened out, twists untwisted, invaginations withdrawn, if this be possible by reasonable effort. On the other hand the surgeon should be prepared to find bowel which has apparently lost its vitality or is actually necrotic, either for a few inches or for several feet, and he will soon realize that to leave such gangrenous masses within the abdomen is to accomplish naught, while to remove them is to subject the patient to a procedure longer and more severe than he can bear. He must, then, decide whether to close the abdomen for form’s sake and let the patient die a natural death, or whether to undertake the risk of resection, or perhaps to leave a considerable portion of the intestinal canal upon the outside of the body, opening it and establishing an artificial anus in the hope that the sloughing portion may be cast off, and that the artificial anus, having served its purpose, may be subsequently closed by another operation. Such cases live, though not very often. Here, perhaps as often as anywhere, can be seen the most desperate expedient succeed and the most trifling measure fail.

Another question is what to do with distended and paralyzed intestine, especially when it appears impossible to restore it to the abdominal cavity. Paralyzed as it is, it is almost too much to hope that it may recover its tone, and distended as it is, it is practically unmanageable. To open it at one point would be to empty several loops, at least of gas and probably of fluid fecal matter, all of which will help. One cannot but reflect on the toxic nature of all fecal matter so retained and feel that could it all be evacuated the patient would, other things being equal, be in vastly better condition. And so operators have often made openings, taking all possible precautions to prevent contamination, and have not only evacuated a considerable length of the intestinal canal, but, as suggested by Mixter and others, have washed it out.

A more perfect method, however, of accomplishing this purpose has been suggested by Monks, of Boston, in the use of a large glass tube, from twenty to twenty-four inches in length, strong and with smooth ends. He has shown how, an opening having been made, say just above the obstruction, it is possible by manipulating the bowel with gauze pads to draw it over the tube (as shown in Fig. 563), to an extent of several feet, and to thus more completely evacuate it than could be accomplished in any other way. Monks is undoubtedly entitled to priority for this suggestion over Moynihan, who has elaborately figured and described it. All in all this permits better management and more complete effect than any other method. The bowel having been emptied, the opening is closed by the usual double row of sutures and is then easily dropped back into the abdominal cavity. Cases occur where this procedure might be carried out at two different points, say above and below the obstruction.

[Illustration: FIG. 563

Method of inserting a tube (through an enterostomy opening) a considerable distance into the intestine by drawing the intestine around it with the help of a piece of dry gauze. The tube used in this case has a curved extremity, the opening being on the concavity of the curve. It is shown entire at the lower left corner of the illustration. The longer the abdominal incision and the longer the tube the greater the length of intestine which may be drawn upon it and emptied of its contents. (Monks.)]

What may be done with the obstruction produced by local and septic peritonitis, such as is especially seen in acute cases of cholecystitis, appendicitis, and pyosalpinx? Here the surgeon deals not only with twisted, kinked, and obstructed bowel, tensely distended, but with much infected lymph and perhaps a collection of pus and a gangrenous appendix. Such a condition becomes appalling and every such case should be dealt with upon its merits. Any collection of pus should be evacuated and drained, and it must then be decided whether to endeavor to withdraw entangled loops, disengage and straighten them out, or to be content with an artificial anus for temporary purposes, the latter often being the safer course, even though it may lead to a tedious convalescence and the necessity for subsequent operation. It might even be advisable to evacuate pus and remove a sloughing appendix, if it were easily found, and then make an enterostomy, opening at some other point, in order to keep the two procedures and fields of activity quite distinct.

A case may occasionally be seen where the question of affording some relief is paramount to every other consideration, and where, at the same time, the patient’s condition is such as to make anything extra-hazardous. I have saved life under conditions of this kind by making a simple enterostomy under cocaine, the intent being only to attach a loop of distended bowel to the parietal peritoneum and to open it then or a little later, thus establishing an artificial anus. This may be done with local cocaine anesthesia. I have even seen the fecal fistula thus produced close spontaneously in the course of time, and, while the exact character of the lesion was never known, have had the satisfaction of thus saving a life which I believe would otherwise have been lost.

One of the most unfortunate accidents that can occur during operation for acute obstruction is to have the patient practically drown in his own fecal vomit. This may occur either on the operating table or soon after leaving it. The term implies simply this--that there is regurgitation of fecal matter into the stomach, and that as this is ejected by a patient in his unconscious condition he is not able to prevent its aspiration into the trachea, with the occurrence of all that essentially constitutes drowning. Even a few ounces of fluid material drawn into the lungs, under these circumstances, would be sufficient to cause asphyxia and death.

The accident is to be prevented not alone by _lavage_, both before and at the conclusion of the operation, but by placing the patient upon his side in such a way that any gush of fluid into the mouth may escape from it and not be sucked into the lung. The amount of fluid that may arise is sometimes astonishing. The introduction of harmless fluid, under these circumstances, would be sufficient, but the entrance into the lungs of a viscid, offensive, and septic fluid, even in small quantity, would quickly serve to induce a septic pneumonia if nothing else. The accident once having occurred, resuscitation is almost impossible. Under the relaxation of anesthesia it may occur without outcry and almost unsuspected, and with the patient on his back, death may be determined even before the attendant has noticed anything

## particularly wrong. To prevent this accident tubes have been devised

having balloons around them which can be inflated with air, to the desired degree, and the esophagus thus be plugged.

Hence it will be seen that the surgeon should temper his measures to the condition of the case, its exigencies and its surroundings. Operation, therefore, may be exceedingly mild or exceedingly severe, taxing the resources of the best-equipped clinic.

Strangulations recognized from surface indications are usually dealt with according to standard indications. Those discovered only after abdominal section are to be dealt with each on its merits.

CHRONIC OBSTRUCTION OF THE BOWEL.

The expressions of chronic obstruction are essentially those of acute, in which they usually terminate, occurring meantime in milder degree. Their causes are nowise different from those tabulated above.

=Symptoms.=--The symptoms of chronic obstruction are those of intermittent colic, constipation, perhaps with local tenderness, with change in shape of the abdomen due to the primary cause or to intestinal distention, and in many instances with some characteristic appearance or shape of the feces. Thus the stools are often loose, or scybalous masses when removed by cathartics, and these are followed by diarrheal stools containing many gaseous bubbles. Obstruction of the lower bowel will frequently cause the hardened fecal masses to assume a tape-like shape. With increasing obstruction there is increasing severity of symptoms, until finally they become acute.

=Treatment.=--The treatment of chronic obstruction is also operative, either radical or palliative. When the exciting cause can not only be detected on exploration but removed, it should be radical. If, however, this be not possible then enterostomy or entero-anastomosis only can be practised. Thus in cancer of the rectum or sigmoid, colostomy is the last resort. In cancer of the bowel above the sigmoid anastomosis may relieve the obstruction and permit the patient to linger until he dies of the natural progress of the disease.

Here, as elsewhere, operation should not be too long delayed. To wait for a chronic obstruction to merge into one of the acute forms, and then to wait until the patient is moribund, is to have deliberately deprived him of that which otherwise might have prolonged his life.

For chronic obstruction whose cause is not easily revealed the hypothesis of cancer affords the most common explanation. This may be intrinsic or extrinsic, so far as the bowel itself is concerned, the results however not differing. It matters but little whether cancer is producing an annular stricture or involving a considerable extent of bowel, something should be done. When health has gradually failed, and obstructive symptoms have come on slowly, and when distinct cachexia is present the presence of cancer within the abdomen may be suspected. When a distinct tumor is palpable or when the abdomen gradually fills with fluid there is little doubt. When to these signs is added _pigmentation of the abdominal wall_ the diagnosis may be considered certain. Even now exploratory section is justified, in the hope that some operative measure may offer comfort and at least temporary relief.

On the other hand, when obstructive symptoms appear and increase without the accompaniment of other serious indications, it may be hoped that the condition is benign rather than malignant. Obstruction with ascites may possibly be due to _tuberculous_ lesions, which are not uncommon, especially in children. The recognition of enlarged mesenteric nodes would corroborate this diagnosis. A history of typhoid fever or of injuries or foreign bodies might confirm the theory of cicatricial stenosis. The possibility of enteroptosis of the colon and impaction of hardened fecal matters should not be disregarded and that of enteroliths, especially gallstones, not forgotten.

FECAL FISTULA; ARTIFICIAL ANUS.

A fecal fistula implies any communication between the intestinal tract and the exterior of the body or one of its other cavities. Thus it is possible to have a _rectovaginal_ fistula as well as a vesicovaginal. In rare instances we may meet also with intestinal communication with the bladder, the other viscera, or even the pleura or lungs.

Fecal fistulas are always abnormal productions, and result either from congenital causes, previous injury, or disease. Among the traumatic causes may be mentioned penetrations or ruptures of the intestines, injuries to the bowel occurring in the course of abdominal operations (for instance, the inclusion of some part of the bowel wall within a ligature or suture), while the pathological causes include the possibilities of perforation of any form of ulcerative lesion, cancer, actinomycosis, or the secondary sloughing which may follow appendicitis, or even the pressure of a drainage tube. Fistulas result also from escape of foreign bodes (for instance enteroliths or bone fragments), which may work their way into some other viscus, or out through the abdominal wall to the body surface. Old pelvic and abdominal abscesses also occasionally cause perforation and fecal fistulas. These fistulous tracts may be long or short, and direct or indirect. They may also permit the escape of a large amount of fecal matter or the smallest appreciable amount. The majority of them tend to close spontaneously in the course of time, but this time is sometimes so prolonged that a surgical operation is preferable to waiting for natural processes. The communications may be high in the intestinal canal. In such a case matter that escapes will be but partially digested and will have the character of chyme rather than of feces; and patients suffer in consequence, as products of digestion are not complete and opportunities for absorption have been too limited, and they are deprived of all that should normally happen further along in the bowel. In such a case there is temptation to operate much earlier than is advisable. Another form of fistula results from certain cases of strangulated hernia, in consequence of necrosis of the strangulated loop of bowel. In fact this is true of any of the mechanical causes of acute obstruction, where this expedient may be resorted to under compulsion and we produce a fistula as an emergency measure.

The difference between intestinal or fecal fistula and artificial anus is that the former is an undesirable and untoward event, whereas the latter is deliberately produced by operation practised for the purpose. _Artificial anus_ is in the main limited to cases of cancerous or other hopeless or inoperable obstruction of the lower bowel, and in such case is purely a palliative measure. It is made occasionally at the upper end of the colon in order to give a diseased colon physiological rest and permit of more perfect irrigation of that tube, the intent being to later close the opening. It is an inevitable emergency measure in certain cases of acute obstruction, where the patient is in no condition to bear anything more extensive or prolonged.

The operation for making an artificial anus, usually referred to as _enterostomy_ or _colostomy_, will be described below.

Fecal fistulas should be treated largely according to their causes; when they are the product of actinomycotic or cancerous disease little can be done, and perhaps nothing should be. On the other hand, when resulting from traumatism, from sloughing of some portion of the bowel, or from strangulation, much can be accomplished.

A small, fistulous tract should be kept clean and stimulated occasionally with silver nitrate or something of the kind, and perhaps by introducing into it every day a small piece of gauze, which provokes the granulation process as well as fills the opening. It is bad practice, however, to simply close the outer end and let the lower portion distend with feces. Much will depend upon whether it now connects with the bowel. This may be determined by injecting into the fistula some methyl blue and then noting the subsequent stools. When communication with the bowel is evidently free the surgeon may feel like making a deeper operation, perhaps with intestinal suture or even intestinal resection, whereas if there be little or no actual fecal leakage it may be sufficient to enlarge the outer end of the fistula, to thoroughly scrape it with the sharp spoon, and then, lightly packing it, see it close with granulations. A passage-way which is exceedingly short may be treated by simple superficial plastic operation, including freshening of the entire margin of the opening and the passage around it, and a purse-string suture, with or without a circular incision of the skin. By drawing this suture tight the external opening may be closed. This is a neat way in which to dispose of a small fistulous opening resulting from a previous enterostomy or appendicitis operation.

A _rectovaginal fistula_ may be closed by formal operation, similar to that for closure of a _vesicovaginal fistula_, based upon the simple principle of freshening the edges of the opening and then holding them together with suitably placed sutures. A rectovesical fistula would, in most instances at least, require a laparotomy, with careful separation of the rectum from the bladder, and then a separate suture of each opening. Such an operation might be quite difficult, made so not by its plan of performance but by the conditions which necessitated it. Any bladder thus attacked should be kept perfectly empty for several days by the use of a self-retaining catheter. Every case of fecal communication with any large abscess cavity, or through the diaphragm, directly or indirectly, as with a bronchus, should be treated on its individual merits, it being a grave question whether operation would be indicated or not.

Certain fecal fistulas will justify more formidable operation, in which, after opening the abdomen and carefully protecting its contents against contamination, the adhesions should be separated entirely and that portion of the bowel which is involved removed, making either an end-to-end suture or a lateral approximation. If this be done it will be best also to completely excise the old fistulous tract through the abdominal wall, and to remove everything that was involved in the previous condition.

It is possible to atone for almost every opening of this character, save those produced by some seriously malignant disease. If such a condition be the result of cancerous extension then it is practically hopeless.

OPERATIONS UPON THE INTESTINE.

=Intestinal Suture.=--Intestinal suture is by no means a new or modern operation. It was spoken of by the ancient writers and was evidently practised in the middle ages by the “Four Masters” of the School of Salernum and their followers. But until it was reduced to a science by the French surgeons, Jobert and Lembert, during the first quarter of the past century, it was always a hazardous measure. Success with intestinal suture depends upon exact hemostasis of the edges to be united and their accurate approximation in layers (_i. e._, mucosa to mucosa and serous and muscular coat to its like). Save when haste compels, this accurate application is effected by two distinct suture rows, the first or deeper (of hardened gut) made to include the mucosa alone, the suture being usually continuous, but knotted at intervals, with stitches close together and drawn tightly to amply secure against leakage from the relatively large vessels of this membrane. It is better to apply this row by itself, as any suture drawn through the mucosa and out again through the serous coat is liable to contaminate the latter, it being much better to keep the contaminated row of sutures distinct. The first row having been applied and the surface carefully cleansed the operator may then coapt the balance of the annular wound by a continuous row of fine silk sutures, made to include the serous and muscular coats and to avoid the mucosa. The stomach and the colon are sufficiently thick to take a row of rather coarse sutures for this purpose, but most of the small intestine is so thin-walled that these need to be applied with caution as well as with dexterity.

Every row of sutures should be so applied and directed that the lumen of the bowel be not reduced by its presence, it being a serious matter to greatly encroach upon the diameter of the bowel, since obstruction will thereby be favored and extra tension made upon the sutures (Figs. 564 and 565).

[Illustration: FIG. 564

Application of the interrupted Lembert suture. (Richardson.)]

[Illustration: FIG. 565

The continuous Lembert stitch. (Richardson.)]

So many different forms of intestinal suture have been devised that it is useless to attempt here to describe them all.

Any minute puncture of the bowel may be closed by purse-string suture. Any perforating wound should be not only first carefully cleansed, but also slightly enlarged, cutting away its more or less contused margins in order that fresh, viable tissue may be exposed. This is particularly true of gunshot wounds. Many of the operations now practised include inversion of the end of the bowel, a method illustrated in Fig. 566, showing a method equally applicable to burying the stump after removing the appendix, closing the end of a portion of the small or even the large bowel.

Most operators now use for the mucosa a carefully prepared and reliable chromicized catgut, the smaller size being preferable, with the ends cut short after the knots are tied. It is well also to use for intestinal suture needles which are round rather than made with cutting edges, as by the latter openings are made larger and vessels sometimes cut, this requiring the insertion of extra sutures for their securement. Whether the operator shall use curved or straight needles, and shall do the work with his fingers or depend upon various forms of needle holders, is purely a matter of choice and training. _Success or failure depend not so much upon the needle holder as upon the holder of the needle_, and his care and attention to detail. In the presence of multiple lesions the procedure may have to be repeated to meet each indication.

=Anastomotic Operations.=--For the general application of the principle of anastomosis to intestinal work the profession is largely indebted to Senn. The principle having been once recognized will never be rejected, but methods have already varied much from those first introduced, and will be improved by the substitution of simpler procedures for the more complex.

In general an anastomotic opening may be made between any distinct portions of the alimentary canal, and almost any one part may be thus, as it were, connected up with any other. Gastrojejunostomy has already been described. Only under compulsion does one thus connect the stomach with any other part of the alimentary canal. From the jejunum down to the rectum one may, however, effect attachments of this kind at any desired point. These operations are in the main done for one of the following purposes:

(_a_) In cases of obstruction of the bowel;

(_b_) For the purpose of exclusion of a certain length; or

(_c_) As a substitute for end-to-end reunion, after resection of a portion of the bowel.

The method of performance will depend not so much upon the nature of the difficulty requiring the operation as upon the condition of the patient, the equipment, and the operative skill of the surgeon. With a patient in extremely serious condition that method which may be most quickly performed is obviously the best. When time and method are under control, then that is best which can be most perfectly performed by the operator, or that which he is compelled to adopt, as when, for instance, he resorts to a suture method because he has no button at hand.

In order to simplify the subject as much as possible the following methods alone will be mentioned here:

The _method by suture_ is essentially similar to that described as gastro-anastomosis, the surfaces which are to be brought together being properly placed, and approximated, first, by a row of silk suture, the openings being then made with excision of a strip of mucosa, and the mucosa being next sutured with chromic gut, first on the further side, then on the near side of the opening, after which the serous membranes are accurately sutured around the opening by continuation of the first row of silk sutures. The actual opening made for the purpose should be at least an inch in length, preferably an inch and a half or more, while when the lower bowel is attached to the colon such an opening may well have a length of at least 2¹⁄₂ inches, for if successful it will be followed by a certain degree of cicatricial contraction and will never remain of its original size (Figs. 566, 567, 568 and 569). The suture may be combined with the _elastic ligature_, the method again being similar to that for uniting the jejunum with the stomach, already described. The rubber ligature used for the purpose is of the same size, and there is no difference to be made in the directions already given. The elastic ligature, however, can not be relied upon in emergency cases where it is necessary to effect a communication at once. It is serviceable only in instances where there is a leeway of at least three or four days. This method has for one of its advantages the fact that in its performance it is not necessary to clamp or secure the bowel by any instrument, simply to empty it for the moment with the fingers, it not being opened during the operation by anything save the needle puncture, which is promptly filled with the rubber. It does require, however, that the rubber used for the purpose shall be reliable and new, it being unfortunately the case that pure rubber which will last for a long time is seldom found in the market.

[Illustration: FIG. 566

Entero-anastomosis of intestinal loops which have been resected and the bowel ends closed; the first row of sutures has been applied and the line of opening indicated. (Lejars.)]

[Illustration: FIG. 567

Suture of the distal edges of the mucosa.]

[Illustration: FIG. 568

Insertion of the last (fourth) row of sutures. (Lejars.)]

[Illustration: FIG. 569

Resection of intestine with lateral anastomosis. Posterior suture inserted. The free ends of the bowel inverted and sutured. (Richardson.)]

The button method depends for its success upon a mechanical device of Murphy, known everywhere as the “_Murphy button_,” or upon one of its modifications. Fig. 570 illustrates the component parts of this device, which is made in various sizes and, in fact, in various shapes for different purposes, though the circular forms suffice for practically all cases. In Fig. 572 it is seen in actual use, while Figs. 573 and 574 illustrate the method of its insertion and securement.

[Illustration: FIG. 570

The Murphy button.]

[Illustration: FIG. 571

End-to-end union of intestine by means of the Murphy button: the two portions of the Murphy button, held in position by purse-string sutures, are ready to be pressed together. (Richardson.)]

[Illustration: FIG. 572

Union--end to end--with the Murphy button.]

The underlying principle of the Murphy button is that each half can be inserted separately and that then, by pressing these halves together, an opening is at once afforded from one part of the bowel to the other. If the halves be pressed together with the proper degree of firmness they produce, first, adhesion between considerable areas around their circumference, followed in the course of a few days by a necrosis of the central portion, which sloughs because deprived of its circulation by the pressure. So soon as this separation or sloughing is complete the button drops into the intestinal canal, being completely loosened, and is now carried along by peristalsis and by the fecal current from above, its position shifting as would that of a scybalous mass or a fecal concretion, until it finally emerges from the intestinal tube, being passed from the anus. How soon it will thus appear will depend in large measure upon the point of the intestinal canal into which it is thus intruded. If this be high up it will be slower in appearing. If low down it may be expected sooner. While it usually appears within ten days or two weeks it may, however, be longer retained, and in one case of my own was not passed for three months, although the anastomosis was made with the ascending colon, into which it must have dropped.

Fig. 573 shows one of the halves held in the grasp of a forceps, being inserted into a small buttonhole opening just large enough to receive it, around which there has been passed a buttonhole or purse-string suture of silk. This portion once thus inserted should not be lost within the bowel, it being necessary to retain control of it by the forceps until its application to the other half. Both halves being inserted and brought opposite to each other, as in Fig. 574, the smaller is introduced into the larger, and they are then pressed together until the included serous surfaces are brought into contact, with sufficient pressure inflicted to bleach them, in order that their subsequent necrosis may be ensured. A circular row of sutures should now be placed around the surfaces thus applied, in order to more widely secure them in contact. The procedure being completed in this way, the parts are dropped back into the abdomen and the abdominal wound closed.

[Illustration: FIG. 573

Introduction of one-half of a Murphy button. (Bergmann.)]

[Illustration: FIG. 574

Intestinal anastomosis with a Murphy button, showing the halves in position ready to be pushed together. (Bergmann.)]

_End-to-end reunion_ can be accomplished by the same method, or the end of the small intestine may be applied to the side of the large, after a method which will be best understood by reference to Fig. 571, it being necessary here to draw the squarely cut end of the intestine around the button with a circular suture, and, at the same time, to so grasp the button that it shall not recede into and be lost in the bowel.

Small buttons have been made for the purpose of uniting the gall-bladder to the upper bowel and extra large ones are made for the large intestine.

The particular advantage of the button method is the shortness of the time required for its performance, as it can be conducted in a few moments by one who might take four times as many minutes in using sutures. The disadvantages attaching to it are these: (1) That it depends for its success upon necrosis, _i. e._, of the part of the bowel included within its grasp; (2) that it might itself serve as a foreign body and produce acute obstruction, a not unknown event; (3) that it is not always at hand, especially in emergency cases, and that to rely upon it is to be limited in one’s abilities.

There is but little question that, when properly performed, the simple suture methods are the best of all, and the operator who has never seen a button used should abstain from its use. Still it has given many good results. My belief is that the better the surgeon’s judgment, and the more developed his skill, the less he will rely upon any mechanical expedient of this character, and the more upon what he can accomplish with the needle in his own fingers.

_End-to-side anastomosis_ is in no essential respect different from resection, only it may be done for the purpose of exclusion when nothing is absolutely removed. Thus in case of cancer of the cecum a lateral implantation can be made of a lower loop of the ileum upon the side of the ascending colon, using for this purpose a button, having divided the ileum on the proximal side of the ileocecal valve, and turned in both ends and invaginated the stumps. Here one resects nothing, but makes a direct communication between the bowel above and below the cancer, short-circuiting the intestinal canal, as electricians would say, and all for the purpose of giving temporary relief. Thus end-to-side or end-to-end anastomosis may be made, according as circumstances dictate, and, if one chooses, with the Murphy button.

_Resection of some portion of the large or small intestine_ is required under a variety of different circumstances. Thus after certain injuries, contusion and rupture, or numerous punctures or gunshot perforations, it may be decided to remove a considerable length of bowel rather than be compelled to give special attention to a number of distinct lesions, believing it a time-saving measure, and, therefore, for the welfare of the individual. The same measure will be indicated when, either by injury or disease, the blood supply of any portion of the bowel is apparently compromised or certainly shut off. Here necrosis is so certainly to be expected, or perhaps has already occurred, in such a way as to necessitate removal of whatever length of bowel may thus be involved. Several of those cases, already mentioned, which produce obstruction of the bowel will demand resection, as, for instance, when reduction of an invagination is impossible, with gangrene threatening. In a few instances extensive gangrene, precipitated by embolism or thrombosis of the mesenteric vessels, has been successfully treated by resection of considerable lengths of bowel. Again, the bowel is resected for closure of fecal fistula or artificial anus, as well as for relief of stricture due to various causes. Finally, nearly all of the tumors of the intestine itself, and especially all of the malignant forms, will require removal of at least a few inches of gut, save in those cases where this is shown to be impracticable because of the presence of cancer elsewhere, in which case it may be sufficient to make an anastomosis.

When intestinal resection is not an emergency measure there should be as much preparation as the case will permit, including lavage of the stomach, the ingestion of sterilized food, the use of antiseptics and the most thorough emptying of the bowel which can be accomplished.[58]

[58] Sanderson has suggested a new method of sterilization of the interior of the bowel at the time of operation. He injects a solution of acetozone through a hypodermic needle, or, after opening the bowel, freely irrigates with the same.

One of the greatest difficulties attendant upon the operation is the avoidance of all contamination by contact of peritoneum with intestinal contents. Against this the most minute precautions should be taken. This is never an easy matter, and in the presence of distended bowels and the emergency of acute obstruction it sometimes taxes every resource at hand. A variety of clamps have been devised by different operators, the intent being to so clasp the bowel beneath their blades as to completely occlude it. These blades are covered with sterilized rubber tubing to keep them from acting too harshly, and it is necessary to use pressure upon the handles with great discretion, lest permanent injury be done to the bloodvessels. The bloodvessels of the bowel are essentially terminal, and the blood supply should be kept sufficient for every part which is not removed. These vessels are, moreover, numerous and relatively large, and hemorrhage is not always easy of control, especially when clamps are not at hand. As a substitute for clamps tapes of sterilized gauze may be used, being tied around the bowel, or the fingers of a reliable assistant may be substituted. Such use of the fingers is not easy nor simple, not only because they become tired and relax their grasp, but since they slip so easily, and because the escape of one drop of fecal matter may cause a fatal contamination.

Resection of the bowel may imply in one case a removal of but two or three inches of its length, while the other extreme is not reached until several feet of bowel have been removed. I have been able to successfully remove eight feet and nine inches of intestine, the lower

## part including the cecum and a portion of the ascending colon, and

there are now on record nearly twenty cases where over 200 Cm. of bowel have been resected, nearly all of them recovering. Success in this procedure depends partly upon the condition necessitating the operation, as well as the general condition of the patient, but in no small measure hangs upon the perfection of the operator’s technique.

[Illustration: FIG. 575

End-to-end or circular anastomosis by enterorrhaphy. First row of distal sutures in serosa. (Type of needle differs from that used in this country). (Lejars.)]

[Illustration: FIG. 576

Completion of last row of sutures, begun as shown in Fig. 575. (Lejars.)]

Whatever be the condition which requires such resection it should be made sufficiently extensive to completely include and permit the total removal of the diseased or injured portion. The abdominal incision should be large enough to permit the delivery upon the surface of the body of all that portion to be removed. Unless this be done the difficulties are greatly enhanced. Save where there is some distinct indication for opening elsewhere, this incision is made in the middle line. The compromised bowel having been sought and thus delivered and one having decided exactly where to divide it, clamps are so placed both above and below each line of division as to prevent leakage. Underneath the bowel to be thus divided gauze is placed in such a way as to receive the small amount of discharge which will escape from the portion between the clamps. The exposed bowel surfaces should then be thoroughly cleaned, the contaminated gauze removed, fresh pieces substituted for it, and the other division of bowel made in the same way. While in some cases it may be well to tie off the mesenteric border and secure all its vessels before dividing the bowel, this may at other times be delayed until after the division. At all events it is the next step. Whether the mesentery shall be simply separated along the intestinal border and tied off in small portions, one after another, or whether a triangular resection of a portion of the mesentery itself should be made, securing the larger vessels nearer to its root, will depend on the nature of the case and upon whether the mesentery itself be involved in the disease. In dealing with cancer it is often necessary to remove, at the same time, every enlarged lymphatic. It may be inferred that no incision or tear, no matter how short, can be made in these tissues without danger of subsequent hemorrhage unless the parts be secured against it. A series of ligatures and sutures is therefore called for here which may consume no small proportion of the entire time of the operation. (See Figs. 575 and 576.)

All that portion of bowel which has been condemned having been removed and a careful toilet of the parts having been made the surgeon next proceeds to restore the bowel lumen. A V-shaped defect in the mesentery should be united with sutures. The line of former mesenteric border left after removal of bowel should be not only carefully protected with ligatures, but the whole margin should be overcast and so folded in or drawn together in tucks as to make it easy to bring the bowel ends together without undue stress.

[Illustration: FIG. 577

FIG. 578

Circular anastomosis of portions of the bowel having different lumina. (Bergmann.)]

The sutures by which the divided bowel is restored should begin at the mesenteric border, and every care should be taken to make the joint at this point absolutely water-tight. Suture methods have been described. To unite bowel ends of the same diameter it is an easy matter to suture together first the mucosa and then the outer layer, so long as the intestine is on the outside of the body and equally accessible on all sides (Fig. 578). The surgeon is sometimes compelled to do this work within the body cavity, as in resection of the rectum for cancer. It may be advisable to first place a row of sutures between the serosa and muscularis on the further side of the margins to be united, then to close the mucosa completely around, and then to finish the outer layer of sutures. So long as differences of size are not conspicuous, end-to-end approximation can be made almost anywhere. When, however, it is necessary to attach small bowel to large, the size of the larger opening should be reduced to fit the smaller, or one or both ends may be closed, turning in the stump, as already described, and then making lateral or end-to-side anastomosis. Any such anastomotic opening should be so placed, and bowel so directed, that there shall be no interference in the direction of the natural bowel stream, failure to observe this precaution producing not only added immediate danger but more or less permanent obstruction (Figs. 579 and 580).

[Illustration: FIG. 579

Isoperistaltic lateral apposition.]

[Illustration: FIG. 580

Antiperistaltic lateral apposition (bad).]

All that has been said above with regard to the Murphy button and its use in anastomotic operations holds equally good here with regard to its usefulness after resection.

Numerous devices, either instruments for the purpose of holding the bowel together while it is sutured, or of affording substitutes for the Murphy button, have been planned by operators all over the world. There are few of them, however, which give any better results than the simple methods above described, to which I prefer to limit description here because of their very simplicity.

Intestinal suture or any other method of completing the resection having been finished, a careful toilet of all exposed parts should be made, by which bowel may be dropped back into the abdominal cavity and the latter closed without drainage.

The _subsequent management_ of these cases will consist in two or three days’ starvation, in order that peristalsis may be reduced to a minimum, the patient being meanwhile fed by the rectum. Then will come a time when both fluid food, and cathartics a little later, should be gently and discriminately administered. Any satisfactory suture method will rarely give way after forty-eight hours. Buttons, on the contrary, may break loose after many days or even weeks, and this fact affords another argument against their use.

[Illustration: FIG. 581

Enterostomy; preliminary fixation of a loop of bowel to the peritoneum. (Lejars.)]

[Illustration: FIG. 582

Enterostomy; fixation of margins of opened gut to skin. (Lejars.)]

=Enterostomy.=--Enterostomy for establishment of fecal fistula, or _artificial anus_, is performed for relief purposes and sometimes as an emergency measure. It consists in attaching some portion of the bowel, naturally that above the constriction or disease which compels the operation, to the parietal peritoneum through a small wound in the abdominal wall. When the large intestine is opened for this purpose the operation is usually referred to as a _colostomy_, and this preferably is done in the left iliac region. When enterostomy of the smaller bowel is preferable it may be done at any point on the abdominal surface. Thus if through a median incision a condition be found necessitating it the bowel should be attached at the lower end of the abdominal opening, for here drainage will be better and contamination less likely. When enterostomy is done for acute obstruction, it is preferable to place the opening in one iliac fossa or the other.

Enterostomy consists essentially of the following steps: opening through the abdomen, recognition of the parietal peritoneum, which is seized with forceps on either side, opened and secured with these forceps, after which the first tensely distended loop of bowel which presents is taken, and, with a series of fine sutures in a round needle, the serous surface of the gut is attached to the margins of the parietal peritoneum (Figs. 581 and 582). In the more desperate cases a portion of the bowel may be brought out through the wound and fixed there in such a way that it cannot recede. If the emergency is great the bowel may be immediately punctured, the patient so placed and so protected that fecal contents shall escape away from the body rather than over it. If one can take a little time he may wait a few hours for the adhesion which is sure to take place between the peritoneal surfaces and the consequent shutting off of the abdominal cavity from the outer wound. Thus after twelve hours the surface of bowel exposed through the wound may be punctured either with a knife, scissors, or the actual cautery, and this may be done without causing pain to the patient. Escape of bowel contents will instantly ensue after puncture. After permitting all to escape that will, abundant protection should be provided for the reception of the discharges, which will continue at reduced rate. The best way to do this is to pass into the bowel in the proper direction a rubber tube, as large as it can accommodate, or a glass tube, bent at an angle, which shall connect with a flexible tube, and thus conduct away all discharge.

Another method of performing the operation is to bring out the loop of bowel, open and empty it, then to introduce a glass or rubber tube, around which is snugly fastened the bowel margin. The intestine is then stitched in place and the tube so arranged as to conduct away all discharge.

Just how much may be expected of such a relief opening will depend upon the case. These operations, especially for cancer of the rectum or the lower bowel, may prolong life for two or three years. An emergency opening into the small bowel for relief of acute obstruction may need to be kept open for but a few days, after which the tube may be removed and the fecal fistula be allowed gradually to contract. According to the case an intestinal resection may be made or the opening may be closed by one of the plastic methods.

=Appendicostomy.=--Appendicostomy is the more complete form of carrying out a suggestion first made by Hale White, of opening the colon on the right side in cases of intractable colitis. Gibson suggested to accomplish this by a method similar to Kader’s for gastrostomy, making a valvular colostomy through which the colon might be irrigated, without escape of feces. In 1902, Weir, intending to do this operation, found the appendix rising so invitingly into the wound that the inspiration occurred to him, and was promptly acted upon, to utilize it for the purpose.

In performing the operation the smallest possible incision should be made through which the appendix may be delivered, its mesenteric artery is tied, and its mesentery stripped down to its origin. At the latter the cecum is fastened to the parietal peritoneum by a suture on either side, avoiding the appendicular artery itself. The balance of the wound is then closed as usual, the appendix being fastened to the lower angle by suture, the protruding part then wrapped with gutta-percha tissue and included in the dressing. At the end of two days the external portion may be divided about 1 to 4 inches from the skin, after which a catheter is passed along its lumen and the stump tied around it. This serves the double purpose of preventing leakage and severing the appendix flush with the skin. The catheter is introduced from 2 to 4 inches, and its external portion left open to allow escape of gas, or doubled and fastened to prevent leakage, as circumstances may require. Irrigation may be begun on the third or fourth day.

When the appendix is used for the purpose of forming an artificial anus it will be probably in instances where there is more of the emergency element present, and it may be sufficient then to simply utilize it for the purpose of anchoring the cecum to the abdominal wall, or with the purpose of dilating it after the expiration of a few hours. In other words, the method may be modified to meet the indication.

It is scarcely necessary to devote space to any other operative procedures upon the small intestine. Consequently it will simply be mentioned here that the upper part of the jejunum can be used for artificial feeding and _jejunostomy_ made to take the place of gastrostomy under those rare circumstances which may demand it.

Upon the large intestine _colopexy_ may be practised, attaching it to the anterior abdominal wall or to the border of the liver or the gastrohepatic omentum. Andrews’ suggestion to attach the colon to the lower border of the liver, after certain operations upon the biliary passages, will be described in connection with the latter. In cases of extreme dilatation, with loss of muscular tone, etc., involving especially the colon, an _enteroplication_ may be practised corresponding to gastroplication, and having the same purpose, with a technique practically identical with the other. Thus when the sigmoid flexure is so dilated as to largely fill the abdominal cavity, with an enormous S-shape, much can be done by thus reducing its dimensions, the only objection being the fear that the causes which produced the condition will conspire to reproduce it even after enteroplication.

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