Compression and Contraction of the Bowel

Obstruction of the bowel is sometimes occasioned by compression or traction exerted on the intestine by abdominal tumors or cysts. Fibrous tumors of the uterus, ovarian cysts, hydatid growths, or indeed any form of abdominal tumor, may by pressure on some part of the intestinal track produce fatal obstruction. Several inches of bowel may thus be compressed and rendered impervious, or if traction is exerted by the tumor, which is often adherent to the bowel, the tube may be sharply bent or twisted and its action interfered with. A case is reported of compression of the bowel from a great accumulation of fat about the colon. Adhesions of intestinal coils from chronic peritoneal inflammatory changes constitute a large and important class of cases of intestinal obstruction. This condition is known as contraction of the bowels: 23 of the 124 cases reported by Bryant were of this character.

The usual site of stricture is the large bowel: contraction is far more frequently seen in the small intestine, and is caused by an effusion of lymph following simple peritonitis or the inflammation attending the formation of cancer or tubercle of the peritoneum. Coils of intestine are matted together or to neighboring parts in this way by bands of lymph or false membranes, and the action of the bowel interfered with or obstructed. Constriction of a length of bowel may be found after death, or a sharp, angular bend by which complete obstruction has been produced.

Circumscribed peritonitis may produce adhesion of a portion of bowel by bands of lymph to the uterus or its appendages, or to some part of the large intestine, or to the abdominal wall, and the action of the bowel become embarrassed by traction, constriction, or bending. In consequence of the irritation following this condition, spasmodic contraction may follow and add to the difficulty, or enteritis may ensue; and this will especially be the case if the circulation of the part is interfered with, and render complete what before was a partial obstruction. Distension and fulness of the bowel above the obstruction, with contraction and emptiness of the portion of the gut below, are found after death in cases of contraction, just as we see in fatal cases of stricture. The history of the case and presence of a tumor will generally enable the practitioner to determine when obstruction is due to the presence of some adventitious growth. When contraction is complicated with the presence of tubercle or cancer, symptoms attending these conditions will be present.

Obstruction of the intestines from contraction generally comes on insidiously. The patient may date the beginning of his trouble from an old attack of circumscribed peritonitis which probably took place weeks or months before. He has attacks of colicky pains, indigestion, and constipation. The last is difficult to overcome, continuing for hours before it is relieved by medicine or the efforts of nature. During the attack of almost insurmountable constipation violent peristaltic movement of the bowel above the impediment may be noticed. The patient may gradually become more and more feeble from suffering and interference with nutrition, and die from exhaustion, or fits of obstinate constipation may continue to recur, until finally one of them becomes insuperable and fatal.

The symptoms of contraction closely resemble those of stricture, but it is important to distinguish one from the other, as the treatment, especially if surgical interference is demanded, is very different. A rigid analysis of all of the signs will usually, but not invariably, enable the practitioner to make the distinction.

There is an important difference between the constipation of stricture and that of contraction. In the former the difficulty is in defecation, emptying the large bowel, the usual site of stricture; in the latter the difficulty is in the passage of the contents of the gut along the narrowed and contracted small intestine, the common site of contraction. In stricture the calibre of the bowel is diminished by some sharply-defined mechanical impediment seated in the cavity or in the walls of the tube; in contraction the bowel is bent or kinked by adhesions, or coils of intestine are matted and glued together and peristalsis interfered with. In stricture defecation is difficult and painful; in contraction the alvine discharges are painless. In the former blood and mucus are not unfrequently seen in the feces; in the latter the motions are healthy. In stricture constipation alternates with diarrhoea; in contraction looseness of the bowels is rarely seen. In stricture distension of the abdomen is lumbar and epigastric; in contraction the distension is less and is central and hypogastric. In both conditions violent distinct peristaltic action is seen during a fit of constipation, and in both the bowel above the constriction is distended and hypertrophied. In contraction the powerful, writhing peristalsis involves the small intestine above the impediment, and in stricture the large bowel above the obstruction. In both stricture and contraction inflammation of the bowel and peritoneum may supervene. In contraction, when inflammation sets in or when enteritis and peritonitis are absent and the attack of constipation is insurmountable, I have noticed that the symptoms are more urgent and rapid in their course, and danger of death from collapse greater, than when these conditions exist in stricture.

DIFFERENTIAL DIAGNOSIS.—In every case of intestinal obstruction a careful examination should be made for external strangulated hernia. All of the regions of the abdomen in which hernia may occur should be thoroughly inspected, as the symptoms of the two conditions are identical. A small or incomplete external strangulated hernia may easily be overlooked. An individual with an old hernia may suddenly have symptoms of intestinal obstruction, and it may be doubtful whether the obstruction is due to internal constriction or to the external hernia. Diagnosis is especially difficult when the chronic hernia is irreducible in character. If the cause of the impermeability is internal and below the external hernia, that portion of intestine in the hernial tumor becomes swollen, tense, and hard, and closely resembles the local symptoms of strangulated hernia. If the external hernia is reducible, reduction en masse may take place and a retro-peritoneal hernia be formed. When the case is doubtful and urgent, an operation for strangulated hernia should be performed.

Functional obstruction of the bowel is sometimes seen, closely simulating obstruction from one of the structural changes mentioned. Cases of functional obstruction are seen usually in hysterical or nervous women, and are generally recognized by the history, course, and termination of the malady. The fact that local enteritis, peritonitis, or typhlitis, by paralyzing a portion of the bowel, may produce all the signs of acute and complete obstruction, should not be lost sight of.

In cases of congenital stricture or malformation, or the presence of foreign bodies in the intestine, or acute internal strangulation, or twisting of a length of bowel, and generally in intussusception, symptoms of acute obstruction are present. The individual may have been in perfect health, and suddenly symptoms of the gravest character set in. Intense pain, referred to some special part of the belly, is the first sign of trouble. Nausea soon follows, and with it great prostration; the depression of vital power approaches, and sometimes reaches, syncope; the patient rolls and tosses in agony; his mental distress is equally great, and if old enough he is conscious of his danger and is anxious and despondent. Vomiting succeeds the nausea: at first the contents of the stomach, and then those of the small intestines, are thrown up; after a time the vomiting is stercoraceous. The belly becomes swollen, tympanitic, and exquisitely tender; the weight of the bed-clothes or the slightest touch of the finger upon his abdomen is intolerable; he keeps his head and shoulders raised and his lower limbs retracted to avoid pressure of the abdominal muscles. Constipation is complete and insuperable. If the abdominal wall is thin, the violent motion of the intestines can be seen and felt through it. These painful peristaltic movements of the bowel are paroxysmal and attended by loud rumbling or gurgling noises. The pain gradually increases; the patient is very restless and complains of great thirst; his pulse is small, hard, and frequent, his extremities cool and features pinched. If not soon relieved, exhaustion comes on; he has muttering delirium, cold clammy perspiration, hiccough, twitching of the tendons, and death soon follows from collapse or from peritonitis or gangrene, or from both. The average period of death is from six to eight days. It may occur in thirty-six or forty-eight hours, or the patient may last for two weeks.

In congenital occlusion and malformation the history of the case, the age of the patient, and the fact that the deformity in such cases is almost always confined to the anus and rectum, usually render the diagnosis sufficiently easy.

Obstruction caused by foreign bodies impacted in the intestines can generally be diagnosed. The history of the case may show that foreign bodies have been swallowed or that the patient has been subjected to some of the conditions which cause the formation of enteroliths. These stony concretions are usually found in the cæcum or colon, and frequently give rise for days and weeks to symptoms of indigestion, emaciation, constipation, and other evidences of bad health before complete occlusion of the intestine takes place. Not unfrequently, before the sudden attack of impermeability of the bowel the patient has had repeated attacks of typhlitis, and has been conscious for a long time of the presence of a tumor in the region of the cæcum or colon. Possibly he has passed on some former occasion pieces of the stony concretion.

Diagnosis of obstruction by gall-stones is often aided by the fact that the patient has recently suffered characteristic pains of hepatic colic and by the icterous condition of the skin. Possibly the individual has suffered repeated attacks of hepatic trouble and has previously passed a gall-stone. Obstruction from this cause is seen four times as often in women as in men, and always after the middle period of life.

In obstruction occasioned by internal hernia or the presence of membranous bands, loops, mesenteric pouches, the symptoms are often such as to baffle all attempts at accurate and certain diagnosis. The onset of the symptoms is sudden and the course of the disease rapid; prostration of vital power is extreme, sometimes amounting to syncope; vomiting incessant and persistent; pain constant and fixed. The most characteristic symptom of internal strangulation is the very great and prolonged depression of vital power; it occurs generally in early adult life.

Erichsen states that in twisting of the bowel the abdomen is unevenly distended, it being tympanitic on one side and flattened on the other. This condition of the bowel is usually seen after middle age. In intussusception the principal signs are, usually, the early age of the patient—obstruction from other causes in children being rare—the suddenness of the onset of symptoms, the frequent desire to go to stool, the tenesmus, and the characteristic bloody mucus discharges. By abdominal palpation frequently the sausage-like tumor can be recognized, and very often the intussuscepted part can be felt in the rectum or seen protruding through the anus. When invagination involves the upper part of the small intestine, diagnosis of the cause of occlusion is almost impracticable.

In obstruction of the bowel from fecal accumulation, inflamed and thickened intestine, stricture, compression and traction, and contraction of the gut from cancerous deposit, the symptoms are gradually presented and chronic in character. They are unlike the signs of acute obstruction, which occur in persons apparently in perfect health and are sudden and violent from the beginning. In chronic obstruction of the intestine the patient has probably been complaining for some time, with symptoms of abdominal trouble. He has been unwell for weeks, his appetite poor, digestion disordered, strength diminished, and bowels constipated. The last symptom is the most distressing of all. Purgatives do not give the relief ordinarily obtained, but add to the griping, colicky pains, nausea, and general depression. When his bowels do act, the stool is sometimes liquid, sometimes very hard (scybalous), or the form of the matter passed is tape-like or pipe-like. Sometimes, in his frequent attempts at stool, the only discharge is blood and mucus or pus. Attacks of eructation and vomiting often take place during the progress of the disease. Stercoraceous vomiting is, however, rare, and only seen in the later period of the attack. Abdominal distension is slow in making its appearance, but after a time is well marked, and due more to tympanitis than to constipation; the tympanitic distension is accompanied by loud rumbling and gurgling noises in the bowels. After a period which varies much in different cases, inflammation, suddenly or gradually, is set up, and all the symptoms of acute obstruction are presented, grafted on signs of chronic occlusion. We have pain, nausea, vomiting, great distension and tenderness of the abdomen, peristalsis plainly seen and felt if the abdominal wall is thin, the small, frequent, wiry pulse, clammy perspiration, prostration with hiccough, tendinous twitchings, and death, very like that following a case of external strangulated hernia.

Obstruction due to fecal accumulation generally happens in persons who have passed middle age, and can often be diagnosed by digital rectal examination and palpation of the abdomen, by the presence of fecal tumors, and the history of long-existing constipation with its manifold consequences; previous attacks of impermeability, and relief by discharge of enormous masses of feces.

Obstruction caused by the presence of some abdominal tumor is generally known by the history of the case, the fact of the existence of the tumor being known to the patient or discovered by the physician by an examination through the abdominal walls or through the vagina or rectum. The progress of such cases is essentially chronic, but acute symptoms may at any time come on. Diagnosis of obstruction due to stricture is frequently made by examination of the rectum and sigmoid flexure, the usual sites of constriction from this cause. Complete occlusion from stricture is almost always preceded by well-marked premonitory symptoms.

When the obstruction is situated in the lower part of the colon and rectum, its precise seat can be determined by digital or manual examination or the use of a bougie or tube. When the site of obstruction is above the sigmoid flexure, it is difficult, and occasionally impossible, to determine its exact locality. As a rule, when the constriction is in the small intestine the symptoms are acute and urgent; pain is intense, vomiting comes on soon, and prostration is early and extreme. When the large intestine is involved, except in volvulus, the symptoms are generally chronic. In twisting of the gut the symptoms are rapid and uncommonly severe. The higher up the obstruction, the earlier stercoraceous vomiting begins. Above the constriction the bowel is distended and tympanitic; below the constriction it is generally collapsed. In obstruction of the large intestine the outline of the tympanitic and distended gut may be traced with the eye and hand. In constriction of the small intestine the secretion of urine, as has been shown by Hilton, G. Bird, and Barlow, is less than where obstruction is seated in the large bowel. Besides rectal and vaginal examinations, which should never be neglected in any case of intestinal obstruction, abdominal palpation may also aid in determining the site of constriction. It should not be forgotten, however, when a tumor is found—as, for instance, in invagination—that the bowel may be displaced; a distended cæcum may be pushed into and occupy the left side of the belly. Cases are not uncommon where the symptoms are so combined and uncertain as to render accurate diagnosis of the site of obstruction impracticable.

Very little light is thrown upon the diagnosis by pain, constipation, or vomiting when these symptoms are considered separately. Pain is common to many diseases of the abdomen; obstinate constipation, lasting for days and weeks, is often seen where there is no mechanical obstruction; and vomiting attends many morbid conditions of the body. But when these symptoms are combined and examined along with the history of the case and mode of invasion, they are often characteristic of constriction of the intestine. Pain in acute obstruction is fixed, umbilical, and intermittent; in chronic cases it is more diffused and increases with the distension. In acute cases constipation is complete and insuperable; in chronic cases this symptom gradually increases; in intussusception we have frequent discharges of a dysenteric character, and hemorrhage, sometimes copious, when the small bowel is involved. The bowel below the seat of complete constriction may be full of fecal matter, and the discharge of this spontaneously or by the aid of enemata may induce the attendant not to regard the case as one of occlusion. Stercoraceous vomiting, as a rule, comes on early in acute and late in chronic cases of complete occlusion of the gut; in spasmodic ileus or impermeability not due to mechanical occlusion feculent vomiting is only occasionally seen.

The duration of life in acute intestinal obstruction varies very much in different cases: death may ensue in a few hours or not for ten or twelve days; the average period is six days. The duration depends upon the site of the constriction and the mechanical injury to the bowel; the nearer to the pylorus the constriction, the more rapid the progress. In volvulus involving the sigmoid flexure, when injury to the bowel is great, the symptoms are acute in the extreme. After peritonitis or enteritis begins, progress toward a fatal issue is very rapid, the patient rarely living more than three or four days. In occlusion from stricture, compression, fecal impaction, and chronic intussusception the patient may live for weeks or even months.

The statistics of Leichtenstern show that from 5 to 10 fatal cases of intestinal obstruction occur every year among every 100,000 inhabitants; and according to the mortuary records of England an average of 1 death from this cause is seen in every 260 deaths. Brinton reports 1 death from intestinal obstruction in every 280 deaths; his statement is based upon 12,000 promiscuous autopsies. The first author states that the statistical reports of the general hospital of Vienna inform us that out of 60 cases of ileus, 6 or 10 per cent. recovered. This report, however, is too meagre to be of much value. From Brinton's statistics of 500 deaths from obstruction we find that out of 100 cases, 43 are intussusception, 17 stricture, 4.8 impaction of gall-stones, 27.2 internal strangulation, and 8 torsion.

TREATMENT.—There are few conditions of the body which cause the practitioner more anxiety and embarrassment than cases of intestinal obstruction, and when the precise seat and nature of the occlusion are not known the treatment is almost entirely empirical. The distinction, however, between acute and chronic cases of obstruction of the bowels, or of acute supervening upon chronic symptoms, can almost always be made, and a patient investigation of the history of the case, the mode of invasion, and a rigid analysis of all the symptoms presented will generally enable the attendant to come to some positive conclusion as to the cause and site of the occlusion. One fact in the treatment which cannot be too strongly impressed upon the mind, especially of the young practitioner, is not to use purgatives and irritating enemata, formerly so much in vogue, in the hope of forcing a passage through the occluded bowel. The patient is urgently solicitous for medicine which will open his bowels, but the use of purgatives to overcome internal strangulation is as senseless and hurtful as when used to overcome the constipation of external strangulated hernia. These agents only add to the nausea, vomiting, pain, and peristalsis. The latter is violent enough already to render coils of intestine visible, and with every paroxysm is adding to the entanglement and impermeability. It is said that cathartics in some instances have unlocked the bowel in intestinal obstruction: these cases are exceptional, and many of them were probably functional and not structural in character. The only exception to the rule of avoiding purgatives is as stated by Jonathan Hutchinson: "In certain cases when impaction of feces is suspected, and in cases of stricture when fluidity of feces is desirable."

Formerly, some of the best practitioners resorted to the exhibition of one or two pounds of quicksilver, in the hope of overcoming intestinal obstruction by the weight of the metal. This plan has properly been almost if not quite abandoned. Crude mercury is very slow to reach the obstruction, is divided into small portions by the peristalsis, which its presence increases, and if it should finally arrive at the point of constriction in any considerable quantity, it is more liable to add to than overcome the difficulty.

The great remedy in intestinal constriction is opium, in large or small and repeated doses. Its use arrests the vomiting, stops the pain, and quiets the violent movements of the bowel. Very often by it the intestine is preserved and the life of the individual saved. No special dose can be prescribed: it should be administered until slight narcosis is obtained and pain and vomiting cease. Small doses of morphine, given hypodermically and quickly repeated, is the best plan of exhibiting it. It may be given by the stomach, but under such circumstances it is apt to be rejected, or if retained absorption goes on slowly, or possibly not at all. If for any reason its hypodermic use is impracticable, it had better be given by the rectum. Opium lessens the danger of death from collapse: it gives nature an opportunity to untwist the gut in volvulus, or to unroll it in intussusception, or to cut off the invaginated part by gangrene; and in internal hernia, morbid adhesions, strangulation by bands of lymph, stricture, and other forms of obstruction, it diminishes violent peristaltic action, postpones inflammatory infiltration, fixation of the strangulated portion, and keeps the parts in better condition for operative interference, which in many cases offers the only hope of relief. To carry it farther than slight narcosis and arrest of the most painful symptoms of obstruction is an abuse of the remedy. By such abuse the symptoms will be masked and both patient and practitioner deceived.

When obstruction is due to fecal impaction or spasm, the opium treatment is still often indicated. Not unfrequently, after pain and vomiting are relieved and slight narcosis kept up for some hours, the bowels relax and spontaneous evacuation takes place. If not, discharge of the contents of the bowel should be assisted by the administration of castor oil, calomel, or repeated enemata of warm water. These agents should not be used, however, as long as there is pain, tenderness of the belly, or any evidence of peritonitis, but the opium treatment continued until all signs of inflammation have disappeared. It has been proposed to give belladonna in place of opium; in small doses and carefully watched it may be added to the opium, but should not be substituted for it.

The local application of ice-water or pounded ice to the abdomen has been recommended; and it is asserted that the danger of general peritonitis is lessened, and that the strangulation itself has disappeared, under the influence of cold. If, however, cold increases pain and peristalsis, it should be abandoned. The local application of moist heat or fomentations will more probably do good and give a grateful sense of relief to the sufferer. General bleeding should never be resorted to, and the use of leeches, except to ward off or subdue some local inflammation, is of doubtful expediency. Blisters, ointments, and cups are useless in such an emergency. Cracked ice, strong coffee, and carbonated water in small quantities are valuable in allaying thirst and nausea.

Cases are reported where obstruction of the bowels has been overcome by the use of electricity; both the continuous and induced currents, but chiefly the former, have been used; its value in such cases is improbable.

Abdominal taxis or massage has been earnestly recommended and frequently practised in cases of constriction. Successful results from this procedure have been reported. It has been attempted while the patient was in a warm bath or under chloroform or while taking large enemata of warm water. Abdominal traction by the use of large cups to the belly has also been advised. We can only hope for success from these measures in the early stages of obstruction, before inflammatory action or fixation of the strangulation has taken place, and any attempt of this kind should be made with tact and gentleness. Inversion of the body has also been suggested.

The injection of large quantities of warm water into the bowels to overcome obstruction should never be omitted before resorting to operative interference. The author has seen this plan in five or six instances succeed after all other means had failed. Simple warm water should be used, introduced by means of the common Davidson or a fountain syringe. The injection should be made slowly, with occasional intervals of rest, to allow the fluid time to pass through the intestinal coils. During the operation the patient should be in the knee-elbow or Sims's left lateral position, and under the influence of an anæsthetic. One or two gallons of water may be used. In place of water, the bowel may be inflated with air, introduced by a pair of common bellows to the nozzle of which a piece of India-rubber tubing is attached. The addition of castor oil, turpentine, carbonic acid gas, and other irritants will more likely detract from than add to the efficacy of these measures. In chronic intussusception, or in acute cases when fixation of invagination is believed to have taken place, and especially when inflammation is great, gangrene threatening or in existence, injections of air or water should not, of course, be attempted.

In invagination, when the intussuscepted part is low down in the rectum or protruding from the anus, replacement by fingers or sound should be tried; reduction begun in this way may be completed by injections of air or water. The propriety of introducing the whole hand into the rectum is very questionable. In occlusion of the gut by compression and traction the cause should be found, and, if possible, removed. An abdominal or pelvic tumor may be pushed out of the way of the compressed bowel, a cyst punctured, a displaced womb replaced.

Great care should be taken to support the strength of the patient by concentrated and nutritious food, and in the later stages by stimulants. When the bowels are distended by gas an injection into the rectum of ten grains of sulphate of quinia will often give marked relief.

It has been proposed to tap the distended gut with a fine trocar when accumulation of gas is enormous, causing dyspnoea and great general distress; temporary relief is often obtained by this plan, which is an imitation of a common practice among veterinary surgeons. Something more than temporary relief may, however, follow the tapping. In twisting of the bowel, in internal strangulation by band or loop or ring, and in some cases of invagination, the constriction is kept up by the enormous gaseous distension. The obstruction is continued as much by causes within as without the intestine. When tapped and the gas drawn off, the bowel collapses, and may escape from its constriction and return to its natural condition. Tapping is not always certain or safe. The trocar or aspirating tube may pass between the convolutions and no escape of gas take place, or it may be followed by fecal extravasation into the peritoneal cavity. Notwithstanding the risk, the plan is a valuable one, and in suitable cases should be resorted to.

SURGICAL TREATMENT.—In cases of acute obstruction of the bowel from bands of lymph, diverticula, internal hernia, slipping of a portion of gut into some opening, or twisting, when the treatment suggested has been tried and fails, laparotomy should be performed; that is, the abdomen should be laid open, the cause of the obstruction searched for, and, if possible, removed. In acute cases a few hours, at most one day, may be spent in trying the medical means recommended. After that time, if the patient is not relieved, the sooner laparotomy is resorted to the better the chance to save life. Acute internal strangulation of the bowel from these causes has the same symptoms, course, and termination that acute external strangulated hernia has. It demands the same treatment—removal of the cause of the constriction. Delay in performing the operation in the former is as certain to be followed by peritonitis, gangrene, and death as it is in the latter; and the surgeon who hesitates to open the abdomen and attempt to remove the constriction in a case of acute obstruction after a fair trial and failure of medical measures, is as culpable as the one who delays the operation of herniotomy for unrelieved strangulated hernia.

In rare instances spontaneous self-reduction of external strangulated hernia takes place; the cases are exceptional, and the fact is no apology for postponing herniotomy. So in occasional instances acute internal strangulation is spontaneously relieved; here too the cases are exceptional, and the occurrence should be no excuse for delay in laparotomy. To justify the operation it is not necessary that the precise site and nature of the mechanical impediment should be determined, although this can usually be done. It is only necessary to know that the cause of the acute obstruction is not enteritis or peritonitis, but a constriction mechanical in character, which no medicine or manipulation or expectant treatment can relieve. When diagnosis is clear and laparotomy is indicated to save or prolong life in intestinal obstruction, the aid of the surgeon should at once be invoked. Delay is fatal. Peritonitis beginning or in actual existence makes abdominal section more dangerous and lessens materially the chances of recovery. To make the operation absolutely the last resort when the bowel is injured beyond repair, when peritonitis is in full progress, gangrene threatening, or the patient on the verge of collapse, is a useless cruelty to the sufferer and his friends, and only serves to bring surgery into disrepute. If the truth were known, many of the cases of death following laparotomy should be ascribed not to the fact that the knife was used, but to the fact that it was used too late.

In intussusception not relieved by medical means the propriety of abdominal section is questionable. The subjects of this condition are usually children. Dislodging the invaginated bowel is not always practicable, and the opium or expectant treatment may end in spontaneous cure by the bowel righting itself or by sloughing of the intussuscepted part. It is doubtless true that many of the so-called cures from the latter process subsequently die from contraction of the cicatrix at the site of the separation of the slough. In 43 cases collected by Ashhurst of laparotomy for invagination, 13 recovered and 30 died. The record is bad, and to some extent the heavy mortality is due to the fact that the operation was put off too long—delayed in acute cases until sloughing had taken place, and in chronic cases until adhesion of the invaginated parts had occurred. Indeed, some of the cases reported were moribund when the operation was undertaken. Recently many successful cases have been reported, and it is fair to presume that the percentage of recoveries in the future will be greater than they have been in the past.

In acute intestinal obstruction due to bands, internal hernia, volvulus, or the presence of foreign bodies, as gall-stones, there is no question that laparotomy should be performed after other measures for relief have been employed and failed. Death in such cases is inevitable and imminent, and operative interference should not be postponed until peritonitis has set in. After the abdominal cavity has been opened the distended gut can easily be found and the fingers of the operator carried on down until the site of the constriction is reached and the cause of the obstruction discovered. If the constriction is due to the presence of bands or adhesions, they should be cut or broken up and the gut relieved. If an internal hernia is found or a portion of bowel has slipped into some fissure or pocket, it should be withdrawn and the parts restored to their natural position. If the cause of the obstruction is a volvulus, the bowel should be untwisted. If a foreign body is felt impacted in the bowel and closing it, unless it can be readily and without danger of lacerating the coats of the gut pushed on by the fingers of the operator until it has passed the ileo-cæcal valve, the foreign body should be removed from the bowel by an incision and the wound in the bowel afterward closed by sutures. If the case is one of intussusception, the invaginated parts should be pulled out: this is practicable where adhesions are absent or slight, but if the adhesions are very firm, and it is impossible to restore the parts to their natural position, the gut should be laid open above the occlusion, the edges of the opening should be attached to the margin of the external wound, and a fecal fistula established. If the case of acute obstruction be due to stricture of the small intestine, which is exceedingly rare, the gut may be laid open, and the patient recover with fecal fistula, or entorectomy or resection of the diseased part of the gut be resorted to. The operation of entorectomy has been recommended by many surgeons, and a large proportion of the cases reported recovered. In one case by Koeberle six and a half feet of the gut were successfully excised.

The following table by Ashhurst shows the results of laparotomy. It will be seen that in 230 cases 68 recovered:

Operations for— Cases. Result not ascertained. Recovered. Died.

Volvulus 14 1 4 9

Strangulation continuing after herniotomy or taxis 18 ... 6 12

Invagination 43 ... 13 30

Foreign bodies, impacted feces, gall-stones, etc. 18 1 7 10

Strangulation by bands, adhesions, or diverticula 76 1 20 55

Obstructions from tumors, strictures, ulcers, etc. 28 2 7 19

Internal hernia and ileus 20 1 7 12

Obstructions from other causes 4 ... 1 3

Causes of obstruction not ascertained 9 1 3 5

Aggregate 230 7 68 155

Surgery, p. 835.

Enterotomy is an operation originally performed by Nélaton. It is done by making an incision, preferably in the right groin, above the crest of the ileum and parallel with Poupart's ligament. When the abdomen is opened a coil of intestine is found and carefully stitched to the walls of the incision. A very small opening is then made into the bowel, and a fecal fistula established. Enterotomy is less dangerous than laparotomy, as by it there is less interference with the peritoneum; but no relief could be afforded by this procedure in cases of intussusception or acute obstruction from bands, hernia, or volvulus. It is applicable to cases of intestinal constriction when the obstruction is about the lower part of the small or upper part of the large intestine. It may be resorted to as a palliative measure when exact diagnosis as to the character and site of the obstruction is not clear, the case being otherwise hopeless, or in cases of obstruction where severe symptoms persist and death is near, and yet for any reason laparotomy or colotomy is inapplicable; or it may be performed in cases of contractions after failure of patient and persistent medical treatment. Many successful cases of enterotomy have lately been reported, and the operation has been earnestly advocated by Trousseau, Maunders, Wagstaffe, Bryant, and others. In chronic constriction due to stricture or other mechanical obstructions, malignant or otherwise, not remediable by any medical measures, colotomy should be performed. By this operation the colon is opened and an artificial anus established. The sigmoid flexure in the left lumbar region is the part selected for the colotomy if the obstruction is situated in the gut below that point. When the obstruction is higher up in the colon or its exact site cannot be determined, the cæcum in the right lumbar region is the part chosen. In cases of obstruction from the mechanical pressure of tumors, the possibility of relieving the compressed bowel by treating the tumors should of course be considered before resorting to colotomy.