The Diagnosis and Medical Treatment of Acute Intestinal Obstruction

Med- MONOGRAPHS. No. \ical I. The Diagnosis and Medical Treatment of ACUTE INTESTINAL OBSTRUCTION. 2&P ill. I?, fU3,>w:& Cuppleg €J)f Algonquin i^urti, $uMi$bet£, S&ogton. Jnfeeftnaf OBefrucfton. R. H. FITZ, M.D. Reprinted from The Boston Medical and Surgical Journal. THE DIAGNOSIS AND MEDICAL TREATMENT OF ACUTE INTESTINAL OBSTRUCTION. BY REGINALD H. FITZ, M.D. Professor ofPathological Atiatomy in llTTrvard University, and Physician to the Massachusetts Getteral Hospital. BOSTON CUPPLES AND HURD, Publishers Algonquin 1889 THE DIAGNOSIS AND MEDICAL TREAT- MENT OF ACUTE INTESTINAL OB- STRUCTION. 1 BY REGINALD H. FITZ, M. D., OF BOSTON. In the consideration of intestinal obstruction from a medical point of view, the subjects of chiefest importance undoubtedly relate to diagnosis and treatment. The present communication is intended to call attention to those features which may possibly serve to characterize the former, and to mark the limits of the latter up to the point of surgical interference. It will be admitted without much question that the difficulties of exact diagnosis, and the possibilities of permanent relief, are greatest in acute, internal forms of obstruction. It is, therefore, to this part of the subject, in particular, that the present enquiry is directed. The term intestinal obstruction would seem to be equivalent to stoppage of the bowels, and refers to the absence of an important function of this appa- ratus. The conspicuous causes of such a stoppage are essentially mechanical, and the anatomist finds the bands and cords, the slits and pouches, the 1 Read before the Congress of *merican Physicians and Surgeons in Washington, D. C., Sept. 13, 1883. 6 Intestinal Obstruction. invaginations, twists and knots, the strictures, tumors, and abnormal contents. But in another class of cases the stoppage is present, the patient dies, and there is not found an en- tirely satisfactory, mechanical cause of obstruction. If the intestinal coils are agglutinated or adherent in such a manner that valve-like projections into the canal are formed, these are considered by some a satisfactory explanation of the symptom. If the mesentery of any coil is so contracted that the legs of the loop are closely approximated, this change is frequently considered a sufficient cause. But agglutinated and adherent coils are frequently found in the absence of symptoms of intestinal obstruction, and the contracted mesentery is seen in cases where no stoppage of the bowels has occurred. This symptom takes place in still another series of cases where the anatomist finds no suggestion of a lesion which offers the remotest possibility of acting as a mechanical cause. The physician then says the obstruction must be due to a paralysis of the muscular coat, or a spasm of the circular fibres, or a faulty innervation, orto some peculiar modifica- tion of function. Intestinal obstruction, in a technical sense, how- ver, means something more than stoppage of the bowels. The latter symptom may be present at the outset, it may occur later in the course of the disease, or frequent loose movements may be a most characteristic symptom of the especial variety of obstruction, as in intussusception. Frequent dejec- tions may also occur in the early stages of other varieties of obstruction, and throughout the course Intestinal Obstruction. 7 of the disease when faeces are the cause. Stoppage of the bowels is thus not only unnecessary as a symptom of intestinal obstruction, but, when present, its particular consideration has led to frequent errors of diagnosis. Of all the causes of stoppage, which have given rise to an erroneous diagnosis of obstruction, there is none more frequent than peritonitis. In a general peritonitis the bowels are expected to remain inactive, and medical efforts are frequently directed to this result. In the circum- scribed variety the important symptoms of local- ized pain and paralyzed bowels have often led to the diagnosis of acute, internal obstruction. This is particularly true in the case of inflammation of the vermiform appendix, a disease which is con- stantly being mistaken for acute obstruction. This error in diagnosis leads to corresponding errors in treatment. Because the bowels have been opened in such cases by powerful cathartics, quicksilver, electricity, violent movements of the body, and the like, therefore these are claimed to be valuable and efficient remedies in obstruction. Too often the speedy death of the patient results from such treatment, the local peritonitis being made general. The only intestinal obstruction which deserves the joint consideration of surgeons and physicians is that due to well-recognized, mechanical causes. It is the acute, internal variety of mechanical, intestinal obstruction which forms the subject of this paper. There are four, main questions which require consideration in any given instance:— 8 Intestinal Obstruction First, Is the case one of acute, internal obstruction ? Second, Where is the obstruction seated ? Third, What is the variety ? Fourth, What is to be done ? The statements which follow in this paper are essentially based upon the study of a series of cases collected from the English, German, and French medical literature since 1880. Its claim to consideration lies in the fact that all the cases have been submitted to the severest criticism, with the resulting exclusion of a very large number. They are included under the heads of strangulation by bands, cords, etc., intussusception, knots and twists, obstruction by abnormal contents, strictures, and tumors. The entire number is two hundred and ninety-five, and they are divided as follows: — Strangulation 101 cases = 34 per cent. Intussusception 93 “ =32 “ Abnormal contents 44 “ =15 “ Twists and knots 42 “ =14 “ “ " Strictures and tumors 15 = 5 295 “ 100 Excluding from this series the cases of acute obstruction from abnormal contents and from strictures and tumors, which are of the least importance in practice, there remain— Strangulation 101 cases = 45 per cent. Intussusception 93 “ =59 “ Twists and knots 41 “ =18 “ 230 “ 100 “ It is interesting to compare these figures with the larger number in the collections of Duchaussoy, 2 Brinton, 3 and Leichtenstern: 4 — 2 Duohauesoy, Memoirs de l’Acactemie (le 1850, xxiv. 97. 3 Hrinton, Intestinal Obstruction, 1807, 88. ♦ Leichtenstern, Ziemssen’s llandb. d. Sp. I’ath. und Therapie, 1876, vii. 2, 528. Intestinal Obstruction. 9 cases o Knots Percentage of relative frequency of the of more prominent causes of acute and intestinal obstruction. included. bp Intussusception. Number Slr Twists Duchaussoy 347 54 39 6 Brinton 481 33 54 5 10 Leichtenstern 1134 35 39 6 STRANGULATION. First in numerical importance as a cause of acute, intestinal obstruction is strangulation by bands or cords. These are most frequently the result of a pre- existing peritonitis, and are either fibrous adhesions alone, or are formed by adherent appendages of the intestinal or genital tract. The former are epiploic, vermiform, diverticular, omental, or mesenteric. The latter are Fallopian tubes and pedunculate ovarianor uterine tumors. The diverticular appendages are either Meckel’s diverticulum, (the omphalo-mesenteric or vitelline duct,) or the persistent remains of the vitellineblood-vessels. The formeris usually at- tached by the latterto some part of theabdominal wall or contents. It may also be thusattached from peritonitis in the absence of the latter. The persistent vitelline blood-vessels or their remains may likewise form the strangulating cord in the absence of the diverticulum. Omental cords may be adherent in consequence of peritonitis, or they may result from the presence of slits or fissures in the omentum. 5 Brinton gives forty three percent, of intussusception in his tableofsix hundred cases of intestinalobstruction by this lesion bands, adhesions, diverticula, or peritoneum external to the bowel, strictures (including a few tumors) Involving the iutes tinal wall, and torsion of the bowel on its axis. op. cit., 3s 10 Intestinal Obstruction. The mesentery serves as a cause of strangulation when it is fissured by a slit. Peritoneal pouches and openings may be added to the above list. There seems to be no essential difference in the nature of the symptoms which arise from these causes of obstruction. Cases of knots and twists of the small intestine might be added to the list from the nature of their symptoms, but their number is so small, only two of each, that for practical purposes they may be omitted. The immediate anatomical causes of the one hundred and one cases of strangulation are as follows, the numbers being regarded as equivalent to per- centages : — Adhesions 03 cases. Vitelline remains 21 “ Adherent appendix 6 “ Mesenteric and omental slits 6 “ Peritoneal pouches ami openings a “ Adherent tube 1 " Pedunculate tumor 1 “ 101 •• 84% of the total number of cases were due to bands and cords in a limited sense. It is noteworthy that cases of diaphragmatic hernia, which form 19% of Leichtenstern’s cases, were not reported in the past eight years. The following table shows the bearing of sex in the frequency of obstruction from strangulation: — Adhesions. VitellineRemains. Appendix. Slits. Pouches. Tube. Tumors. Total. Males 39 19 5 5 2 70 Females 24 1 1 1 1 1 1 30 63 20 6 6 3 1 1 100 Intestinal Obstruction. 11 It thus appears that 70% of the cases of obstruction from strangulation occurred among males. Further, that nearly all the cases of obstruction from vitelline remains, adherent appendices, and slits were found among men. The percentage of bands of intestinal origin and those of pelvic origin was about equal in the two sexes. The age at which the obstruction took place is shown in the following table: — Years of Age. Adhesions. VitellineRemains. Appendix. Slits. Pouches. Tube. Total. 1-5 to 5—10 rf- 10 15 C.T 15 20 *■* CO 20—25 1 25—30 ~ 30—35 c: 35—40 - W 40—45 - -4 45—50 IO 50 55 OO 55—00 ~ K> - C 60-05 *■* >*.— 65-70 K> 70—76 t-* o« CO C5 <T.

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