OPERATION. - The amount of opera tive intervention will depend upon the condition of the patient. Very com monly the surgeon is called in late and the patient is in a much weakened and collapsed condition; in such cases the use of a general am esthetic is full of danger, for vomiting is almost certain to occur, and the vomited fluids are likely to be drawn into the lung, caus ing death by suffocation or by subse quent bronchopneumonia. In such ur cases the operation is best per formed with local anmesthesia. The in cision should be made in the median line below the umbilicus, unless there is con siderable certainty as to the location of the obstruction, in which case the in cision may be made over the site of the obstruction. Only a short time should be devoted to exploration; if the cause of obstruction is not found an artificial anus should be made, which will put the patient for the time out of danger, and the operation may be completed at a later date. The first object is to save the patient's life. In seeking the site of ob struction it should be remembered that the most dilated coils are above the ob struction and will rise nearest to the surface, usually near the umbilicus, and by following the most distended and congested portion of the intestine the stricture will generally be found. If the obstruction is not found in this manner, the hand may be inserted. If the cecum is first examined and found distended, the cause of obstruction is probably located lower clown in the colon; if not distended, the seat of ob struction is sought in the small bowel. The measures taken for relief of con striction will depend upon its cause and upon the condition of the bowel. A volvulus should be untwisted, the mes entery shortened, and intussusception reduced by drawing the invaginated portion out. The treatment of intussus ception by inverting the patient and by injecting large amounts of gas or fluid in the colon has not given very satisfac tory results, and, unless immediately successful, operation should not be de layed.
If there is excessive distension of the bowel it will be necessary to relieve it after removing the cause of obstruction. This may be done by one or more in cisions, carefully protecting the ab dominal cavity by packing gauze about the opening, which should be closed at once by Lembert sutures. In some cases in which the intestine is found gan grenous resection may be necessary.
Very excessive distension would some times call for the formation of a tempo rary artificial anus. In the after-treat ment opium should be avoided, as it tends to paralyze the bowels, causing distension and checking all the secre tions. If gas or fluid is not passed and the distension does not diminish, the ab domen should be reopened and enter otomy performed. Rectal feeding may be necessary for several days until food is well borne by the mouth.
In chronic intestinal obstruction the treatment will depend on the number and severity of the attacks. If the gen eral health of the patient is suffering, operation is indicated.
In chronic obstruction due to stricture or tumors resection may be possible; but, if malignant growth has progressed too far to admit of this, enterostomy or colostomy is indicated. In the case of foreign bodies, such as gall-stones, it is sometimes possible to break them up, by pressure or by needling, or to pass them along after the abdomen is opened with out opening the intestine. As a rule, however, it is best to extract the body through the incision. (See also AP PENDICITIS and ABDOMEN, INJURIES OF, volume i.)