INTESTINAL OBSTRUCTION.
Cases of obstruction of the bowel are usually grouped into the acute and chronic forms, but a large percentage of acute cases occur in patients who have been suffering from some chronic obstructive lesion which suddenly causes complete blocking of the intestinal canal.
In acute obstruction, before any form of treatment can be thought of, the physician's duty is to exhaust every means of finding out the cause of the blockage, though he is never justified in delaying treatment till he has satisfied himself about the diagnosis of the cause. To do so, in the majority of cases is to abandon the patient to his fate, as the only hope, speaking generally, lies in early operation. The possible causes of the obstruction being recalled to his mind, he rapidly eliminates each till he arrives at the conclusion of the most probable and that the abdomen will require opening.
The rectum should be at once explored, and if impacted forces are discovered these should be broken up by a scoop or by the fingers of the gloved hand, and the colon flushed out by a large enema of tepid water. Even when the bowel is found empty one copious enema should always be administered slowly, with the patient lying upon his left side, the pelvis being raised and the head depressed. If possible, 4 to 6 pints or more should be slowly injected with the hope that if any obstruction exists in the colon (scybake, intussusception, (Sze.) it may be passed by the stream of water and the whole of the large intestine distended by the fluid. If no result follows the enema should not be repeated; the physician should abstain from passing the long tube, and purgatives must never be administered.
A malignant growth or a stricture in the rectum affords clear indication for a rectal operation. The hernial regions should be carefully explored both at the usual sites and at the sciatic notch and obturator foramen. The presence of a hernia at once demonstrates the nature of the attack, and demands the relief of the strangulated knuckle of bowel. If an old empty hernial sac be discovered the indications for operation are almost equally clear. The surgeon should cut down upon it and fully explore the peritoneal opening with the hope of finding and relieving any internal strangulation in the immediate neighbourhood of the internal ring.
When the above examinations fail to reveal a removable cause of the obstruction, the pain, vomiting and abdominal distension continuing, without waiting for a confident diagnosis the physician should decide upon calling in the aid of the surgeon in order to have an exploratory incision made. Whilst awaiting operative procedure intense pain may be relieved
by hot poultices or ice to the abdomen and a single hypodermic injection of Morphia. The objection to Morphia as a routine is a real one. It relieves pain and paralyses peristalsis, and thus masks the symptoms and misleads the judgment of both the physician and surgeon regarding the gravity of the case, and so tends to the postponement of operative pro cedures till the patient has become poisoned by the toxins which accumu late above the seat of obstruction.
Lavage of the stomach should always be carried out before operating, and it often affords considerable relief to the vomiting whilst arrangements are being made for opening the abdomen.
The abdomen should be opened in the middle line between the umbilicus and pubes (unless when it is considered desirable to explore an old hernial sac). The incision should be adequate, and the first point which the surgeon should make for after exploring the hernial rings is the cacum. This must be thoroughly examined, since if found empty the block is likely to be in the small intestine, whilst its distension will signify that the obstruction is somewhere in the great bowel. Should the cecum be empty the fingers are to be directed into the pelvis, and search made there for any loop of bowel which is not distended; such an empty coil must obviously be on the distal side of the obstruction. The intestine is next passed between the fingers bit by bit till the obstruction is reached; the same process is applied to the colon should the cxcum he found full, the fingers being passed along the large bowel till the site of obstruction is reached. Should there he any great difficulty in following the intestine, the incision in the abdominal wall must be enlarged with scissors so as to admit the entire hand; the surgeon should avoid drawing out the intestines through the abdominal wound if possible, owing to the difficulty often experienced in returning them. When eventration or evisceration is absolutely necessary the protruded bowel should be enveloped in cloths saturated with hot saline solution, and covered over with a layer of thin mackintosh.