The obstruction is then to be dealt with according to its nature—Bands, Meeker s diverticula, strangulations caused by internal hernia at the foramen of Winslow, apertures in the mesentery or pouches in the peritoneum must be divided as in external herniie.
/ntussusception should he reduced after firm pressure has been made on the tumour to dissipate oedema; the sheath must be compressed from below upwards so as to squeeze the intussusceptum backwards, avoiding traction on the entering loop, as rupture is liable to occur. Should the bowel be found to be dead or if redut don is impossible owing to inflamma tory adhesions the tumour must be excised along with a portion of the dilated bowel above the intussusception. Oecasionally it is possible to assist reduction by gentle dilatation of the opening through which the int II SSil SMIAC I IS enters.
l'olvidns is most commonly met with at the sigmoid flexure, and the coil of bowel must be untwisted after emptying it ; when this is found to be impossible, or when gangrene has already occurred, the twisted coil of bowel must be excised or an artificial anus established above the volvulus by colostomy.
Adhesions causing matting together of adjacent coils of bowel should, if possible, be separated so as to remove all kinking. Cicatricial contrac tion of the mesentery is also often present, and the gluing together of the intestines may be so intimate as to prohibit all attempts at separation, especially when malignant disease is present. In this latter case there is no resource left but to establish an anastomosis between the bowel below and above with or without removal of the occluded mass.
Stricture ol the bowel, malignant or cicatricial, if found to be the cause of the obstruction, must be relieved by resecting the stenosed area, cutting wide of all diseased tissue, the operation when performed upon the small intestine being known as enterectomy, and when on the colon as colectomy; the divided ends of the bowel are brought together by end-to-end suture if in the small intestine or side-to-side if in the large intestine. Enteroplasty is only applicable to rare and very circumscribed cicatricial strictures where there is no suspicion of malignancy.
Where the stricture is malignant and acute complete obstruction has occurred, the best procedure is to open the bowel above the scat of occlu sion, and to insert a Paul's or other tube, and after the relief of urgent symptoms has been achieved and the patient has recovered from the shock of the attack, a second operation should be undertaken within a week.
When the mass is found to be irremovable the only course left to the surgeon is to make an anastumosis by connecting the divided end of the intestine above the growth with the colon, or to make on artificial anus when the malignant tumour is situated in the pelvic portion of the colon.
In rare cases the abdominal obstruction has been found to be due to thrombosis or embolism of the superior mesenteric vein or artery, in which case if the main trunk has not been involved the gangrenous portion of the intestine may be resected.
Gall-stones or foreign bodies when found to be the cause of intestinal obstruction should be removed by a free incision made in the bowel opposite to its mesenteric attachments, hut above the site of obstruction; this latter should be carefully examined, and if ulceration or gangrene is present a piece of the bowel should be completely excised after removing the calculus or foreign body, which should never be pushed onwards.
Idiopathic dilatation of the sigmoid and colon (llirschsprung's Disease) is more likely to cause chronic than acute obstruction. When the accumulated faxes cannot be removed by massage and enemata the dilated colon must be excised after the establishment of an artificial anus, and an anastomosis made between the lower part of the small intestine and the pelvic portion of the colon.
In every operation for acute intestinal obstruction the contents of the distended bowel should be removed by enterotomv. An incision being made into the distended coil, a long glass tube attached to several feet of rubber tubing is inserted, and the contents siphoned off in order to prevent the poisoning liable to follow on the absorption of the toxins produced by the Bacillus coll. The opening into the bowel should be closed after thorough sterilisation by the insertion of a double row of sutures before returning the intestine into the abdominal cavity.