In all desperate cases where the cause of the obstruction cannot be sought for, or when found cannot be dealt with owing to the critical condition of the patient, the only thing available is to perform an Enter ostomy. The surgeon seizes the first distended coil of bowel which presents in the abdominal wound, draws it out, and whilst an assistant clamps it with his fingers an incision is made into the gut and a Paul's glass double flanged tube inserted and tied securely in position. After the bowel has been emptied into a receiver by siphoning through a rubber tubing attached to the Paul's tube the coil of bowel is returned to the abdomen, a portion of its circumference being attached by sutures to the parietal wound to prevent the tube falling back into the abdominal cavity. After some days, when the condition of the patient warrants a further operation, the cause of the obstruction may be again sought for and removed, the wound in the intestine being closed by a double row of sutures.
The older methods of dealing with acute intestinal obstruction by pouring in quantities of metallic Mercury into the stomach, inflating the colon by pumping in air, forcible massage of the abdomen, inversion of the patient's body, dosing with large amounts of Morphia or Atropine to paralyse peristalsis, and the continuous use of copious enemata and O'Beirne's long rectal tube, have been abandoned for the direct surgical procedures already mentioned.
The treatment of chronic intestinal obstruction should be undertaken before acute symptoms supervene; in the majority of cases the cause is malignant disease, Lecal impaction or the kinking of the bowel caused by inflammatory or tuberculous mischief. The treatment consists in the removal of the cause after laparotomy when this is possible, or by the establishment of entero-anastomosis or of a Local fistula by colostomy, or by excision of the rectum when the obstruction is within reach from the anus or by the sacral route.
The after-treatment of intestinal obstruction is almost as important as the surgical methods employed for the immediate relief of the symptoms.
The danger of shock is to be minimised by external warmth and large injections of warm saline solution into the rectum, or Murphy's method of continuous rectal infusion or intracellular injection may be resorted to. Strychnine or Pituitrin hypodermically is usually indicated. When the precaution of a thorough wash-out of the stomach before operation has been seen to there will as a rule be no necessity to repeat the lavage, and when the bowel has been well emptied before concluding the operation meteorism will seldom supervene, but should abdominal distension show itself a Saline purgative-3ij. Sodii Su1ph.—should be given every 2 hours or small doses of Calomel may be administered. Severe abdominal pain may be relieved by one hypodermic dose of Morphia combined with gr. Atropine, but morphia when possible should be avoided in order to minimise the paralysis of the inflamed intestine so liable to follow. No food should be permitted for the first 24 hours, but the mouth can be kept moistened by teaspoonfuls of water at short intervals.
INTUSSUSCEPTION—see preceding article on Intestinal Obstruction.
The physician will be wise who refrains from making any attempt at reducing the imagination; he should without delay requisition the services of the operating surgeon. Should surgical aid, however, be not imme diately available, he will he justified during the delay in administering an and gently squeezing or kneading the sausage-shaped tumour through the abdominal wall as an assistant elevates the pelvis. Failing to dissipate the tumour by this gentle manipulation, he may try the effects of a large enema of tepid water, or he may distend the colon with air by means of a Higginson's syringe. Unfortunately, the partial reduction of the intussusception which often follows is liable to lead him to conclude that the blockage has been overcome, so that postponement of operation is decided upon with disastrous results, as the only hope for a satisfactory issue from operative procedures lies in their being resorted to without an hour's unnecessary delay.