frequently accompanies carcinoma of the duodenum, sometimes cicatricial con-
traction following ulcer. If the orifice of tin 1 duel i> obstructed, the patienl
will sutler from chronic jaundice, occasionally from attacks of pain resem-
bling biliary colic from gall-stones. In the recorded cases the signs of disten-
tion <>l' the gall-bladder have nol been marked. The urine will contain bile
pigment, the stools will he pasty and clay-colored; they may contain free fat;
there nmy he glycosuria. It will usually he impossible before operation to
make an exacl diagnosis. Disease of the pancreas, carcinoma, primary in the
gall bladder, <>r cholelithiasis with lodgmenl of ;i stone in the common duet
nil may presenl similar symptoms.

3. Stenosis of /he Duodenum below the Papilla. — In this condition the bile

and pancreatic juice readily enter the intestine, hut ]>ass on through the nar-
rowed portion with more or less difficulty. If the stenosis is of a high grade,
bile in greater or less quantity will regurgitate into the stomach. There will
he, in addition, a dilated stomach, si^ns of motor insufficiency of a more or
less marked grade, and a phenomenon resembling that observed in hour-glass

contraction of the stomach — i.e., if the stomach he washed (dean, a sudden

subsequent flow id' fluid may occur; the distinguishing character of this fluid
will he its distinctly biliary character, thus differentiating it from the foul
material free from Idle sometimes obtainable by this procedure in hour-glass

cent ract ion of the stomach.

General Symptoms. — It is (dear from the foregoing outline that the clin-
ical symptoms of stenosis of the duodenum with the exception of those cases
< • : 1 1 1 - i i i o- obstruction of the biliary and pancreatic duct resemble rather affec-
tions of the stomach than of the intestine. Only in cases of very marked ste-
nosis dees the stomach dilate, and rarely, if ever, does the dilatation of the
duodenum itself give rise to definite and recognizable physical si^ns. The
patients all suffer from marked symptoms of dyspepsia, pyrosis, belching of
wind and attacks of vomiting, more or le>s frequent. Fermentative changes in
the vomited material will he more or less marked, according to the degree oi
interference with the passage of Iced. They develop absolute loss of appetite,
and suffer from severe attacks "/ colicky pain, such that, though anxious to rat.

the fear of certain suffering I" follow renders lliem unable to swallow suffi-



78 SURGICAL DISEASES OF THE INTESTINE

cient food. The general health suffers in consequence, often slowly, but surely ;
they become emaciated, weak, neurasthenic, and miserable. The symptoms
of stenosis of the upper part of the jejunum resemble more or less closely
obstruction of the duodenum ; the gastric disturbances are prominent. The
lower down in the small intestine the obstruction lies the less the stomach symp-
toms are in evidence. Vomiting, however, continues to occur in stenosis of
the small gut, no matter where situated, if at all narrow. It is to be remem-
bered that vomiting of a fecal character may occur even when obstruction
exists high up in the small intestine. The stagnation of the contents of the
bowel, the imperfect bactericidal action of the gastric juice from disordered
gastric digestion, favor multiplication of bacteria and stinking decomposition
of the contents of the gut above the stricture. Some regurgitation of this
material into the stomach is common even when the stenosis is not of a very
high grade. When for any reason obstruction becomes temporarily complete
distinctly fecal vomiting is the rule, even though the obstruction is not far
below the stomach. If the obstruction remains permanent, the other signs and
symptoms of acute intestinal obstruction follow at once. If it is finally over-
come, the fecal vomiting will subside. Only when situated some little distance
from the duodenum do the really characteristic local signs and symptoms of
chronic intestinal obstruction become marked. They are, in addition to the
colicky pains, localized tympanites, the occurrence of visible and palpable
peristaltic waves in a definite uniform portion of the abdomen, and the occur-
rence of intermittent rigid contractions of the wall of the bowel, recognized by
palpation, sometimes aided by inspection.

It goes without saying that these phenomena are more readily appreciated
when the abdominal wall is thin and relaxed. Under normal conditions the
intestines never become visible as distinct coils through an abdominal wall of
normal thickness. In cases of ventral hernia or separation of the recti, sepa-
rate coils may be visible ; on palpation they feel entirely soft and yielding.
In cases of chronic obstruction the distinctness of the physical signs will
depend upon the situation of the stricture ; the degree of stenosis, the degree
of hypertrophy of the wall of the gut above the stricture ; the thickness of the
abdominal wall. When the abdominal wall is fairly thin, and the stenosis
marked and not too near the duodenum, the phenomena may occur in one of
two forms. Each is regularly accompanied by attacks of colicky pain, rarely
absent, and may be followed by vomiting from regurgitation of intestinal
contents into the stomach from unavailing efforts on the part of the gut to
force its contents through the stricture. In the first form rhythmical con-
tractions of the visible coils of distended gut occur, beginning always at the
same point, and ending at some other point, indicating the position of the
stricture. The peristaltic movements are accompanied by pain. On percus-
sion the distended coils give a high-pitched tympanitic resonance. On aus-
cultation gurgling sounds can often be heard, or they may be distinctly audible
from a distance. They are distinctly appreciated by the patient. Succussion



[NTESTINAL OBSTRUCTION 70

splashing sounds may sometimes be elicited. These phenomena are obsei
over a greater or less area of the abdomen, according i" the Length of gul
involved. They begin and end ;it definite points in the abdomen, and these
points are the same in each attack. In less well-marked cases th<- individual
coils may nol be distinguishable, but simply a more <>r less definite area of
abdominal swelling, accompanied by pain and the other signs, appearing inter-
mittently at intervals of seconds or minutes. These phenomena may occur
spontaneously; they may follow the ingestion of food, psychical disturbances,
or local irritations of tin- abdominal wall, whether mechanical or from exposure
to licat or cold. Their recurrence in a uniform definite area serves to distin-
guish them from the somewhat rare localized tympanitic distention and
peristaltic activity observed in hysterical and neurotic patient-. In these cases
localized tympany may occur, but its situation will lie variable, changing its
position from time to time, and appearing in different portions of tin- abdomen.
The second form consists of a rigid tonic contraction of one or several coils of
gut, coming on spontaneously or from the same causes as the first form. The
contraction usually comes on quite suddenly, and is accompanied by an attack
of colicky pain. If the abdominal wall is not too thick, one or several coils
of intestine suddenly become visible as sausage-shaped tumors beneath the
abdominal wall, upon palpation the gut can be felt as a firm cylindrical mass.
Thi' accompanying signs and symptoms resemble the first form. The contrac-
tion lasts for seconds or a minute or two, and then subsides; the contri
coils of gut suddenly disappear. This siijn is quilt: characteristic of marked
stenosis of (lie small intestine

The movements of the bowels in chronic intestinal obstruction of the small
gut show nothing characteristic. The movements are diminished in quantity,
according to the degree of stenosis, the frequency of vomiting, the quantity of

f 1 which actually passes the stricture, and usually there is constipation. If

catarrhal inflammation of the colon exists as a complication there may be diar-
rhea. The nearer the obstruction lie- to the ileo-colic junction the more the
symptoms will simulate obstruction of the large bowel.

The urine is diminished in quantity, and, as is regularly the case when
retention of the contents of the bowel and excessive putrefactive changes coexist,
indican will be found in the urine in an increased quantity.

Chronic Obstruction of the Labge Entestine

The signs and symptoms of stenosis of the large intestine vary a good deal.
according to the situation of the obstruction. The nearer it i- to the ileo-cecal
valve the more the signs will resemble obstruction of the small gut. When
situated in the cecum or tirst part of the ascending colon, a greater or less por-
tion n\' the ileum will become h\ pert rophied and dilated, and the si^ns of vis-
ible peristalsis or hardening of the bowel, as already described, will Ik- ob-
served; further, if in the cecum, there will usually be a palpable tumor in the



80 SUEGICAL DISEASES OF THE INTESTINE

right iliac fossa, carcinoma or tuberculosis of the gut being the commonest
causes of chronic obstruction in this region. When, however, the obstruction
is far removed from this point, the characteristic signs of active peristalsis will
be absent, and the disease, for reasons about to be explained, will be far more
likely to run a latent course long unrecognized. The peristaltic movements
of the small gut are far more active than those of the colon. In the latter they
are slower, less frequent, and less vigorous, consequently signs of active move-
ment and intense local irritation rarely appear until the obstruction becomes
suddenly absolute. The contents of the colon often slowly accumulate above
the obstruction, and may give the signs of fecal impaction. The patient may
suffer from severe constipation; often there will be moderate general tym-
panites. There may be diarrhea from catarrhal inflammation of the colon
above and below the obstruction; sometimes diarrhea and constipation will
alternate. The diarrheal movements are often preceded by attacks of colicky
pain, or such attacks may occur at intervals without diarrhea. If the process
be an ulcerative one, pus, blood, or fragments of tumor tissue in the diarrheal
movements may furnish a clew to the condition. Very often the diarrheal
movements on account of putrefactive changes taking place in the distended
bowel above the obstruction will be horribly offensive. If the obstruction is
in the sigmoid there may be a band of tympanitic resonance in each flank.
If the obstruction lies in the splenic flexure or transverse colon, such an area
of tympanites may be confined to the right side. The information to be
derived in these cases by inflation of the bowel with air or water is sometimes
valuable. (See Diagnosis of Diseases of the Abdomen.) A good many cases
of chronic obstruction of the large intestine are treated for constipation, for
diarrhea, for colitis, etc., for a long time before the diagnosis is made; very
often it is only made upon opening the abdomen for the relief of a sudden
attack of acute intestinal obstruction or for perforation peritonitis, the exist-
ence of a chronic stenosis of the gut having been entirely unsuspected. Unless
the obstruction is as low as the beginning of the rectum, no valuable informa-
tion is to be derived from the shape of the stools. The tapelike stools which
sometimes occur in cancer of the rectum itself are not observed in obstruction
of the large intestine. The effect of chronic intestinal stenosis of a grade
sufficient to produce symptoms upon the general health of the individual varies,
as may be gathered from the foregoing paragraphs, widely in different cases.
In cases due to malignant disease of the gut or to 'progressive processes of any
sort, extensive ulceration due to syphilis or tuberculosis with cicatricial con-
traction, the result is inevitable death after a longer or shorter period, the end
coming as the result of complete obstruction or from pressure perforation above
the stricture and peritonitis, unless the condition be relieved by a radical or
palliative operation. In other cases of a character not so essentially progressive
the patients may drag out a miserable existence for many years, suffering from
digestive disturbances, vomiting, constipation, diarrhea, abdominal pain, ema-
ciation, anemia, chronic autointoxication from absorption of poisonous products



[NTESTINAL OBSTRUCTION 81

from the bowel, neurasthenia, and general wretchedness. I nder the mosl
favorable conditions of hygiene and diel the outlook i- grave unless -ni_
relief is possible.

ACUTE I CTTESTINAL I >BSTB1 CTION ; [LEU8

Acute stoppage of the bowels may be due to two entirely different sets of
conditions: In the firs! there is no annul mechanical closure of the lumen of
the gut, but an absence of muscular activity In the intestinal wall i. ••.. intes
tinal paralysis. In the second the stoppage is due to actual mechanical closure
of the lumen of the bowel from one or more of many causes.

Intestinal Paralysis. — By far the mosl frequenl and importanl cause of
intestinal paralysis is acute peritonitis of the infectious type, a- already
described under peritonitis. It was there stated that one of the most char-
acteristic phenomena of well-developed diffuse septic peritonitis was paralysis
of the gut, absence of the passage of gas and feces per rectum, tympanites,
repeated vomiting, finally becoming -tercoraceous, together with progressive
symptoms of collapse continuing until death. Localized peritonitis may pro-
duce localized intestinal paresis merely, which is often recovered from,
though nol always. Tn addition to peritonitis may be mentioned violent and
prolonged handling of the intestines during operations. Prolonged efforts at
taxi- in the reduction of large incarcerated or strangulated hernia. Eviscera-
tion and strong traction upon or operations upon the mesentery, thus paralyzing
its nerves. Occasionally blows upon the abdomen with contusion of intestinal
coils, marked and prolonged distention of the gut above a chronic obstruction
by feces and gas; finally, as the result of embolism of the superior mesenteric
artery in cases of endocarditis. We have already dwelt sufficiently upon the
symptoms and diagnosis of intestinal paralysis as -ecu accompanying perito-
nitis. Under the head of differentia] diagnosis in acute intestinal obstruction
we shall refer to it again. Embolism of the superior mesenteric artery is an
invariably fatal condition, and presents a fairly typical picture; it always
ends in gangrene of a large portion of the small intestine. A typical history
of such a case is related by Tuholske (Journal of the American Medical Ass
elation, February, 1904); the important details of the case are here repro-
duced: A middle-aged man, who had suffered from attacks of acute articular
rheumatism and had a mitral heart lesion, was suddenly seized with violent
abdominal pain, most intense at the umbilicus, prostration, and vomiting. 1 hir-
ing the next two day- the abdomen became distended, lie continued to vomit
and passed nothing per rectum. On the third day his condition became very
grave indeed, lie had a large movement from the bowels of black, tarry putrid
blood. Abdomen distended, rigid, tender, frequenl vomiting. Collapse threat-
ened, clammy skin, pointed nose, sunken eye-; rapid, feeble pulse; tempera-
ture, I'M V. Incision of abdomen, foul bloody fluid escaped from peritoneum.
Three feet of ileum gangrenous. Embolus in superior mesentery artery, wide-
spread infarction of vessels of mesentery and small intestine. Death.

58



82 SURGICAL DISEASES OF THE INTESTIXE

Mechanical Obstruction of the Bowel. — The second set of cases are due to
actual mechanical obstruction of the bowel. They may be divided into two
groups: (a) Obstruction by strangulation; (b) obstruction by obturation. In
" A Study of One Thousand Operations for Acute Intestinal Obstruction and
Gangrenous Hernia/"' Gibson found that thirty-five per cent of the cases were
due to strangulated hernia, nineteen per cent to intussusception, a similar per-
centage to bands, twelve per cent to volvulus.

Group A. Strangulation. — In this group of cases not only is the lumen
of the gut closed, but usually its nutrition and that of its mesentery is de-
stroyed or endangered. To it belong all the varieties of external strangulated
intestinal hernia?, except such as involve but a portion of the wall of the gut:
Femoral, inguinal, umbilical, ventral, obturator, ischiadic, perineal, lumbar,
vaginal. In this group, also, is included obstruction by bands. Such bands
arise most commonly from adhesive peritonitis, following attacks of acute peri-
tonitis, injuries and surgical operations upon the abdomen, notably those in
which surfaces remain behind bared of peritoneum. An adherent appendix
or a Meckel's diverticulum may act in the same manner. Bands may be cord-
like, round, flat, or may consist of broad adhesions closely uniting broad sur-
faces, favoring angulation, or of firm sheets of fibrous tissue; slits in or inter-
stices between such sheets may form orifices through which coils of gut pass
and become strangulated. An adherent portion of omentum, especially if thick-
ened by a former inflammation, may act in the same manner. Bands may act
to produce strangulation in various ways. If the band is short and strong, a
coil of gut slips beneath it and is compressed to the extent of strangulation.
If long and free, the band may knot itself about a coil or coils. Rarely, accord-
ing to Xothnagel, a coil may slip over a rigid band, and as it is filled and dis-
tended may become more or less completely strangulated by its own weight.
Slits, whether merely anomalous, such as congenital orifices in the mesentery
or omentum, or acquired, from ruptures of the uterus, the bladder, or even
in the parietal peritoneum, may permit the passage of a coil of gut, which
subsequently is pinched and strangulated. Resections of intestine, when the
loss of substance in the mesentery has not been properly closed by suture, may
furnish a similar opportunity. According to Sehlange, slits in the broad liga-
ment, in the suspensory ligament of the liver, have caused strangulation in the
same way. Further, the various forms of internal hernia- : diaphragmatic,
through the foramen of Winslow into the lesser sac ; into the fossa duodeno-
jejimalis (Treitz fossa) ; into the intersigmoid fossa, and in the pericecal peri-
toneal pouches.

Intestinal obstruction from strangulation is more common in the small
than in the large intestine. The greater mobility of the ileum, its proximity
to the various hernial orifices, its relations to the vermiform appendix and to
Meckel's diverticulum ; the frequency of adhesive peritonitis among its coils ;
the tendency of the small intestine to fall or be dragged by adhesions into the
bottom of the pelvis, all favor the occurrence of strangulation. There is, how-






INTI-STIXAI. 0BS1 IM < TIOX

ever, one fonn of obstruction caused h\ rotation of intestinal coils, more com-
mon in the sigmoid flexure than elsewhere i.e., volvulus. Of 121 <•■
by ( ribson, 73 were in the colon, 58 in the sigmoid flexure, and 15 in other parts
of the colon ; and only -';•'>, less than one third, were found in the small intestine.
Vol 'nil us. Twists may also occur in other portions of the large and small
intestine, 1ml they are less common. The sigmoid flexure becomes the seal of
volvulus, as will be explained, as the result of congenital or acquired conditions.
The rotation may occur in one of three ways (Rokitansky) : (1) The b
may make a half or a whole turn upon its own axis, and thus its lumen may
be occluded. (2) More commonly, rotation of a loop occurs with the whole
or a portion of its mesentery as an axis. The mesentery twists with the intes-
tine. A rotation of from 270 to 360 degrees is necessary to produce occlusion
of the gut ( Lawson). Combinations <»f axial rotation of the gul and of rota-
tion aboul the mesentery may also occur. (3) One loop of intestine may form
a band about which another loop rotates, thus forming in some cases a knot
or knots. The sigmoid with a long mesentery and a loop of ileum are com-
monly associated in this condition. Predisposing causes of volvulus are a sig-
moid having a long narrow mesentery; as stated, this may be a congenital
anomaly. In other ca'ses it appears to be an acquired condition due to improper
feeding during childhood and chronic constipation; the sigmoid may thus he
dilated and unduly long; though the volvulus is more apt to occur during the
later years of life. According to Fitz, in 34 cases the largest number in any
decade was between the thirtieth and fortieth year. In 121 cases collected
by Gibson, the average age was forty-five years. As the result of chronic
constipation the sigmoid is often distended, its mesentery lengthened and nar-
rowed by traction. If, now, on some particular occasion, the upper loop is
distended with accumulated feces, a sudden jar of the body, a violent muscu-
lar effort, or pressure upon the abdomen, may be sufficient to cause the up]*?r
loop to fall downward over the lower loop. The rotation is thus started;
further distention of the twisted gul serves to render the twist more complete
and incapable of spontaneous reduction; complete strangulation of bowel and
mesentery follows. A> already stated, such distention may be extreme. Volvu-
lus of other portions of the colon occur more rarely, and are favored by a long
mesentery. Thus volvulus of the splenic and hepatic flexures have been observed
as great rarities. As stated, the transverse colon may hang down in a long, -harp
loop to the pubes, and may he the seat of volvulus. Volvulus of the small intes-
tine is favored by a short, narrow mesenteric attachment and a long mesentery.
As an extreme case favoring such an occurrence, the congenital abnormality
illustrated in Fig. 21 will serve as an example. Local pathological conditions
may also predispose to volvulus of the small gut A coil of ileum long pro-
lapsed in a hernial sac may have its mesentery unduly narrowed and length-
ened. Cicatricial contraction of the mesentery from former attacks of perito-
nitis predisposes to volvulus in a similar manner. I operated upon a child.
aged seven years, for a volvulus of the small intestine, which occurred as the



84 SUEGICAL DISEASES OF THE ENTESTIXE

result of a violent push from behind. The ileum had a congenitally short
mesenteric attachment, while the mesentery itself was unusually long. A
single coil of ileum about eighteen inches in length was twisted one and a half
times round, including its mesentery, and was gangrenous. The gangrenous
coil was resected, but the twist in the mesentery had so far interfered with the
circulation of the entire small intestine that the gangrene spread widely above
and below the resected portion, and the child died with more than half his small
intestine necrotic. Volvulus of the small intestine is, as stated, often associ-
ated with and caused by hernia ; the two may coexist. It is well for the sur-
geon to bear in mind when operating upon an irreducible hernia in the pres-
ence of symptoms of intestinal obstruction that, failing to find the gut in the
hernial sac strangulated, a volvulus may be causing the obstruction. Vaughan
in 1903 (" Volvulus of the Small Intestine," etc., American Journal of the
Medical Sciences, May, 1903) published records of collected cases, including
his own. He collected 61 cases. Of them, 21 involved torsion of the entire
mesentery ; 40 were partial only, a portion of the mesentery and small intes-
tine being involved in the twist.

Angulation. — A further group of cases of acute obstruction are those caused
by angulation of loops of bowel. They are, as stated, frequently caused by
bands and adhesions. Very striking examples of angulation are the cases
of obstruction of the duodenum, or of a pylorus fixed by adhesions, from the
sagging of a dilated stomach. I operated on a case a few years ago of a peculiar
character. A middle-aged woman of a highly neurotic temperament suffered
from attacks of abdominal pain, with obstinate constipation, accompanied some-
times by vomiting. During the attacks her abdomen became somewhat dis-
tended and tender in the lower half. Upon opening her abdomen an unusually
long sigmoid loop was found ; the apex of the loop was firmly adherent to the