tine, the bladder or vagina. Rupture may also take place outward through
the abdominal wall. Metastatic abscesses in the liver may be set up through
portal embolism or pylephlebitis.
Symptoms. Mild catarrhal inflammations of the appendix are likely to
cause but slight, often hardly noticeable, symptoms; of these pain in the right
iliac fossa and slight tenderness are the only ones worthy of mention; indeed
the process may proceed to the ulcerative stage without exciting any appre-
26
402 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
hension on the part of the patient. When the inflammation has involved
the peritoneeum locally the symptoms usually become marked. There is
pain, at first general, but after a few hours localized over the seat of the lesion
in the right iliac fossa when the appendix is normally situated, but the tendency
of this organ to be in anomalous situations may result in localized pain in any
part of the abdominal cavity — under the liver, in the left iliac fossa, etc . Change
of position increases the pain, as does deep inspiration or coughing.
The tongue is likely to be dry and coated. Vomiting is often present but
the yomitus is not characteristic in any way. The bowels are usually con-
stipated this being due to paralysis of the intestinal musculature. At times
this symptom is so marked as to suggest obstruction and it may be accom-
panied by fsecal vomiting. More rarely the bowels are loose.
The temperature is usually elevated, ioi°-io3° F. (38.5°-39.4° C), at first,
gradually falling as the process goes on to resolution, or assuming the charac-
teristic irregularity if pus is present, although rarely such cases may occur
without pyrexia. The pulse is full and rapid — loo to 120. Abdominal dis-
tention may be present and is most marked in perforative cases. A leuco-
cytosis of 20,000 to 30,000 is not unusual.
Physical Examination. The patient usually lies on his back with the
right thigh flexed on the pelvis, this position offering some relief to the pain.
Upon palpation a point of more or less localized tenderness will be found.
The classical situation for the point of maximum tenderness is at the middle
point of a line drawn from the right anterior superior iliac spine to the umbil-
icus, although in anomalously situated appendices it will be found over the
site of the inflammation. An important diagnostic sign is rigidity of the
abdominal muscles of the right side, these structures going on guard imme-
diately when any attempt at palpation is made.
After the tissues have been matted together by plastic adhesions or when
abscess formation has taken place a tumor of varying size and consistency
may be palpable. Observers with a highly specialized sense of touch may
at times be able to feel the enlarged and inflamed appendix.
Over the tumor, when such exists, the percussion note is dull and in the
presence of a considerable quantity of pus may be flat. Excessive distention
of the intestine by gas gives a note more tympanitic than normal.
The prognosis for recovery in attacks of the simple catarrhal type is good
but recurrences are frequent. In the cases with perforation and abscess
formation the outlook is much less favorable, especially where surgical inter-
vention is postponed.
Treatment. Probably there is no point in medicine or surgery upon which
authorities are so prone to disagreement as upon the proper management
of this disease. While early surgical intervention in every case has its advocates
and these of such character as to demand consideration, it is the part of con-
APPENDICITIS. 403
servatism to treat an attack of catarrhal appendicitis by medical means and to
consider the advisability after recovery, of the so-called interval operation.
Every patient suffering from catarrhal appendicitis should be kept at absolute
rest in bed. For the relief of the pain the question of the advisability of the
administration of opium is a debatable one. While this drug puts the intestine
at rest, thus favoring resolution, as no other drug will, it is insisted by some
that its exhibition masks the symptoms indicating the necessity for operative
interference. The point against this assertion is that the careful observer
will receive sufficient information as to the time for operation from the pulse,
temperature, general condition of the patient and the state of the appendiceal
tumor. Opium itself, given by mouth or in suppositories, is to be preferred
to morphine — the latter, however, may be given hypodermatically when the
opium itself for any reason cannot be administered by the other channels men-
tioned. The tincture of opium may be administered in doses of 10 or 12
minims (0.66-0.8) every hour until 2 or 3 doses have been taken, then 5 minims
(0,33) may be given every 3 hours until the pain is relieved. If the pain
recurs another such a course of medication may be instituted. The resulting
constipation need cause no alarm but should not be allowed to persist longer
than a week.
Local applications to the painful area, of the ice coil, ice bag or ice compress
are indicated and will be found to greatly relieve the pain and perhaps retard
the progress of the inflammation. Warm compresses may be used after the
temperature has fallen to normal and the inflammatory process is quiescent.
The use of blisters and leeches is unadvisable since if operation becomes
necessary the resistance to infection of the skin at their points of application
is impaired.
Whether or not to administer laxatives is a debatable question. Active
purgatives should never be given. There is no doubt that oftentimes attacks of
iliac pain, emesis and constipation with what seems to be a tumor in the appen-
diceal region quickly recover after a free movement of the bowels, but there
is reasonable doubt as to whether such are cases of true appendicitis. Early
in appendicitis the object is to keep the intestine as nearly in a state of
complete rest as possible, consequently here as well as when perforation is
imminent or after suppuration has set in purgation is contraindicated. Con-
stipation may be allowed to last 5 or 7 days and when the chances of perforation
are past the bowels may be moved by carefully given rectal irrigation and
kept regularly open thereafter.
The elaboration of an antitoxin from the colon bacillus — since this organ-
ism is so often concerned in the causation of this disease — has been suggested
with the idea in view that patients may be immunized against relapses and
against the danger of secondary infection by pus during operation.
The diet during the acuity of the attack should be entirely liquid, milk,
404 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
soups, the artificial infant foods, etc., and in quantity should be smaU; certain
clinicians even advocate feeding per rectum in preference to that by mouth.
SmaU amounts of water may be taken. When the acuity of the symptoms
has subsided semi-solids may be allowed and later, sweetbreads, scraped
beef, cereals, etc., may be added.
The indication for surgical intervention is, in the minds of many competent
authorities, the establishment of the diagnosis of the disease, but it is certain
that many cases recover under careful medical treatment. Concerning such,
the t[uestion of an interval operation is one to be decided among the patient,
his physician and his siu-geon. The most conservative clinicians concur that
operation is indicated in all cases in which the symptoms do not ameliorate
within from 24 to 48 hours, in cases in which an abscess has formed and in
early cases of general perforative peritonitis. Advanced cases of diffuse peri-
tonitis which are in a state of practical collapse with rapid and feeble pulse,
clammy and cold skin are hardly fit subjects for operation. Here stimulation,
heat to the extremities, high rectal irrigations of normal saline solution and
the other means usually employed in such conditions are indicated. Very
rarely does recovery take place.
INTESTINAL OBSTRUCTION.
Definition. A condition in which the normal passage of faecal matter
through the bowel is impeded. This may result from mechanical obstruction
or paralysis of the intestinal musculature and may be due to a number of
different causes.
Intestinal obstruction occurs in two forms:
a. The acute, which may be caused by congenital anomalies, internal
strangulation, volvulus, intussusception, foreign bodies or abnormal intestinal
contents and intestinal paralysis.
h. The chronic, which is the result of narrowing of the calibre of the bowel
from new growths within this structiure, cicatricial contraction, from the
outside pressure of tumors of neighboring organs or structures or of the
accumulation of impacted faeces.
I. Congenital Anomalies.
These are the result of insufi&cient or improper foetal development and
may be situated at any part of the digestive tract. The most frequent sites
are at the pylorus (see p. 360), in the duodenum, in the ileum and at the
anus. Oftentimes there may be stenoses at two or more of these situations.
Symptoms. In cases of imperforate anus there is no passage of meconium
and the examining finger will at once perceive the defect. When the obstruc-
EXTERNAL STEANGULATION. 405
tion is at other parts of the digestive tract the symptoms usually do not appear
until food has been taken. Here the symptoms are vomiting, at times ster-
coraceous in character, abdominal pain and ineffectual efforts to pass faeces.
At times visible peristaltic action may be detected upon inspection of the
abdomen. The prognosis is not good.
Treatment is whoUy surgical. An imperforate anus may easily be relieved
by means of the knife. A stricture at a higher level offers difficulties since
the diagnosis of its situation is weU-nigh impossible. Death, however, being
certain without operation, this latter should be undertaken, and the stenosis
being found, either a resection should be done or an artificial anus formed.
Either operation is unsatisfactory for death from inanition is practically
sure to supervene.
2. External Strangulation.
This is the most frequent variety of intestinal obstruction and is caused by
compression of the bowel by inflammatory adhesions or bands, foetal remains,
such as the omphalo-mesenteric duct, the slipping of a knuckle of the intes-
tine into one of the peritonseal fossse, through the foramen of Winslow,
through the diaphragm, etc. The small intestine is involved in the great ma-
jority of cases and the affection is most common in males in early adult life.
S5miptoms. Of these the most prominent is sudden, very severe pain which
is, as a rule, constant, but may be accentuated at intervals. Persistent vomit-
ing occurs and after 2 or 3 days becomes stercoraceous. The bowels are
constipated, but absolute constipation does not come on until the bowel
below the obstruction has emptied itself. The intestine above the obstruction
is distended with flatus and may be demonstrated upon physioal examination.
The temperature is at first unaffected, later it may rise to ioi°-io2° F.
(38.5°-38.9° C); the pulse is rapid and weak. In the various forms of acute
obstruction a useful diagnostic symptom is the gradual increase in abdominal
girth which is due to the augmenting meteorism. This symptom may be
demonstrated by taking measurements at intervals.
Treatment. This consists in operation as soon as the diagnosis is made.
In cases in which consent to operate is withheld, means for relieving the patient's
symptoms should be instituted as described under the treatment of intestinal
obstruction in general (p. 409).
3. Volvulus.
This form of intestinal obstruction is due to a twisting of a loop of the
intestine about the mesentery as an axis. It occurs most often in men of
middle age and is rather infrequent. The small intestine is usually involved
406 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
although cases of volvulus of the stomach and of the colon have been recorded.
The torsion of the gut causing interference with its blood supply, peritonitis
and at times necrosis vidth rupture may result. This type of obstruction is
not an infrequent sequela of abdominal operations.
Symptoms. The pain of this form of obstruction is less severe than in any
other variety. The constipation, however, is absolute and abdominal dis-
tention is a marked feature. The vomiting and other symptoms are similar
to those of obstruction due to strangiilation.
Treatment other than by operation will be dealt with under the general
management of intestinal obstruction (p. 409).
4. Intussusception.
Intestinal intussusception consists in the telescoping of one section of the
bowel into another. The invagination consists of the intussuscipiens, the
outer layer, and the intussusceptum, the two inner layers. The condition
may be simulated for purposes of illustration by slipping one part of a glove
finger into another. The condition is named in accordance with the part or
parts of the intestine involved, e.g., enteric when the small intestine alone
is affected, ileo-coecal when the ileum and coecum are invaginated into the
colon, etc. Usually the upper part of the gut makes up the intussusceptum
but in rare instances reverse intussusception occurs, in which case the oppo-
site condition obtains.
.etiology. Intussusception is seen most frequently in children under a
year old but is not unknown in adult life. As a cause of obstruction it is nearly
as common as strangulation. It is predisposed to by diarrhoea and consti-
pation, and while its actual cause is not well understood, it probably results
when one portion of the bowel, due to some nervous distiu-bance, suddenly
contracts while a neighboring segment remains relaxed. Intussusception
just ante mortem frequently takes place and the condition is found on autopsy
without having caused symptoms during life.
Pathology. Inflammatory processes arising in the serous siu-faces of the
bowel brought into contact by the invagination may set up adhesions and
permanent attachment between intussusceptum and intussuscipiens. Also
the invaginated portion may necrose and, the adhesion being of such character
as to prevent exit of the intestinal contents into the abdominal cavity, being
passed, spontaneous recovery may take place. In other cases the adhesions
being insufl&cient the sloughing may result in rupture with general peritonitis.
Symptoms. The first of these are sudden pain and vomiting. The pain
is usually paroxysmal and very severe in character; as a rule it is not distinctly
locahzed although in some cases it may be referred to the umbilical region.
It is most severe during the first 2 or 3 days of the attack, later it becomes
INTUSSUSCEPTION. 407
less marked. The vomiting is usually persistent and difl&cult of control, it
may be projectile in character but is rarely faecal in infants, though in older
children it may become so. Bloody stools with mucus are a frequent symptom
in children and when the intussusception involves the rectum tenesmus is a
common manifestation.
The constitutional symptoms are those of marked prostration, with muscular
relaxation, pallor, cold extremities and subnormal temperatvire, which late
in the disease may rise as high as 104° F. (40° C.)
Examination shows the presence of a " sausage-shaped " abdominal tumor
in the majority of cases, and when the lower colon is involved it may be
possible to feel or even to see the intussusceptum. To the finger it resembles
the cervix uteri and it may even protrude for an inch or two. Measuring
the circumference of the abdomen from hour to hour is very important
and in the diagnosis of obstruction, if the abdomen is gradually becoming
larger it is a strong point in favor of the probability of this condition.
The affection may terminate by spontaneous reduction or by sloughing
of the invaginated gut, rupture of the intestine being guarded against by
adhesions. Death from shock may take place — in the more acute cases — from
peritonitis, or from exhaustion.
Treatment consists in attempts at reduction by means of inflation of the
intestine or the injection of fluids. When these measures are ineffectual
immediate laparotomy is necessary.
Inflation is practiced by means of a soft rubber catheter to which an ordinary
bellows is attached. The air should be forced in very gently and may be
prevented from escaping by compressing the nates. The hand should be
kept upon the abdomen to determine the degree of tension of the intestine.
If reduction follows, rumbling sounds may be detected and the tumor may
disappear, but often there is no proof of the success of the treatment ; here the
air should be permitted to flow out and a thorough manual examination of
the abdomen undertaken. Even then the continuance or the remission of
the symptoms is the only index of the efl&cacy of the procedure. Anaesthesia
is necessary for the proper carrying out of this mode of treatment unless the
abdomen is greatly relaxed.
The injection of fluids is a legitimate method of treatment and is preferred
by some to inflation. Either normal saline solution or milk and water at a
temperature of from 100° to 105° F. (37.4°-4o.5° C.) may be employed. The
injection is given from a fountain syringe placed about 5 feet above the patient
and through a soft catheter, the exit of the fluid being prevented by com-
pression of the buttocks. Inversion of the patient, if a child, should be
practiced at intervals. The fluid should be allowed to flow for about a quarter
of an hour, then it may be permitted to escape. Whether reduction has been
accomplished may then be determined as after inflation.
4o8 DISEASES OF THE DIGESTIVE SYSTEM AND PERITON>S:UM.
The after treatment consists in absolute rest in bed and the administration
of moderate doses of opium for several days. No laxatives should be admin-
istered during this period and the diet should consist entirely of fluids.
Unfortunately a recurrence of the intussusception not infrequently takes
place.
5. Obstruction by Foreign Bodies or Abnormal Intestinal Contents.
Tfeie most common cause of this form of obstruction is a biliary calculus;
other foreign bodies such as coins, fruit pits, buttons, intestinal parasites,
enteroliths, etc., may be mentioned but are much more infrequently causes
of intestinal occlusion. This variety of obstruction takes place in most cases
in the small intestine, not infrequently at the ileo-coecal valve.
The symptoms so closely resemble those described under the sections
devoted to other types of occlusion as to need no separate discussion.
6. Strictures and New Growths.
Obstructions due to these causes are rare and occur chiefly in adults beyond
middle life. They seem to be more common in females than in males and
are met usually in the large intestine. Cicatricial strictures foUow healed
ulcers especially those due to tuberculosis. Syphilitic stricttire of the rectum
also has been observed.
Annular stricture of the intestine, and particularly of the rectum occiirs in
intestinal cancer of the coUoid type and also in cylindrical-celled epithelioma
(see the section on intestinal cancer, p. 419). Various benign neoplasms of
the bowel may cause occlusion, and tumors external to the intestine and inflam-
matory processes of the neighboring structures, by pressing upon the gut,
may cause obstruction.
7. Obstruction Due to Faecal Impaction.
Faecal obstruction as a result of chronic constipation or paralysis of the
intestinal musculature is not infrequent. Its most common site is low in the
large intestine and it is seen more often in old persons and in women rather
than in men.
Etiology. This condition is predisposed to by chronic constipation and by
chronic intestinal and peritonaeal inflammations. It is particularly frequent
in the insane and in hysterical and neurasthenic individuals. Its usual site
is the large intestine, particularly the coecum and sigmoid flexure. The mass
of faeces gradually accumulating in atonic conditions of the intestine becomes
THE TREATMENT OF INTESTINAL OBSTRUCTION IN GENERAL. 409
dry and firm and sets up irritation of the intestinal lining. The intestinal
musculature above the impaction may undergo hypertrophy and the internal
irritation may spread to the peritonaeal coat of the gut, resulting in a local
peritonitis.
S5miptoms. Of these the most important is an increasing constipation.
The abdomen is distended and tympanitic. The breath is foul, the tongue
coated and the patient feels weak and languid. Physical examination reveals
a faecal tumor situated in the coecal region or other part of the colon. The
mass is more or less firm in consistency but may be indented by pressure.
If it is in the sigmoid flexure it may consist of a number of separate masses;
in the colon proper it is likely to be sausage-shaped and of varying length.
Cases of this type with partial occlusion are subject at any time to com-
plete obstruction with its attendant symptoms.
The Treatment of Intestinal Obstruction in General.
The difl&culty in the treatment of this condition is to determine when oper-
ative interference may be postponed and internal treatment relied upon.
In general it may be stated that when there is reason to suspect strangulation,
operation should be done at once and that internal measures may be employed
only in such cases as give no evidence of abnormal circulatory conditions.
Increased pulse frequency and vascular tension are contraindications to con-
servative methods of treatment. In other words cases of obstruction due to
foreign bodies and fascal impaction, when the constitutional condition is
unaffected, may receive internal treatment, and cases in which the obstruction
is manifestly due to strangulation or volvulus should be put into the hands
of the surgeon at once.
The question as to how long unsuccessful medical treatment may be contin-
ued is also important. The answer to this naturally depends upon the same
factors as does the decision as to whether or not medical means are justifiable,
namely, upon the patient's condition. It may be definitely stated that sur-
gical interference should be delayed not longer than three days at most, and
may become indicated after a much shorter period should the heart and cir-
culatory apparatus give symptoms of weakening.
Having decided that internal treatment may be employed remains the
decision as to of what this may consist. The means suggested for the medical
management of intestinal obstruction have been many and of these the most
approved will be discussed.
Drugs. Opium is opposed by many, and especially by surgical authorities,
on the ground that it induces an apparent improvement and obscures symp-
toms which if unaffected by the drug would indicate operation; consequently
opium should be given only in the earliest stages, when the pain is unendurable
4IO DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
and when a probable diagnosis is impossible. Here a hypodermatic injection
of ^ to |- of a grain (0.016-0.022) of morphine sulphate is admissible. Follow-
ing this a second dose may be given if no relief is experienced.
Atropine recently has been advocated in the treatment of ileus but statistics
are insufficient to justify any positive statement as to its efficacy. The prin-
ciple on which is has been administered is based upon its supposed anti-
spasmodic effect upon the intestinal musciilature. It may be given in moder-
ate doses, YYir to -^-^ of a grain (0.0005-0.001) and hypodermatically three
or four times in 24 hours.
Purgatives are distinctly contraindicated in intestinal obstruction unless
an absolutely certain diagnosis of faecal impaction can be made. In the
latter case laxatives may be given; of these perhaps calomel in repeated doses
of J to ^ a grain (0.016-0,032) is to be preferred. Treatment by high rectal
injections of warm water in considerable quantity, retained as long as possible
and repeated, frequently if necessary, is also indicated. Low rectal impac-
tions may be removed by the finger or a blunt instrument.
Metallic mercury in large amounts is an old form of treatment but one
which is dangerous and consequently should be employed with the utmost
caution if at aU.
Gastric lavage should be employed in aU cases, even in those to be imme-
diately operated upon. In these latter by this means the possibility of vomiting
during anaesthesia is greatly lessened. The lavage relieves the distressing
vomiting and has been known to relieve the obstruction. One should not be