Intestinal obstruction, its varieties with their pathology, diagnosis, and treatment

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Contents

CHAPTER PAGE

I.— The Classification of Intestinal Obstkuction 1

n.— Some Especial Features in the Etiology of

Chapter I. The Classification Of Intestinal Obstruction

There are several cliiFerent plans upon wliicli a classification of the various forms of intestinal obstruction niaj be based.

Bj one method they may be divided into the two great classes of the congenital and the acquired, according to whether the conditions that produced the obstruction existed at birth, or had been subsequently produced. Among the former may be placed such examples as depend upon congenital stenosis, upon certain congenital deformities, upon Meckel's diverticulum, upon peritoneal bands the result of intra-uterine peritonitis, and the like. Among the latter would be grouped cases of stricture following ulceration, intussusception, volvulus, strangulation by bands produced by peritonitis, cases of obstruction by foreign bodies, and indeed all the principal examples of intestinal occlusion.

By another method the classification is founded upon a discrimination of the different mechanical conditions that produce the narrowing or closure of the lumen of the bowel. Thus in one set of cases the lumen of the canal is obliterated by j^'^^ssiore froin without. This division would include all cases of strangulation by bands and through apertures, and all examples of obstruction by the pressure of a tumour B— 12

2 Intestinal Obstruction. [Chap. i.

outside the bowel. In another set of cases the intestine is occluded in consequence of an alteration in its normal outline and in the relation that its walls bear the one to the other. Under this headins: would be classed examples of volvulus, of occlusion by kinking and bending, and the important series of cases known as intussusceptions. In a third variety of case the lumen of tlie howel is blocked by some substance such as a foreign body that has been swallowed, a gall stone, an enterolith, a mass of ftecal matter, or a neoplasm growing from the intestinal wall. In a still further series of cases the obstruction depends upon changes arising in the wall of the gut itself and under this heading we meet with stenoses and strictures of all kinds, including both those that are simple and those that are cancerous.

By a third method of classification all cases are divided according to their clinical character and are grouped into acute and subacute cases, into chronic cases and into chronic cases that end acutely. This division of the subject has been adopted in that part of the present volume which deals Avith the general subject of diagnosis.

Lastly there is a method of classification based upon 2J(ithological anatomy. This is the method that has been followed in the body of the present work.

This plan consists in grouping together instances of intestinal obstruction tliat are pathologically alike. It consists of such an arrangement and grouping as would probably be adopted if all the specimens of intestinal obstruction in anv larcje museum were taken, and an attempt then made to arrange them in some definite and coherent order. The classification that is founded upon this basis is the following :

Strangulation by bands, etc., or through apertures.

Volvulus.

Intussusception.

Chap. II.] Etiology. Stricture

Obstruction by neoplasms.

Compression by tumours, etc., external to the bowel.

Obstruction by gall stones and foreign bodies.

Obstruction by enteroliths.

Obstruction by fsecal masses.

CHAPTEE IT.

SOME ESPECIAL FEATUKES IN THE ETIOLOGY OF INTESTINAL OBSTRUCTION.

Into the very wide and complicated subject of the general etiology of intestinal obstruction I do not propose to enter in this place, since the more important features in the causation of the various forms of stoppage of the bowels are detailed in the account given of those diflerent forms when considered individually.

There are, however, certain phases of the matter that are well worthy of a separate consideration upon special grounds, and among these may be taken the influence of the following affections in producing intestinal obstruction, viz.:

Peritonitis.

Sti-angulated hernia.

IMescnteric gland disease.

The important subject of the influence of ulceration of the intestine in producing occlusion is fully considered in the chapter on stricture.

Peritonitis. — It is well known that in this affection, and especially in what is known as the adhesive form, a fibrinous exudation appears upon the surface of the inflamed membrane. Any two surfaces so affected may, through the medium of the

4 Intestinal Obstruction. [Chap. ii.

exudation, become adherent if they be brought into contact with one another.

The adhesion may be over a very extensive surface, or may involve only a few isolated points. As the inflammation subsides there is no doubt that a good deal of this exudation is in time absorbed. Such as remains becomes organised into fibrous tissue, and so are produced " adhesions," " bands," " peritoneal false ligaments," and the like.

Some of these adhesions may be extremely loose and delicate, while others are composed of a more callous material. It would appear that many of the more flimsy of these uniting structures in time disappear, even after they have become organised into definite connective tissue. It is much to be regretted that so little is known of the circumstances that favour the absorption of adhesions after peritonitis, and so an important element in the prognosis of that affection is lackino;. One circumstance that has distinct influence in this direction is certainly the movement of the adhering pai-ts. As an illustration of this might be taken adhesions that involve the small intestine, and that are connected with that bowel either by both of their points of attachment or by one.

During the progress of peritonitis the intestines are relatively still. They are, moreover, more or less distended from some paralysis of their walls. As a result of this distension coils of bowel may be brought together that were hitherto far apart, or a certain loop may be placed in association with a comparatively distant point on the parietes. When the inflammation has subsided the parts return, as far as possiljle, to the status quo ante, peristaltic movements spread through the intestine, coils that were close together tend, as a result of those movements, to become separated, and adhesions that attach the

Chap. II.] Etiology. 5

intestine to points upon the parietes are persistently dragged upon. It follows from tliis almost constant tension that the still soft adhesion yields, becomes elongated and thinned, ultimately gives way and is absorbed.

Movement also has great influence upon the future physical characters of the adhesion. Most of the adhesions assume primarily a membranous character, and this they may retain throughout their existence. It is not uncommon to find some coils of intestine matted together by an extensive series of false membranes, which appear sometimes as wide expansions, at other times as thin but broad ribbon-like bandsj of all dimensions and of various lengths (Figs. 1 and 24). If two distant coils of small intestine have been brought together during peritonitis, and have become attached to one another by means of the exudation, or if a like attachment has taken place between the intestine and the parietes, then, as movement is restored in the bowel, the adhesions, which may be quite membranous, are dragged upon, and as a result become elongated. As they increase in length so must they become attenuated in width and thickness. The constant tension, moreover, probably interferes with their already feeble nutrition, and induces a further wasting.

The wide membranous adhesion may thus become narrowed and ribbon-like.

It may, however, undergo a still further change. This adhesion, subjected to the rolling movements of the intestines over one another, and subjected to frequent tortion, now in one direction and now in the other, tends to become rounded and cord-like, and the more that it is stretched the more completely is this transformation favoured. Thus are formed " peritoneal false ligaments " and the bands that are so common a cause of strangulation of the bowel.

6 Intestinal Obstruction. [Chap. ii.

The moulding of the mass of adhesion-tissue into a cord by the movements active within the abdomen is illustrated by the changes that are effected by those movements in the omentum when it becomes adherent. This structure may become attached by its free extremity, and in the course of time, if the abdomen be opened, it will be found to be changed into a cord-like mass. The intestines in their movements have rolled over and under and about the adherent membrane, and at last they have moulded it almost as a piece of clay may be moulded when rubbed betweeli the palms. This change is best brought about when the situation of the adhesion is such as to keep the membrane on the stretch.

A like metamorphosis may be effected in any smaller part of the great omentum that may have become adherent to a distant point.

By a combination of these various circumstances, by a stretching of the adhesion on the one hand, by its consequent attenuation on the other, and its subjection to the moulding influences of moving intestines for the third part, it happens that cords and bands of great length are often produced as a result of peritonitis. Many instances may be given, but one of the most striking is afforded by a case reported by Mr. Obre."^ In this example a cord-like band was found to pass from a coil of small intestine situated near the xiphoid cartilage to the parietal peritoneum about the inguinal canal. The false ligament measured seventeen and a half inches. The patient had had a strangulated inguinal hernia, and there was clear evidence to show that the herniated bowel had been that to which the cord was attached. Subsequent changes in the abdomen, which were associated with much violent peristaltic movement and much distension, had carried the involved coil so far * Path. Soc. Trans., vol. iii., page 95.

Chap. II.] Etiology. 7

away from its original point of adhesion as to produce the band described.

It must be remembered that not only may these Ijands form arcades beneath which coils of intestine may become strangulated, but the longer of them may become separated at one of their points of attachment, and so form floating cords that may lead to strangulation of a loop by " knotting."

Adhesions of all kinds, but especially those attached to parts not susceptible of much movement, may undergo considerable contraction. In cases of extensive peritonitis this contraction may produce great deformity. The mesentery may become so shrunken as to produce obstruction in the intestine to which it is attached. The most severe form of this condition is that known as peritonitis deformans.

Adhesions upon the surface of a fixed part of the intestine may, as a result of their contraction, produce great narrowing of the bowel by compressing it. This condition is not infrequently met with in the colon, and especially in the hepatic and splenic flexures (Fig. 22). In parts of the tube where the gut cannot be compressed against an unyielding surface the contraction of peritoneal adhesions may still produce some obstruction by causing an extensive puckering of the intestinal walls.

Some of the adhesions formed after inflammation oJt the serous membrane are exceedingly complicated, while others are found to unite parts that are usually far separated from one another. Thus I find instances of adhesion between the ascending colon and the ovary, between the transverse colon and the csecum in one case, and the mesentery over the lower lumbar region ii^ another, between the arch of the colon and a part of the parietes not far above the symphysis. Then again the sigmoid flexure has been found connected by adhesions to the bladder, the

8 Intestinal Obstruction. [Chap. ii.

uterus, the rectum, the peritoneum in the right iliac fossa, and the csecum. In all these cases I tliink that the unusual connection of parts may be explained by displacement from distension, the distension occurring duiing the development of the peritonitis. Thus the transverse colon when distended is apt to become bent uj^on itself, and by such bending to reach the lower parts of the abdomen. In the same way the distended sigmoid flexure may turn down into the pelvis, or extend across to the right iliac region, or even mount up in the abdomen and reach the liver.

In addition to the causes of obstruction already alluded to, peritonitis may be the means of bringing about an occlusion in the intestine by other and very difterent methods.

The adhesions may form a part of the bowel into a rigid loop, they may bend it so acutely as to greatly narrow or even entirely obstruct its lumen, they may lead to obstruction by kinking, or they may bring about an arrangement of certain coils of small intestine or of the loop of the sigmoid flexure that especially favours the production of a volvulus.

In another series of cases as a result of local peritonitis, the omentum or the tip of the appendix vermiformis has become adherent at one point, and beneath the arcade so formed coils of intestine have been strangulated. Similar arcades have been formed by the adhesion of the point of a free Meckel's diverticulum, and of the outer extremity of the Fallopian tube.

In still another variety of case a loop of bowel has been strangulated through a slit in a membranous adhesion, or through an aperture formed by adhesions between adjacent viscera, or through the gap left between two parallel adhesions.

With regard to the forms of peritonitis that may lead to adhesions capable of producing obstruction,

Chap. II.] Etiology. 9

it can be briefly said that any variety of peritoneal inflammation from wliicli a patient recovers may become indirectly a cause of intestinal occlusion. In the great majority of cases, therefore, it will be found to have been a very localised peritonitis. The principal examples are furnished by the circumscribed pelvic peritonitis that is comparatively so common in women, by that attending typhlitis or perityphlitis, by that depending upon injury, or upon an ulceration of the stomach or intestine that has not quite advanced to perforation. Another common form has followed upon strangulated hernia. Another has been induced by gall stones, and has led probably to adhesion between the gall bladder and the colon. Another has been set up by faecal accumulations, or by the impaction of some foreign substance in the bowel.

It must be remembered also that peritonitis may occur during intra-uterine life. Dohrn, indeed, rei^oits a case of obstruction in a child eight days old that ended fatally, and was found to be due to adhesions formed evidently before birth. ''^

There is also a form of peritonitis that may occur shortly after birth, and that appears to be due to extension of inflammation from the divided umbilical cord.

The variety of peritonitis known as " infantile," and which is distinct from the localised form just mentioned, is with very rare exceptions always fatal, and in the newly born would appear to be without exception fatal.

Acute diflfused peritonitis is so very seldom recovered from that it can have little concern in the etiology of obstruction. In puerperal peritonitis, according to Bauer, "an absolutely fatal prognosis

* Quoted by Bauer ; Ziemsson's Cyclopaedia of Medicine, vol. viii., page 288.

lo Intestinal Obstruction. [Chap. ii.

must be made," and the same gloomy prognosis applies to the j^eritonitis depending upon carcinoma.

With regard to tubercular peritonitis, it leads in time to a certain death ; but its coui-se is usually chronic, and during its progress it is apt to produce very numerous and extensive adhesions, which are frequently the cause of intestinal obstruction. Indeed, certain writers have included chronic tubercular peritonitis among the varieties of chronic occlusion of the bowels.

StraiigTilatcd hernia.— There is, I think, a fairly common impression that when a strangulated hernia has been reduced and the patient has recovered from the operation, no further evils will result beyond a possible return of the hernia, and with it a risk of a second strangulation. A piece of bowel, however, that has been strangulated in an external hernia and has then been reduced into the abdomen may be the cause of one of many different forms of intestinal obstruction. I do not allude to results immediately following the reduction of the hernia, but to results that are comparatively remote. Among the former, as is well known, it is not infrequent for the once strangulated loop to remain so entirely paralysed after reduction as to continue the symptoms of obstruction until death ensues, and that, too, without either becoming gangi-enous or causing peritonitis.*

The conditions Avith which I propose to deal briefly are remote, and are subsequent to the more or less complete recovery of the patient from the operation.

1. The peritonitis about the reduced loop of bowel may lead to adhesions, and these may cause obstruction

* See cases by Mr. Pitts, St. Thomas's Hosp. Repoi-ts, 1882, page 75 ; and Hemot (Pseudo-etranglements, page 4G). For a general consideration of the immediate effects that may follow reduction, sec " Les Accidents consecutifs a la Reduction de I'Euteroc^le <^trangl^e," by Jules Ferret. Th6se. Paris, 1879.

Chap. II. J Etiology. ii

by kinking or bending of the gut. On the otlier liiind, the oincntnin or a free coil of intestine may become adherent to the inflamed serous surface, and thus a condition be produced that may lead to obstruction."*^

2. The reduced loop may adhere to the abdominal parietes and become obstructed by bending and by the changes known as " traction effects." Examples of this form of obstruction are given in chapter vi.

3. The ad hesions about the reduced and adherent loop may be extensive, and may so contract as to narrow the lumen of the gut by compression.

4. The herniated coil may be retained in the form of a permanent loop by means of adliesions, and this loop, whether an " open " or a " closed " one, may lead to obstruction of the intestine, as is fully explained in a subsequent part of this work.

In one instance at least a fistula bimucosa was formed between the extremities of the loop.

5. Stricture may follow as a result of damage to the walls of the bowel, ulceration of the mucous membrane, and the like. Several illustrations of this condition will be found in the chapter upon cicatricial strictuVe.

C. The great lengthening of the mesentery that is usually found in large hernia? favours especially the formation of volvulus of the small intestine. The connection between these two conditions is well shown in a case reported by Dr. J. K. Fowler, where tliere is little doubt but that a fatal volvulus of the ileum depended upon an unduly long mesentery resulting from hernia, t

* Bull, (le la Soc. Anat., 1804, page 252 ; M. Besnier. See also Patli. Soc, Trans., vol. vii., ])age 11)8 ; Mr. Obro.

i' For a further account of this matter sec a paper by the author on "The Forms of Intestinal Obstruction that may follow after Hernia " [Lancet^ Juno 7, 1884).

T2 Intestinal Obstruction. [Chap. ii.

Mesenteric g:l»iid disease.— Mesenteric gland disease may indirectly lead to obstruction in several different ways.

1. The little local peritonitis excited in tlie serous membrane covering the glands may lead to the adhesion of a free diverticulum, or of the free end of the omentum, or may encourage the development of bands which may in turn prove a cause of intestinal stranojulation. *

2. The local peritonitis may lead to adhesions being formed between two remote parts of the intestinal tube. Thus, in a case recorded by Dr. Hilton Fagge the sigmoid flexure was found attached to the ileum, and in the angle between these two adherent portions of gut was a caseous gland. +

3. The ileum about the seat of a diseased gland in the mesentery may become sharply bent upon itself ; and between the two limbs of the loop so formed, and fusing them together, as it were, will usually be found an old and degenerate gland.

Or the bending may be very limited and well localised, so that a fold of the bowel is turned in and forms a sjoecies of diaphragm. This condition is shown in the remarkable, and, I think, unique, case depicted in Fig. 49.

4. In several instances the shrinking of the mesentery after extensive gland disease has been so considerable, and has produced so much distortion, as to lead to a fatal obstruction of that part of the bowel connected with the diseased area.;};

5. Dr. Leared has reported a case of fatal stran-

* Bee specimens, Guy's Hosp. Museum, No. 1,819 (36) ; and St. Bart.'s Hosp. Museum, No. 2,105 ; also cases by M. Briclieteau (Bull, de la Soc. Anat., 1861, page 118), and by Mr. B. Hill {Lancet, vol. i., 1876, page 773).

f Path. Soc. Trans., vol. xxvii., page 1.57.

j See Path. Soc. Trans., vol. xxi., page 187 ; and cases by Dr. Fagge, Guy's Hosj). lleports, vol. xiv., page 272.

Chap. III.] Strangulation BY Bands. 13

gulation of tlie small intestine through a hole in the mesentery. It was considered that this aperture was probably caused by the breaking down of a mesenteric gland. The patient was a lad aged 14."^

Chapter III. Stkangulation By Bands Ok Through Apertures

HERNIA-LIKE STRANGULATION OF THE BOWEL.

Under this variety of intestinal obstruction may be included :

1. Strangulation by isolated peritoneal adhesions,

2. Strangulation by cords formed from tbe omentum.

3. Strangulation by Meckel's diverticulum.

4. Strangulation by normal structures abnormally attached

(such, as by an adherent vermiform appendix or Fallopian tube, or by a fixed mesentery) , including strangulation by the pedicle of an ovarian tumour and the hke.

5. Strangulation through slits and apertures in the mesen-

tery or omentum, or in certain peritoneal Hgaments, or through membranous adhesions.

These various forms may be conveniently considered together, for although in each case the anatomical cause of the obstruction is different, yet the effects upon the gut are in all instances practically identical. In each the segment of bowel involved is, almost without exception, the small intestine. In each the mechanism of the obstruction is practically the same. In each the symptoms that arise are, with some minute exceptions, so nearly identical that they may be studied as a whole. In each the course and issue of the malady are such that

* Path. See. Trans., vol. xiv., page 156.

1 4 InTES TINA L ObS TR UC TION. [Chap. 1 1 1 .

these various forms may be said to share a common prognosis. Between them all, moreover, there is a close bond of union in the fact that they are adapted for the same form of treatment, and may be relieved by the same operative procedures.

Considered as a whole this form may be taken as the type of acute intestinal obstruction, and as such it assumes a position of considerable importance. It is the strangulated hernia of the interior of the abdomen. It obstructs the gut as a hernia obstructs. It involves the small intestine with about the same frequency as does an external rupture. It is indeed as rare to find a portion of the large intestine strangulated by any of the methods above named, as it is to discover colon in a femoral or inguinal hernia. The symptoms that attend this variety of intestinal obstruction are, in all main points, the symptoms of strangulated hernia, and the prognosis of the two affections depends rather upon the situation of the constricting agent than upon any other factor. It is for many reasons a matter of moment to note that strangulated hernia and the different forms of internal obstruction above described are but varieties of a single malady, that they differ from one another solely on anatomical grounds, that in their pathology and in the broader lines of their clinical history they are the same, and that, excluding the taxis, they are amenable to the same general form of surgical treatment.

It will be convenient to consider the pathological anatomy of these five varieties of obstruction separately, and then their symptoms and the elements of their prognosis collectively.

PATHOLOGICAL ANATOMY.

1. Strangulation by isolated peritoneal adhesions.— Those isolated adhesions (known com-

Chap. III.] Strangulation BY Bands. 15

monly as "bands," "solitary bands," or "peritoneal false ligaments ") are the results or residues of some form of peritonitis. Owing to tlie high mortality of acute diffused peritonitis on the one hand, and the very general and extensive adhesions produced by chronic diffused peritonitis on the other, it follows that these isolated bands are usually due to moderate, chronic, and well localised forms of peritoneal inflammation. It would appear, as has been already pointed out, that in some cases they may be congenital, and due then to intra-uterine peritonitis. The mode of formation of these bands, and the methods whereby they become elongated and cord-like have already been described (chapter ii.).

Their appearance in cases where they have caused obstruction varies greatly.

Most commonly the " band '' takes the form of a firm fibrous cord about the size of a No. 4 or No. 6 catheter. It may be still more slender, and appear as a tough, rigid thread. On the other hand, it may be of comparatively large size ; thus M. Terrier has reported a case of internal strangulation, for which he performed laparotomy, where the constricting band had nearly the dimensions of the little finger.* The cord-like " band " is usually described as being dense and fibrous, and in one or two instances as being of almost cartilaginous hardness. Less frequently the constricting agent has the appearance of an actual l)and, and in such cases is found as a tough ribbon-like membrane, with a width of half an inch or even more. A band of this character is well shown in Fig. 1. 1

The " false ligament " is usually single, and hence the name bestowed upon it by Mr. Gay of "the

* Bull, ct Mem de la Soc. dc Chir. de Taris, vol. iv., 1879, page 5G4.

t London Hosp. Museum, No. Ad. 78.

solitary band." It must not be assumed, however, tliat such a band commonly exists as the solitary adhesion in any given case. It most probably will be the only isolated adhesion, and the only one so modified as to be capable of strangulating the bowel. But in cases where this isolated adhesion is met with other adhesions will very usually be found. This is

Fig. 1.— Strangulation by a broad Pei-itoueal Baud passing between two adjacent Coils of Ileum.

especially the case when the band is due, as it often is, to pelvic peritonitis. The same ajiplies, although in a less degree, to the local peritonitis set up by inflammation in or about the caecum. Here, in addition to any adhesion that may have become isolated, elongated, and cord-like, there will very probably be some matting together of parts in the immediate vicinity of the caput coli. ^lany cases, however, are reported wliere the only relics of a typhlitis have assumed the form of one solitary band, A single false ligament, the representative of a single adhesion,

Chap. III.] Strangulation BY Bands. 17

may be produced by the very localised peritonitis that is sometimes associated with caseous degeneration of a mesenteric gland. I have met with several reported cases, and not a few specimens, that illustrate this circumstance. A single adhesion may readily follow upon the little speck of peritonitis that often attends an intestinal ulcer (Fig, 20). As the ulcer deepens it excites an inflammation over a very limited area of the serous surface. This inflamed spot adheres to some other point on the peritoneum ; a single adhesion forms, which, becoming elongated by the method already described, forms an example of the solitary band. A great many of the cases of " solitary band " described are evidently instances of strangulation by Meckel's diverticulum, or by a diverticular ligament.

In some few cases there have been two or more false ligaments found in the abdominal cavity. , Sometimes these would a})pear to have been produced by the thrusting of a coil of intestine through a broad peritoneal adhesion so as to divide it into two segments. In other instances the bands are inde])endent of one another. Mr. Berkeley Hill reports a case of acute intestinal obstruction where two bands existed, both of which constricted knuckles of small intestine. One constriction was, however, comparatively slight, the other was severe. Laparotomy was performed, and unfortunately the band found and divided was that associated with the minor obstruction. The more serious strangulation was overlooked and the child died. The adhesions in this case appear to have been due to mesenteric gland disease.*

The false ligament, although single, may have a complicated arrangement, and lead to extraordinary forms of constriction of the bowel. Thus in the i8

Intestina l Obs tr uc tion.

[Chap. III.

specimen shown in Fig. 2 "^ there was one isolated adhesion. It was, however, broad and Y-shaped ; one end of the Y was attached to the uterus, while the two other ends were connected with points on the small

Fig. 2.— strangulation of the Ileum by a Y-sliaped Band attached to the

Fundus of the Uterus.

The Uterus is shown at the lower part of the figure.

intestine about one and a half inches apart. Tliere were many adhesions about the pelvic viscera. In Fig. 3 t it will be seen that an adhesion connecting the

* St. Bart.'s Hosp. l\Iuseum, No. 2,164. t Guy's Hosp. Museum, No, 2,507 (50).

Chap. III.] Strangulation by Bands,

Fig. 3.— Strangulation of tbe Ileum by complicated Bands passing between the Uterus and Ovary.

uterus, ovary, and mesentery leads to a complicated form of strangulation and to a double constriction of the bowel.