CHAPTER IT. (Part 11)

understood, cause the accident. So, also, might any interference with, or undue violence in, the rhythmic action of natural peristalsis, by which the bowel in successive portions is first shortened and dilated by contraction of the longitudinal fibres, and then narrowed and elongated by the contraction of the circular fibres. Since the wave of peristaltic action is constantly passing from above downwards, it may easily happen that a narrowed portion may under unfavorable cir- cumstances be caught in a dilated portion just below, and, once engaged, the exaggeration of the condition becomes natural and easily understood. It is to such explanations as this that we have to look in the absence of any palpable cause. Symptoms, — An invagination will cause a very different train of symptoms, according to the part of the bowel affected and the intensity of the constriction. As a rule, the symptoms are more acute and severe in invagination of the small intestine, and are more chronic in the large, because the constriction is more intense in the former than in the latter; but an invagination of the small intestine may approach in symptoms and chronicity to one of the large, and vice versa. Wherever the constriction be located, its first symptom is generally a sharp attack of pain in the abdomen, coming on suddenly, and often in the midst of perfect health. There is nothing characteristic in this * Aitken: Pract. of Med., voL ii. 128 DI8BASES OF THE BBOTUM AND ANUS. pain. It may pass off after a few hours and again return; it may or may not be accompanied by vomiting at the start; it is sometimes relievable by direct pre0sure^ and it is not at first accompanied by any tenderness of the abdomen. Change in the character of the evacuations is also a symptom com- mon to the disease in any part. After the onset there will still be a dis- charge of the contents of the bowel below the constriction, and a certain amount of faeces may still leak through the invagination. Instead of the natural passages, however, the appearance of bloody stools is a very com- mon occurrence, the blood coming, as has already been explained, from the congested and swollen mucous membrane of the outer and middle portions. There is also present at times a dysenteric discharge and a good deal of tenesmus. By careful manual examination, a tumor can generally be discovered in the abdomen, which may be characteristic enough to form a basis for the diagnosis; but this may be concealed by the presence of much fat, or by a general distention of the abdomen with g^>s. The tumor is cylindrical, and may be movable under the hand from its own peristaltic action, or it may be seen to change its position from day to day as the invagination gradually advances, and more and more of the bowel be- comes involved. The other symptoms depend in great measure upon the severity of the strangulation, and, as has been said, are more marked when the small intestine is implicated. In such cases, the symptoms rapidly in- crease in severity. There may or may not be considerable febrile action; the abdomen soon becomes tender to the touch; there is almost complete obstruction, or else only the passage of bloody mucus; the patient rapidly sinks, and the history ends either in death or in the slough- ing of the included part. The latter is shown by a re-establishment of the calibre of the bowel, and, therefore of the passages; by an abatement of all the worst symptoms, and finally by the appearance of larger or smaller pieces of gangrenous intestine in the passages. The existence and the early appearance of faecal vomiting have been given as points in favor of the diagnosis of intussusception of the small rather than of the large intestine, but they point rather towards complete obstruction than to the particular seat of the obstruction. In invagination of the large intestine, the general history of the case is that of a more chronic trouble. The pain is less severe and the par- oxysms separated by longer intervals; the faecal evacuations are larger, and the dysenteric symptoms are more pronounced; vomiting is variable, and after a time often stercoraceous. This state may continue for several weeks before death results from gradual exhaustion or from the super- vention of acute strangulation. The history of a case of chronic inva- gination may at any time be cut short by the occurrence of a general PBOLAP8E. 129 acute perionitis, and this is particularly apt to happen at the time of the separation of the slough. Diagnosis. — In any case in which the invaginated portion descends near enough to the anus to be felt by digital examination, the diagnosis is easy to the surgeon of ordinary care and intelligence who has studied the symptoms which infallibly point in the direction of intestinal occlu- sion. But when such an examination has been made with a negatiye re- sult, beyond the fact that occlusion exists the surgeon may be completely at a loss. Under such circumstances the differential diagnosis rests be- tween the following conditions: 1. Invagination; 2. Volvulus; 3. Stric- ture; 4. Concealed internal hernia; 5. Pressure from without the bowel by tumors etc.; 6. Obstruction from foreign bodies, as calculi, indurated faeces, etc. ; 7. Peritonitis from perforation. It may be as well to state at once that in these cases the differential diagnosis will often be impossible, and then go on to throw what light upon the question modern science has made available. It is a good plan to divide all cases of intestinal obstruc- tion into the acute and the chronic. An acute case will generally be either an invagination, a volvulus, or an internal hernia. Duplay* also has called attention to the fact that a peritonitis from perforation may cause all the symptoms of an acute occlusion and has given the chief points in the diagnosis of that affection. In peritonitis the vomiting seldom be- comes fascal but remains bilious to the end; the constipation is less Qiarked and the patient generally passes gas and liquid fasces or small quantities of solid matter; the tympanites is also less marked, and the coils of intes- tine are less pronounced; the pain begins with great severity at one point and extends over the whole abdomen (the same thing may happen in acute obstruction, but in such cases the other symptoms — ^faecal vomiting, abso- lute constipation, absence of the passage of gas per anum — are all equally severe, while in peritonitis they do not correspond in severity with the in- tensity of the pain); the temperature is elevated in peritonitis and normal or even less than normal in obstruction. Having then excluded peritonitis from perforation, the diagnosis in any acute case will rest between invagination, volvulus, and internal her- nia. Invagination is indicated by the signs ot partial occlusion, by the moderate tympanites, by the bloody stools mixed with mucus, the tenes- mus, and the presence of the tumor. The diagnosis between volvulus and internal hernia will generally be impossible except as the history may point to antecedent peritonitis, or to a hernia which has ceased to come down; or as the careful exploration of the abdomen by palpation and of the pel- vis by rectal and vaginal touch may show the existence of an induration or resistance limited to one point. In other words, in any acute case of occlusion the existence of invagi- * Duplay: Du Traitement Chirurgical de rOcclusion Intestinal. Arch. Gr^nl. de Med., Dec., 1879. 9 130 DI8BABES OF THE RECTUM AND ANUS. nation may be decided by the presence or absence of its peculiar symp- toms, and if excluded the diagnosis rests either with volvulus or internal hernia, but with which it may bo impossible to decide. In a case of chronic intestinal occlusion, the diagnosis rests between invagination, occlusion by the pressure of solid or fluid tumors outside the bowel, stricture of the intestine, abnormal adhesions of the bowel, and obstruction by foreign bodies within the bowel, such as biliary calculi, indurated faeces, tumors, etc. l^e easiest of these to diagnosticate is that which comes from the pressure of a tumor without the bowel. Chronic invagination may be made out by the symptoms already given. For the symptoms of stricture, we must refer the reader to the chapter on that subject, and these symptoms are much the same whether the obstruction be due to a narrowing of the calibre of the bowel by a de- posit in its wall, or to the presence of a foreign body, or abnormal ad- hesions of the peritoneum which cause acute flexures and obstructions in its calibre. It will thus be seen that the differential diagnosis is shrouded in difficulty, and that the difficulty is rather greater in a case of chronic than of acute obstruction. A well-marked case of invagination, whether acute or chronic, is, however, the easiest of all the forms of occlusion to distinguish, and the diagnosis can generally be made with sufficient approach to certainty to guide the surgeon in the selection of his plan of treatment. Treatment. — ^It is evident that the treatment of the conditions we have been describing must differ in every particular from that of those previously described. When the invagination has occurred in the rec- tum, that is, when the upper part of the rectum has become telescoped into the lower, and has appeared as a prolapsed mass outside of the anus, the case may still be relievable by the methods of reduction and taxis. The mass must be replaced by a process exactly the reverse of the one by which it came down, the most dependent portion being first carried into the body, and the entanglement unfolded in this way. In a child, with the assistance of anaesthesia, the inverted position, and gentle manipulation with the fingers or possibly a soft bougie, this may some- times be accomplished where the point of constriction is low down near the anus. Prall* reports a case where replacement was successfully accomplished by manipulation with the tube of a stomach-pump, though the mass could only just be felt in the rectum. In cases, whether of adults or children, where the constriction is still higher in the intestine, and manipulation with the hand or bougie is out of the question, various other mechanical means may be tried with a prospect of success. These consist in applying indirect pressure to the invaginated portion, and to the constricting part by means of copi- > Brit. Med. Joum., July 81st, 1880. PROLAPSE. 131 ous injections of water or air^ but it should be understood that they are only applicable to cases affecting the large intestine alone^ and the lower down in the large intestine the constriction may be, the better is the prospect of their success. In cases of this kind, the mechanical treat- ment may be assisted by the previous administration of opium and bella- donna in full doses, the one to quiet peristalsis, the other to relax the nnstriped muscular fibres of the intestine. To these means may be added the reversal of position and anaesthesia, and then the copious injection of large quantities of warm fluid, or of air by means of a bel- lows, may in a few cases be successful. The following case illustrates the method of treatment by injection, and what, under favorable circumstances, may be accomplished by it.* Case XIII. — ^A well-nourished infant, seven months old, was in per- fect health till noon of the day of attack, when she suddenly screamed, and immediately afterward became pale, cold, and collapsed. She was put into a warm bath, after which she lay quietly in the nurse^s arms for an hour and a half, the bowels acting slightly once or twice. At 3 P.M., the child had become warmer, and was sleeping quietly, occasion- ally, however, waking up with a scream, and drawing up her legs with an expression of severe pain. There was occasional vomiting, and at 6 P.M., two passages of bloody mucus. At 11 p.m., a distinct but ill-de- fined oval tumor, about an inch and a half in its longest diameter, could be felt through the parietes, at a spot two inches to the left of the umbilicus. A considerable quantity (perhaps a drachm) of dark blood came away, and it was determine.d to distend the large intestine with thin gruel. The child was put thoroughly under the influence of chloroform, and placed on the table with the nates well raised on a pillow. The gruel was slowly injected by means of a Higginson's syringe, the upper part of the nozzle being pressed firmly against the anus to prevent any from escap- ing. After a pint or more had been injected, the abdomen became tense, and the distended bowel could be felt like a hard rope an inch in diameter, across the upper part of the abdomen, almost as far as the right iliac region, and considerable force would have been required to inject any more of the fluid. When the nozzle of the syringe was re- moved, a portion of the gruel escaped, and soon afterwards a much larger quantity. The child slept well at intervals during the night, took the breast well, and there was neither vomiting nor pain. Next morning the skin was a little hot and the pulse a little quick, and one small healthy motion had been passed. The tumor which had been felt in the abdomen had disappeared. At 1 p.m., all the feverish symptoms had disappeared, and the child had passed a copious motion of green color, and there had been no pain or spasm. At 4 p.m., there was another large motion of the same character. From this time the child appeared » Dr. N. P. Blaker, Brit. Med. Journ., Jan. 11th, 1879. 132 DISEA.SBS OF THE BEOTUM AND AKUS. in perfect health, but the motions retained their unhealthy look for four days longer. The success of this treatment undoubtedly depended in a great mea- sure upon the speed with which it was adopted before reduction became difficult from strangulation. Instead of warm gruel the enema may consist of simple water, or of soda-water from a siphon, or of a portion of a seidlitz powder," the idea in the latter case being to gain the distention by the gas as well as by the water. A good formula when it is desired to make use of the pressure of gas is two parts of a solution of bicarbonate of soda, and one of tartaric acid injected separately. There are now many cases recorded in which these means have been successful, and the relief following such a proce- dure has been instantaneous, but as a rule injections of fluid are more easily managed, the amount of pressure produced by them better gauged, and, therefore, they are safer. There is much to be said against the practice of trying to relieve the condition of distention by puncture of the intestine, though Broadbent reports a very successful case in which cure was affected by that means. The danger is that faecal extravasation may occur, and to guard against this he offers the following suggestions: 1, To secure, if possible, absolute freedom from peristalsis by an extra dose of opium. 2, To select, if pos- sible, a coil of intestine which shall contain only gas and not liquid. This will be found (if anywhere) in the jejunum, and therefore above and not below the umbilicus. An indispensable condition is that scarcely any food shall have been taken during the entire attack. 3, To pierce the coil exactly at its most convex part. The abdomen should be carefullly watched for some time at every visit, and especially before the operation. In some cases where the walls are thin the outlines of various coils may be traced even in repose; but this will be more distinct when peristalsis is provoked by pressure or manipulation of any kind; it will be seen also which coils shift and which keep the same position when contracting. The spot chosen for puncture should be as near as possible over the centre of a coil which does not roll about, and by preference in the linea alba. 4, To exercise great care and patience during the escape of gas. The needle should be held lightly but rather firmly, perpendicular to the abdominal wall, and should not be allowed to follow too freely the rolling of the coil of intestine. As the gas escapes from the coil which has been punctured, it will collapse, and the flow from the needle will cease; very soon, however, the air in the intestine will distribute itself and enter the empty portion, when it will again escape. This may be aided by gentle manipulation and pressure. Should the tube get blocked, aspiration may free it; but it is safer to drive a little air through the tube into the bowel * Case, Dr. Morton, Practitioner, July, 1875. PSOLAP8B. ISS than to exert powerful suction which may draw the mucous membrane against the point of the needle. Dr. Broadbent, in spite of the rules for its use which he has so carefully laid down, believes that puncture can relieve obstruction only very ex- ceptionally. His own experience leads him to recommend it as a pallia- tive, and he suggests that it may be a nseful preliminary to inflation, manipulation, suspension in the inverted position, etc., in the treatment of intussusception. The chief hope of relieving an invagination, however, lies in prompt and eflScient surgical interference by opening the abdomen. The pro- priety of such a course has in the last few years been the subject of much argument. In its favor have been adduced the rarity of ultimate recov- ery from the disease even after sloughing of the included portion and temporary relief;