INTESTINAL OBSTKUCTION.

By Rutherford Morison, F.R.C.S., Surgeon to the Royal Infirmary,

and Consulting Surgeon to the Dental Hospital, Newcastle-on-
Tyne.
Complete Operations.?3 cases; 2 recovered, 1 died.
Enterostomy.?3 cases; 1 recovered, 2 died.
C^costomy.?6 cases; 5 recovered, 1 died.
Left Inguinal Colostomy.?4 cases; 3 recovered, 1 died.
Lateral Anastomosis.?8 cases; 7 recovered, 1 died.
Enterostomy (Secondary).?2 cases; 2 recovered.
Enterotomy.?2 cases; 2 recovered.
Resection.?7 cases; 2 recovered, 5 died.
Total 35.?Recoveries 24, Deaths 11.
Tiieke is no problem in the diagnosis of abdominal lesions more
difficult to solve, than that afforded by some occasional cases of
intestinal obstruction.
The majority of acute abdominal lesions are ushered in by
1
Statistics supplied by G. Grey Turner, Surgical Registrar, Royal Infirmary,
Newcastle-on-Tync, of cases of intestinal obstruction operated upon by Mr. Morison
during 1903 in the Infirmary and private Hospital.
 intestinal
JL1> llioxxx,. OBSTRUCTION. 39

similar symptoms; for of of the viscera,

attacks from gall or example, perfoiation
anv

twisted pedicle, kidney stones, choie , cySt with

leaking
The first question ectopic gestation,
ana kidney cases.
requiring answer m al ig therefore?
1. Is this Case one uGTI0N ??If a
patient, previously
with
in
good health, of^JESTI < been suddenly seized
abdominal pain which is frequent griping
paroxysms, if vomiting is an aS?iava, if there is entire
urgent symp ,

inability to pass flatus, it is safe to the case is one of

intestinal obstruction. In the caseassuma o maIlj jnured to
hardships, with strong will-control ant ,

energy, t^ie
symptoms will be less pronounced than m.1 a sensitive
woman or a
if young person, and the mitia y m8in the elderly,
serious, must hfve
more than usual ^ to them,
,

The next
The patientproceeding is to make a 00 P ~ination.
?

should lie in an easy portW?^ raised shoulders

and with the
abdomen fully exposed ma ? ht
First examine the hernial sites. e tance
,
0f this rule
.

cannot be p
overrated, for I still frequent y sacrificed by its
neglect. Not
only the ordinary, but
sites as well, should ,.aordinary hernial
?

be male it is well to
observe if both testiclesscrutinised;
are present in
and m
i for a strangu-
lated hernia in cases of
undescended tes ic hidden in the
inguinal canal. If a hard tender m(j in one or other
of the swelling
hernial sites in an obstruction case, i
that this has necessary to believe
is proved everything to do with the i contrary
byoperation.
Exposure of the abdominal surface o 00i air may cause
visible intestinal
movements, and these ai most conclusive
evidence of intestinal obstruction.
The whole
abdomen must be sys em,?f;Pqllv and carefully
inspected, palpated, and percussed, then -nation will be
concluded by rectal examination under any
(which never,
circumstances,
tion, when feasible.
be omitted), and in women
by a vaginal
0
exaniina-

2. Wheiie . .
is the mi1.u raore difficult
tion to Block??This is a ques-
answer at the bedside than is su?8 ted by text-book
statements, and
sible to in a considerable percen aS cases it is impos-
to give a reasonable opinion. It is o utmost importance
know whether the
lesion involves ?mnll or the large
intestine. Acute obstruction is more li ve y situated in the
small than in
the large intestine; but the no ^ cases show
many
definiteexceptions,
rule.
which prove that this can down as a
The age of
the patient ?

for before 40 the

,
, j
chances are in favour may be a usefu g >

in the
large intestine. The of an obstruction in affcer
stricture of
tne reason for this is tha i:ffnant
colon is ?
one of the most common causes o ^t^ction, and
40 RUTHERFORD MORISON.

though there is no age exempt from malignant disease, it occurs

infrequently before 40. It has to be remembered, however, that
some relation to the character of the
apart from this fact, age has
attack.An obstruction which would have caused the most acute
symptoms in youth, may be attended by relatively mild symptoms
in aged persons. Indeed, a malignant stricture of the colon in
a young subject may be the cause of acute and rapidly fatal
intestinal obstruction, for I recently saw a post mortem examina-
tion on a man under 30 who was admitted to the Infirmary mori-
bund from an acute abdominal illness of five days' duration ; and
post mortem examination showed that his death was the result of
acute intestinal obstruction, due to a malignant stricture at the
lower end of the sigmoid flexure. In most of these cases, however,
the rapidity of their course is not due to age, but is best explained
by the fact that the small intestines are distended. This, I believe,
arises from the anatomical condition of the ileo-ccecal valve. If it
can resist the backward
pressure of gas and fluid faeces, the large
intestine alone is distended, and the course is chronic; if, on the
other hand, the ileo-ctecal valve is incompetent, the small intes-
tines dilate and the course is acute. A limited post mortem
experience supports this view, which requires further confirmation.
Localised pain may be a guide to the site of obstruction,
if observation of it be made quite early in the case. Very soon
the pain is referred to the neighbourhood of the umbilicus. In
chronic obstruction the patient may feel pain, which begins or
ends at one spot, and the rumbling of flatus may be felt by the
patient to stop there. Vomiting, in the case of obstruction of the
small intestine, is more obstinate and sooner becomes freeal in
character than when the obstacle is in the large intestine, when
vomiting is often a late symptom and rarely ftecal.
The shock following acute obstruction is greater in the case of
the small intestine. Anuria occurs in some cases of chronic
obstruction in the small but not in connection with the large
intestine. If an enema of nearly a quart cannot be retained, this
fact is in favour of an obstruction low down in the large intestine.
The shape of the abdomen may be an aid in forming an opinion
as to whether the obstruction is situated in the small intestine
or in the large intestine. If the small intestine is involved low
down, abdominal distension is most marked in the centre, giving
the abdomen a similar contour to that produced by an ovarian
cyst. If the obstruction is in the large intestine the abdomen
bulges at the sides as in ascites, and may be enormously distended.
A most useful sign that the large intestine is involved is the fact
that the caecum is distended ; for then it is certainly known that
the obstruction is below this point. In some cases the distension
is quite evident. The right side of the abdomen may be bulging
and the left flat, or the outline of the ceecum may be clearly
mapped out through the parietes. If the distended csecum can be
 INTESTINAL OBSTRUCTION. 41
seen to swell
up and to contract
'

a inteimittently of
peristaltic wave upwards along the co on,, ^ feit to
harden at the same time, and if there is
sp ^ succUs-
sion, the evidence that there is obstruc 1
is where iu the colon
complete. It is only safe to
I have
, ?

the colon; for

say, som?x
learnedthat distension ,

ing value as to the position of of the cxc

the obstructi
^ut little localis-
ijjie contents of
the whole colon '

are liable to be and to distend

the emp le
caecum, leaving the rest of the co .

tracted; and it possibly con-

be of the greatest ^ importance
realise this fact mayCase practical I to

On
(see 12).
inspection, the ladder-like of the distended
intestines, described by Professor Wy 1 , arrang^
be seen in some
chronic cases, and this is an important aid w localisation, for
it occurs
only when the small intestine 1
On
palpation,
and becomes
a tender
spot may m ica ^ obstruction,
of great .

ance, or a importance if a sw g Qr feeling of resist-

temporary tumour can be e
vigorous peristalsis ^ur- all attack of
(see Case 3).
Very firm and painful contractions, wliioh the intestine
becomes as hard as the go far as J have
seen, only when contracting uterus,> '

the small intestine is conce coion and the

stomach contract more feebly than the sma
The >estine does.
sign to which we attach greatest nlT30rtance in the
diagnosis of intestinal
obstruction
unp
y
careful is i .gteis.^
examinationwill
visible, palpable, or audiblediscover eai
} 1
increase o pei
?
cases.
uic movements in
Without
the
intestine, the
when these are diagnosis of obstruction ej t0 be right;
present it cannot be
What is the Nature w*01]?-
TTON ? Jn children,
of the Obs
intussusception is the
adults, in the majon )
cause ustances; in young
over 40,adhesions, most frequently the result of buberc
?
iprcle in patients
malignant stricture of the large m
Intussusception.?The
intestinal evacuation. There attack is o
en. * ^e(j by a free
is sudden Pal ' tinuous at first>
becoming
so
more
severe or so markedly intermittent la ei y0miting is not
'

not persistent as in other acu e constipation is

with
likely to be
complete ; it is usual to a
>.
loose motions
The muco-sanguinolent discharge and ma rectal tenesmus.
finger used for examination of -g apt to be
blood-stained on its removal.
The abc^ fmen
is seldom much
swollen;
vented byindeed, it may be retracted, becau
the frequent
distention is Pre"
of small quail anum-
Examination
oi'
escape
of the abdomen
discover ??
^t iliac fossa,
somewhere in may 1T\ j
uniour which the course of the colon, a io>
,

gausage-shaped
be hardens and relaxes, lei sWelling nia)
00
discovered ^ec
resembling the uterine cervix, <o ^e tumour is
high for this, bimanual examination may 1)resellCe.
42 RUTHERFORD MORISON.

In young children the diagnosis may be rendered difficult by the

apathetic condition sometimes seen in them. There may be lies no

striking abdominal symptom except vomiting, and the patient

in an apparently anaesthetic condition, tolerating rectal and
abdominal examination without complaint. The ease with which
the relaxed and anaesthetic abdomen then allows of examination
makes the discovery of the tumour easy.
Cases of strangulation by bands, diverticulum rings and internal
hernia, are often sudden in their onset, and produce very acute
symptoms. A history of previous peritonitis suggests strangula-
tion by a band or by adhesions (see Cases 4, 5, 24). If there is no
such history, the possibility of a Meckel's diverticulum should be
borne in mind.
Strictures are generally malignant, and are most frequently
met with in the sigmoid flexure of patients past 40. Their usual
history is of attacks of constipation, at first yielding to mild pur-
gatives, but gradually requiring stronger measures. A very
suggestive history is that purgatives caused so much intestinal
commotion that any one in close proximity to the patient could
hear loud rumblings. If abdominal examination does not find any
tumour in the colon, rectal and vaginal examination may. A
growth in the slack of the sigmoid flexure makes it heavy, and it
is apt to drop down into the recto-vesical or recto-uterine pouch.
More than once, in females, I have seen such a hard nodulated
tumour mistaken for a diseased and prolapsed ovary by gynaeco-
logists, who are not likely to miss such a tumour from want of
vaginal examination. In the male, the tumour may be felt in the
recto-vesical pouch, and more readily when the examination is
made with the patient standing upright. As in cases of intussus-
ception, so in cases of malignant stricture, blood may be present
in the stools.
The sudden blocking of a stricture by hard faeces or a foreign
body will cause urgent and acute symptoms. It seems to me as
if the symptoms and signs of intestinal obstruction ?
pain,
disorderly peristalsis, vomiting, vascular and secretory disturb-
ances, etc., in the intestines above the block, are the result of
nerve irritation started by the stimulus of sudden arrest of flatus.
A fallacious belief in the possibility of acute obstruction
arising from impaction of faeces requires exposure. Faecal masses
to symptoms are exceedingly rare, except
large enough cause

in feeble old persons, hysterical women, and lunatics, and they

never cause symptoms of acute obstruction; consequently, what-
ever else may be the cause of an existing obstruction, it is not

likely to be impacted faeces.

Prognosis.?The prognosis of cases of intestinal obstruction is
much more serious than text-books or current litera-
very serious,
ture suggest. Of acute cases the great majority die during the
first week, and seldom live for more than three days after faecal
 INTESTINAL OBSTRUCTION. 43

vomiting has commenced. It is

possible,
practitioner knows,
the most
for these cases to lec
desperate condition ; and these
?Jg^pp^ently
casesof
in

are
'
recovery
impressed upon the memory when e .

fatai result is
apt to be forgotten. caused by toxic
poisoning from
the fatal result absorption
Ear1^
of the foul f^estinal
contents; later,
is generally attributab e ,-,pritonitis, the result
of P
perforation. The course of more chronic oases
cases is steadily
towards a fatal termination, which
the commonly is Dio ? by
development an acute attack.
of
Of general
conditions as aids m or 0 prognosis, the
appearance of the patient and the are the pUfse
safest guides. In the most
serious state t p
c0^ has a pinched,
poisoned and is filled wit an ^ know what js
the cause appearance,
of the attack, and what is to e come> The pulse
steadily increases in rate with the advanci 0 qy,sorption of intes-
tinal toxins.
Of the local ,,
conditions I attach the ?vonfP?t importance to
abdominal distension. A patient wi i ? ,
an(j frequent
P
vomiting, with severe attacks of interim .

an(j without
marked
in such distension,
has a fair chance of reco) y , for'the intestines
a case are still active and able t but
?ne y / themseives;
who does not ^ whose dis-
tension is vomit,
who has no seiious p
Above increasing, is quite unlikely 0 &
^e illness,
and uponeverything else, the prognosis depen P' parlv
-
diagnosis
to this proper treatment. To emphasise J attach
ance
?

statement, and to illustrate my ^e following

extract from a recent address
of mine
Intestinal obstruction eases.?"The may a may not be bad
enough to raise alarm, and its pain
paroxysma c -er an(j accoin-
panying
or wind-rumblings may be placed to ,.fc dyspepsia,
colic, or constipation, or some ot
^

trifling trouble,
During their stay in my wards erjiave developed
symptoms of acute obstruction
will mention due to
in detail the treatment whic
sever^-d
d adhesions, and I
bancjs
them. If the
adopted for i
pain has been severe and paroxy and has been
attended by >

vomiting and wind-rumblings an

peristaltic movements
^ Qr palpable >-

of the intestines, m diagnosis

definite,
has been immediate operation has been t e> ru /
g
diagnosis
less
been ordered. certain, \ gr. morphia mj j1 dermically has
If the cj0 n0t
reappear after eight symptoms are remove y
hours, the rohablv due to
enema are
given to clear up the remaining i
cond'^Q
nothing serious ; but whether or not, a uo of castor-oil and an
jf the case
ls ?ne
of intestinal
produced, obstruction, acute symp
and operation is undertaken at one
o obstruction are
results of this
treatment will
carry greater weight than an)
?

can say."
o
1
Lancet, Loudon, January 31, 1903, 1>. 1?*
44 RUTHERFORD MORISON.

In the absence of both of our

surgical registrars, I am indebted
to Mr. J. W. Heslop for examining the Hospital records from
1900 up to date. He has found a note of eleven patients who
were attacked by acute intestinal obstruction whilst under my
care, and suffering from other conditions. Of these, nine recovered
and two died. One death occurred in patient who was not
a

operated upon, from mistaken diagnosis. Of ten patients operated

upon, nine recovered and one died. The patient who died was a
young man whose appendix had been removed two days previously,
and who developed a complicated volvulus, involving the small
intestine.
It cannot be held of these cases that they were easy from
the surgical point of view. Every one required more serious
manipulation than the reduction of a recent intussusception,
or the release of bowel strangulated by a band, or the
reduction of a kinked or twisted loop of intestine necessitates.
To prove this, I need only read notes of the last case of the sort
that I operated upon, to be quite fair,
prefacing it by the state-
ment that the patient was an unusually robust
young woman.
Case 1.?The patient, a female, set. 35, was operated upon first on
10th June 1902. She was then very ill, with an acute abdominal
illness diagnosed as abscess in the pelvis and in connection with the
vermiform appendix. Her abdomen was opened over the
right iliac
fossa, by an incision extending from the loin behind. Some clear fluid
escaped on opening the peritoneum. The colon and the czecum were
adherent to the parietal peritoneum on the outer side, and on
gently
separating them foetid pus escaped. The appendix was found lying on
the outer side of the cm?cum and colon with its tip
pointing upwards to
the hepatic pouch, and was excised. The pelvic brim was filled with
matted adherent intestine. The abdominal wound was covered
up, and
the patient was placed in the lithotomy posture, the pelvic abscess, from
which a large amount?about one pint?of foetid pus was evacuated,
being opened and drained through an incision in each lateral vaginal
fornix by drainage tubes sewed in. The vermiform appendix contained
a stercolith, and was perforated at its centre. There was a free dis-
charge of pus, especially from the vagina, for some days, but the patient
made a good recovery, and was about to leave, when, on the night of
14th July, one month after the operation described, she was
suddenly seized with symptoms of acute obstruction, and became
very ill. The second operation was performed a few hours later.
The abdomen was opened in the middle line. The small intestines
were congested and beginning to distend, the distended loop leading to

the pelvis where the obstruction was located. It was due to adhesions,
but those in the depths of the
many of which were easily separated,
became more dense. In separating a loop there, a small abscess
pelvis
was opened and pus escaped.
The traction on the inflamed and adherent
the intestine almost completely across.
loop resulted in tearing Six
inches of torn and damaged intestine were excised, and an end-to-end
was made by catgut sutures. The abscess in the pelvis
approximation
 r 45
INTESTINAL OBSTRUCTION.

was
thoroughly mopped, and the whole pelvis
saline solution. The abdomen was entirely
^ patient
recovered, and is now in first-rate health, wi 1 olos^
ckill
These results have not depended on any sPec1^
of mine,for some have come under the caie Assistants, and
their cases have done as well as my own. additional proof of
acute intes-
this, I may state that my results from
?operal^
tinal obstruction involving the small in es in p ,
^
}iaVe
third or fourth day when the small intes 11 ^.^ndcd,
been so bad that I could count the recov fingers,
and I
There is only one explanation of these surpi 8 reSults,
a as str0ngly
want to drive the lesson this experience S
home as I can, and it is that if patients with acute intestinal
obstruction are to have the best chanc , y
I
tQ ^
-point, may
operation without delay. As
f^r^r g^?y
mention the results obtained at the inn y in intussusception,
cute intussus-
From the commencement of 1900, twelve ca
ception have been admitted to the surgica
^ Royal
the wa found
Infirmary for operation. In fonr of the eases gut
to be ie ^
gangrenous, and all of the patients '.
recovered
,
and
in which the
gut was not gangrenous, six p
two died. One of the deaths was caused y gecond intussUscep-
examination.
,

tion, which was not discovered till the pos hours'

The second death occurred in an acute case o HVpnfy_four
duration in a child five months old.
r'
^wrnntion has not
Treatment.?The treatment of intestinal
advanced in proportion to other progress ' ?bstlufntl0?Jomi?al
r(j t0 cases in
surgery; indeed, I think it safe to say tha =,
exciuding
which the obstruction is limited to the sma
those of the large intestine, the general resu no now j^g^er
than they twenty-five years ago.
were .

a(je ciear
is maae
Why is The explanation I have to offei
this ?
in the previous ^
quotation. It is that ?P?ra ^formed before
early enough. To be successful they must P
ftn(j before
.

the patient's heart is weakened by toxic a s p

the intestines have become
paralytic; and nei '^ege condi-
tions take long to practitioners
develop. As soon as physician.3
realise that intestinal obstruction arises on y ^P^anical remove
obstacles, and that the sole rational treatmen 0 , ,

n0j. till
its cause at the earliest
possible^ opportuni y,
then, will the prognosis of intestinal obstruction
>

?j'he
improvement
has-P?-,,
may then perhaps be as stnU became
occurred in the results of strangulated hernia,
generally recognised that early operation was itson y satisfactory
Uttle is
treatment. My reported cases show only too well
to be
expected from late operations.
The lines on which I think treatment should be conducted
,

Will bear some repetition.

46 RUTHERFORD MORISON.

Eelief is demanded for the pain, and opium in one or other of

its forms is the only drug to be relied upon. If administered by
the mouth, it may either be vomited or fail to be absorbed, so
that it should be given by the rectum, or preferably hypodermic-
ally. The first dose should be sufficient (-^ gr. of morphia for an
adult by hypodermic injection; 50 minims of tincture of opium in
warm water as a rectal injection), for repeated small doses of

opium are to be condemned in all acute abdominal cases. Ad-

ministered in frequent small doses the drug masks all symptoms,
and so leads to a false sense of security ; it paralyses the intestines,
and thereby favours toxic absorption; and it produces a hyper-
cesthetic condition of the patient, very unfavourable to recovery
from an operation. Further, a reduction of the accustomed dose
leads to physical and mental collapse, and patients who have been
under its influence for a few days are predisposed to die from
shock after an operation. Though no one who has seen it can
doubt the marvellous temporary improvement in the general
condition of the patient, brought about by the skilful use of
opium, yet I doubt the existence of the real curative influence
ascribed to it by generations of authorities.
Before the administration, careful examination, which should
never be omitted, may have made it obvious that the
patient was
dangerously and acutely ill; in all such cases no time should be
lost in waiting to see what the effect of the opiate may be.
Operation should be undertaken without further delay. Other
cases, less definitely ill, should be seen at short intervals, and
closely watched as the effect of the opiate passes off. If the
symptoms return, then an operation should be done; if not, after
eight hours' rest a dose of castor-oil followed by an enema will
make it clear whether there is obstruction or not.
If the case is not seen until the abdomen has become dis-
tended, and if the symptoms have all been rendered less aggressive
by repeated doses of opium, the question of operation has lost
much of its urgency; indeed, immediate operation may not offer
the best chance of recovery (see Case 21). If a little flatus has
been passed, if occasional peristaltic movements are observable in
the intestines, if the stomach contents are expelled with vigour,
if the distension is not increasing or causing tension, and if the
pulse is retaining its vigour and is not rapid, the case is a favour-
able one for palliative treatment.
The three most material aids to recovery then are?
Stomach lavage, abstinence from mouth feeding (nutriment to
be given by enemata), and repeated small doses of opium. The
tolerance of patients for stomach washing varies. Some experi-
ence so much relief that they ask for
a repetition of
it, others
suffer so much inconvenience during its performance that
clearly
the possible benefit is more than counterbalanced by its risks and
disagreeableness. Occasional large hot drinks to encourage vomit-
 INTESTINAL OBSTRUCTION. 47

ing (weak tea or water are

substitutes. No food by thegenerally liked)
mouth shou as
sickness is a troublesome
g0 jong
symptom. oo nutritive fluids
<

introduced into the stomach only add

patient, and often diminish an already s sufferings of the
chance of recovery,'
After cleansing the
hot stomach, to relieve 1 sips of
water may?be
with cold water asfrequently given, ^ sluiced
often as desired b} of
this should be swallowed.
Ice gives on y tpmr)0rary
P relief, and
does permanent harm. It makes the mou 1
dry; it fills the stomach with cold tongue
wa_er> depressing the
vitality; and it increases flatulent disten ^ nutriment
?

should be administered the colon. T

this is to by metho(j 0f doing
give slowly through a rectal funnel one
pint every two or three
tubeandlaaed^
hours of the following;
beef-tea and milk in equal parts, with on
half an ounce of P ^ ^ and
two or three whisky, at a temperatuie o rj^e
pints are frequently retame \ -n ^is way,
whereas the intermittent
syringe, commonly used for pumping action o> ?ordinaryenerna-
this purpose, s 1 bowel to
expel the injected fluid. When the enematat ,

it is, of begm to com come away,

same time.
course, a favourable omen if sou
. ?
^ ^
Diminution of the abdominal as 8hown by
careful measurement round
the umbilicus, 1 favourable
sign. If the enemata are retained .
for we hours, it is
necessary, as in all cases where foocl B
administer a quart of salt water to clear ou
y^ ^ bowel, to
offensive ddbris.
From the use of
nutrient suppositories little g expected,
and if the . ?

enemata cannot be retained

indication for early operation. In strong
niay be mentioned that their use in the 1
thel^^Xenemata,
c01^ne? 0f intussus-
it
ception is
agreed thatstrongly
recommended by nearly a n ntborities. It is
cases they have no value in the Qr in

is a involving the small intestine. It is ai ?

d that there
certain amount of _

in their use.
danger
Before giving the enema, if this is decide anesthetic
Jiust be
Hot salt administered to assure complet relaxation.
.

and as much water, a drachm to a pint, is the lea |tefcin2 injection,

of it should be introduced as can rstained. The
enema funnel
case of should not he raised more t lan *n ^ie
, .

children, who may be held up by e during the

administration.
is It is
usually impossible to -g llieans
,,

successful; even if a tumour previously dissayini y

to have -g found
disappeared, it is not certain that its ^ been
accomplished,
he and valuable time
may be losi m ^ gee ??
symptoms return. It is safe t
,
that they
do so, usually p P
short period and, except in the more chronic c ,
which a
may be allowed to be wasted aratiVe
48 RUTHERFORD M ORISON.

impunity, operation ought to be done as early as diagnosis

permits.
Repeated small doses of morphia in the favourable cases
previously mentioned are often of great service?a 10-minim dose
of liq. morphia hydrochlor., in 1 drm. of peppermint water, given
by the mouth, when the patient is restless or in pain, secures
bodily and mental rest, and has a steadying effect on both mind
and body.
If nothing short of narcotism brings relief, operation is
urgently indicated.
In addition to the use of stomach lavage, nutrient and
stimulating enemata, and morphia, which are the most important
means of relief, there are smaller details
requiring attention. A
hot, moist poultice, large enough to cover the whole abdomen,
kept on for an hour, and repeated at intervals of eight hours and
replaced by warm cotton-wool, is useful. A hospital bed and
a
good nurse are great comforts, and are important aids to
recovery.
Operation in Acute Intestinal Obstruction.?During the
first twenty-four to forty-eight hours it is possible as a rule to
perform a radical operation which allows the cause of the
obstruction to be dealt with, and which offers a good prospect of
complete success (see Case 3). The rule for these cases should
be, that as soon as the diagnosis is made an operation must
follow.
Preparation of the patient for operation.?Morphia will already
have been given to relieve the pain, and the skin of the abdomen
is prepared in the usual way. The arms and legs and chest of
the patient are to be swathed and bandaged in warmed cotton-
wool, and the room in which the operation is to take place should
be heated up to 70? F. It is also of the greatest importance,
more especially in the case of children, to maintain the body heat

by warm clothing, hot bottles, and towels wrung out of hot lotion,
for the avoidance of chilling is by far the most effective means
we possess for preventing shock.

Special instruments (intestinal clamps and buttons and Paul's

tubes), as well as ordinary ones, should be ready for use, and
everything should be prepared to carry out the operation with as
great expedition as possible after the administration of the anses-
thetic.
If the stomach is distended, it should be washed out, to
prevent its septic contents from being drawn into the lungs of
the antesthetised patient.
Chloroform, in the hands of a skilled administrator, is the
best anaesthetic for general use; and the previous dose of morphia
aids its action, making only a small quantity necessary. Before
commencing the operation, abdominal palpation should be
for a tumour which has previously escaped observation
repeated,
 intestinal obstruction. 49

may now be discovered, and to be

directly over the site of obstruction adds materially
of aterially ^ie chances
success.
When no clue as to the
, . , ,

neig 1 o v.nfi 0f the obstruction is

?

available, the incision is commence above the umbilicus,

includes this in an ellipse, and is
*

p tQ 2 in. below it-

The umbilicus is then
cavity is opened, the
i-^L
excised and m doing t|lis the abdominal

wards with scissors onopening being ^^d

through the umbilical ring.
a
protecting an 0 J^ing
o finger
introduced
The first objcct
now be of the operation--to con
?nnfirm the diagnosis?will
realised; for, from the ear les intestine is
distended and increased m ? >

absence of m-
vascuianty.
flammatory peritoneal exudates exc u ^
ossibiHty of acute
peritonitis, which, in some rare cases,, p duces symptoms and
signs so
as to be closely resembling those o P kanical obstruction
is now indistinguishable until the pel js opened. Search
commenced in the iieighboiir 1 Wound, which
may be opened
up by retractors, the gr being taken to
prevent the
the use of escape of intestines iion abdominal cavity by
warm flat or steri
taught me that muchsponges Experience has
of the disturbance o re]ations and position
small
attended by a intestines, and their exposi
fatal result in these cases.
almost inevitably
,

of occasi0nally reads
successful cases, in which the m e re taken out,
enveloped in hot towels or douched wi ^ opened, emptied,
sewed up, and >

of these returned; the only e*P can given

have a remarkable successes is, tha j"1 e patients appear to
assistancecapacity
for which has been ^
to the
recovery exceptional
The second operator. .

objcct of the operation-- o o0?pvHin whether the

obstruction is in the small or m the la
attained by g intestine?will b?
and noting the position and appeara distended
vascular loops, which are
tion; those below always si ua the obstruc-
besides its positionare contracted and pa e. large intestine,
and relation to ie j.unlj is easily
recognisable by the
The third longitudinal bands o mliscular coat,
he in the object of the operation -supposi o obstruction to
of the small intestine-mil
be to find it with.as Jitu
little handling
of distended and friable gut as ^ ^
obstruction possib e.
first pale will be best ascertained c forward the
?

and y
?r
down inch contracted loop, by fixing this a following it UP
until the by inch, putting each loop back as withdrawn,
block is
readily through adiscovered.
small
If the obstru ^ found
be
e*tended incision, the origin should
downwards towards the pubis, ^ always
retaining
in the intestine
with
aIL_
elsewhere
surgery, to see what is hot done fiat sponges. '

MED.
being is of first-rate |mp0rtance;
F
589?NEW SER.?VOL. XVI.?I.
50 RUTHERFORD MORISON.

and a long incision which allows of this is less dangerous than

one so short as to make it necessary to grope in the dark. With
the long incision it is easiest and quickest to examine the caecum
first. If that is distended and reddened, the obstruction is in the
large intestine; if it is empty and pale, the obstruction is in the
small intestine.
The end of the ileum as it enters the colon serves as a guide
to the small intestine, which should be followed steadily upwards
to the seat of obstruction.
When the csecum indicates obstruction in the large intestine,
the next step is to draw the sigmoid flexure out of the pelvis. If
it is pale and empty, the obstruction is above. By drawing down
the omentum and elevating it, the transverse colon is exposed,
lying on its under surface. If it is empty and pale, the obstruc-
tion must be found in the ascending colon, or in the hepatic
flexure.
The cause of the obstruction has now been found; and this
should not occupy any long time, if the schematic method
suggested is carried out with prompt precision. Time, so
important in these operations, is too frequently lost by a want
of well-considered method in their performance ; the plan now
suggested, one which has been developed for my own guidance,
has stood the test of experience; I therefore hope it may prove
of some use to others.
In the early cases, and those alone have entered into con-
sideration as yet, a radical and complete operation for the
removal of the cause can be performed with good prospects of
success (see Case 3).
Unfortunately surgeons seldom have as yet the chance of
treating these cases early enough, and the chief object of my
paper is to impress the fact that the present great mortality
from intestinal obstruction is the result of delay in operating.
The illustrative cases convey this important lesson more emphatic-
ally than any words of mine could.
Patients with acute intestinal obstruction are even worse
than they look; and if the small intestines are considerably
distended, they seldom get well after a complete or prolonged
operation, however satisfactory, from the operative surgical point
of view.
The operation of choice for such patients is enterostomy. It
has been my misfortune to perform this operation, and to find,
on subsequent post mortem examination, that the intestinal

opening was 12 in. below an impacted gallstone lying immediately

under the anterior abdominal wall, the intestine being red and
disturbed from commencing peritonitis; to discover, after an
immediately successful enterostomy, that death on the ninth day
was due to gangrene of a loop of
bowel ensnared by a string-like
adhesion easily accessible; and to see curdled milk oozing through
 INTESTINAL OBSTRUCTION. 51

the fistulous opening soon after it had been swallowed, showing that
the incision had been made so high in the jejunum that death
from starvation must shortly be expected. Against these dis-
appointing results, which a more thorough surgical procedure
could have averted only by the certain sacrifice ot the patient s
life, must be placed the cases in which enterostomy has afforded
another chance of life, which the more complete operation did
not. A second operation is generally required after enterostomy,
but it is not an unique experience (see Case 22) to find the
symptoms permanently relieved, and to see the patient completely
cured, with spontaneous healing of the ftecal fistula.
Enterostomy may generally be regarded as a protest against
delay; but until early operation becomes more frequent, it holds
a useful
place in the treatment of intestinal obstruction (see
Cases 4, 5, 12, 13, 18). . . . .

The operation.?A short oblique incision in the rig i i ic

fossa, which can be made in bed and under local anesthesia, ?Pe"s
the abdomen and exposes the caecum. If this is not distended,
the nearest loop of distended small intestine is drawn orwar s
out of the abdomen, packed round with gauze, and opened away
from the wound. Into the opening a Paul's tube is firmly tie
with silk, and the ligatured bowel is wrapped in iodoform gauze.
A gauze and wool dressing, freely sprinkled with powdeie
boracic acid, is applied round the tube, and a firm many-tai e
bandage, keeping the dressing in position and preventing the
bowel from prolapsing,
completes the operation.
Stricture of the Large Intestine.?These cases form a
large percentage of the cases of intestinal obstruction, and are
consequently of great importance ; and the same rules are not
applicable to them as hold good for obstructions in the small
intestine. The first fact, of such great surgical importance that
it deserves special
recognition, is that distension, limited to the
large intestine, is no barrier to satisfactory exploration, if the
general condition of the patient is sufficiently good. Collapse
and disaster do not
frequently follow manipulation of the dis-
tended colon, as we have seen to be the case when the small
intestine is in question. Consequently, if the patient is vigorous
enough, the operation is undertaken with two objects in view
(1) The remote one of a radical cure, and (2) the immediate one
of giving relief. The first demonstrates, for future
guidance, the
exact situation of the
disease; its character; whether a
growtli is
fixed or movable; and the or otherwise of enlarged
presence
glands or secondary deposits in the peritoneum, liver, or elsewhere.
To attempt to remove a
growth in the colon in the presence
of obstruction is to court
disaster; for the added chance of sepsis
from the passage of foul intestinal contents, the fact that wounds
in the colon do not unite so
readily as those in the small intestine,
and later, the
passage of solid faeces, all combine against success.
52 RUTHERFORD MORISON.

In inoperable conditions, left inguinal colotomy is the

operation of selection if the obstruction is too low down to admit
of anything else. It is preferable to a permanent opening else-
where in the colon, because further from the fluid contents of the
caecum and the small intestine, so that the irritation and incon-
venience and disgust of constant escape of fluid faeces are thus
averted. If the original exploratory opening has been made in
the middle line, a second incision, in. in length, should be
made in the left iliac fossa; and 3 in. of the highest available
portion of the sigmoid flexure should be passed through it, and
fixed by clip forceps pushed through its mesentery. The bowel,
after the incision in the mid-line has been sutured and protected,
should be at once opened and drained by a Paul's tube tied in.
If a long indiarubber tube is fixed on to the glass one, the
contents of the bowel can be discharged into a receptacle under
the bed, and the wound and the dressing may be left untouched
till the portion of bowel made gangrenous by the ligature tied
round the tube, sloughs and allows of faecal leak. This occurs
from the fourth to the eighth day. The operation is completed
by transverse division of the exposed bowel on the tenth day.
This small operation is often followed by haemorrhage, sometimes
so profuse as to be dangerous, and
always difficult to arrest
(see Case 6); I have therefore adopted the simple plan of securing
the division by an elastic ligature. This is drawn through the
hole in the mesentery by the forceps left in it, and tightly tied
over the bowel, below or over the
sloughing hole left by separation
of the tube to allow of the escape of gas (see Case 8, etc.).
I have previously expressed my belief as to the indications
for permanent inguinal colotomy; briefly, it is that it should be
undertaken to save a life threatened by intestinal obstruction due
to incurable cancer. In very rare cases of rectal carcinoma
attended by severe haemorrhage and rectal tenesmus, or com-
plicated by a recto-vesical fistula, there may be found an excuse
for it; but there is no excuse for the wholesale application of it
suggested by some surgical text-books. A recovery after inguinal
colotomy, unless performed as a last resource, is not by any
means a surgical triumph; nor is it an operation likely to evoke
the grateful recognition of. the public for benefits received.
If exploration shows that a removable growth is present,
except when the growth is in a freely movable portion of the
sigmoid flexure or of the transverse colon, my practice is to open
and drain the caecum for the relief of the obstruction; and I do
the same if the patient's general condition does not allow of
exploration. The pressure of the intestinal contents is greater
in the caecum than elsewhere, consequently patchy gangrene of it
the obstruction in the colon may be; the
may occur wherever
ctecum is sufficiently movable to be drawn forward with ease, and
a caecostomy opening
in the right iliac fossa is well out of the
 INTESTINAL OBSTRUCTION. 53

way of subsequent incisions, hence the choice of this part of the

colon. The operation is performed through a small oblique
incision in the right iliac fossa; through this the ctecum is drawn
forward, then opened and drained by a Paul's tube. Two or
three hare-lip pins passed through it and resting on thick pads
suffice, with the help of a good dressing, to keep the bowel in
position. After the patient has recovered, and the bowel has
been thoroughly cleansed, the removal of the growth can be
undertaken; and the lumen of the bowel may be restored by an
anastomosis. Then, at a later stage, the opening in the ctecum
should be closed, if it does not do so spontaneously.
Entailing, as this programme does, a prolonged illness and
three distinct operations, some doubt may be felt as to its wisdom.
I do not doubt at all, being convinced that this is the only
method which offers a fair chance of recovery in these serious
cases. What does concern me, and this, I think, is a point as yet
unsettled, is the question of the manner in which the anastomosis
is to be made. The best published results, so far as I know them,
are those of Mr. Caird of
Edinburgh, Mr. Littlewood of Leeds,
and Mr. Bilton Pollard of London. It is
significant that they all
advocate end to end anastomosis with suture alone, and have
obtained their remarkable successes by this method. Neverthe-
less I am not persuaded. My own best results, though they
cannot compare with those mentioned, have been obtained by
lateral anastomosis and a large opening and simple suture, after
closure of the divided bowel ends. The next best results have
been obtained by end to side
approximation. Our worst have
been by end to end juncture, those obtained
by suture and button
being equally bad. Up to recent times I have strongly advocated
a
simple suture; but this year, guided to some extent by
American views and statistics, I have, as will be observed, used
the button for
everything; and I have invented one of decalcified
bone,1- which possesses, I think, most of the advantages of the
ingenious and well-known Murphy, and few of its disadvantages.
If the growth is in the slack of the
sigmoid flexure or of the
transverse colon, it should be drawn well out of the abdomen,
and fixed there by forceps
through the mesentery, and left till
firm adhesion has occurred (ten to fourteen
days).
The bowel above is immediately opened and drained. As
soon as the
patient has recovered (in perhaps two weeks), and the
intestine has been cleansed, a second operation is undertaken for
the removal of the
growth. If care be taken to prepare the skin
and the bowel for a few
days, resection of the growth, followed by
closure of both divided ends, lateral anastomosis, and return of
the whole into the abdomen, is a
very safe and satisfactory
1
I am indebted for
many of the details of this button to Mr. G. Gray Turner,
under whose directions it has been made
by M'Queen & Son, surgical instrument
makers, Newcastle-on-Tyne.
54 RUTHERFORD MORISON.

operation. I feel confident that one of my recorded cases (see

Case 18) died in consequence of my inability from indecision to
make sufficient use of the information in my possession. With
the operation I have described, the result would almost certainly
have been success instead of failure.
A further question, for which I have no satisfactory answer,
concerns the use of purgatives after suture of the colon. I am
disposed to think that in my anxiety to keep the motions fluid,
and so to avoid strain on the suture line, I have erred.
In a third class of case the cause of obstruction is found to be
inoperable. What should be done ? The patient has only a short
time to live. Is it worth while subjecting him to the incon-
venience, depression, and risk of several operations to make
temporary recovery more certain ? I am disposed to think not.
My view is that the risk of an immediate anastomosis and
complete closure of the abdomen should be accepted (see Cases
15, 20). The position of the obstruction and the anatomical
conditions will determine where the anastomosis is to be made.
A favourite method of mine, when the sigmoid mesentery is long
enough to allow of it, is to draw the omentum down, to pull the
sigmoid flexure up over it, and join it to the csecum, the omentum
lying underneath the junction and separating it from the small
intestines like a pad.
More than once I have seen the ileum, united to the sigmoid
flexure in obstruction, situated between the csecum and sigmoid.
The result has been distension, gangrene, and perforation of the
csecum, and death from peritonitis a few weeks after the operation.
Though I have drawn attention to this self-evident fact before,
self-evident if the usual competency of the ileo-cracal valve to
resist the escape of any of the csecal contents backwards be
remembered, it does not seem, judging by recorded cases, to have
met with universal recognition.
If csecostomy has been performed, transverse division of the
ileum and ileo-sigmoidostomy is a good operation, because it saves
a third one for the closure of the csecum (see Cases 13 and
14). Some
patients are so fastidious as to object to the trifling prolapse and
mucous discharge which, under those circumstances, escapes from
the csecostomy opening. If fluid, introduced into the rectum,
and freely out of this
passes through the colon opening, it will
be safe to close it completely, but not otherwise. In the latter
case discomfort may be minimised by suturing the opening up
round a small indiarubber tube, which must be worn permanently.
Mistakes in Diagnosis during the year. Several patients
suffering from general peritonitis were sent in as cases of intes-
tinal obstruction, in the course of the year. In some of them
obstruction were present; and as post
symptoms of intestinal
mortem examination has proved that distended sticky kinked
small intestines are indeed mechanically obstructed, a correct
 INTESTINAL OBSTRUCTION. 55

diagnosis may occasionally be impossible. The history is some-

times a useful guide. Intestinal obstruction commences suddenly
and without fever. The rupture of the vermiform appendix and
leak into the peritoneum occurs suddenly too, but the sudden
attack has been preceded by a day or two of considerable
abdominal trouble. In the early days of peritonitis there is fever.
The chief pain of obstruction occurs in severe paroxysms which
are characteristic. Vomiting is more troublesome in obstruction
than in peritonitis. Inability to pass flatus or fajces may be
present in both, liigidity of the abdominal muscles and tender-
ness of the parietes are marked in
peritonitis, absent in intestinal
obstruction. To see and to feel increased peristaltic movements
and to hear increased rumbling are the
signs by which cases of
intestinal obstruction may be
distinguished from other simulating
conditions.
The abdomen was uselessly explored once, in the belief that
a stricture of the colon
might be the cause of serious symptoms.
The patient was a middle-aged man, who, after an illness of six
weeks' duration, alternating diarrhoea and constipation being the
chief symptoms, was seized suddenly with an attack of complete
intestinal obstruction which lasted for seven days and was only
relieved with difficulty. He had lost two stones in weight since
his illness commenced. Careful examination was negative in
result, but it was decided to explore his abdomen. No evidence
of anything wrong with his intestinal track was found. He
recovered.
One case of acute pancreatitis, as so often happens, was sent
in as an intestinal obstruction. A definite
diagnosis was made in
this instance, as will be reported in a later
paper, by palpation of
the enlarged and tender pancreas.
Kidney disease may cause attacks of abdominal pain and other
symptoms so closely simulating intestinal obstruction as to lead
to error in diagnosis. The following is a good example1:?

Case 2.?T. C., male, set. 59, was admitted under the care of Mr.
Morison on the 6th January 1902.
The following is an abstract from the clinical notes :?Six months ago
the patient began to suffer from
paroxysmal attacks of abdominal pain
with chronic constipation,
borborygmi, and difficulty in passing flatus.
With these attacks vomiting occurred at intervals. For three or four
months he had got rapidly thinner, and had become very weak and very
drowsy. He had sometimes passed blood per anum during stool. He
was sent in as a case of
malignant stricture of the sigmoid flexure, causing
chronic intestinal obstruction.
On admission he was in
poor general condition, had a grey, pinched
look, furred tongue, and complained of thirst and nausea. The pupils
were contracted.
Temperature normal. Pulse 120, and radial artery
atheromatous. Urine, sp. gr. 1010 ; no albumin. Nothing definite
1
See Northumberland and Durham Mcdical
Journal, January 1903, p. 50.
56 J. DIXON MANN.

was made out on examination of the abdomen or the rectum. After

careful observation for some days in
hospital, a diagnosis of granular
kidneys with pseudo-obstruction of the bowels was made. Ko operation
was consequently advised, and the patient was sent home on the 16th
of January 1902.
January 24, 1902.?The patient died at home. We are indebted to
Dr. Smith of Eyton for a report of the necropsy. He found marked
granular kidneys, with hypertrophied heart. There was no intestinal
obstruction, and no other lesion to account for the illness.
(To be continued.)