The entire intestinal canal is sometimes too short and sometimes fails to develop sufficiently in caliber, or sections of it may remain undeveloped. None of these changes have interest or importance for the surgeon as such, save those which produce acute or chronic obstruction or conduce to acute inflammatory affections.
Intestinal diverticula are usually of that type described by Meckel and everywhere known by his name. Aside from these the others usually met are irregular sacculations or hernial protrusions which may be due to previous disease or to some congenital anomaly of structure. These are sometimes seen in multiple form, and in one case recently under my observation over one hundred of them were found scattered along the intestinal canal, but, inasmuch as the patient died practically of old age without a history of serious previous disease, it could not be ascertained whether the pouches were of congenital or acquired origin.
The genuine Meckel diverticulum is a relic of the tubular structure which leads from the primitive intestine to the vitelline or yolk sac, and which should persist until about the end of the second month of embryonic life. After this time it should be completely obliterated and disappear. When this does not happen there may result a fecal fistula at the navel, which is then usually referred to as persistent omphalomesenteric duct, and which implies a continuous passage-way between the skin and the interior of the bowel.
When the umbilical portion alone persists there results a small cyst on the posterior side of the navel.
When the intestinal end alone persists a protrusion or sacculation will remain to mark its site.
The duct may become obliterated and yet fail to disappear, thus leaving a fibrous cord which represents the original omphalomesenteric structures and vessels, which will be probably mistaken for an inflammatory band and may serve as a later cause of acute obstruction. If such bands lead to the umbilical region their identity may be easily established.
The presence of Meckel’s diverticulum may cause serious abdominal mischief. It may become involved in a localized process exactly as the appendix often does, which may then be referred to as a diverticulitis, where ulceration and perforation may occur. It may constitute the whole or a portion of the contents of a hernial sac. I have twice found it in inguinal hernia, once in umbilical hernia, and by others it has been reported in all the ordinary hernial locations. Porter has collected from literature 184 cases in which its presence caused serious abdominal crises. The condition itself is probably present in at least 1 per cent. of mankind, and is stated by Halsted to be the cause of intestinal obstruction in 6 per cent. of cases. In the 184 collected cases above mentioned it caused obstruction in 101. Out of 21 cases of the above collection it was not only found in the hernial sac, but in all but 1 was shown to be the actual cause of the trouble. In 5 of these cases the diverticulum was open at the umbilicus. In such a case if the opening be large the gut wall might prolapse and thus form a hernia.
Diverticulitis has been repeatedly mistaken for appendicitis, its symptomatology not being distinctive. Exact diagnosis is seldom possible before operation.
On general principles, considering their possible dangers, it would be well to remove all diverticula which are found in the course of ordinary abdominal operations, whether they appear to be causing trouble at the time or not.
While the average length of Meckel’s diverticulum is three inches it may exist as a mere nipple-like projection, or it may be a free tube attaining a length of several inches. Its attached end is usually larger than its distal portion and its diameter usually less than that of the gut from which it arises. It may be provided with a scanty mesentery or may hang independently. While ordinarily its distal end is free it may nevertheless be continued as a solid cord attached, as above mentioned, to the umbilicus. This cord frequently contracts secondary adhesions, and it is under these conditions that it most often constricts the bowel by forming a loop within which the intestine becomes entangled. Free diverticula of sufficient length are sometimes found tied in a genuine knot in a manner which is absolutely inexplicable. There are numerous ways by which such a diverticulum may produce strangulation of the normal bowel; thus, by formation of a ring in which its own free end projects, in which is later entangled a bowel loop, or by surrounding the pedicle of an intestinal loop as might a noose. Again bowel is sometimes tightly drawn over such a diverticular band, just as a shawl may be thrown over the arm, obstruction following in the displaced bowel. When much contraction is brought to bear the gut may be so acutely bent as to become occluded. Finally the bowel at the point of origin of the diverticulum may undergo gross structural changes, the result of long-continued traction, which may lead to cicatricial narrowing. More indirectly diverticula seem in some unknown way to predispose to intussusception at their point of origin, or they have been found inflated and hanging from the intestine after obstructing it (Fig. 559).
Fig. 559
Meckel’s diverticulum still attached at the umbilicus and producing obstruction. (Lejars.)
Of acquired malformations of the small intestine we have mainly to deal with those which are produced by injury or disease. Among the former would be the results of violent contusions or of any of the lacerated, incised, or gunshot wounds to which the bowel is so often exposed. Should recovery ensue cicatricial contraction is likely to result. On the other hand, such previous disease conditions as ulcerations—tuberculous or typhoidal—or the so-called chronic catarrhal or malignant, may in one way or another occlude and thus finally obstruct the lumen of the bowel. Distention diverticula may also result, which correspond to the traction diverticula of the esophagus already described.
The small bowel, like the larger or the stomach, may be ruptured in consequence of abdominal contusions, the condition depending on the nature of the injury, the degree of fulness of the bowel itself, and other obvious causes. This character of injury has been already sufficiently considered in dealing with rupture of the stomach. Their symptoms are not essentially different, neither are the principles of ordinary surgical treatment. Of all gunshot wounds those of the abdomen constitute about 6 per cent., being more frequent than stab wounds.
—Gunshot wounds of the intestine would by themselves fill an interesting chapter in a work on surgery. In such an epitome as this they can be given but short consideration. The condition was for centuries hopeless, until the American surgeons Parkes, Bull, and Senn took up the subject and taught the profession how to more quickly recognize the injury as well as to treat it. The special dangers of all punctured wounds of the bowel, like those of the stomach, are hemorrhage and escape of fecal contents. The great length of the intestinal tube, and its coiled arrangement within the abdominal cavity, subject it to the possibility of multiple punctures, from a dozen to twenty having been inflicted by the passage of one bullet. The multiplicity of these injuries, therefore, gives a still more formidable character to their presence. Much will depend upon the size and velocity of the bullet and the distance from which it is fired. The perforated gunshot wounds of the abdomen which occur in civil life are usually inflicted by a smaller bullet than those occurring in actual warfare, while, at the same time, the distance is usually short.
Gunshot wounds are followed by an apparently disproportionate amount of collapse. There is no accurate method of recognizing from the exterior the amount of harm done by the passage of a bullet into or through the abdominal cavity. This constitutes one of the greatest arguments in favor of immediate exploration, an argument which is strengthened by the fact that almost every penetrating wound of the abdomen is complicated by injury of some abdominal organ. The greatest danger attaches to perforation of the transverse colon or of the small intestine, because these are the most movable parts of the intestinal canal. The dangerous wounds are those which lie in the frontal plane. Bullets which pass through the abdomen obliquely are perhaps less likely to produce fatal result. Astonishing differences prevail between the severity of those accidents received upon the field of battle and in civil life. In battle men are shot through the abdomen and not conspicuously disabled, recovering sometimes with no other treatment than antiseptic occlusion. It is impossible to assume that the bowels have not been injured, and yet they recover. The fact thus stated best indicates the reason for abstention from intervention on or near the firing-line in battle, and its most prompt and early performance when the patient is in a well-managed civil hospital.
—The symptoms of intestinal perforation in these cases are not so prompt as when the stomach is wounded. Blood may occur in the vomitus or in the stools, but only ordinarily after the expiration of a few hours. Should fecal matter be found within the external wound evidence would be complete, but this is rarely the case. The probe may show whether the abdominal wall has been completely perforated or not; beyond this it will give little information. By far the best probe is the sterile finger, introduced through the opening enlarged for the purpose. With this more distinct information may be gained. Some years ago Senn proposed the method of inflating the colon and small intestine with hydrogen gas, on the expectation that it will escape through any intestinal perforation into the abdominal cavity, which it would distend, and that then by inserting a small glass tube in the abdominal wound it could be lighted and made to thus identify itself at the distal orifice of this tube; but this method requires special conveniences which are rarely at hand in emergency cases, and has been practically abandoned.
A study of the direction of the abdominal wound which may be sometimes made from an accurate account of the accident, and at other times by noting the location of the wounds of entrance and exit, will do much to determine whether intestines were probably in or out of harm’s way. If it can be established that the bullet has probably avoided them then some would wait for the inception of the first serious sign of mischief before exploring. On the other hand, if it should seem inevitable that such injury must have occurred, or, without such reasoning, if the patient present a serious condition, he should be promptly operated unless practically moribund.
The general principles of recognition and treatment of gunshot wounds have been considered in an earlier chapter and the subject will not be further considered here except as regards treatment.
—The principles of surgical treatment for gunshot wound of the intestines include a free abdominal incision, an inspection of the entire length of the intestinal canal, which can only be made by passing it through the examining fingers while exposed to sight upon the abdominal surface, the accurate securement of all bleeding vessels, and the closure of all punctures. Any portion whose blood supply has been so completely cut off as to threaten or produce gangrene should be removed by resection, with end-to-end or a lateral anastomosis. The patient having been thus eviscerated and the intestinal viscera examined, the abdominal cavity should be further explored, not so much to find the missing bullet as to discover what further harm may have been done; while if such be found the indication should be met. Then after an exceedingly careful toilet of the peritoneum the intestines may be restored, it being of course assumed that every puncture has been fully recognized and properly sutured and secured. Nearly all of these cases will call for some abdominal drainage, which may or may not be posterior, as shall seem best.
The location of the bullet is a matter of minor importance. Should it lie where it can be easily identified and removed this should be done. Otherwise one should not waste valuable time in hunting for it, remembering that he is performing not an autopsy but an operation.
There is no point of the intestinal tube between the pylorus and the anus which may not be involved in an ulcerative process, either acute, chronic, or malignant. Acute ulcers of the upper bowel are usually of typhoidal origin, while those of the lower bowel may be due to either typhoid, tuberculosis, or syphilis. At certain points ulcers assume somewhat distinctive character. Thus the acute catarrhal ulcer, so called, seems to have a more definite entity than a declared pathology, it being somewhat difficult to account for its existence. The peculiar duodenal ulcers which have been met with after operations or burns have been elsewhere discussed, and are to be regarded as of an acutely toxic origin. A special type of ulcer of the duodenum has also been noted opposite the anastomotic opening which is made in the ordinary gastro-enterostomy, for whatever purpose performed. This appears to be due to the outpour of the gastric juice upon a surface not normally prepared for it, upon which it acts as an irritant, in time producing more or less acute ulceration. This is the so-called peptic ulcer of the duodenum, an occasional complication of gastro-enterostomy.
—Duodenal ulcer of a type corresponding to gastric ulcer has been recently determined to be a more frequent lesion than has been supposed. A series of over fifty operations for this condition, reported by Moynihan, in 1905, thus occurring in the practice of one surgeon, will dispose of the question as to its great rarity. Its symptoms are often so characteristic as to admit of reasonably easy diagnosis, and it has, therefore, become more and more a matter of greatest interest to the surgeon, since duodenal like gastric ulcer is essentially a surgical condition.
These ulcers are usually located in the first portion of the duodenum, i. e., in at least 90 per cent. of cases. They may be solitary or multiple, and may be associated with gastric ulcers. In the ordinary postoperative peptic ulcer the sequence of events is usually gastric ulcer, hyperchlorhydria, and duodenal lesion. It may occur at any age, and is the frequent cause of melena of the newborn or of the young.
—Symptoms of duodenal ulcer include pain, hematemesis, and melena. Pain may be a vague uneasiness or may be severe. It is usually described as of a burning character, felt mainly in the middle line or along the right costal margin. It becomes gradually more severe and may finally disable. It is sometimes described as cramp-like. When severe it is referred to the right of the middle line. In cases where there are adhesions to the liver or gall-bladder, pain radiates upward to the right breast, or even around the chest to the back. The pain is associated, by more or less marked time limit, with the ingestion of food, coming on from two to four hours after a meal, whereas that of gastric ulcer comes soon after eating. Sometimes it is even regarded as a “hunger pain,” and patients find that the taking of a little food will give relief. So soon, however, as this is digested pain returns, when they again call for more food. Hematemesis and melena may be present together or either may appear without the other. Small quantities of blood in the vomitus is more likely to attract attention than considerable quantities in the stools. It has been estimated that in from 25 to 30 per cent. of acute cases hemorrhage is frequent, and occurs in 40 per cent. of chronic cases. In the stools blood is found in perhaps one-half of the instances. The amount of blood may be considerable, even sufficient to produce faintness. In fact, the intestine has been found full of blood when the abdomen was opened, and Moynihan has seen even the colon distended with blood.
The more serious complications of duodenal ulcer, aside from hemorrhage, are those of perforation, cicatricial contractions or stricture formation (obstructing the bowel or the common duct, or both), local peritonitis, cancer, and indirectly gall-bladder or pancreatic disease. Next to hemorrhage perforation is more likely to occur in a duodenal than in a gastric ulcer and with more disastrous consequences. Such perforation affords a peculiar mimicry of acute, gangrenous appendicitis which, as Moynihan has shown, is due to the direction taken by the extravasated fluid down along the right of the transverse mesocolon toward the iliac fossa. In fact, the condition is more likely to be mistaken for one of acute appendicitis than for anything else.
With a primary ulcerative lesion in the duodenum it is easy to realize that infection may readily travel up the common duct, involving both the pancreas and the biliary passages, while the resulting cholecystitis will intensify and spread the local peritonitis previously produced, and all combined will cement the viscera in this region into one common mass in which anatomical identity is easily lost. A good history, when obtainable, will help very much in diagnosis, especially when the absence of previous gastric symptoms can be established. This, with the symptoms already given above, and the tenderness over the duodenum, which is rarely absent, will afford good basis for diagnosis in the more chronic cases. Duodenal perforation may even be mistaken for rupture of an extra-uterine pregnancy, as well as for perforation of the stomach or of the gall-bladder, or, as mentioned above, of an appendix.
Quite recently attention has been called to a condition of the duodenum resembling that known as hour-glass stomach, and produced in much the same way. It seems to be the result of cicatricial contraction of an old ulcerated area, and may cause almost complete constriction. Hour-glass duodenum is amenable to surgery only, and should be treated either by gastrojejunostomy or possibly by a resection with end-to-end suture.
—For duodenal ulcer when recognized before perforation, there is but one treatment, i. e., gastro-enterostomy, preferably posterior, performed exactly as for gastric ulcer, for the same reason, and with the same prospect of relief, inasmuch as it affords physiological rest for the diseased area. In rare instances it may be possible to so expose the duodenum as to make it justifiable to attack the ulcer directly, but the simplest and, in general terms, the best procedure is that just mentioned.
For perforated ulcer of the duodenum the indication is not alone for a gastro-anastomosis, but for exposure of the site of perforation, removal of all extravasated material, a most careful toilet of the peritoneum, and suture of the perforated area, this being the indication when possible. Provision should be made for drainage, while at the same time affording a direct outlet from the stomach into the first portion of the jejunum beyond. Should the surgeon operate apparently for appendicitis and discover that he has to deal with a perforated duodenum he should extend far upward the incision made for the former purpose, and, having thus widely opened the abdomen, should thus find himself perhaps better provided with space in which to work than had he opened at first directly over the duodenum.
—Typhoidal ulcers of the intestines have a tremendous surgical interest in that they not infrequently lead to perforation, and that this almost always is fatal if let alone. It may be possible, however, by prompt recognition of the occurrence of the perforation and by immediate intervention to cleanse the peritoneal cavity of extravasated feces and close the opening thus made.
—The symptoms of perforation are at first not unlike those of hemorrhage, in that shock is immediate and profound, and pain, usually intense, is produced. These are quickly followed by abdominal rigidity, while a blood count will show a rapidly increasing and high leukocytosis. To the expressions of local peritonitis are quickly added those of one which is generalized, with well-marked rigidity and great meteorism.
The condition having occurred admits of but one remedy—namely, operation. One of the latest collections of statistics includes 63 operations for typhoid perforation, with 11 recoveries, although probably today the percentage is somewhat better than in 1903. Operations to be effective should be immediate. Patients are usually too profoundly collapsed to justify general anesthesia, unless perhaps this may be secured with ethyl chloride or somnoform. Many of them have been operated under local anesthesia. This has its disadvantages, however, in that it is so difficult to make free opening and exploration or free toilet. Opening having been effected, the loops of intestine must be successively examined until the site of the perforation is discovered. Here sutures must be applied, if possible. Should the condition of the bowel render it absolutely unreliable, i. e., should it be too extensively gangrenous to retain sutures, it should be brought out and an artificial anus made, at least for temporary purposes. In addition to these measures the most careful toilet of the peritoneum is needed, perhaps including extensive irrigation, unless it can be shown that the area contaminated by extravasation is localized and shut off.
Perforation of tuberculous, dysenteric, cancerous, or other ulcers will cause symptoms very much like those of typhoidal perforation, and the case will differ essentially only in this respect, that in most of the latter the general condition of the patient will not be so extreme, and the danger of administering an anesthetic or of operating not so great. Otherwise the indication, the necessity, and the method do not differ.
—Tuberculous lesions of the small intestines produce less destructive features than when situated in the colon. Tuberculous infection of the intestinal tract occurs more often through the swallowing of infected sputum, and, consequently, is a frequent condition among consumptives. Such lesions in the small intestines will lead to infection of the mesenteric nodes which, in time, may become serious or even fatal, or it may lead to tuberculous peritonitis with its finally disastrous consequences. As a rule, however, tuberculous ulcers are not so likely to perforate, this being in large measure due to the frequency with which they contract adhesions or affix diseased surfaces to others, thus rather guarding against such an accident.
—Tuberculosis may also appear throughout the intestinal tract in miliary form, or we may find tuberculous gummas, either in the folds of the peritoneum or subperitoneally in the wall of the bowel. Any of these lesions may lead to any of the others, and by the time the case has been diagnosticated or has come to operation or autopsy it is sometimes difficult to say what was the primary lesion. Diagnosis is made partly with the thermometer and partly by inspection and palpation, where one may be able to discover mesenteric enlargements or the presence of fluid, as it usually collects in tuberculous peritonitis; and perhaps partly by the general appearance of the stools, in which a careful search may possibly, although by no means with certainty, reveal the tubercle bacilli.
—The treatment of such tuberculous lesions is largely constitutional. When the case assumes the aspect of tuberculous peritonitis much more can be accomplished by abdominal section and irrigation, at which time it may be possible to remove some localized focus without thereby doing more harm than good. The usual constitutional measures, including oxygen, are indicated; but there maybe difficulty in forcing hypernutrition because of the actual state of ulceration. In this case foods which are cared for by the stomach should be given in preference. Such intestinal antiseptics as creosote or other remedies of its class may also be pushed to the point of toleration.
The other granulomas produced by either syphilis or actinomycosis may give rise to ulceration and its consequences and sequels, in a way resembling those of tuberculosis. While the lesions they produce may give rise to uncertain symptoms, a diagnosis can hardly be made without accurate history and without the co-existence of other lesions in more accessible parts of the body, by whose character they may be determined. Primary actinomycosis of the intestinal tract is more common than is generally realized. As it develops it tends to spread to adjoining viscera and form tumors which later may break down. The debris thus resulting will be indicative, especially when the characteristic calcareous particles are felt in it, or the characteristic ray fungus discovered with the microscope. (See Actinomycosis.)
Save in rare instances where stricture may be due to congenital defect the condition is never primary, but is secondary to some previous and active disease. Stricture proper should be distinguished from obstruction produced by compression from without and should usually be made to include those cases due to intrinsic disease of the intestinal wall. Here it is in the vast majority of cases either due to cicatricial contraction, following the healing of some previous lesion, or else to the infiltration and progress of malignant disease. In the former instances a great deal may be accomplished by operation. In the latter much will depend upon the relative period at which the case is seen by the surgeon.
—The symptoms of stricture are those of bowel obstruction. The tumor which produces it may be identified by palpation, or by the fecal impaction, at least accumulation, which is likely to occur above it, which may appear as a tumor and be mistaken for it until cleared away by suitable cathartic measures. Ordinarily the surgeon never recognizes stricture of the small intestines, then, save by its obstructive features.
—The treatment consists in what can be done by radical surgical measures, and this can only be determined after exploratory abdominal section.
Benign tumors of the small bowel are relatively infrequent, perhaps the most common being the lipomas which develop along the mesenteric border, usually as excessive epiploic appendages. But circumscribed and even pedunculated lipomas are seen occasionally in this location and are of surgical interest largely because, at points where they are located, intussusception is peculiarly liable to occur. In fact, the condition figures as one of the predisposing causes of invagination. Fibromas develop occasionally in the intestinal walls and adenomas grow from the glandular structures which abound therein. Other benign tumors are exceedingly rare.
Besides predisposing to intussusception these tumors are innocent, save that in time they constrict or obstruct the lumen and produce one form of stricture with obstruction, which will first be chronic and then terminate acutely and fatally unless promptly relieved.
All benign tumors of the bowel should be removed with the least harm possible to the bowel itself, but when a neat extirpation without reduction of intestinal caliber is not possible no hesitation should be felt about resecting a sufficient portion of the gut; or should this be impracticable in making an anastomosis, thus excluding that part of the bowel involved.
—In the small intestines by far the most common type of malignant tumor is the round-cell carcinoma, epithelioma rarely appearing except in the lower part of the rectum, where flat epithelium is met. Adenocarcinoma, then, is common, and sarcoma relatively rare, the latter arising, of course, from mesoblastic elements. A diagnosis is made by first noting symptoms of intestinal obstruction plus certain added features of cachexia, lymph involvement and possibly of metastasis, for which a benign stricture would not account. Sometimes a tumor is easily felt within the abdominal wall; at other times one simply makes the general diagnosis of intestinal obstruction, presumably cancerous, because of age and cachexia, and leaves the rest to be determined by operation. Cancer of the bowel will naturally spread in the direction of the lymphatics at the root of the mesentery, and these will nearly always be found involved. It is fortunate if a case may come to operation before this invasion has occurred.
—Cancer of the bowel permits of but two methods of treatment, one excision of the entire infected area, both of bowel and of mesentery, in cases not too excessive, the other an anastomosis, by which temporary relief at least may be afforded. In all cases I am strongly inclined to advise the use of the x-rays, for a long time after operation; in favorable cases because it exerts a prophylactic influence, in the unfavorable cases because it nearly always relieves pain and retards growth, seeming sometimes even to disperse it. Such treatment should always be tempered by the best of judgment, lest x-ray dermatitis complicate or prevent it.
The somewhat badly derived and indefinite term “ileus,” in common use abroad, is coming into more fashionable use in the English-speaking profession, which is rather unfortunate, for it has not always meant exactly the same thing in the writings of different authors. It will be used, however, in this chapter as practically synonymous with acute obstruction or strangulation.
Acute obstruction may be classified in two ways, as to types and as to causes. For the first purpose the best classification is perhaps the simplest, and, as recently rehearsed by Murphy, is as follows:
Conditions which permit the adynamic type may include those of spinal origin, those interfering with mesenteric nerve supply or that of the walls of the intestines (for instance, in cases of fracture of the spine), or, again, where extensive operations have been performed on the mesentery, or where there have been extensive wounds. Thus in removal of mesenteric tumors, unless care is exercised in separating the mesentery from the tumor and in ligating bloodvessels without including nerves, a paralytic ileus may promptly result. Gunshot wounds of the chest or of the spine may also include injuries to nerves, by which paralysis of the bowel ensues. So, too, adynamic ileus sometimes results through the paralyzing reflexes which follow strangulation of the omentum—as, for instance, in a hernial sac—or it may be due to biliary calculus acting in the same way.
The dynamic forms, as well as the mechanical, are much more likely to be characterized by pain and violent symptoms than are the paralytic. Gastric tetany is a condition to be differentiated from reflex ileus. Enormous distention of the stomach immediately after operation leads perhaps to a belief that a patient has acute obstruction of the intestine, when the fact is that such a case may be relieved by vomiting or passage of a stomach tube. Local peritonitis of septic type, as well as peritoneal traumatism, tends to weaken if not to paralyze peristalsis. In general peritonitis the entire intestinal tract is involved, partly from reflex paralysis, partly from inflammation of the intestinal wall. The embolic type of paralytic ileus may be due either to interference with nerve supply or with blood supply. In thrombophlebitis symptoms develop more slowly, especially when this follows abscess of the liver or spleen. Here there is not so much meteorism, and the bowel may be even nearly empty, while we have the other symptoms of pain, nausea, and vomiting. Borborygmus is one of the most pronounced manifestations of mechanical ileus and the stethoscope will then give much assistance. In fact auscultation of the abdomen, with a recognition either of active motion within or of absence of peristalsis, should not be neglected; when one can hear intestinal waves the condition is much more likely to be one of purely mechanical obstruction.
Classified by causes, we may make out the following well-marked groups:
—By far the most common of all the causes of acute obstruction are strangulated hernias. These are, however, treated by themselves in a distinct chapter.
—These terms imply a protrusion or prolapse of one part of the intestine into the lumen of an immediately adjoining portion. This is found to be the cause of perhaps one-third of the total number of cases. Enteric invaginations occur along any portion of the small intestine, being more common in the lower portion and rare in the uppermost. They seldom attain great length and are often very short. The ileocecal is the most common variety, since obviously it is the easiest of occurrence, the ileum protruding into the cecum or the ileum and cecum together passing into the ascending colon. Colic invagination may occur anywhere along the large bowel, being again more common near its distal termination. The colon may descend into the colon or the sigmoid into the rectum, even to such an extent as to present at the anus or possibly protrude. Statistics show that the ileocecal occurs in 44 per cent., the enteric in 30 per cent., the colic in 18 per cent., and the ileocolic in 8 per cent. of cases.
While the surgeon is concerned only with the obstructive form of intussusception it is of interest to know that the condition occurs occasionally shortly before death and is then spoken of as the intussusception of the dying, being usually due in these cases to irregularity and uncertainty of peristalsis during the concluding hours of life; paralysis occurring at one portion of the intestinal tube and abnormal activity just above it. These conditions are discovered at autopsy, and can be recognized as such by the absence of exudate or of any attempt either at repair or inflammation. They occur most commonly in the young and may also be multiple. In direction intussusception is practically always descending, although there may be a secondary and associated ascending movement, the latter being unimportant.
Double intussusceptions are somewhat common, and triple or multiple have been described.
Cross-section of an invaginated bowel will show that on each side one must pass through three distinct layers of bowel wall. That portion which is intruded is spoken of as the intussusceptum, while that portion which receives the latter is known as the intussuscipiens (Fig. 560). Obviously when invagination occurs the mesentery should be drawn in with the intussusceptum, while traction upon it should increase with advance of the included bowel. This is particularly often seen in ileocolic varieties where the ileum, with its mesentery, may travel the whole length of the colon and even present at the anus. Moreover, this may occur within a relatively astonishing short time, and the fact that the intussusceptum may be felt in the rectum within a few hours after the occurrence of the first symptoms is a fact not easily to be explained.
Fig. 560
Diagrammatic section of an intussusception: A, reflected tube; B, receiving tube or sheath; C, entering tube.
—The causes of intussusception are obscure, postmortem findings or even the revelations of a laparotomy demonstrating conditions, but not often affording explanations. The presence of tumors, especially lipomas, which may even be pedunculated along the small intestine, has been demonstrated in a number of instances, and they have been supposed to be active factors in the first disturbance. Everything points to the association of disordered intestinal movements with the mechanical condition of obstruction, and the former are more frequently seen in the intestinal complaints of the young, along with the presence of masses of undigested food or impacted feces within the bowel, or the occurrence of intestinal polypi. The most complicated case of ileocecal invagination which ever came under my notice was associated with the presence of a polyp in the ileum. All of these conditions, save the presence of tumors, pertain more frequently to the young than to the aged. The influence of the ileocecal valve is also undeniable, and that at this region parts are more predisposed to invagination than elsewhere is quite obvious. In at least half of the cases that have been recorded no satisfactory cause could be shown. Any condition which causes severe intestinal colic may give rise to intussusception; the next most common causes are paralysis or weakening of some part of the bowel, such as may follow injury or disease, or the presence of tumors, while even the role which they play is not entirely explained (Fig. 561).
That invagination will produce mechanical obstruction is obvious, while the fact that such obstruction is not always nor necessarily complete incites surprise. The orifice of the intussusceptum is distorted, while the included portion may be greatly bent or curved upon itself, in addition to which the obstruction to the circulation leads to congestion, exudation, and swelling, and predisposes to active inflammation, all of which tend to still further narrow the passage-way. If, in addition to this, some tumor or hardened fecal mass be included in the grasp of the bowel involved it may be seen how complete shutting off of the intestinal tube may occur within a few hours. Invagination having occurred tends quickly to become irreducible; most commonly by the formation of adhesions, as lymph quickly exudes and bowel surfaces are by it thus glued together. Such adhesions may persist throughout the whole involved length of bowel or may occur at various scattered spots. As pressure becomes greater circulation of the invaginated portion is impeded and finally shut off, gangrene of the intussusceptum thus resulting. Cases occasionally terminate favorably through this actual condition, the included portion being finally cast off as a slough and passing onward and outward. It is on record, for instance, that six feet of invaginated bowel have thus been obtruded from the rectum after having sloughed, the patient eventually recovering. While this possibility, then, is present it is never safe to wait for it, and it is to be regarded simply as a happy accident when it occurs. Unless, then, a case of intussusception be very early and promptly operated, the included portion of the bowel may be regarded as dangerous and unsafe, unless upon disengagement it prove to have been but very slightly affected. Even then there is danger of immediate recurrence of the previous condition because of distention of the bowel above, paralysis of the part disengaged, and stretching of the part below. In proportion as obstruction becomes more complete distention of the bowel above the lesion, from accumulation and gas formation, will cause more and more distress, until finally complete paralysis of the muscular coat and possibly eventual rupture may terminate the case.
Fig. 561
Invagination of ileum, cecum, and ascending colon into transverse colon. One probe is passed into the appendix, the other into the invaginated portion of the ileum. (Rafinesque.)
In addition to the conditions above described, all of which are acute, there is known also a chronic form of intussusception, whose whole course is much slower and less severe, where symptoms of obstruction never become more than partial, but may involve any portion of the bowel, and with about the same relative frequency as the acute forms. Such a condition in the rectum, for instance, has been mistaken for cancer.
—The special symptoms by which intussusception may be recognized, or at least by which suspicion is aroused, are, in addition to those common to all forms of acute obstruction, the abrupt onset, which may even occur during sleep, the late rather than the early occurrence of vomiting, complaint of tenesmus, the wave-like or colicky character of the pain, and the fact that along with the violent peristalsis of which this colicky pain is an indication diarrhea is a common accompaniment, the actual local coprostasis being masked by this fact. As the lumen of the bowel becomes occluded and fecal matter fails to pass, the evacuations become more bloody and contain little but mucus. Finally, almost pure blood may be passed. In no other form of obstruction is the passage of blood so distinctive as in this. Urine elimination is but slightly influenced, and strangury is an exceedingly rare feature. Meteorism is also less pronounced. The discovery of a tumor formed by the invagination will lend further aid in diagnosis. It may be felt either through the abdominal wall or by the rectum, and may be noted in about half of the cases. It is most frequently found in the ileocecal and colic varieties, and felt in the rectum with the lower colic forms. In children it is more distinct than in adults. The tumor may even take the outline of the involved bowel, is usually movable, but may be fixed. When such a tumor is felt within the rectum it may have to be distinguished from some intrinsic neoplasm of the lower bowel; but the history of the case should prove satisfying if the physical examination leaves one in doubt.
—Spontaneous cure of an intussusception by a sloughing process has been mentioned above. Cure may also occur by spontaneous reduction. It would seem possible also only in recent cases and in the enteric forms. Cure may also occur by formation of a fecal fistula, although this is most rare.
—The term “volvulus” implies some form of twisting or of revolution of a part of the bowel upon itself or its mesenteric axis, the result being knotting or intertwining of intestinal coils to an extent causing their partial and finally complete obstruction. A common site for volvulus is the sigmoid flexure. Still no part of the intestine which hangs loosely is exempt.
The most common causes of volvulus are chronic constipation and fecal impaction, with distention and ptosis. Intestine thus displaced and overloaded becomes more or less paralyzed, its circulation more or less impeded, and any twist which has once occurred is not likely to right itself. The twisted loop having been engorged becomes distended with gases, and thus tends to increase the difficulty. In these cases the bowel loop is closed at both ends. Unless relief be afforded by operation it is a question merely of how soon the loop will become gangrenous from aggravation of every one of the features above recounted. Bowel thus involved permits easy passage of bacteria, and thus to the other features are rapidly added a septic peritonitis. The resulting abdominal distention may appear early and will become more prominent.
—A condition of extreme coprostasis, or fecal impaction, to a degree producing actual obstruction, may occur without necessary volvulus or twisting of any portion of the bowel. As fecal impaction increases the overloaded bowel becomes more and more paralyzed until there may occur final and complete arrest of peristalsis, with gradual development of symptoms of obstruction. The longer the condition persists the less the prospect of restoration of peristaltic movement. Moreover the condition may be complicated by the development of ulcers above the obstructed segment, known as stercoral ulcers, due partly to gangrene from pressure and partly to the chemical effects of long-retained decomposing material. They may appear as sloughs of the mucous membrane and finally lead to perforation.
This form of ileus is more common in the large than in the small intestine, and especially so in the cecum. Here there is little chance of retrograde movement, while fecal matter coming down from above will continue to pack the colon, and thus the cecum may have to bear the brunt of great pressure. The amount of fecal matter which may be thus collected is sometimes astonishing, for the bowel may dilate to the diameter of six or even ten inches, and contain many pounds of impacted feces. Such masses of collected feces can usually be palpated through the abdominal wall, and will at least indicate the location of the principal disturbance, if not its actual character.
—The most common causes of cicatricial stenosis in large or small intestine are the results of cicatricial contraction following recovery from local ulceration or repair of injury, as, for instance, after reduction of a strangulated hernia. The exact character of the ulcer does not matter. Any lesion which may granulate and heal will also contract, and the extent of the stricture will be proportionate to the area first involved. Should this extend well around the mucous membrane there may be a distinct annular stricture. Stricture may also result from infiltration and thickening in connection with a more active diseased process, and such a condition may be multiple. This is particularly true in cancerous involvement of the bowel.
Previous history of the case will shed much light on the probable existence of intestinal stricture. Thus a history of typhoid, of dysentery, of tuberculosis, or of syphilis will be most suggestive, for in any of these diseases there may be numerous intestinal ulcers. A history of hernia, reduced or operated, or of injury, is also of importance, as also is one of operation upon other viscera, especially within the pelvis, the lower bowel being often involved in a disease process within this cavity which may have left its marks.