Cttlumbm 29ntt)er^ftp CoUege of S^i^^iitiam anij ^urgeong Eibrarp /?^ . /^^f INTESTINAL OBSTRUCTION ITS VARIETIES WITH THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT SIR FREDERICK TREVES, Bakt., Iv.C.V.O., C/B., '"f.r.c.s. SERGEANT SURGEON TO H.M. THE KING SURGEON IN ORDINARY TO H.R.H. THE PRINCE OF WALES CONSULTING SURGEON TO AND EMERITUS PROFESSOR OF SURGKRY AT THE LONJJON HOSPITAL LATE EXAMINER IN SURGERY AT THE UNIVERSITY OF CAMRRIDGE WJTH J is ILLUSTRATIONS NEW AND KEVISED EDITION JVEW YORK WILLIAM WOOD & COMPANY 1904 en CD to PRE FAC E. The first edition of this work was published in 1884. It was ill substance the essay to which the Jacksouian Prize had been awarded by the Royal College of Surgeons of England. During the fifteen years Avhich have elapsed since the book came into existence, extensive additions to our know- ledge of the pathology and clinical manifestations of intestmal obstruction have been made, and a great and far-reaching change has affected the modes of treatment of that disorder. To embody these additions and to do justice to this change, it has been necessary to re-write the book almost entirely, and to introduce many emendations into such parts of the original essay as have survived the vicissitudes of fifteen years, and have been retained. The entire arrangement of the work has been altered. It has been found more convenient to divide the subject into three distinct parts, and to consider first the pathology of intestinal obstruction, then its clinical manifestations, and tinally its treatment. In the account of the treatment of the trouble I have refrained from introducing the actual details of the various operations named, since such matters are very full}- discussed in the text-books on Operative Surgery. A large number of new illustrations has been added, for which I am indebted to Mr. Berjeaii. Frederick Treves. 6, WiMPOLE Street, W. June, 1899. Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/intestinalobstro1904trev CONTENTS Introduction 1 PATHOLOGY AND MORBID ANATOMY. CHAPTER I.— Genekal Pathology ov Intestixai, Obstkvction . .9 II. — The Morbid Anatomy of Pakticllar Forms of Intestinal Orstrvction, Strangulation bv Bands, etc. . . 24 III. — Anomalous Forms of Obstruction Due to Isolated Bands AND Adhesion? . . . . . .75 IV. — Internal Herxi.ti: . . . . . . .102 v.— Volvulus . . . . . . . .126 Yl. — Intussusception . . . . . . . 141 YII. — Obstruction Due to Foreign Bodies, Gall Stones, and Enteroliths . . . . . . .185 Ylll. — Stricture of the Intestine ..... 202 IX. — Obstruction Due to Tumours Growing i-rom the Bowel Wall 259 X. — Obstruction Due to the Pressure of Tumours, etc., Ex- ternal to the Bowel ..... 2GS XI. — Fji:cal Accumulation ...... 27a PART II. THE CLINICAL MANIFESTATIONS. I. —The Clinical Varieties of Intestinal Obstruction IT. — The Significance of the Leading Symptoms ill. — The Symptoms as Modified by the Position of the Obstruc tion ....... IV. — The Diagnosis of the Differe.vt Forms of Intestinal Ob STRUCTION ...... V. — Acute Intestinal Obstruction . . VI. — The Course and Prognosis in Acute Intestinal Obstruction Vir. — Chronic Intestinal Obstruction .... VIII. — The Course and Prognosis in Chronic Intestinal Obstruction IX. — Chronic Intestinal Obstruction Ending Acutely X. — The Differential Diagnosis. Errors in Diagnosis 285 289 310 321 323 373 391 430 435 439 JNTES TIXAL OB 8 TR U(J TION. TREATMENT. CHAPTER PAGE I. — The General Theatment of Acute Txtestinal Oisstkuction 449 IT. — The Opeuatiye Treatment of Acute Intestinal Oksthuction 475 III. — The Operative Treatment of Particular F(jrms of Acute Intestinal Obstruction ..... 494 IV. — The Prognosis After Operation for Acute Intestinal Obstruction . . . . . . .519 Y. — The Treatment of Chronic Intestinal Obstruction . . 523 YI. — -The Pp.ognosis After Oper.ation for Chronic Intestinal Ob- struction ....... 559 Index ......... 561 LIST OF ILLUSTRATIONS Kader's experiments to demonstrate the production of Meteorism . Great sacculation of the Transverse Colon due to a Stricture at the Splenic Flexure ....... Stricture of the small Intestine with Pouch .... StrangiJation by a broad Peritoneal Band passing- between two adjacen Coils of Ileum .... . . Strangulation of the Ileum by a Y-shaped Band attached to the Fundus o the Uterus ....... Slrangnlation of the Ileum by complicated Bands passing hetween the Uterus and Ovary .... Strangulation of small Intestine hy a solitarj' Band attached at either end to the Mesenter)^ ...... Strangulation by a Band ...... Strangidation by an adherent Diverticle .... Strangulation by Meckel's Diverticulum .... Diagram to show a possible method of snaring by a long liganiorit One mode of Strangulation by the Diverticulum Strangulation by the Diverticulum hy a double Knot Portion of Ileum strangulated by a tibrous cord (the remains of th' omphalo-mesenteric duct) which terminated in a rounded mass of fat Stenosis of the Ileum above the origin of a Meckel's Diverticulum Multiple Sacculi or Diverticula of the Small Intestine Distension Diverticula ..... Diverticulum of the Lower Jejunum Portion of Colon constricted by one of the appendices epiploicte which has become adherent to the omentum, which is itself attached to the bowel by moderate adhesions . . . . . Site of congenital hole in the Mesentery ; Pouch in the Peritoneum Strangulation of small Intestine throug-h a hole in the Great (Jniiutum Stenosis of ascending Colon from the contraction of Peritoneal Adhesions . Sigmoid Flexure showing a broad membranous Peritoneal Band passing from the Mesocolon to the Gut Adhesions forming the Bowel into a Loop . Fistula bimneos.H, with formation of a Loop in the Ileum Diffused Peritoneal Adhesions The Fossa Duodeno-jejunalis Small Hernia into the Fossa Duodtno-jejunalis Hernia of medium size into the Fossa Duodeno-jejunalis Hernia in the Fossa Duodeno-jejunalis Hernia into the Fossa Duodeno-jejunalis PAGK 11 20 34 47 48 49 50 .51 GO 61 G.') G7 69 89 90 92 93 9.) lOS 109 110 111 112 X INTESTINAL OBSTRUCTION. PAGE Hernia into the Foramen of Winslow .... 117, 118 The Tntersigmoid Fossa . . . . . . 119, 120 The Ileo-colic Fossa . . . . . . . .121 Ileo-ctecal Fossa ........ 122 Sub'Csecal Fossa3 ........ 123 Volvulus of the Sigmoid Flexure .' . . . . . 127 Volvulus of Lower Ileum . . . . . . . 138 Volvulus of Small Intestine ....... 140 Vertical and Transverse Sections of an Intussusception . , . 141 Intussusception of Jejunum ....... 142 Intussusception of the Jejunum, one inch and a half in length . . 143 Ileo-colic Intussusception . . . . . . . . 147 Intussusception of the Dying . . . . . ,150 Intussusception of descending Colon into Sigmoid Flexure . . 155 Ileo-c^cal Intussusception with great swelling of the Intussusceptum . 160 Intussusception of the Ileum . . . . . . 161, 163 Intussusception of the Ileum. Protrusion of the Intussusceptum through an ulcerated Opening in the Sheath . . , . .165 Portion of the Small Intestine, 40 inches long, voided per anum as a slough, the result of Intussusception ..... 166 Slough of the Ileum, with a Meckel's diverticulum, passed after acute intussusception ....... 167 Chronic Intussusception with Ejjithelioma of the Internal Layer . .170 Section of an Intussusception ...... 171 Vertical Section of Bladder and Rectum, showing an Intussuscep- tion of Eectum due to a Growth which projects from the Bowel Wall 180 Invagination of a Meckel's Diverticulum. The process projected into the Ileum and led to a fatal Intussusception .... 181 Invagination of the Vermiform Appendix ..... 182 Double Lateral Invagination . . . . . .184 Vulcanite Tooth-plate, swallowed by a young girl and passed per anum in forty-two hours. Natural size . . . . .186 A Glass Drop of a Lustre swallowed by a boy six years of age and passed per anum in fifty-two hours. Natural size . . . .186 Passage of an Iron Teaspoon, which had been swallowed five weeks previously, from the Colon through the Abdominal Parietes . 190 Gall Stone impacted in the Ileum . . . . . .193 Obstruction of the small Intestine bj' a Concretion of Magnesia . .198 Tuberculous Ulcer of a Peyer's Patch in process of Healing . . 205 Healed Tuberculous Ulcer of the Ileum ..... 206 Portion of Jejunum showing two Strictures, the result of Tuberculous Ulceration ........ 207 208, 209 . 210 . 211 .211 . 212 ure above a Carcinoma Tuberculous Stricture of the Ileum . Syphilitic Ulcers of the Colon Syphilitic Stricture of the Ileo-ca3cal Valve . Dysenteric Ulcers of the Lower Part of the Colon Stricture of Colon after Dysenteric Ulceration Extensive Follicular Ulceration of the Sigmoid Flex of the Rectum ........ 213 Stricture of the Ueo-cjecal Valve. A quill is passed through the Stricture. Outside the Bowel is an enlarged Lymphatic Gland . . .215 Stricture of the Ileo-cajcal Valve ...... 217 LTST OF ILLUSTRATIONS. xi Stenosis due to in-turning of the Intestinal Wall, the result cf Mesenteric Gland Disease . . . . . . • .220 Epithelioma of the Colon ....... 22;5 Epithelioma of Colon. Bird's-eye view of the Interior of the Bowel . 224 Almost complete occlusion of the Colon by a very small Carcinoma . 225 Cylindrical Epithelioma of the Transverse Colon, forming an annular (Stricture ........ 226 Congenital Occlusion of the Duodenum by a Transverse Septum . . 234 Membranous Diaphragm in the Lower Ileum .... 230 Congenital Stricture of the Ileum . . . . . .237 Mrs. Boyd's case of Congenital deformity of the Colon . . 241, 242 Idiopathic Dilatation of the Colon . . .... 253 Polypus-like pi'ojections from the Mucous Membrane of the Colon . 260 Small Intestine showing Lymphadenoma of Solitary Glands and Beyer's Batches . . . . . • . ' . 266 Lympho-Sarcoma of the Ileum implicating Beyer's Batches . . 268 Dilatation of the Colon above a Stricture of the Splenic Flexure . . 313 Dilatation of the Sigmoid Flexure above a Stricture at the lower end of the Flexure. . . . . . . . .314 Dilatation of the Colon and small Intestine above a Stricture of the Sigmoid Flexure ....... 315 Dilatation of the Ascending Colon and Ileum above a Stricture at the Hepatic Flexure of the Colon . . . . . .316 Dilatation of Coils of small Intestine' above an Obstruction in the lower Ileum . . . . . . . . ..317 Dilated Coils of small Intestine. " Organ-pipe " arrangement . 318 Gall Stone impacted in the Ileum ... ... 370 Contraction of Colon after the separation of an Intussusception . . 387 Diagram showing the positions in which fffical masses are common . 427 Figures to show the sequestering of a raw bleeding surface and the securing of a bleeding point 'by stitching . , . . 495 Lund's Infiator . . . . . . . .510 Barker's Operation for Intussusception . ... 515 INTESTINAL OBSTRUCTION. INTRODUCTION. Under the title of " intestinal obstruction " are included a great variety of conditions, which, although unlike in character, have yet the common property of bringing about, mechani- cally, an obstruction to the passage of matter along the intestine. The obstructing agent may, on the one hand, be a peritoneal adhesion, by means of which a loop of bowel is snared and actually strangulated ; on the other hand, it may be represented by a ring-like growth of epithelioma in the wall of the gut which very gradually narrows and perhaps closes its lumen. The bowel may be obstructed at one time by the torsion of a loop of gut around an axis at right angles to the line of its own course, as seen in volvulus of the sigmoid flexure ; or at another by the invagination of a certain portion of the bowel into the segment below it as illustrated by intussusception. The intestinal canal may be blocked by a gall-stone within its walls or be occluded by the pressure of a tumour entirely without its confines. The symptoms produced b}^ the various mechanical causes may be exceedingly acute on the one hand or exceedingly chronic on the other. The case may run its entire course from its commence- ment to the patient's death in the short space of forty-eight hours, or the phenomena of obstruction may persist for years, and may not at tbe end be the direct cause of death. When the clinical phenomena come to reviewed, it is at once evident that too much prominence must not be given to the mere circumstance that the bowel is obstructed. Obstruc- tion of the bowel is the prominent symptom, but it is not the sole basis upon which the great issues of the malady depend. Indeed, in certain acute cases it is neither the most prominent nor the most serious of the manifestations. 2 INTESTINAL OBSTRUCTION. In acute intussusception the disease may run its course and end in death without there having been produced a definite obstruction in the kimen of the bowel. The duration of the obstruction to the passage of the faeces is also not an inevitable criterion of the gravity of the case. A loop of gut may be strangulated within the abdomen and death may follow within a week, no material passing through the alimentary canal in the meanwhile. On the other hand, the colon may be actually plugged with a hardened mass of faecal matter, and while no trace of a motion may be passed for four or more weeks, the patient may yet make a good recovery. In the acute cases, as Avill be immediately shown, the actual fact that the bowel is obstructed is comparatively unimportant. The obstruction, gttd obstruction, does not produce the more urgent symptoms, nor does it act as the direct, nor, indeed, as the prominent cause of death. As an abstract proposition, it may be stated that obstruction of the lumen of the bowel for a period of a week, or even more, is not in itself — all other circumstances being disregarded — a condition which need cause death or even distressing inconvenience. If the clinical phases of quite acute and quite chronic forms of intestinal obstruction be studied comparatively, the following general features become evident : — In the very acute cases, as illustrated by strangulation by a band, the grave initial symptoms obviously do in no way depend upon the undoubted fact that the bowel is obstructed. Time must elapse before the mere obstruction can produce phenomena of discomfort. When a loop of gut is snared by a band, the initial symptoms are due solely to a sudden and severe injury to the peritoneum and to the numerous important nerves of the implicated part. These symptoms, which are mainly those of intense abdominal pain, with collapse and usually with vomiting, are by no means peculiar to intestinal obstruction, but are common rather to nearly all acute lesions within the abdomen. They have been described collectively under the title of " peri- tonism." Such symptoms may attend the passing of a gall- stone and the twisting of the pedicle of an ovarian tumour, and, in fact, both these conditions have during the initial stages been mistaken for acute intestinal obstruction. The symptoms which depend upon the injury to the bowel, in distinction to the mere obstruction of its lumen, remain prom- inent for some little time, and, other things being equal, depend in their degree of severity upon the amount of INTRODUCTION. 3 intestine involved, the tightness of the strangulation, and the nearness of the loop to the stomach. Certain phenomena which follow are due undoubtedly to the actual obstruction, and prominent among them nuist be placed the constipation, the incessant vomiting and the distension of the belly. This latter symptom, however, is not solel}' dependent upon mere accumulation of matter in the gut above the narrowed part, as will be explained sub- sequently (page 13). The final sj'mptoms of acute intestinal obstruction — the symptoms which precede death — are again not so much those due directly to occlusion of the lumen of the bowel as those depending upon septic infection of the whole body from the disordered intestine. The subjects of acute intestinal obstruction die for the most part with the phenomena of septic poisoning, and if a certain stage has been passed the mere relieving of the obstruction does not save life. In chronic intestinal obstruction, as illustrated by the closure of the colon by a ring of malignant growth, the phenomena are much more distinctly the direct outcome of actual obstruction. The bowel becomes filled up, but so long as the obstruction is not complete and a little matter can escape from time to time, the distress occasioned may be quite slight. Two results follow. The irritation, septic and mechanical, of the long-retained faeces leads to catarrh, and the expression of that takes the form of a spurious diarrhoea. At the same time the bowel becomes hypertrophied in its persistent attempts to empty itself of its contents, and enlarged coils are usually seen and felt in movement through the walls of the abdomen. A certain degree of septic intoxication is not uncommon even in the early stages of the disease, and the ending is often by acute obstruction, or by the septic poisoning which follows upon peritonitis. The infection in those forms of peritonitis which depend upon intestinal obstruction comes from the bowel, and a conspicuous element in the surgical treatment of obstruc- tion is not only to relieve the actual mechanical cause of the trouble (as by dividing a band), but to relieve also the engorged bowel by emptying it of its putrid contents. CLASSIFICATION The circmnstances which bring about an obstruction ol the bowel are — as has just been stated — numerous and varied 4 INTESTINAL OBSTRUCTION. .iiid no one scheme of classification will meet all the con- ditions upon which a consideration of the subject may be based. Two principal methods of classification at once suggest themselves; first, that based upon the onechanical conditions which cause the obstruction; and, second, that founded upon the clinical manifestations which that obstruction may pro- duce. The first plan of classification will be followed in dealing with the morbid anatomy and. pathology of intes- tinal obstruction ; and the second in discussing the sy7nj)toiiis with which the trouble is attended. 1. The Classification of Intestinal Obstruction accord- ixci to the Mechanical Conditions producing it. 1. Strangulation. The Eowel is snared. Exanvples : Strangula- tion by bands or through apei'tures. Hernite. 2. Torsion. The Bowel is twisted. Examples : Volvulus. Obstruction by kink- ing. 3. Invagination. The Bowel is invagin- Example: Intussuscep- ated. tion. 4. Obturation. The Bowel is blocked. Examj^les: Ohsivncixon due to foreign bodies, gall-stones, etc. Fte- cal accumulation. 5. Stenosis. The Bowel is narrowed. Examples : (a) Stric- tures. (6) Compres- sion from without. In the first four of the above classified varieties it is to be noted that there is no primary or essential change in the intestine itself, so far at least as its actual wall is concerned. In the first variety a normal loop of bowel is snared and strangulated, as seen in the common circumstance of a strangulated hernia. The strangulating agent may be a peritoneal band or adhesion, or an adherent Meckel's diver- ticulum, or the margins of the foramen of Winslow, or of a slit in the mesentery. In the second variety a loop of bowel, together Avith its mesentery or mesocolon, is twisted upon itself, the con- dition being most commonly illustrated by volvulus of the sigmoid flexure. This subdivision will also include the occlusion of the bowel by kinking or the bending of the INTRODUCTION. 5 gut acutely upon itself, just as a thin tube of indiarubbov may be kinked. In the third form a certain part of the intestine is invagin- ated into the part immediately continuous with it. It is true that in this variety changes rapidly occur in the wall of the invaginated portion of the bowel, and that these changes play a very important part in the production of obstructive symp- toms. Such changes are, however, secondary and, in a limited sense, accidental. In the fourth variety the lumen of the bowel is simply blocked, the obstructing agent having no structural con- nection with the intestinal wall. The fifth variety of intestinal obstruction — that known as stenosis — calls for more detailed consideration. In this mechanical form the lumen of the bowel is narrowed, but such narrowing may be due to two perfectly distinct causes. In the first of these two kinds the stenosis is due to changes in the bowel wall itself. In that wall there is a growth or a cicatrix whereby the lumen is narrowed and obstruction symptoms are produced. This sub-variety is iUustrated by the many forms of stricture which may be due to a malignant growth of the gut on the one hand or to the contracting cicatrix of a non- malignant ulcer of the bowel on the other. In the second of the two forms of stenosis the lumen of the bowel is narrowed by changes which are outside and beyond the actual intestinal wall This kind is illustrated by cases in which the bowel is compressed by a tumour- — such as a cancerous uterus — out- side the canal or by contracting peritoneal adhesions, or by a diffuse growth which has arisen beyond the bowel but has grown around it and compressed it. As a further amplification of the table above given, a classification niay be based upon the degree of the obstrue- tion, for it is evident that cases of intestinal blocking may be divided into those in which the lumen of the tube is completely occluded and those in which the closure is in- complete, and the passage is only imperfectly obstructed. Such a classification arranges itself as follows: — 1- Occhision. Closure of Lumeji of gut complete. Passage of contents impossible. Illustrated by ^^1) .strangulation and (2) torsion. 2. Obstruction. Closure of lumen of gut incomplete. Passage of contents difficult. Illustrated by (3) invagination, (4) obtura- tion, and (5) stenosis. It is unnecessary to state that considerable differences both as regards symptoms and prognosis, exist between the 6 INTESTINAL OBSTIiUCTION "cases in which the liunen of the howel is absokitely occkidcd and thos-e in Avhich the passage is merely obstructed, such obstruction beino- incomplete. Finally it will be found convenient when dealing with the morbid aTioiomy of intestmal ohstruction to arrange the anatomical varieties of the affection in the following order : — 1. Strangulation by bauds and through ajjcrtures, including " internal heruiiB." 2. Volvulus. 3 Intussusception. 4. Obstruction due to foreign bodies, gall-stones, and enteroliths. 5. Stricture. 6. Obstruction due to tumours growing from the bowel wall. 7. Obstruction due to the pressure ot tumours, etc., external to the bowel. 8. FfBcal accumulation. This method of classification will be observed in the sections which follow on the pathology and morbid anatomy of intestinal obstruction. 2. The Classification of Intestinal Obstruction ac- cording TO THE Clinical Manifestations pr(.)duced. 1. Acute obstruction. 2. Chronic obstruction. 3. Cases in which symptoms of acute obstruction supervene on those indicative of chronic obstruction. The acute cases are of so severe a type that the majority die, if unrelieved, in some six or seven days. Examples of this form of obstruction are provided by cases of strangula- tion by bands, by volvulus, by acute intussusception, and by abrupt blocking of the bowel by gall-stones or foreign bodies. Chronic obstruction, on the other hand, may pui'sue a course extending over months or even years. It is illustrated by tke various form of stenosis of the bowel, by chronic intussusception, and by fiecal accumulation. The cases which come under the third category are those in which the syinptoms of chronic obstruction are suddenly interrupted by the phenomena of acute occlu- sion of tke bowel. This A^ariety is illustrated, in case of stricture of tke intestine in which the narroAved part of the gut becomes suddenly occluded, by bending or kink- ing of the bowel, or by the blocking of its lumen by INTliODUGTION. 7 a foreign body which has been swallowed, or by a Uiass of undigested food. liELATIVE FREQUENCY OF THE VARIOUS FORMS. Precise information upon this point is not very easy to obtain. Statistics based upon post-mortem records must obviousl}^ be incomplete, as only a proportion of the examples of intestinal obstruction are fatal. Hospital records deal for the most part with the severer forms of the trouble, although it must be acknowledged that such examples of intestinal obstruction as are not serious or severe are few in number. Tables based upon the published records of individual cases are the least suited of all for the present purpose. Such records are largely concerned with instances of successful treatment on the one hand, and with pathological surprises and anatomical curiosities on the other. An examination of the records of the London Hospital shows that the cases ascribed to faecal accumulation are the most numerous ; then come cases of stricture of the large intestine, then intussusception, and next in order of fre- quency strangulation by bands. Obstruction due to tumours external to the bowel ranks next ; then follows the blocking of the gut by gall-stones or foreign bodies ; while the remain- ing forms of intestinal obstruction may be spoken of as rare. THE PORTION OF BOWEL INVOLVED. Strangulation by hands most commonly involves the small intestine. The small intestine also is most often concerned in internal hernias. Volvulus is most frequent in the sigmoid flexure, and is, indeed, rare elsewhere. Intussusception has its most usual seat in the ileo-Cfecal segment of the bowel. Strictures of all kinds are more conmion in the colon than in the lesser intestine. They are more common in the lower segments of the colon than in the upper. Obstruction due to pressure from without may be met with in any part of the canal, but more usually concerns the large intestine as being the less movable, and especially the rectum and sigmoid flexure from their position with reference to the pelvis. Foreign bodies often lodge in the lower ileum and in the cfecuni, and gall-stones are apt to become impacted in the jejunum or upper ileum. Fcecal accumulation of necessity is met with only in the colon, and often in the caecum and sigmoid flexure, or in the hepatic or splenic flexures. 8 INTESTINAL OBSTRUCTION. THE QUESTION OF SEX AND AGE. Strangulation by hands and through apertures is a little more coirimon in males than in females, is met with mostly in young adults, and is rare after forty. It is still rarer before ten. Internal hernice have been shown to be more common in males, and the greater number of the recorded cases have fallen between the ages of twenty- live and forty-five. Vol- vulus of the sigmoid flexure is about four times more common in men than in women. It is most usual between forty and sixty, and is, indeed, rare before forty. Acute intussusception is a little more often met with in the male sex. It mostly attacks the young. Fifty per cent, of the cases are under the age of ten years. Strictures are equally coirtmon in the two sexes. The non-mahgnant occur about early middle life. The cancerous stricture is rare before forty. (Certain strictures of the intestine are congenital. Obstruction due to tumours external to the bowel is obviously more common in women, and in adults of that sex. Obstruction due to impacted gall-stones is more usual in females than in males, and the average age lalls between tilty and sixty-five. Fcecal accwmulation occurs with greater frequency in women than in men. It is most common in adults and the aged, and is, as may be imagined, not infrequent in the insane and hystericaL PART I. PATHOLOGY AND MOEBID ANATOMY. CHAPTER I. GENERAL PATHOLOGY OF INTESTINAL OBSTRUCTION. Ix this section of the work the subject will be dealt with in the following order : The General Pathology of Occlusion of the Bowel. The General Pathology of Obstruction of the Bowel. The Morbid Anatomy of Particular Forms of Intestinal Obstruction. The General Pathology of Occlusion of the Bowel. — ■ In the variety of intestinal obstruction now to be considered the closure of the lumen of the gut is complete, the passage of intestinal contents is impossible, and, in fact, the obstruc- tion is absolute. This variety is illustrated hj the many forms of strangulation of the bowel and by volvulus. The bowel concerned is, at the time of the accident which occludes it, normal ; the occlusion is sudden, and is practically complete from the first ; the segment of intestine involved is usually the small intestine, and when the colon is implicated the lesion most commonly takes the form of volvidus. As a typical example of the condition may be selected the strangulation of a loop of ileum beneath an adherent peritoneal adhesion. The small intestine, by its mobility, by the smoothness of its surface and by its relatively small girth, is much more apt to be snared by a band than is a loop of the colon. The wall of the lesser bowel is comparatively thin and frail, and the effects ot strangulation are very soon made manifest in its deHcate tissues. The nerve supply of the lesser bowel is elaborate, and in close association with the great nerve centres of the abdomen. The colon, on the other hand, has stouter walls, its sacculi and the appendices epiploicse may offer some obstacle to the smooth gliding of a loop beneath a band, and, if lightly snared, the disposition of its muscular layers would 10 GENERAL PATHOLOGY. facilitate its escape. The colon is cast in a coarser mould than is the lesser bowel. Its physiological purpose is less important. It is, indeed, little more than a receptacle for debris discharg-ed from the intestine above it ; and, as one might expect, its nervous organisation is not so elaborate, nor is its connection with the great nerve centres of the abdomen so intimate and direct as it is in the case of the jejunum and ileum. It thus happens that the phenomena of strangulation are much more pronounced, both as regards the pathological and clinical aspects, when the small intestine is concerned than they are when the segment snared belongs to the colon. Other things being equal, the strangulation of six inches of ileum is a much more severe lesion than is a corresponding strangulation of six inches of the sigmoid flexure. It is not only much more severe, in the sense of being more clearly marked in all the phenomena produced, but it is in a corresponding degree more serious. If a strangulation of the colon is to produce manifestations equal in degree with those which attend strangulation of the lesser bowel then a greater extent of intestine should be involved. When a considerable segment of the colon is implicated, as in volvulus of the sigmoid flexure, the phenomena are verj^ acute, and are quite on a par with the efl'ects attending a strangulation of the lesser intestine. In such instances what the colon has lacked in fineness and sensitiveness of structure it has made up in the extent of tissue involved. The changes brought about in the bowel by absolute occlusion of the kind now under consideration are identical with those which attend a strangulated hernia. The difference between the intestine above the obstruction and that below is very sharply marked. Lavater, in graphically describing the effects of strangu- lation, observed that the bowel above the obstruction grows red, the bowel below it grows white, and the coil involved grows livid and purple. The intestine above the seat of strangulation is dis- tended and tilled with gas and fluid. The degree of dis- tension varies, but the bowel may be often found to be twice or even three times its normal size. The distended gut is a dull red. This tint is due to a certain degree of congestion, and upon the serous surface the dilated blood- vessels form a dense tracery. The dilated gut may be actually much thickened by oedema, but it never shows any traces of hypertrophy. Indeed, if there be no oedema the bowel STRANGULATION OF THE BOWEL. ]l Avail will be found to be actually thinned, and this condition can be often seen in coils which are at some distance from the obstruction, but Avliich have nevertheless taken part in the general distension. These thinned coils will be pale. The mucous membrane of the gut near to the occlusion is found to be swollen with (sdema, aud of a deep red colour. Superficial erosions are not infrequent in the gut just above the obstruction, but the ulcers which are so common, and indeed so usual, in the intestine above a stenosis are in this instance absent. Now and then gangrenous patches are found in the wall of the intestine which is immediately above the involved loop. This condition is, however, only found in cases ot strangulation which have been of imusually long duration. In no circumstances is it common ; in internal strangu- lation it is quite rare, and the examples met with are usually provided b}'' cases of strangulated hernia. The intestine below the strangulation is pale, con- tracted, and empty and accords with the condition of the " starvation intestine." As a rule, the contrast between the bowel above the obstruction and that below is . very marked, but now and then I have seen quite a definite deoree of congestion in the bowel immediately below the implicated coil. It may be mentioned in this connection that in certain cases of strangulated hernia the bowel below the stricture has been the seat of acute enteritis. The strangulated loop will exhibit those changes which have been so carefully observed and so elaborately described in connection with strangulated hernia. The strangled loop becomes congested and oedematous. As the engorgement increases the colour changes from a dark blue to a reddish blue, and thence to a chocolate or a port-wine colour, and finally, in extreme cases, to black. These colour changes, and, indeed, all the phenomena of strangulation, are more marked in instances in which a small loop is well snared than in cases attended Avith the strangulation of a large coil. In the earlier phases of strangulation the individual vessels can be seen upon the bowel Avail, but as time passes the outline of the separate vessels is lost. The snared boAvel preserves for a Avhile its normal smooth and lustrous surface, l.'Ut this is soon replaced by a surface Avhich is dull, cloudy, and sticky. Finally, upon the serous membrane will be apparent the effects of local peritonitis. Noav and then quite an extensive layer of coagulated fibrine, irregularly disposed, may be found upon 12 GENERAL PATHOLOGY. the strangled coil. The snared bowel is tense, owing to the infiltration of its coats, and the distension of its cavity with gas. To the touch it feels thick and fleshy. Within the loop will be found, as a rule, only a little thin, dirty-looking fluid, which in an instance or two may be stained with blood. Clots of blood have been found within the loop. Finally — if the patient live long enough — the bowel becomes gangrenous. It loses its elasticity, and feels soft and doughy. The gangrenous parts may be black in colour, but are more often ashen grey. The extent of the gangrene shows considerable variation, from a mere patch to the destruction of a considerable loop of gut. At a gangrenous point the gut may become per- forated S|3eeial stress comes upon the bowel at the line of the actual constriction, and changes follow which are identical with those met with in strangulated hernia. Linear gangrene is very apt to occur at this line. Under the influence of pressure the mucous membrane perishes flrst, then the muscular coat, and last of all the serous tunic. The effect of the strangulation is, as a rule, more marked in that end of the loop which is continuous with the bowel above the line of constriction- It is by no means alwa3^s easy to tell whether the strangulated gut is still living or is dead ; it is still more ditiicult to foretell that, although damaged, it will recover. If the covering of the bowel retain its lustre, if the vessels in its walls can be seen to empty and I'etill on stroking, and if the gut bleeds when pricked, it is evidently still living. On the other hand, the lustre of the serous coat may soon be destroyed by inflammation, the individual vessels may be lost to view, and an extravasation of blood may have taken place at the point under examination. Mere depth of colour IS not an infallible sign of the state of the gut. A loop almost black in colour may undergo complete recovery, while a like loop that is merely a bluish purple may give way alter it has been liberated. The interpretation of the varied changes found in the intestine after occlusion of its lumen has been the subject of much discussion. It cannot yet be said that the pathology of the condition is to be explained in a manner which is entirely satisfactory. The causes of the changes found in the wall of the strangulated loop are not ditiicult to explain. It has been long ago pointed out that distension of a loop of intestine is PATHOLOGY OF METEORISM. 13 attended with such a loss of its contractile ability as soon to reach the point of paralysis. It is not difficult to understand that the distended bowel might become congested owing to gross disturbance of its circulation, but, following upon this, come definite difficulties in the way of explaining the distension which is so much in evidence. Thus it happens that most of the interest attaching to this subject has centred around the pathology of meteorism. It was assumed in a general way that meteorism was due to the circumstance that gas accumulated in the bowel and that this accumulation depended upon the simple fact that the bowel was blocked up. The conclusion which must follow from this assumption is that the degree of meteorism in intestinal obstruction must depend in the main upon the seat of the blocking and that the nearer this be to the anus the greater must be the distension of the belly. Clinical facts, however, do not quite support this con- clusion, and but very little examination into the matter from a clinical standpoint makes it evident that the explanation is not entirely satisfactory. A good deal of light has been thrown upon this subject by certain experiments upon animals. The most valuable series of experiments was performed by Kader,^" and as his work deals with many phases of the pre- sent subject it is well that it should be considered in some detail. Kader's experiments are divided into four groups. Group I. A loop of intestine was strangulated together with its mesentery. The bowel was therefore completely occluded in two places and the circulation of blood in its walls was arrested. The lesion was intended to imitate acute strangulation by a band. Group II. A loop of intestine was occluded at two points some little distance from one another. This was so done as not to disturb the circulation of blood in the isolated loop. These experiments imitated the conditions attending stricture of the bowel and occlusion by foreign bodies, etc. Group III. The bowel was left untouched, but the mes- entery of a certain loop was so ligatured that the circulation in that loop was arrested, the lumen of the bowel being per- fectly free. Here were reproduced the conditions attending thrombosis of the mesenteric vessels. Group IV. The mesentery of a certain loop of intestine was ligatured as in Group III. The bowel immediately above the loop thus deprived of blood was occluded so that no fa3cal * Beutsch. Zeitsch.filr Chir., 1891, p. 57. u GENERAL PATHOLOGY. matter passing from above could enter the section of intestine attached to the damaged mesentery. (See Fig. 1.) The changes observed in the intestine as the results of the lesions just enumerated are as follows : — Group I. When the strangulating cord is not too tightly drawn the loop of bowel presents at first the condition of venous hypertemia and then of venous stasis. The bowel wall becomes oederaatous and often presents extravasations of blood. A serous exudation takes f)lace into the umen of the gut. If the strangu- lating cord be drawn as tightly as possible the loop becomes pale and then cyanotic. As the blood supply is abruptly and entirely cut off there is little or no cedema, no extra- vasation and no exudation into the lumen of the bowel. In any case the coil of strangulated bowel soon be- comes paralysed. Gas develops in this coil and dis- tends it. If the loop be apparently empty still gas develops, but if the gut contain fsecal matter then the formation of gas is more copious. The vessels of the strangulated mesentery become thrombosed. The bowel becomes gangrenous in whole or in part. Perforation may take the form of a large and very evident hole, or there may be numerous minute capillary )>erforations which may easily be overlooked but which allow the escape of gas. The bowel above and below the strangu- lated coil at first contracts for a few moments as if from cramp. The bowel above then becomes distended. This distension takes place much slower than in the strangulated loop. The bowel becomes less and less contractile, although not actually para- Ivsed, and its mucous membrane becomes congested and its lumen occupied by stagnant faeces. The intestine below the Group [I[. Tig. 1. Groui) IV. -Kader's experiments to demonstrate the production of Meteorism. KADER'S EXPERIMENTS. 15 damaged part remains empty and to some extent contracted. Experiments by others have shown that the wall, of the damaged bowel very soon permits bacteria to escape and reach the peritoneum and that such escape takes place long before there is any suspicion of perforation. As a result early peritonitis is induced, and this deepens the paralysis of the bowel and so favours an increase ot the meteorism. Group II. If the isolated loop contains no: intestinal matter very little gas is developed in it. If it does contain such matter some gas is formed, but it is small in amount and does not lead to distension of the loop. The contractility of the walls of the loop is only very slightly diminished, and no gross changes — such as just described — take place in the tissues of the bowel. The intestine above the isolated loop becomes more distended than is the loop itself and its con- tractility becomes a little diminished. The bowel below remains unchanged or becomes somewhat contracted. Group III. Marked changes take place in the segment of intestine which is deprived of blood. Its contractility diminishes to the point of paralj^sis. Its walls become thickened and oedematous, and exudation takes place into the lumen of the tube Much gas develops in the affected segment, and in time the bowel exhibits the phenomena of gangrene. Group IV. Like changes occur to those just described. The damaged bowel becomes the seat of local meteorism in spite of the fact that nothing can enter it from above, and it can empty itself freely below. The intestine above the occlusion in the tube becomes more or less distended. From these experiments it will be evident that the gas which causes the meteorism is the product of the decom- position of the intestinal contents, and that its amount is to some extent determined by the quantity of matter in the bowel at the time. Inasmuch as absorption from the bowel is arrested when obstruction occurs, the fluid contents of the intestine above the occluded part appear to be very copious. To some degree the bowel above the obstruction is distended by the actual accumulation, and such accumu- lation tends to favour congestion of the bowel wall. Meteorism is not due to a mere collection of gas which cannot escape. The circumstances which most favour it are such as lead to gross disturbance in the circulation of the gut. clinically, this is very noticeable. Meteorism is marked when the mesentery or mesocolon is largely involved in stran- gulation. Tliis is well illustrated by examples of extensive 16 GENEBAL PATHOLOGY. volvulus. No distension of the intestine can equal that ex- hibited by a volvulus of a sio^ruoid flexure of exceptional length in which the mesocolon has been so twisted as to cut off the blood supply from the whole coil. Thrombosis of the mesenteric vessels tends to favour intense meteorism. In- deed, one of the most extreme examples of flatulent distension of the abdomen which I have seen occurred in a patient who had no intestinal obstruction, but who exhibited post •niortem extensive thrombosis of the mesenteric veins. In the cases of intestinal obstruction the meteorism is obviously favoured by the loss of contractility in the bowel, and this condition is very marked when the circulation in the loop has been arrested. (Compare Groups II. and III.) The advent of peritonitis increases the degree of paresis, and is followed by an augmentation of the meteorism. Mere abrupt occlusion of the gut without disturbance of its circulation leads to an accumulation of the bowel contents above the strictured part. Gas collects at this point, and is unable to escape downwards, but the actual distension of the bowel produced is, in these acute cases, compara- tively slight, and can hardly be said to reach the degree of meteorism. The General Pathology of Obstruction of the Bowel. — The condition to be considered under this heading is illustrated by stricture of the bowel or any stenosis of gradual formation. The bowel is narrowed, but not oc- cluded. The intestinal contents can pass, but pass with difficulty. There is obstruction, but not occlusion. It is to be assumed that the narrowing has formed slowly and gradually, and therefore that the case is chronic. The best example of this condition is afforded by a malignant stricture of the colon. The bowel below the obstruction is empty and con- tracted. It contrasts in a very marked manner with the intestine above the seat of stenosis. It is in a state of feeble tonic contraction, the so-called " inanition contraction," its colour is pale, and its walls are unchanged. It is in the con- dition, in fact, of the starvation intestine. Now and then it may show some distension due to gas produced by the decomposition of such matters as have passed through the strictures. These matters in neglected cases may form sub- stantial accumulations in the bowel, and may even be rx:fained long enough to induce catarrh. The rectum below an obstructed colon may be found to be dilated, and in the condition known as the " ballooned rectum." This curious state is apparently the result of some nerve disturbance. EFFECTS OF OBSTRUCTION. ]7 and I have never seen any condition equivalent to it in any part of the colon below a stricture. The distension of the colon with gas, which is occasion- ally met with below the stricture, has never in my experience been sufficiently marked to lead to the risk of the coil being mistaken for a loop above the stricture. This is a matter of some moment because cases have occurred in which a colotomy has been performed, and the opening found to have been made below the obstruction. The bowel above the obstruction becomes dilated, and its walls hypertrophied. These changes are most intense close to the stricture, and gradually diminish as the site of the obstruction is departed from. They are more marked when the colon is involved than when the stenosis concerns the small intestine. In lono-- standing cases the changes in the bowel above the stricture are considerable and far spread. Thus, in cases of stricture of the sigmoid flexure, not only has the whole colon been found dilated and hypertrophied, but also the terminal portion of the ileum. The bowel may be greatlj^ contorted and much lengthened. The distension, especially where the colon is involved, may be enormous. Thus, in a case of cancer of the sigmoid flexure causing stricture, reported by Dr. Fagge,"^ the splenic flexure of the colon was found to be as large as a distended stomach. In a case of stricture of the splenic flexure by the same author the csecum was found to be as large as the calf of the leg. In another instance, where the stenosis had involved the descending colon, the large intestine above the obstruction had a diameter of from eleven to twelve inches.f The enormous distension of which the colon is capable is well illustrated by a specimen in St. Bartholomew's Hospital Museum,! showing the large intestine of a child (who died of rectal stricture) that has a diameter of more than one foot. The hypertroph}^ is a true hypertrophy of muscle, and not a mere hyperplasia. It is due to abiding efforts on the part of the intestine to force matters through the narrow strait in the bowel. It is the outcome of overwork. The hyper- trophy concerns more conspicuously the circular fibres. Ex- periments upon animals shoAv that this hypertrophy may commence as early as the fifth day after the lumen of the bowel has been narrowed, and that it may be quite evident by the ninth day. When the intestine has attained a certain * Guy's Hosp. Reports, vol. xiv., p. 272. t Lancet, vol. ii., 1876, p. 505. J Xo. 1052. C 18 GENERAL PATHOLOGY. degree of h3q3ertropliy, and has yet failed to overcome the obstruction, there iinally appears a degeneration and an atrophy of the hypertrophied fibres. The bowel wall becomes enormously increased in thickness. The intestine feels heavy, firm, and leathery. In the colon the longitudinal bands stand out with remarkable clearness. The vessels of the intestine are very prominent, and the gut becomes a little deeper in colour. The mucous membrane of the bowel is thickened from chronic catarrh, and is very commonly ulcerated. These inflammatory changes are more marked in the colon than in the small intestine, and are most pronounced just above the narrowed part. They are due to the long-continued distension, to the constant pressure of retained fyecal matter, to the actual mechanical impact of solid masses, and to the chemical and bacteriological effects of decomposition set up in long-retained intestinal matters. It will be evident, therefore, Avhy such manifestations of inflammation are more marked in the colon. In the small intestine ulcers are found above the stricture, and perforation of these ulcers is a common cause of death. The ulceration is, as a rule, situated just above the stenosed part, and if perforation occurs it will occur here. There are a few exceptional cases. Thus, for example, in a case of stricture of the ileo-cascal valve a perforation was found to have taken place in the middle of the ileum, and on the other hand several feet of the small intestine above a stricture may be the seat of ulceration. These changes, however, in the mucous membrane above the stricture are best studied in the colon. This segment of the colon commonly presents a con- dition of extensive colitis. The degree of this inflammation varies. It is usually of a chronic type, the mucous mem- brane is pigmented, and may appear in places to be sloughy. Some ulceration is usual. The ulcers may be quite super- flcial, and appear as mere erosions. As a rule, however, they extend in depth and size, they present ragged and irregular edges, and in time lay bare the muscular coats. They spread and fuse together, and so produce immense tracts of severe ulceration. Ulceration of this type may involve the Avhole colon. In some reported cases of stric- ture of th.e rectum the entire colon is described as being " worm-eaten " with innumerable ulcers. Certain of the less aggressive ulcers are evidently of long standing, and show marked nigmentation. lu the majority of instances the ulceration is of limited EFFECTS OF OBSTRUCTION, 19 extent. When the stricture is at some distance from the valve, ulceration may be noted in two distinct j^laces, namely, just above the obstruction and in the cnecum, the intervening mucous membrane being healthy. This has been met with several times in stricture of the sigmoid flexure. When perforation occurs in colic strictures the abnormal aperture may be either just above the stricture or in the ciecum. The relative proportion of perforation in these two places is as seven to four. In several cases where ulcers have been found in the csecum similar lesions have been at the same time met with in the ileum. In one instance of simple stricture of the splenic flexure there was an annular ulcer in the colon just above ithe obstruction, and six large ulcers in the lower end of the ileum. No other part of the bowel, not even the caecum, was involved. A fatal perforation had occurred in the loAver ileum. "^ The perforating ulcer above the stricture need not open into the peritoneal cavity. In a few rare cases where adhesions have formed the perforation has been so j)]aced as to give temporary relief at least to the obstruction. Thus in one case of stricture of the valve, the ileum opened into the commencement of the colon, forming a fistula bimucosa through which the faeces could pa.ss.t Other cases of relief by the formation of such a fistula have been reported ; also an instance where the colon above a stricture in a distorted sigmoid flexure was found to have opened into the bladder and rectum. J If the perforation take place very slowly, a sacculated fsecal abscess may be produced, or there may follow a severe and ill-conditioned cellulitis of the retro-peri- toneal tissue. I have seen a case in which a fsecal abscess in the left iliac fossa was the first sign of cancer of the sigmoid flexure. Sometimes the changes in the bowel above the obstruc- tion pass the limits of ulceration, and the part becomes gangrenous. Gangrene developed in these circuujstances is usually found in obstructions of the colon onl}^, and it is only in this part of the intestine that gangrene of an extensive character is met with. Dr. Moxon has recorded a good example of this condition. The stricture was in the sigmoid flexure, the patient an adult. The anterior wall of the ascending colon was wanting (having sloughed) over * Bull, de la Soc. Anat., 1870, p. 27. t Path. Soc. Trans., vol. xxi. p. 171. X Ibid., vol. i., p. 261. •20 GENERAL PATHOLOGY. an area measuring five inches by one inch and a half. Ef.cape of the contents had, however, been prevented by the great omentum, "which had become adherent over the gap, and had closed it. Dr. Goodhart has placed upon record a still more pronounced instance. In this case the sUicture was also at the sigmoid flexure, and the patient i'lO. 2. — Great saccii'-ation of the Transverse Colon due to a Stricture at the Splenic Flexure. Tiie wall of the gut is miicli liypertrophied. {Royal CM. of Surg. Mus., No. 2453a.) an adult. A great part of the transverse colon and nearly the whole of the descending colon . were gangrenous, the mucous membrane here being especially involved. Cases of less extensive gangrene leading to rupture of the gut are fairly common. The gangrene in these instances is due partly to obliteration of the vessels in the intestinal wall by pressure and distension, and partly to the irritating action of retained feeces. Often above the stricture is a distinct pouch diiC to distension acting probably upon walls already diseased. The walls of the pouch are thin, the mucous lining is frequently EFFECTS OF OBSTRUCTION. 2l ulcerated, and that ulceration often leads to fatal per- foration. These pouches are more connnonly met with in connection with simple than with malignant strictures, and are more common in the small than in the large intestine. An extreme degree, however, of sac- culation of the colon above a stricture is shown in Fig. 2. {See also page 57.) It is remarkable in how many cases cherry and plum stones have been found in these pouches or in the distended intestine above a simple stricture. The most curious case of this kind is reported by Dr. Wickham Legge. The patient, a female aged twenty-six, for several years before her death evacuated, on various occasions, cherry stones with her stools. She also vomited a few. During life a mass of cherry stones could be felt through the parietes, giving to the hand a peculiar sensation as they were rubbed together. At the autopsy a stricture of the ileo-ca3cal valve was found, and above it in the small intestine an imperial pint of fruit stones.^ In another case of stricture of the ileo-csecal valve nearly a litre of cherry stones was found above the obstruc- tion, t In a case reported by Dr. Peacock there were found in a pouch above a stricture of the small intestine thirty- three plum stones, sixteen cherry stones, and six orange pips. J In another very similar instance there were only three plum stones in the pouch. § Dr. Moore has recorded a case of accumulation of a large number of cherry stones above a simple stricture of the descending colon. || In most of the instances these foreign bodies had led to perforation of the bowel In one case in which I was excising the sigmoid Hexure for an epitheliomatous growth which had caused a tight stricture, I found in the greatly dilated bowel above the stenosis a number of cherry stones which had been swalloAved nine months before the operation. In one curious case of stricture of the lesser bowel a conical pouch or funnel was found to hang down into the lower part of the intestine. It had an aperture at its apex, and through it all the faeces had passed. The funnel-like process was large and conspicuous, and is well depicted in Fig. 3.^ It was probably produced by the excessive * Path. Soc. Trans., vol. xxi., p. 171 . ■ t V Union 2Ied.,'\^bQ, 1^0 bl. X Path. Soc. Trans., vul. x., p. 154. § Tbid., vol. iv., p. 1.52. II Lancet, vol. ii., 1876, p. 505. U St. Thomas's Ho.sp. Museum, No. Q. 129. GEXEBAL PATHOLOGY. enlargement of a simple poucli formed above the strictm^e. The fimdiis of the pouch would be pressed against the wall Fig. 3. — Stricture of the small Intestine with Pouch. a aiKl a' point to fraiia holding in position a lemarlialjle ponch of niiicous membrane. ot the gut below the stricture, until at last perforation into that part of the intestine would occur, and the formation of the lunnel-like process would be complete. It may be noted that in the specimen the mucous lining of the process EFFECTS OF OBSTBUGTIOX. 23 can be seen to be continuous with that of the intestine above. It is common to find about simple strictures of the lesser bowel certain frpena and bars of cicatricial tissue which are appaiently the products of an irregular ulcera- tion, and possibly of the adhesions of adjacent inflamed surfaces. 24 CHAPTER II. THE ]\IORBID ANATOMY OF PARTICULAR FORMS OF INTESTINAL OBSTRUCTION. Strangulation by Bands or through Apertures. — Under this variety of intestinal obstruction may be included : — 1. Strangulation by isolated peritoneal adhesion. 2. Strangulation by cords formed from the omentum. 3. Strangulation by Meckel's diverticulum. 4. Sti'angulation by normal structures abnormally attached (sucli as by an adherent vermiform appendix or Fallopian tube, or by a fixed mesentery), including strangulation by the pedicle of an ovarian tumour and the like. 5. Strangulation through slits and apertures in the mesentery or omentum, or in certain peritoneal ligaments, or through membranous adhesions. These various forms may be conveniently considered together, for although in each case the anatomical cause of the obstruction is different, yet the effects upon the gut are in all instances practically identical. In each the segment of bowel involved is, almost without exception, the small intestine. In each the mechanism of the obstruction is practically the same. In each the symptoms that arise are, Avith some minute exceptions, so nearly identical that they may be studied as a whole. In each the course and issue of the malady are such that these various forms may be said to share a common 23roo-nosis. Between them all, moreover, there is a close bond of union in the fact that they are adapted for the same form of treatment, and may be relieved by tlie same operative procedures. Considered as a whole, this form may be taken as the type of acute intestinal obstruction. It is the strangidated hernia of the interior of the abdomen. It obstructs the gut as a hernia obstructs. The symptoms that attend this variety STRANGULATION BY BANDS. 25 of intestinal obstruction are, in all main points, the syniptoins of strangulated hernia, and the prognosis of the two aft'ections depends rather upon the situation of the constricting agent than upon any other factor. It is for many reasons a matter of moment to note that strangulated hernia and the different forms of internal obstruction above described are but varieties of a single malad}^ that they differ from one another solely on anatomical grounds, that in their pathology and in the broader lines of their chnical history they are the same, and that, excluding the taxis, they are amenable to the same general form of surgical treatment. It will be convenient to consider the pathological anatomy of these five varieties of obstruction separately, and their symptoms and the elements of their prognosis collectively. " Internal hernia; " are considered in a separate section (page 102). Certain of these hernia? conform to the type of intestinal obstruction now under dis- cussion ; others by no means so conform. The conditions described as internal hernise present such varied ana- tomical features and such diverse clinical developments that they are conveniently dealt with under one special heading. 1. Strangulation by Isolated Peritoneal Adhesions. The CAUSES OF THE BAND. — Theso isolated adhesions (known commonly as " bands," " solitary bands," or " peritoneal false ligaments ") are the results or residues of some form of peritonitis. Owing to the high mortality of acute diffused peritonitis on the one hand, and the very general and ex- tensive adhesions commonly produced by chronic diffused ^peritonitis on the other, it follows that these isolated bands are usually due to moderate and well localised forms of peri- toneal inflammation. Among the phases of local peritonitis the following may be mentioned as the most common antecedents of the "band" or " false ligament " : — perityphlitis, pelvic peritonitis, peri- tonitis following upon injury, upon abdominal operations, upon strangulated hernia, upon ulceration of the bowel and upon mesenteric gland disease. Tuberculous peritonitis which has ended in real or apparent recovery may also be a factor in the etiology. Among six cases of strangulation by bands alluded to by Dr. Coats"^" no less than four appear to have owed their origin to healed tuberculous trouble. This form of strangulation may occur even during the » Trans. Path, and Clin. Soc, Glasgow, 1893, vol. iv. 26 MORBID ANATOMY. progress of the disease. Larguier des Bancels^ reports the case of a boy, aged eight, who daring the progress of tuberculous peritonitis developed symptoms of acute obstruction, of which he soon died. The autopsy revealed a coil of the lower ileum strangulated by a band, one of the many resulting from the disease of the serous membrane. So little is known of the reputed " intra- uterine perito- nitis " that -the assertion that some bands are due to this condition may be considered as not proved. Most of the " congenital bands " depend upon developmental defects in the vitelline duct. From my own experience I should say that one of the most common causes of the peritoneal false ligament is perityphlitis. It is needless to state that of all forms of limited peritonitis this form is the most frequently met with. I have knowledge of several instances in which " pelvic inflammation," " metritis," or " pelvic cellulitis " appears with- out doubt to have provided the band. In one fatal case of acute strangulation under my care the obstructing false ligament was produced by a localised peritonitis which had followed an excision of the rectum. The instances in which intestinal obstruction of the present type has followed upon an abdominal operation are quite numerous. Lucas- Championnieref makes mention of five instances in which symptoms of intestinal obstruction appeared in a few days after operations which concerned the abdominal viscera. Dr. G. RoheJ in a very exhaustive paper upon this sub- ject deals with seventy-five examples of death from intestinal obstruction following upon abdominal operations. In the majority of the instances the obstruction was duo to adhesions and peritoneal bands. It is well, however, to mention here that certain reported cases of death from in- testinal obstruction after laparotomy certainly appear to be rather cases of peritonitis. This is especially the case in the somewhat numerous instances in which death is ascribed to "septic intestinal paralysis." I have described elsewhere§ the various forms of intestinal obstruction Avhich may follow after hernia, and although strangulation by an adherent band or omental cord has been * Sur le Diagnostic et le Traitement des Elranglements Internes. These do Piiris, 1870. t Revue de Chinirgie, 1892, p. 264. X American Journ. of Obstetrics, Oct., 1894. § Lancet, June 7, 1884. STRANGULATION BY BANDS. 27 met with after hernia it is not a conniion phase of the trouble. (See page 41.) The patch of peritonitis which may form over the site of any deep intestinal ulcer may attract a fringe of omentum and form an omental cord, or it may lead to an adhesion between another coil of bowel which may in time become a strano'ulating aa^ent. With regard to mesenteric gland disease, the little local peritonitis excited in the serous membrane covering the glands may lead to the adhesion of a free diverticulum, or of the free end of the omentum, or may encourage the development of bands which may in turn prove a cause of intestinal strangulation.'^ This is not, however, the only form of obstruction which may be indirectly due to this variety of gland disease, and to avoid repetition they may be alluded to in passing. The local peritonitis may lead to adhesions being formed between two remote parts of the intestinal tube. Thus, in a case recorded by Dr. Hilton Fagge the sigmoid flexure %vas found attached to the ileum, and in the angle between these two adherent portions of gut was a caseous gland. f The ileum about the seat of a diseased gland in the mesentery may become sharply bent upon itself; and between the two limbs of the loop so formed, and fusing them together, as it were, will often be found an old and degenerate gland. Or the bending may be very limited and well localised,' so that a fold of the bowel is turned in and forms a species of diaphragm. This condition is shown in the remarkable case depicted in Fig. 92. In several instances the shrinking of the mesentery after extensive gland disease has been so considerable, and has produced so much distortion, as to lead to a fatal obstruc- tion of that part of the bowel connected with the diseased area. X The Mode of Formation of the Band. — The actual production of the band-like adhesion after peritonitis is easily demonstrated. It is well known that in this affection, and especially in the so-called adhesive form, a librinous exudation appears * See specimens, Guy's Hosp. Museum, No. 1819 (36) ; and St. Bart.'.s Ho=p. Museum, No. 2165 ; also cases by M. Bricheteau (Bull, de la Soc. Anat., 1861, p. 118), and by Rlr. B. Hill {Lancet, vol. i., 1876), p. 773. f Path. Soc. Trans., vol. xxvii., p. 1.57. X See Path. Soc. Trans., vol. xxi,, p. 187; and cases by Dr. Fagge, Guj's Hosp. Keports, vol. xiv., p. 272. 28 MORBID ANATOMY. upon the surface of the inflamed membrane. Any two sur- faces may, through the medium of the exudation, become adherent if they be brought into contact with one another. The adhesion may be over a very extensive surface, or may involve only a lew isolated points. As the inflamma- tion subsides there is no doubt that the greater part of the exudation is in time absorbed. I have many times found the extensive soft adhesions exposed in operating for perityjjhlitic abscess to have entirely vanished when the affected region has been laid open at a second operation. It is, so far as I know, impossible to state under what conditions adhesions will persist on the one hand or vanish on the other. Extensive and tough adhesions may folloAV upon a peritonitis of moderate degree, while little or no trace may be left of a peritonitis of a quite acute character. That there is, however, considerable absorption of the fibrinous exudation in every case there is little doubt. What remains becomes organised into fibrous tissue, and so are produced " adhesions," "bands," "peritoneal false ligaments," and the like. Some of these adhesions may be extremely loose and delicate, while others are composed of a more substantial material. It would appear that many of the more flimsy of these uniting structures in time disappear, even after they have become organised into definite connective tissue. One circumstance which has distinct influence in this direction is certainly the movement of the adhering parts. During the progress of peritonitis the intestines are re- latively still and more or less distended. As a result of this distension coils of bowel may be brought together which were hitherto far apart, or a certain loop may be placed in association with a comparatively distant point on the parietes. When the inflammation has subsided, the parts return, as far as possible, to the status quo ante; peristaltic movements spread through the intestine, coils which were close together tend, as a result of those movements, to become separated, and adhesions that attach the intestine to points upon the parietes are persistently dragged upon. It follows from this almost constant tension that the still soft adhesion yields, becomes elongated and thinned, ulti- mately gives way and is absorbed. Movement also has great influence upon the future physical characters of the adhesion. Most of the adhesions assume primarily a membranous character, and this they may retain throughout their existence (Fig. 85). It is not uncom- mon to find some coils of intestine matted together by an STRANGULATION BY BANDS. 29 extensive series of false membranes, Avhich appear sometimes as wide expansions, at other times as thin but broad ribbon- like bands, of all dimensions and of various lengths (Figs. 4 and 30). If two distant coils of small intestine have been brought together during peritonitis, and have become attached to one another by means of the exudation, or if a like attachment has taken place between the intestine and the parietes, then, as movement is restored in the bowel, the adhesions, which may be quite membranous, are dragged upon, and as a result become elongated. As they increase in length so must they become attenuated in width and thickness. The constant tension, moreover, probably interferes with their already feeble nutrition, and induces a further wasting. The wide membranous adhesion may thus become narrowed and ribbon-like. It may, however, undergo a still further change. The adhesion, subjected to the rolling movements of the intestines over one another, and to frequent torsion, now in one direction and now in the other, tends to become rounded and cord-like, and the more it is stretched the more completely is this transformation favoured. Thus are formed " peritoneal false ligaments " and the bands and cords now under discussion. The moulding of a mass of adhesion-tissue into a cord by movements within the abdomen is illustrated by the changes effected by those movements in the omentum when it becomes adherent. This structure may become attached by its free extremity, and in the course of time, if the abdomen be opened, it will be found to be changed into a corcl-like mass. The intestines in their movements have rolled over and under and about the adherent membrane, and at last they have moulded it almost as a piece of clay may be moulded when rubbed between the palms. This change is best brought about when the situation of the adhesion is such as to keep the membrane on the stretch. A like metamorphosis may be effected in any smaller part of the great omentum which may have become adherent to a distant point. By a combination of these various circumstances, by a stretching of the adhesion on the one hand, by its consequent attenuation on the other, and its subjection to the moulding influences of moving intestines for the third part, it happens that cords and bands of great length are often produced as a result of peritonitis. Many instances may be given, but one of the most striking is afforded by a case reported by Mr. Obre.^ In this example a cord-like *Path. Soc. Trans,,, vol. iii., p. 95. 30 MORBID ANATOMY. band was found to pass from a coil of small intestine situated near the xiphoid cartilage to the parietal peritoneum about the inguinal canal. The false ligament measured seventeen and a half mches. The patient had had a strangulated inguinal hernia, and there was clear evidence to show that the herniated bowel had been that to which the cord was attached. It must bo remembered that not only may these bands form arcades beneath which coils of intestine may become strangulated, but the longer of them may become separated at one of their points of attachment, and so form floating cords which may lead to strangulation of a loop by " knotting.'' The Form axd Disposition of the Baxd. — The appear ance of these false ligaments and bands, in cases in which they have produced obstruction, varies greatly. Most commonly the " band " takes the form of a firm fibrous cord about the size of a No. 4 or No. 6 catheter. It may be still more slender, and appear as a tough, rigid thread. On the other hand, it may be of comparatively Fig. 4. — StraDgulation by a broad Peritoneal Band passing between two adjacent Coils of Ileum. large size ; thus M. Terrier has reported a case of internal strangulation, for which he performed laparotomy, where the constricting band had nearly the dimensions of the little finger.^ The cord-like " band " is usually described as being dense and fibrous, and in one or two instances as being of almost cartilaginous hardness. Less frequently * Bull, et Mem. de la Soc. de Chir. de Faris, vol. iv., 1S79, p. 56i STRANGULATION BY BANDS. 31 the constricting agent has the appearance of an actual band, and in such cases is found as a tough ribbon-hke membrane, with a width of half an inch or even more. A band of this character is shown in Fig. 4.^ The false ligament is usually single, and hence the name bestowed upon it by Mr. Gay of " the solitary band." It must not be assumed, however, that such a band commonly exists as the solitary adhesion in any given case. It most probably will be the only isolated adhesion, and the only one so modified as to be capable of strangulating the bowel. But in cases where this isolated adhesion is met with other adhesions will often be found. This is especially the case when the band is due to tuberculous or pelvic peritonitis. The same applies, although in a less degree, to the local peritonitis set up by inflammation about the caecum. Here, in addition to any adhesion which may have become isolated, elongated, and cord-like, there will very probabl}^ be some matting together of parts in the immediate vicinity of the appendix. Many cases, however, are reported where the only relics of a perityphlitis have assumed the form of one solitary band. A single false ligament, the repre- sentative of a single adhesion, may be produced by the very localised peritonitis which is sometimes associated with caseous degeneration of a mesenteric gland. I have met with several cases, and not a few specimens, which illustrate this circumstance.! A single adhesion may readily follow upon the little speck of peritonitis attending an intestinal ulcer (Fig. 32). As the ulcer deepens it excites an inflannnation over a very limited area of the serous surface. This inflamed spot ad- heres to some other point on the peritoneum ; a single adhesion forms, which, becoming elongated by the method already described, forms an example of the solitary band. A great many of the cases of " solitary band " described are, however, evidently instances of Meckel's diverticulum or a diverticular ligament. {See page 46.) I am, indeed, under the impression that the majority are of this character. In some few cases there have been two or more false, ligaments found in the abdominal cavity. Sometimes these would appear to have been produced by the thrusting of a coil of intestine through a broad peritoneal adhesion, so as to divide it into two segments. In other instances the bands are independent of one another. Mr. Berkeley Hill * London Hosp. Museum, No. Ad. 78. t Case of Glenard's Disease, treated by operation by tbe author (Brit. 3Ied. Journ., Jan. 4, 1896). 31 MORBID ANATOMY. reports a case of acute intestinal obstruction where two bands existed, both, of which constricted knuckles of small intestine. One constriction was, however, comparatively slight, the other was severe. Laparotomy was performed, and unfortunately the band found and divided was that associated with the minor obstruction. The more serious strangulation was overlooked, and the child died. The Fio. 5.— strangulation of the Ileum by a Y-staped Band attached to the Fundus of the Uteru?. The uterus is .showu at the lower part of the figure. adhesions in this case appear to have been due to mesenteric gland disease."^ Mr. Lupton f records a case in which the bowel was constricted ' by no less than four bands in four separate places. Symptoms of obstruction had lasted over seven .days. The operation revealed only one of the bands. The patient survived the operation twenty- four hours. The false ligament, although single, may have a com- plicated arrangement, and lead to extraordinary forms of * Lancet, vol. i., 1876, p. 773. t Laneit, May 1, 1897, p. 1204. STRANGULATION BY BANDS. 33 constriction of the bowel. Thus in the specimen shown in Fig. 5* there was one isolated adhesion. It was, how- ever, broad and Y-shaped; one end of the Y was attached to the uterus, while the two other ends were connected jj^o, 6. Strangulation of the Ileum by complicated Bands passing between the Uterus and Ovary. with points on the small intestine about one inch and a half apart. There were many adhesions about the pelvic viscera. In Fig. 6t it will be seen that an adhesion connecting the uterus, ovary and mesentery leads to a complicated form of strangulation and to a double con- striction of the bowel. * St. Bart.'s Hosp. Museum, No. 2164:. t Guy's Hosp. Museum, No. 2507 (50). D 34 MORBID ANATOiUY. In many cases ot strangulation by a false ligament the circumstances of the obstruction are complicated by simple adhesions of the same age, and due to the same cause as the so-called ligament. These adhesions may have matted together into a knuckle the very segment of the bowel which has become strangulated, or may have so attached them- Fio. 7.— StraTigulalion of small Intestine by a solitary Band attached at either end to the Mesentery. selves to the involved intestine as to encourage a volvulus of it v/hen beneath the constricting band. The attachments of these peritoneal false ligaments exhibit the greatest possible variety. To be capable" of pro- ducing a strangulation of the intestine the band must have at least two points of attachment, and there is scarcely any conceivable combination of connected points which is not illustrated in the history of these adhesions. Most commonly the strangulating band is connected by one end with the mesentery. In one very frequenfr variety the band is attached by both its extremities to the mesentery. STRANGULATION BY BANDS. 35 the points of attachment being at a variable distance apart. This disposition of the band is illustrated by Fig. 7,"^ and it would appear to be frequently due to a limited peritonitis incident upon mesenteric gland disease, f A certain number of " bands " so attached are, however, without doubt relics of incomplete development connected with the vitelline duct. In that large series of cases where the isolated adhesion is due to pelvic peritonitis, it may be found to be attached by one end to some pelvic viscus, and by the other to a neighbouring part. Thus bands are iound passing from the uterus, or ovary, or bladder, to the parietal peritoneum of the pelvis or abdomen ; or, starting from the same source, they may attach themselves to the coecum or sigmoid flexure, or with much greater frequency to some part of the lower ileum or its mesentery. In several instances the constricting band has merely passed from one point on the pelvic wall to another. When the band has been caused by some local peri- tonitis in connection with hernia, one of its extremities may be found attached in the vicinity of the femoral or inguinal rings, while the other end may be fixed to the intestine, the mesentery, or the posterior parietal peritoneum. When the band has followed after perityphlitis, both ends ot it may be found connected with the cajcum or appendix-, as is apparently the case in a specimen in the Royal College of Surgeons Museum ;:|: or it may pass between the caecum and the peritoneum lining the iliac fossa, or attach itself to the ileum or to its mesentery, or become connected with the lining of the anterior abdominal wall. In some cases, and I think this especially occurs after very localised peri- tonitis due to intestinal ulcer, a single band passes between two neighbouring coils of intestine. The early stage of such a band is well shown in Fig. 82. Among the less usual attachments of these b;^nds may be mentioned the following : Between the descending colon and the mesentery. § Between the mesentery near the c;ifcum, and the anterior surface of the rectum. || Between the transverse colon and the caecum^ (the band in this case occurred in connection with extensive adhesions due to peritonitis after ulcer of the stomach). Between the / * University Coll. Museum, No. 1161. t See specimens at St. Bart.'s Hosp. Museum, No. 2165; and Lond. Hosp. Jluseiiin, No. Ad. 79. t No. 1360a. § St. Thomas's Hosp. Museum, No. R 15. II Mr. Ward; Path. Soc. Tr.ns., 1852, p. 362. IT Dr. Hilton Fagge ; Guy's Mosp. lieports, vol. xiv., 1869, p. 272. 36 MORBID ANATOMY. ■ymentum and the mesentery.* Between the ascending and descending colon. f Between the colon and the ovary.J In not a few cases isolated cords ot adhesion are described as passing between the sigmoid flexure and distant parts. In this way the flexure has been connected with the csecum, with the mesentery near the csecum, and with the parietal perito- neum in the right iliac fossa. Rokitansky§ reports a case of adhesion between the sigmoid flexure and a coil of small in- testine in the right hypochondriac region. It is well known that the distended sigmoid flexure may reach the right iliac fossa, or even the right hypochondriac district, and cases like the above may be explained on the assumption that the flexure became greatly distended during the time that the jjeritonitis w'as active from which the adhesions were derived. Methods of Strangulation. — When a portion of the in- testine is strangulated by an isolated peritoneal adhesion the gut will be found to be constricted in one of two ways. 1. It may be strangulated beneath the band as beneath a shallow and narrow arch. 2. It may be snared and constricted by a noose or knot formed by the false ligament itself ]. Stra'tig Illation beneath a bavd can only occur when the band is comparatively short, and when it is stretched along a firm surface. From an examination of some fifteen cases, where the constricting cord is well described, it would appear that its average length in this form of strangulation is about one and a half to two inches. The arch beneath which the implicated bowel passes is variously described as large enough to admit one, two, or three fingers. Larger arches have been formed permitting much intestine to pass beneath them, but tliese great apertures are exceptional in acute cases. Since the cord must be stretched along a firm surface it happens that this form of strangulation is much more commonly found about the posterior abdominal parietes than elsewhere. It is often met with about the iliac fossie, especially that of the right side, and about the brim of the true pelvis. When a band passes between two points on the mesentery a coil of small intestine may readily be strangulated beneath it, the resisting parts between which the bowel is compressed being the fabe ligament on the one hand, and the mesentery on the other. It will be readily understood also that a knuckle of the small intestine may be strangulated with little difficulty when it passes between a band and a solid viscus like the uterus. * Dr. Hilton Fagije, loc. cit. t Seerig; Rust's Magazin fiir Heilkuiifie, band xlvi. X RokitHnsky ; Brit, and For. Med.-Chir. Review, vol. iii. § Mauual uf Path Anatomy (Syd. Soc), vol. ii. , 1850. STRANGULATION BY BANDS. 37 Fia. 8. In some few cases the firm basis required for this form of obstruction appears to have been provided by a rigid mass of adhesions, across which the false hgament has been stretched A loop caught beneath a band is very apt to undergo rotation, and such twist or volvulus may contribute more to the actual obstruction of the bowel than does the band which represents the strangulating agent. The bowel so snared and twisted may become untwisted and escape. 2. Strangulation by a noose or knot requires a long false ligament which must lie loose and free in the abdominal cavity, being attached only by its two ends. The snaring of a coil of small intestine by this means nmst be a matter of some difficulty, and must be almost impossible in cases where the bowel is perfectly normal. As Leichtenstern has well pointed out, the gut in these cases will usually be found to have been in an abnormal con- dition previous to the occurrence of the strangulation. A knuckle of gut may be rendered so adherent that it could not slip out of the way by peristaltic movement when it had become involved in the noose or knot. It is probably a still more common circumstance for two ends of a loop of in- testine to be matted together by a little mesenterial peritonitis, so that if the noose should slip over such a loop, the constricting cord will find at the base of the loop a nar- rowed neck around Fia. 9. -Straiigulatinn by a Band. {Astlei/ Cooper.) anterior abdominal parietes ; b, band passing from a lieriiial sac to surround tlie intestine ; c. bind return- ing to the hernial sae ; d, loop or noose lorMie