Med- 
\ical 
MONOGRAPHS. 
No. 
I. 
The Diagnosis 
and 
Medical Treatment 
of 
ACUTE 
INTESTINAL 
OBSTRUCTION. 
2&P ill. I?, f U3,>w:& 
Cuppleg 
i^urti, 
$uMi$bet£, 
€J)f 
Algonquin 
S&ogton. Jnfeeftnaf OBefrucfton. 
R. H. FITZ, M.D. 
Reprinted from 
The Boston Medical and Surgical Journal. THE 
DIAGNOSIS AND MEDICAL TREATMENT 
OF 
ACUTE 
INTESTINAL OBSTRUCTION. 
BY 
Professor of Pathological Atiatomy in llTTrvard University, and 
Physician to the Massachusetts Getteral Hospital. 
REGINALD H. FITZ, M.D. 
BOSTON 
CUPPLES AND HURD, Publishers 
Algonquin 
1889 THE DIAGNOSIS AND MEDICAL TREAT- 
MENT OF ACUTE INTESTINAL OB- 
STRUCTION.1 
BY REGINALD H. FITZ, M. D., OF BOSTON. 
In the consideration of intestinal obstruction 
from a medical point of view, the subjects of 
chiefest importance undoubtedly relate to diagnosis 
and treatment. 
The present communication is intended to call 
attention to those features which may possibly 
serve to characterize the former, and to mark the 
limits of the latter up to the point of surgical 
interference. It will be admitted without much 
question that the difficulties of exact diagnosis, and 
the possibilities of permanent relief, are greatest in 
acute, internal forms of obstruction. It is, there- 
fore, to this part of the subject, in particular, that 
the present enquiry is directed. 
The term intestinal obstruction would seem to be 
equivalent to stoppage of the bowels, and refers to 
the absence of an important function of this appa- 
ratus. The conspicuous causes of such a stoppage 
are essentially mechanical, and the anatomist finds 
the bands and cords, the slits and pouches, the 
1 Read before the Congress of * merican Physicians and Surgeons 
in Washington, D. C., Sept. 13, 1883. 6 
Intestinal Obstruction. 
invaginations, twists and knots, the strictures, 
tumors, and abnormal contents. 
But in another class of cases the stoppage is pres- 
ent, the patient dies, and there is not found an en- 
tirely satisfactory, mechanical cause of obstruction. 
If the intestinal coils are agglutinated or adherent 
in such a manner that valve-like projections into 
the canal are formed, these are considered by some 
a satisfactory explanation of the symptom. If the 
mesentery of any coil is so contracted that the legs 
of the loop are closely approximated, this change is 
frequently considered a sufficient cause. But ag- 
glutinated and adherent coils are frequently found 
in the absence of symptoms of intestinal obstruction, 
and the contracted mesentery is seen in cases where 
no stoppage of the bowels has occurred. 
This symptom takes place in still another series 
of cases where the anatomist finds no suggestion of 
a lesion which offers the remotest possibility of 
acting as a mechanical cause. The physician then 
says the obstruction must be due to a paralysis of 
the muscular coat, or a spasm of the circular fibres, 
or a faulty innervation, or to some peculiar modifica- 
tion of function. 
Intestinal obstruction, in a technical sense, how- 
ver, means something more than stoppage of the 
bowels. The latter symptom may be present at the 
outset, it may occur later in the course of the 
disease, or frequent loose movements may be a most 
characteristic symptom of the especial variety of 
obstruction, as in intussusception. Frequent dejec- 
tions may also occur in the early stages of other 
varieties of obstruction, and throughout the course Intestinal Obstruction. 
7 
of the disease when faeces are the cause. Stoppage 
of the bowels is thus not only unnecessary as a 
symptom of intestinal obstruction, but, when 
present, its particular consideration has led to 
frequent errors of diagnosis. Of all the causes of 
stoppage, which have given rise to an erroneous 
diagnosis of obstruction, there is none more frequent 
than peritonitis. 
In a general peritonitis the bowels are expected 
to remain inactive, and medical efforts are fre- 
quently directed to this result. In the circum- 
scribed variety the important symptoms of local- 
ized pain and paralyzed bowels have often led to 
the diagnosis of acute, internal obstruction. This 
is particularly true in the case of inflammation of 
the vermiform appendix, a disease which is con- 
stantly being mistaken for acute obstruction. This 
error in diagnosis leads to corresponding errors in 
treatment. Because the bowels have been opened 
in such cases by powerful cathartics, quicksilver, 
electricity, violent movements of the body, and the 
like, therefore these are claimed to be valuable and 
efficient remedies in obstruction. Too 
often the speedy death of the patient results from 
such treatment, the local peritonitis being made 
general. 
The only intestinal obstruction which deserves 
the joint consideration of surgeons and physicians 
is that due to well-recognized, mechanical causes. 
It is the acute, internal variety of mechanical, in- 
testinal obstruction which forms the subject of this 
paper. 
There are four, main questions which require 
consideration in any given instance:— 8 
Intestinal Obstruction 
First, Is the case one of acute, internal obstruc- 
tion ? 
Second, Where is the obstruction seated ? 
Third, What is the variety ? 
Fourth, What is to be done ? 
The statements which follow in this paper are 
essentially based upon the study of a series of 
cases collected from the English, German, and 
French medical literature since 1880. Its claim 
to consideration lies in the fact that all the cases 
have been submitted to the severest criticism, with 
the resulting exclusion of a very large number. 
They are included under the heads of strangulation 
by bands, cords, etc., intussusception, knots and 
twists, obstruction by abnormal contents, strictures, 
and tumors. The entire number is two hundred 
and ninety-five, and they are divided as follows: — 
Strangulation 101 cases = 34 per cent. 
Intussusception 93 “ =32 “ 
Abnormal contents 44 “ =15 “ 
Twists and knots 42 “ =14 “ 
Strictures and tumors 15 “ = 5 " 
295 “ 100 
Excluding from this series the cases of acute ob- 
struction from abnormal contents and from stric- 
tures and tumors, which are of the least importance 
in practice, there remain — 
Strangulation 101 cases = 45 per cent. 
Intussusception 93 “ =59 “ 
Twists and knots 41 “ =18 “ 
230 “ 100 “ 
It is interesting to compare these figures with the 
larger number in the collections of Duchaussoy,2 
Brinton,3 and Leichtenstern:4 — 
2 Duohauesoy, Memoirs de l’Acactemie (le 
1850, xxiv. 97. 
3 Hrinton, Intestinal Obstruction, 1807, 88. 
♦ Leichtenstern, Ziemssen’s llandb. d. Sp. I’ath. und Therapie, 
1876, vii. 2, 528. Intestinal Obstruction. 
9 
Percentage of relative frequency of the 
more prominent causes of acute 
intestinal obstruction. 
Number of cases 
included. 
o 
bp 
rSl 
Intussusception. 
Twists and Knots 
Duchaussoy 
347 
54 
39 
6 
Brinton 
481 
33 
54 5 
10 
Leichtenstern 
1134 
35 
39 
6 
STRANGULATION. 
First in numerical importance as a cause of acute, 
intestinal obstruction is strangulation by bands or 
cords. 
These are most frequently the result of a pre- 
existing peritonitis, and are either fibrous adhesions 
alone, or are formed by adherent appendages of the 
intestinal or genital tract. The former are epiploic, 
vermiform, diverticular, omental, or mesenteric. The 
latter are Fallopian tubes and pedunculate ovarian or 
uterine tumors. The diverticular appendages are 
either Meckel’s diverticulum, (the omphalo-mesen- 
teric or vitelline duct,) or the persistent remains of 
the vitelline blood-vessels. The former is usually at- 
tached by the latter to some part of the abdominal wall 
or contents. It may also be thus attached from peri- 
tonitis in the absence of the latter. The persistent 
vitelline blood-vessels or their remains may likewise 
form the strangulating cord in the absence of the 
diverticulum. Omental cords may be adherent in 
consequence of peritonitis, or they may result from 
the presence of slits or fissures in the omentum. 
5 Brinton gives forty three percent, of intussusception in his 
tableofsix hundred cases of intestinal obstruction by this lesion 
bands, adhesions, diverticula, or peritoneum external to the 
bowel, strictures (including a few tumors) Involving the iutes 
tinal wall, and torsion of the bowel on its axis. op. cit., 3s 10 
Intestinal Obstruction. 
The mesentery serves as a cause of strangulation 
when it is fissured by a slit. Peritoneal pouches 
and openings may be added to the above list. 
There seems to be no essential difference in the 
nature of the symptoms which arise from these causes 
of obstruction. Cases of knots and twists of the 
small intestine might be added to the list from the 
nature of their symptoms, but their number is so 
small, only two of each, that for practical purposes 
they may be omitted. 
The immediate anatomical causes of the one hun- 
dred and one cases of strangulation are as follows, 
the numbers being regarded as equivalent to per- 
centages : — 
Adhesions 03 cases. 
Vitelline remains 21 “ 
Adherent appendix 6 “ 
Mesenteric and omental slits 6 “ 
Peritoneal pouches ami openings a “ 
Adherent tube 1 " 
Pedunculate tumor 1 “ 
101 •• 
84% of the total number of cases were due to 
bands and cords in a limited sense. It is noteworthy 
that cases of diaphragmatic hernia, which form 19% 
of Leichtenstern’s cases, were not reported in the 
past eight years. 
The following table shows the bearing of sex in 
the frequency of obstruction from strangulation: — 
Adhesions. 
Vitelline 
Remains. 
Appendix. 
Slits. 
Pouches. 
Tube. 
Tumors. 
Total. 
Males 
39 
19 
5 
5 
2 
70 
Females 
24 
1 
1 
1 
1 
1 
1 
30 
63 
20 
6 
6 
3 
1 
1 
100 Intestinal Obstruction. 
11 
It thus appears that 70% of the cases of obstruc- 
tion from strangulation occurred among males. 
Further, that nearly all the cases of obstruction 
from vitelline remains, adherent appendices, and 
slits were found among men. The percentage 
of bands of intestinal origin and those of pelvic 
origin was about equal in the two sexes. 
The age at which the obstruction took place is 
shown in the following table: — 
1-5 
5—10 
10 15 
15 20 
20—25 
25—30 
30—35 
35—40 
40—45 
45—50 
50 55 
55—00 
60-05 
65-70 
70—76 
Years of Age. 
o« 
Adhesions. 
Vitelline 
CO 
Remains. 
C5 
- - 
Appendix. 
<T. 
*■* ~ ~ *■* 
Slits. 
to 
K> 
Pouches. 
- 
Tube. 
cc 
CO 
t-* K> >*. C OO IO -4 W c: —1 CO C.T rf- to 
Total. 
Strangulation in early youth was, hence, rela- 
tively uncommon. When it occurs it is most likely 
to result from vitelline remains. At least 40% of 
the cases of strangulation occurred between the ages 12 
Intestinal Obstruction. 
of fifteen and thirty years, and adhesions as the 
cause of the same were more than twice as frequent 
as vitelline remains. After the age of thirty years 
adhesive bands are the usual cause. 
In the etiology of adhesions a record of previous 
peritonitis, or perityphlitis, was found in ten of the 
cases, about one-sixth of all, and of an associated 
hernia in seven instances. In a small fraction errors 
in diet, violent muscular exercise, blows upon the 
abdomen, surgical operations for pelvic caries and 
cancer of the bowels, were important in the etiology. 
In nearly one-half of the cases of vitelline -re- 
mains previous attacks of abdominal pain were re- 
corded, and in one instance there was the history 
of a yellowish discharge from the navel in infancy. 
One-half of the cases of adherent appendix were 
preceded by an attack of perityphlitis. Evidence 
of a pre-existing attack of intestinal obstruction was 
found in one case of mesenteric slit; another was 
preceded by chronic dysentery for a year. A case 
of protrusion of the intestine through an opening 
in the coronary ligament suffered, three years before, 
from a severe attack of inflammation of the bowels, 
with intervening colic and repeated diarrhoea. The 
immediate attack of obstruction in two cases of 
mesenteric slit followed a fit of coughing in the one 
and took place at the stool in the other. 
Evidence of antecedent peritonitis thus existed 
in 13% of the cases, the band then being an adhe- 
sion or an appendix. In 7% of the cases a hernia 
was associated with the band. In 80% of the cases 
there was no factor of diagnostic importance. 
Abdominal pain was the first important symptom Intestinal Obstruction. 
13 
noticed in 82% of all the cases of strangulation. 
The percentage of its frequency in each variety of 
strangulation is shown as follows : — 
In Adhesions in 50 cases = 79 per cent, of all the cases 
“ Vitelline remains “ 18 “ = 80 “ ■ “ “ 
“ Adherent appendix.“ 0 “ =100 “ “ “ 
“ Slits “ C “ = 100 " “ “ 
“ Pouches and openings... “ 2 “ = 66 “ “ “ 
82 
It was usually sudden, severe, rarely slight, and 
was described as colicky. It was only exceptionally 
accompanied, at the outset, with tenderness. In 
the majority of cases it was simply stated to be 
abdominal. 
It was located at the navel in eight instances, at 
the epigastrium in five, in the right iliac fossa in 
four, at the hepatic flexure and in the right hypo- 
chondrium each in three cases, in the left iliac fossa 
in two, in the lumbar region, splenic flexure, along 
the spermatic cord, and in the spine and back each 
in one case. An exact localization of the incipient 
pain was thus recorded in 29% of all the cases. 
There seems to be no diagnostic importance to 
be attached to the seat of pain as evidence of 
strangulation, or of its special cause, as will be- 
come apparent when the seat of the obstruction is 
stated. 
The initial pain was found to be early associated 
with nausea or vomiting, either alone or together, 
in 69% of the cases. The date of appearance, and 
the frequency in the special varieties of strangu- 
lation are given in the following table : — 14 
Intestinal Obstruction. 
1st (lay 
2nd “ 
3rd “ 
4th “ 
Oth “ 
Not given 
d 
► 
H 
S 
4^ 
to 
-1 M to to M M 
Adhesions. 
—1 
4*- 00 
Vit. remains. 
C5 
•— Cl 
Appendix. 
to 
Slits. 
tv 
- 
Pouches, etc. 
42 
13 
3 
3 
1 
Total. 
A comparison of these figures shows the occur- 
rence of this symptom on the first day in G8% of 
those cases in which it was possible to determine the 
date with accuracy. It took place on the first day 
in at least one-third of the cases of adhesions, in 
more than one-half of those of vitelline remains, 
in five-sixths of those of adherent appendix, and in 
one-third of those of peritoneal slit. The propor- 
tion is evidently much greater when the number of 
cases is considered in which the date of occurrence 
could be definitely ascertained. The relative fre- 
quency then becomes more than one-half in the case 
of adhesion, two-thirds in those of vitelline re- 
mains, five-sixths in adherent appendix, and one- 
half in strangulation by a slit. 
Its occurrence on the first day is most suggestive 
of an adhesion, a vitelline cord or diverticulum, an 
appendix, a slit, or a pouch, in the order stated. 
The occasional absence of nausea or vomiting is Intestinal Obstruction. 
15 
noteworthy, and is mentioned in two cases of 
strangulation by adhesions, one of which terminated 
fatally, the other in recovery, after laparotomy. 
The vomit, as in all cases of intestinal obstruc- 
tion, was usually composed, at the outset, of the 
food last taken. It then became mixed with bile, 
eventually yellow, and finally fecal. It was fre- 
quently noticed that the vomiting only became con- 
stant when material was persistently taken into 
the stomach. 
Fecal vomit is a term which is somewhat loosely 
applied, and is in no way to be regarded as other 
than conventional. There was no evidence to war- 
rant the idea that the contents of the large intes- 
tine were ever vomited. The distinction between 
a yellow vomit and the fecal or stercoraceous vari- 
ety seems to depend chiefly upon the length of 
time during which a pyloric insufficiency has ex- 
isted. It is quite probable that among the records 
of fecal vomit are those in which this term was 
applied to the ejection of a yellow, odorless, intes- 
tinal fluid. The term should be more exclusively 
applied to the offensive ejections which have re- 
mained sufficiently long above the point of obstruc- 
tion to become fetid. The following table shows 
the date of this intestinal vomit in thirty-seven 
cases:— 16 
Intestinal Obstruction. 
0 
3* 
o 
3 
5 
-* 
r> 
r> 
» 
-1 
5 
?s 
r 
j* 
r 
-c 
l 
- 
V. 
o 
- 
0* 
< 
Date. 
to 
00 
yi 
-* 13 
—* to to 
r> co 
to 
Adhesions. 
4- 
— 09 
— 
to to 
Vit. remains. 
ce 
to 
Appendix. 
to 
- 
Slits. 
5 
O 
- 
to 
to 
- 
CO 
- 
4- 
Total. 
The vomit thus became fecal most often on the 
third and fifth days, although on these dates in 
only about one-fifth of the cases in which definite 
dates were given. 
Tympany is next in importance to abdominal 
pain and vomit as a symptom of obstruction from 
strangulation. Its occurrence in 56% of all cases 
is recorded, and the date of its appearance is given 
as follows : — Intestinal Obstruction. 
17 
( 
s. 
< 
3 
-c 
5 
10t,h “ 
nth “ 
* 
3* 
fith “ 
5th “ 
**- 
IT 
Sill “ 
O 
- 
» 
< 
Date. 
C/S 
4“ 
* 
— 
O 
* 
+■*■ *0 
o 
Adhesions. 
cc 
—* 
O 
-9 
* 
to 
Vit. remains. 
— 
to 
Appendix. 
Slits. 
Pouches. 
■ 
£ 
-1 to 
* 
W 
CC 
-1 
3D 
30 
a 
Total. 
Tympanitic distention of the abdomen thus oc- 
curred in more than one-half of the cases of strang- 
ulation, and was most frequent from the second to 
the sixth days inclusive. It may be wholly absent 
as late as the eighth day, and may be much on the 
first day. It was sometimes enormous during the 
first week, but much more often slight or moderate. 
The distended abdomen was not especially tender 
to the touch. 
An abdominal tumor was sometimes noticed in 
cases of strangulation, and a distinction is to be 
drawn between tympany and tumor, although tym- 
panitic intestines may be the cause of each. Under 18 
Intestinal Obstruction. 
the general head, tumor, are included circumscribed, 
distended, visible intestinal coils as well as local 
swellings not thus characterized. The latter were 
either palpable or their limits were determined by 
dulness on permission in an elsewhere resonant and 
unusually distended abdomen. Such tumors and 
visible coils occurred as follows in the cases of 
strangulation : — 
Tumors. 
Visible Coils. 
Adhesions 
4 
7 
Vitelline remains 
4 
3 
Appendix 
1 
1 
Slits 
1 
10 
11 
Tlius in less than, one-fifth of the cases tumors 
were to be recognized. The numbers are not suf- 
ficient to serve any purpose of differential diagnosis. 
Fever was noted in 22 °J0 of all the cases. It 
rarely occurred before the second day, was some- 
times absent altogether, and, when present, the 
temperature was below 100° F. in nearly one-half 
of the cases. Its occurrence and intensity were of 
no positive value in the diagnosis of obstruction 
from strangulation. 
Hiccough was a symptom of such infrequent 
record as not to demand any especial attention. 
As a rule no mention was made of any peculiar- 
ities of the urine or its flow. The latter was some- 
times mentioned as scanty during the first few days 
and after the tenth day, while it was often stated 
as normal on the thirteenth day. Its composition Intestinal Obstruction. 
19 
was usually noted as normal; occasionally it was 
reported to contain albumen or indican. The cases 
furnished no evidence that any alteration of the 
quantity or quality of the urine is of any diagnos- 
tic value. 
In like manner with regard to collapse. The 
date of its occurrence was given in 23 °j0 of the 
cases, but the figures are too few to aid much in 
fixing upon the time when all efforts at purely 
medical treatment shall cease. 
1st day 
2nd “ 
3rd “ ■ 
4th “ 
5 th “ 
6th “ 
7th “ 
9th “ 
10th “ 
11th “ 
13th “ 
0 
K 
- 
— •“* ►—* k— |* t£ H- 
Adhesions. 
CO 
------- 
Vit. remains. 
U> 
- 
Appendix. 
- 
- 
Pouches, etc. 
n 
Total. 
The occurrence of collapse is not to be regarded 
as necessarily indicative of a fatal termination, as 
in several cases recovery followed laparotomy, 
where collapse was noted at or before the time of 
operating. 20 
Intestinal Obstruction. 
The bowel obstructed was recorded as follows in 
74% of the cases : — 
0 
Small 
Intestine Obstructed. 
4** 
« § 
Adhesions. 
- 
- 
V it. remains. 
05 
* 
Appendix. 
c: 
15 4* 
Slit. 
CO 
H- fcO 
• 
Pouches, etc. 
*- 
CO §5 
Total. 
The part of the intestine obstructed in strangula- 
tion, as determined in fully three-fourths of all the 
cases, is the small intestine in nearly 90% of the 
cases, and the large in 10%. 
The region of the abdomen in which the strangu- 
lating object was found was as follows in 72% of 
the cases :— 
J Adhesions. 
Vit. remains. 
Appendix. 
3> 
Pouches, etc. 
Total. 
Right iliac fossa 
19 
21 
G 
1 
1 
48 
Pelvis 
7 
1 
8 
Left iliac fossa 
5 
1 
G 
Left lumbar region 
3 
3 
Right lumbar region 
2 
2 
Umbilical region 
2 
2 
Right hypochondrium 
i 
1 
2 
Left hypochondrium 
i 
i 
40 
21 
6 
2 
3 
72 Intestinal Obstruction. 
21 
The position of the strangulating object was 
thus in the right iliac fossa in 67%, and in the 
lower abdomen in 83% of the cases in which its 
position was given. It was present in the lumbar 
and umbilical regions in 10%, and in the upper ab- 
domen in 7%. 
It is obvious that an absolutely exact diagnosis 
of obstruction from strangulation is only to be made 
by a post-mortem examination or a laparotomy. 
From this point of view the mortality is total un- 
less operative interference has been tried with suc- 
cess. Of one hundred and one cases, seventy-five 
died and twenty-six recovered. 
The following tables were prepared to show the 
date of death in the absence of surgical treatment, 
and the relation of deaths to recoveries after surgi- 
cal interference. 22 
Intestinal Obstruction. 
Date of death in thirty cases of strangulation 
under purely medical treatment:— 
2nd day 
3rd “ 
4th “ 
5 th “ 
6th “ 
8th “ 
9th “ 
10th “ 
11th “ 
18th “ 
37th “ 
Date. 
Ci 
<-* lO >-* ►— K> CO *•* 
Adhesions. 
»-* IO <— _ 
Vit. remains. 
- 
- 
Appendix. 
- - — 
Slit. 
- 
Pouches, etc. 
CO 
O 
»-« CO »-* K> to CO »-t c?t -1 
Total. 
It is evident that death occurred from the second 
to the fourth days, inclusive, in more than one-half 
of the cases where no surgical treatment was ap- 
plied. Intestinal Obstruction 
23 
Operative interference took place in 67 % of the 
cases, and with the following result: — 
1st day 
•2nd “ 
3rd “ 
4th “ 
5th “ 
Oth “ 
7 th “ 
8th “ 
9th “ 
10th “ 
11th “ 
12th “ 
13th “ 
14th “ 
16th “ 
25th “ 
Not given 
Date. 
£;|os Adhesions. 
CO 
Vit. remains. 
Ci 
m m n> — J Appendix. 
** 1 
Slit. 
H 
Pouch, etc. 
- 
i-1 | Tumor. 
3 j CCH-**—l-3K>OlCC**-GOC/0 00 £2 Q9 fcO | Totftl. 
t Ml— laOlMOSMOSMOlKWMh-l Death. 
s 
(►MM m KiMtoiaoo* m | Recovery. 
The percentage of recoveries after surgical inter- 
ference in cases of strangulation was 39%. 
Of all the varieties of acute, internal, intestinal 
obstruction that which most often presents the 
INTUSSUSCEPTION. 24 
Intestinal Obstruction. 
clearest clinical picture is intussusception or invag- 
ination. 
Its relative frequency among the more important 
causes is nearly constant at 39%, and ninety-three 
cases are included in the series collected since 1880. 
None were recognized as such unless the diag- 
nosis was substantiated at an autopsy, by laparot- 
omy, rectal examination, or by the discharge of a 
slough. 
It occurred among males in fifty-two cases, among 
females in twenty-seven; about two-thirds of the 
cases were thus found in the former sex and one- 
third in the latter. The relative frequency at 
various periods of life is shown belowr: — 
Year of age. Number of cases. Per cent. 
Under 1 31 34 
From 1—2 5 
2— 3 
3— 1 
4— 3 
5— 4 
6— 1 
7— 1 
8— 2 
Under 10 51 56 
From 10—20 6 
20—30 13 
30—40 9 
40—50 5 
50—60 2 
60—70 4 
70-80 1 
91 
Exciting causes were absent in forty-two cases, 
45% ; and the following were possible causes in 
fifty-one cases, 55%: — 
Diarrhoea in 13 cases. 
Habitual constipation “ 12 “ 
Protracted abdominal paiu “ 7 “ 
Indigestible food “ 0 “ 
Violent exertion “ 1 “ 
Injury “ 3 “ 
45 “ Intestinal Obstruct io n 
25 
Single cases occurred in the course of typhoid fever, gastro 
enteritis, variola, pregnancy, after an operation for incarcer- 
ated hernia, and after the use of cathartics, —in all, six cases 
A preceding like attack was observed in two instances. 
These possible factors are of but little value in 
differential diagnosis; and tlieir frequency without 
injurious sequences makes their further considera- 
tion of little or no importance. 
Our knowledge of the method of production of 
the invagination has been rendered relatively exact 
by the experiments of Nothnagel6 and of Senn.7 
The former found that a contracted bit of intestine 
pushed itself into a passive portion from above 
downwards. This contraction was induced8 by a 
faradic current, and in the course of a minute or 
two the invagination might become four inches 
long. He found that the internal and external 
cylinders were formed below the tetanized part, 
almost without exception. If the intestines were 
paralyzed by crushing no invagination occurred. 
These observations go to show that the invagina- 
tion is always descending and is rather spasmodic 
than paralytic. Senn also found that the invagina- 
tion was early formed in a relaxed bowel and could 
not be produced in the contracted gut. 
The most important symptoms of intussusception 
are abdominal pain, nausea or vomiting, tympany, 
tumor, bloody stools, and tenesmus. 
6Nothnagel. Zeitschr. f. klin. Med., 1882, iv. 555. 
78enn. Annals of Surgery, 1888, vii. 4. 
8Nothnagel. Wien. Med. Bl.,1883, v. 14:i'5. 26 
Intestinal Obstruction 
Their relative frequency was reported as fol- 
lows : — 
Pain in 65 cases = 70 per cent. 
Nausea or vomit “ 60 “ = 71 “ 
Tympany “31 “ = 33 “ 
Tumor “64 “ =09 “ 
Bloody stools “ 56 “ = 60 “ 
Tenesmus - “33 “ =35 “ 
The date of the appearance of these principal 
symptoms of intussusception is represented in the 
following table: — 
1st day 
2nd “ 
3rd “ 
4th “ 
5th “ 
6th “ 
Later or not given 
Total no. of cases 
Datk. 
S j - » 2 
Pain. 
5 
in 
4“ . - CO CO — 
Nausea or 
Vomit. 
CO 
C* CO 4- CX> C£ bO ** 
Tympany. 
CO 
o 
CC to CC Ki C 
Abdomen 
£ 
4k. 
o 
0} 4k tO CO -1 GO © 
o 
Rectum. ? 
§ 
4k- CO '* CO 05 -1 
Bloody 
Stools. 
S? +. „ a. *. 5 
Tenesmus. 
Where pain was recorded as a symptom, it ap- 
peared on the first day in nearly all the cases. Its 
early absence, on the contrary, was conspicuous in 
rare instances. It was usually described as abdom- 
inal, and was sometimes located at the navel, in 
the stomach and epigastrium, and in the right iliac 
fossa. 
It was referred to the left iliac fossa in rectal or 
colico-rectal varieties of intussusception. Of five 
cases in which the pain was said to be at the navel, Intestinal Obstruction. 
27 
the intussusception was of the ileum in three in- 
stances. The seat of the pain in the right iliac 
fossa frequently led to the diagnosis of typhlitis, 
perityphlitis, or typhoid enteritis. 
It was usually sudden, severe, perhaps violent, 
and was frequently spasmodic. In one case it was 
so intense as to lead to an attempt at suicide. Its 
importance in the diagnosis of the seat of the intus- 
susception was merely relative. The possibility is 
obvious that its seat in either iliac fossa might 
serve to differentiate an intussusception of the 
colon or rectum from one near the caecum. In like 
manner its position at the navel might serve to 
suggest the small intestine as the seat. 
Nausea or vomiting occurred on the first day in 
nearly nine-tenths of the cases in which a definite 
date could be fixed. If nausea occurred in the first 
instance it was rapidly followed by vomiting. The 
latter presented no characteristics of any value in 
differentiating this variety of intestinal obstruction, 
except in the rarity of its becoming fecal. Among the 
ninety-three cases of intussusception fecal vomit is 
noted in only twelve patients, and it appeared 
on or after the fourth day in all but two of these. 
In nearly one-third of the twelve cases, the obstruc- 
tion was fixed at or below the caecum. In two-thirds 
the intussusception was of the small intestine; in 
at least one-half of these certainly away from the 
valve, in the other half possibly near the valve. 
This symptom, therefore, has no absolute value in 
determining the existence of an intussusception ; if 
the latter is rendered probable, fecal vomit suggests 
that the seat is at or above the caecum. 28 
Intestinal Obstruction. 
Tympany is perhaps the least important symp- 
tom of obstruction by intussusception. It occurred 
only in one-tliird of the cases, and in one-half of 
these on the third and fourth days. 
A tumor was found in sixty-one cases,— nearly 
two-tliirds of the entire number. It was found in 
the abdomen only in twenty-three cases, in the rec- 
tum only in twenty-one cases, and in the abdomen 
and rectum in sixty-one cases. It is stated to have 
been absent in four instances, while in twenty-eight 
its presence is not mentioned. It was found on the 
first day in more than one-tliird of the cases, on the 
second day in one-fourth, and on the third day in 
more than one-fifth of the cases. Thus in more 
than one-half of all cases it was present in the first 
two days, and in the first three days in more than 
three-fourths of the cases. The relative frequency 
of its presence in the abdomen or rectum on these 
days is shown in the preceding table. In the cases 
of intussusception of the small intestine a tumor 
was not observed. The general characteristics of 
the tumor of intussusception are sufficiently well 
known. It was often associated with a relaxed 
sphincter. 
The rectal discharges in intussusception are of 
the greatest importance in diagnosis, especially as 
they not infrequently continue throughout the 
disease. Diarrhoea may immediately precede the 
attack, and the alvine discharges may be wholly 
fecal at the outset, but rapidly become mixed with 
blood. Pure blood or blood and mucus are the 
more frequent discharges. They may occur spon- 
taneously, or immediately follow a rectal examina- 
tion, or the use of an enema. Intestinal Obstruction 
29 
Bloody stools were recorded in three-fifths of the 
cases ; and occurred on the first day in the same 
proportion of cases where a definite date was 
given. 
Tenesmus was stated to be present in nearly one- 
third of the cases, in about the same number as was 
tympany. Its presence on the first day was noted 
in one-half of these, when a fixed date was men- 
tioned. 
Fever occurred in twenty-six cases — 28% of the 
entire number. Its absence in five was conspicu- 
ously stated, while no mention was made in sixty- 
two instances. The temperature was elevated on 
the first day in four cases, on the second in seven, 
on the third in eight, on the fourth in four, and in 
one on each of the three succeeding days. 
Intussusceptions are classified anatomically ac- 
cording to the part of the bowel affected. They 
are, without more minute subdivision, of the small 
intestine into itself, into the caecum, or into the 
colon, of the colon into itself or rectum, and of the 
rectum into itself. The relative frequency of these 
varieties has a decided practical importance ; and 
of sixty-five cases the variety was as follows : — 
Ileo-caecal or ileo-colic 48 cases = 75 per cent. 
Enteric 8 “ — 12 “ 
Rectal 5 “ = 8 “ 
Collcorcctal 4 “ =5 “ 
65 100 
The intussusceptions in the vicinity of the caecum 
thus represented three-fourths of the whole number. 
The question as to the variety in any given case will 
lie essentially between this form and that of the 
small intestine away from the valve, which occurred 30 
Intestinal Obstruction. 
in only one-eighth of the cases. The rectal and 
colico-rectal varieties are usually easily recognized 
on rectal examination. 
These figures differ considerably from those of 
Leichtenstern,9 based upon a collection of four hun- 
dred and seventy-nine cases, which are as follows: 
Ileo-csecal and ileo-colic, 52% ; ileal (enteric), 30% ; 
rectal and colico-rectal, 18%. The chief difference 
lies in the greater frequency of the varieties origi- 
nating near the caecum in the smaller series and in 
the lesser frequency of the enteric variety. It is 
possible that the latter difference may result from 
the more critical exclusion of post-mortem cases. 
The former difference may be due to the inclusion, 
for practical purposes, of ileal intussusception near 
the valve among ileo-caecal forms. 
The mortality in cases of indisputable intussus- 
ception was very great, excepting in the rectal 
variety. The following table shows the number 
and date of deaths of other varieties than the rec- 
tal, when the treatment was by other measures than 
surgical:— 
Date. Death' 
1st day ® 
2nd “ 
3rd “ ° 
4th “ 
5th “ 
6th “ 
1st week 
2nd “ ® 
3rd “ g 
Not given • ~ 
35 
Recoveries 
51 
9Leiclitenstern, op. cit., 501 Intestinal Obstruction. 
31 
It thus appears that of the above series 69% died 
and 31 % recovered. Of the fatal cases nearly one- 
half, and perhaps a larger proportion, died during 
the first five days. The third, fourth, and fifth 
days were especially fatal. 
The following table shows the mortality after 
surgical interference: — 
Date of operation. 
No. of cases. 
Deaths. 
Recovery. 
1st (lav 
2nd “ 
1 
0 
1 
3rd “ 
4th " . 
5th “ 
6th “ 
4 
7th “ 
2 
0 
8th “ 
4 
4 
c 
9th “ 
0 
Not given 
36 
30 
6 
The mortality after surgical treatment was thus 
80%, against 69% of medical treatment. 
TWISTS AND KNOTS. 
Acute obstruction from volvulus or twist oc- 
curred in forty cases, and from knots in two 
instances. As already stated, the symptoms from 
knots are essentially the same as those from strang- 
ulation. Their occurrence is so rare that they may 
practically be disregarded. 
Of the forty cases of volvulus since 1880, the 
vast majority were axial, but in rare cases a part of 
the small intestine was twisted about another por- 
tion. As but two instances of the latter variety 
occurred in the series, these have been included 
among the former, although their symptoms are 
those of cords and bands, while their prognosis is, 
perhaps, more favorable. Their number is such as 32 
Intestinal Obstruction, 
not to materially modify the conclusions to be 
drawn. 
Of thirty-eight cases of volvulus twenty-six 
occurred in males and twelve in females; 68% in 
the former and 32% in the latter. 
The ages of the patients was as follows in thirty- 
four cases:— 
"Ye&r of Number of cuses. 
0..’ \ 
From * 
20—25 2 
25-30 I 
30—35 « 
35—40 £ 
40—45 “ 
45-50 ? 
50-55 I 
55—60 “ 
65-70 } 
70—73 
34 
The extremes of life represented are therefore 
six years and seventy-three years. The greatest 
number of cases in any ten years was between 
the ages of thirty and forty years, and was about 
one-third of all. 
In the etiology of this class of cases of obstruc- 
tion, the previous occurrence of a similar attack 
was observed in five instances. A constipated 
habit was noted in six cases. Hernias existed in 
three. Two of the patients were insane, and one 
was paralytic. One suffered from chronic diarrhoea. 
Upon another the operation of ovariotomy was 
performed six years before the obstruction took 
place. In four cases violent exercise was the 
exciting cause; in another an attack of diarrhoea ; 
and in still another irritating food. Intestinal Obstruction. 
33 
The following table shows the relative frequency 
of the principal symptoms of volvulus : — 
Date. 
Pain. 
Nausea or 
vomiting 
Tympany. 
1st day 
19 
9 
1 
2nd “ 
2 
1 
3 
4th “ 
2 
2 
3 
5th “ 
1 
Cth “ 
1 
1 
2 
Later or not given 
3 
1 
10 
Total no. of cases 
21 
15 
22 
Abdominal pain was thus the first symptom of 
importance in nearly one-half of all the cases, and 
it occurred on the first day in nearly all 
where the date was recorded. It was sudden 
in one-half of the above number. It was either 
severe, intense, extreme or violent in as many cases, 
and in only one instance was there a record of no 
particular pain. It was seated near the navel m 
four cases, in the left abdomen and in the left 
iliac fossa each in two instances ; in the lower abdo- 
men, left groin, right iliac fossa, and near the 
stomach each in one case. 
It was found, therefore, most often, in one-fifth 
of the cases, on the left side, then at the navel in 
one-sixth of the cases, and elsewhere in the abdo- 
men in small but equal proportion. 
The pain was stated to be associated with nausea 
or vomiting in three-fifths of the cases where a date 34 
Intestinal Ob struction. 
was given. In two cases there was no vomit as 
late as the eighth day, in one till the eleventh day, 
and in another there was none at all. 
The vomit was fecal in six cases,— in three on 
the fourth day, in one on the sixth day, in one on 
the eleventh day, and in another no mention is 
made of the date of its occurrence. It was slight 
in two of the cases. It occurred in four instances 
where the small intestine was obstructed, and in 
two where the large intestine was twisted. On the 
contrary, in three cases where the volvulus was of 
the small intestine, there was no fecal vomit. 
Although tympany was recorded in more than 
one-half of the cases, it was present during the first 
week in only about one-half of these. Its occur- 
rence during the first week was oftenest on the 
third and fourth days. It might be much on the 
first day, or slight on the fourth day. It was 
described as enormous on the ninth day. 
Tumors are not a characteristic of twist, but the 
abdominal swelling might be so circumscribed as 
to suggest a tumor. When the flanks alone were 
swollen the twist was of the large intestine ; when 
the umbilical region was conically distended the 
obstruction was either of the large or of the small 
bowel. Visible coils were present only in three 
cases. In one the coil was the transverse colon, 
the twist being of the sigmoid flexure. In a second 
the sigmoid flexure was also twisted. In the third 
the volvulus was probably of the small intestine. 
A record of the temperature was made in sixteen 
cases. In four there was no elevation on the 
third, sixth, and seventh days. In two the tern- Intestinal Obstruction. 
35 
perature was fairly normal or slightly elevated. 
Of the cases of distinct elevation, there were three 
in which the temperature on the fourth day was 
between 99.6° F. and 101.3° F. The temperature 
is first recorded as elevated on the second, third, 
fifth, sixth, ninth, and tenth days, each in one case. 
Since in only about one-fourth of the cases was 
there any noteworthy elevation of temperature, and 
since in two-thirds of these cases it took place on 
no particular day between the second and tenth 
days, it is obvious that fever is no important char- 
acteristic of obstruction from a twist. 
Hiccough was present in three cases, apparently 
without especial dependence on the part of the 
intestine twisted. 
Occasional records were made of the condition of 
the urine. It was rarely reported as modified in 
quantity or quality. In one case only half a pint 
was passed on the seventh day. In another four 
ounces were passed in twelve hours on the ninth 
day. There was retention on the fourth day in a 
single case. In another patient an increased quan- 
tity of indican was reported on the eighth day. 
In all the other cases there was either no record of 
its condition or the flow was * reported as free or as 
abundant. 
The seat of the twist is shown in the following 
table. 
Seat. Number of cases. Per cent. 
Sigmoid flexure 19 49 
lleo-caecal region in 6 ) n 29 
Caecum in 5 \ 
Small intestine 5 13 
Ascending colon 2 5 
Colon 1 2 
Descending colon 1 2 
39 100 36 
Intestinal Obstruction. 
It is thus evident that about one-half of the cases 
of twist took place at the sigmoid flexure, and that 
nearly one-third of them were present in the ileo- 
csecal region. It is further evident that, for all 
practical purposes, 87 % of the cases occurred in the 
large intestine. 
An absolute diagnosis of volvulus is only to be 
made by abdominal section, either before or after 
death. Death is, therefore, to be regarded as the 
probable result of this lesion unless the surgeon 
affords relief. This statement is made despite the 
fact that in five of the cases there was the previous 
history of a similar attack. 
Death occurred as follows in cases not treated 
surgically : — 
Date. Number of cases. 
1st day 1 
3rd “ 2 
5th " 2 
7lh “ 3 
8th “ 2 
9th “ 1 
12th “ 1 
Not given 3 
15 
The date and result of operative interference is 
given in the following table : — 
Date of operation. Number of ca~cs. Death. Recovery- 
3rd day 2 1 1 
4th “ 1 1 0 
5th “ 3 2 1 
6th “ .2 2 0 
7th “ 1 1 0 
9th “ 6 5 1 
10th “ 1 1 0 
11th “ 1 1 0 
16th “ 1 0 1 
26th “ 1 0 1 
Not given 6 6 0 
25 20 5 
It is apparent from tlie above tables that all of Intestinal Obstruction. 
37 
the cases not treated surgically died, and that of 
those thus treated one-fiftli recovered. 
Since, of known dates of death, at least one- 
half took place before the eighth day, it is obvious 
that medical treatment should cease before this 
date. Furthermore, since, of the cases treated by 
the surgeon from the third to the sixth day, only 
one-third recovered, it is suggested that medical 
treatment should cease at the former date. 
OBSTRUCTION BY ABNORMAL CONTENTS. 
Acute obstruction of the intestines by abnormal 
contents, as biliary and intestinal calculi, more or 
less inspissated faeces and foreign bodies, form a 
series, where plugging of the bowel is the im- 
mediate cause of the disturbance. 
Foreign bodies introduced into the mouth and 
rectum, and there causing symptoms of acute 
obstruction, are so immediately recognized and 
their treatment so apparent, that they require no 
consideration in the present communication. If 
taken into the mouth they usually offer no difficulty 
of diagnosis, if intestinal obstruction is to follow. 
The etiology is usually clear; the symptoms, as 
shown in the three cases of this sort occurring 
during the past eight years, are so mild, that the 
chief, if not the sole, evidence of obstruction was the 
absence of a stool for three days in two instances, 
and for twelve days in a third. Pain and nausea 
or vomiting were absent, except in an infant of 
twelve months, who had swallowed wool-fibres. 
There was no tympany. A soft tumor near the 
caecum, on the fourth day of absent stools, was 38 
Intestinal Obstruction. 
found in one case, and was probably composed 
of lumbrici. There were no associated symptoms 
to suggest a more serious cause of tumor in the 
caecal region. 
There were two cases of intestinal calculi which 
offered grave symptoms of obstruction. The cal- 
culus in one case was composed of shellac, in 
the other of date seeds and gritty material. 
The number of cases of obstruction from abnormal 
contents is thus reduced to twenty-three of biliary 
calculi, nineteen of fseces, and two of enteroliths, 
making forty-four in all. 
This number may seem small, but in a critical 
consideration of reported cases, it is necessary to 
exclude many as doubtful. This is especially true 
with regard to gall-stones and faecal masses. If the 
patient dies, and a gall-stone obstructs the bowel, 
the evidence furnished is rarely sufficient to exclude 
the possibility of the obstructive symptoms result- 
ing from a peritonitis,— the latter occasioned, not 
by the presence of the calculus in the bowel, but 
by the destructive processes associated with its 
entrance into the gut. Medical treatment in this 
class of cases may often prove efficient, since the 
symptoms of obstruction may be due to the peri- 
tonitis and not to the plugging. 
Similar statements hold true with regard to 
reported cases of obstruction from faeces. If faecal 
tumors are found, and symptoms of intestinal 
obstruction are present, it by no means follows that 
the symptoms are immediately due to the faeces. 
An associated peritonitis from an inflamed appendix 
is of frequent occurrence, and alone suffices to Intestinal Obstruction. 
39 
suggest the diagnosis of obstruction. With the 
presence of a faecal tumor the diagnosis seems to 
be substantiated. The analysis which is to follow 
will show, however, that enormous faecal accumula- 
tions may exist, and very few symptoms arise to 
suggest an attack of acute internal obstruction. 
The sex of the cases of obstruction from abnormal 
contents, is as follows : — 
Gall-stones. Faeces. Enteroliths. Total. 
Males 5 8 2 15 
Females 18 11 0 29 
23 19 2 44 
Obstruction from gall-stones thus occurred among 
females in two-thirds of the cases; while in ob- 
struction from faeces the question of sex is not 
important. 
The age at which the obstruction occurred is seen 
in the following table : — 
Y EAR OF A OK. 
Faces. 
Enteroliths 
Total 
At 8 
1 
1 
From 10-20 
4 
4 
20-40 
4 
4 
40—45 
1 0 
1 
45—50 
3 0 
3 
50—55 
3 2 
1 
6 
55—60 : 
6 2 
8 
60—65 
3 4 
7 
65—70 
3 1 
4 
70—75 
2 
2 
75-80 
1 1 
2 
22 19 
1 
42 40 
Intestinal Obstruction. 
It is thus apparent that obstruction from gall- 
stones occurred only in adults, and after the age of 
fifty years in six-sevenths of the cases; that ob- 
struction from faeces may occur at any time of life ; 
while enteroliths were found in adult life. 
In eleven cases, nearly one-half, of obstruction 
from gall-stones there was a previous attack attrib- 
uted to biliary calculi. In the nineteen cases of 
faecal obstruction, habitual constipation, often no 
dejection for several weeks, was almost invariably 
present. 
The shellac-calculus was present in a cabinet- 
maker who was accustomed to drink an alcoholic 
solution of shellac. In the cases of faecal obstruc- 
tion loose dejections were occasionally noticed, 
although the bowels contained large quantities of 
faeces. 
The accompanying table shows the date and 
relative frequency of the important symptoms of 
obstruction from gall-stones : — 
Date. 
Pain. 
Nausea or 
Vomit. 
Fecal vomit 
Tympany 
1st (Jay 
13 
10 
1 
2nd “ 
2 
1 
1 
3rd “ 
1 
3 
1 
4th “ 
1 
1 
2 
5th “ 
2 
„ 
Later or not given .... 
6 
3 
7 
5 
19 
17 
14 
13 
Abdominal pain was the initial symptom of the 
attack of obstruction in two-thirds of the cases. Intestinal Obstruction. 
41 
It was usually sudden, severe, or intense, sometimes 
described as griping. It was exactly localized on 
the first day in but two cases. In one the seat was 
referred to the epigastrium, in the other to the 
hypogastrium. After the first day the pain was 
referred to the epigastrium in four cases, to the 
navel in two, to the hypogastrium in two, and to 
the right iliac fossa in one. 
Nausea or vomiting was present on the first day 
in about three-fifths of the cases. The vomit was 
inky in one case on the third day, and bloody in 
another on the fourth day. It was slight in two 
cases. Faecal vomit was present in nearly two-thirds 
of the cases of obstructing gall-stones, and, as far 
as could be ascertained, most frequently on the third 
day. 
Tympany was present nearly as often as faecal 
vomiting. It was usually slight or not excessive, 
and was repeatedly stated to have been absent. 
A tumor was rarely noticed. Once in the right 
iliac fossa, and proved to be the calculus. Twice at 
the navel on the third day. It is stated to have 
been as large as a child’s head in one of these cases. 
The tumor was present in the left inguinal region 
in one case, and once was found on rectal examina- 
tion. 
The temperature was as high as 101° F. in one 
case and between 99° F. and 100° F. in three cases 
on the fourth and fifth days. In the majority of 
cases it was either normal or subnormal. 
Jaundice and hiccough were symptoms in but 
two cases of gall-stones, and these occurred early. 
The urine was diminished in quantity in five in- 42 
Intestinal Obstruction. 
stances, being noted as scanty on the second, fourth, 
and fifth days, and as absent on the sixth day. 
Once it contained cholesterine discharged from the 
rectum. 
Of the twenty-three cases of obstruction from 
gall-stones there were thirteen deaths and ten re- 
coveries. Twelve cases were treated medically and 
eleven surgically; of the former eight recovered 
and four died; of these latter one on the fifth, 
seventh, and tenth days respectively, and one on a 
date not given. 
In the cases of recovery the calculi were passed 
on the fourth, fifth (in two cases), tenth, fourteenth, 
fifteenth, seventeenth, and twentieth days. 
Surgical interference took place as follows : — 
Date. Number of cases. Recovery. Death and date. 
3rd day 1 0 1 8th day 
4th “ 1 0 1 4th “ 
5th “ 1 0 1 5th “ 
7th “ 2 1 1 7th “ 
Slh “ 2 0 2 jgjj ;; 
9th “ 1 0 1 14th “ 
17th “ 1 0 1 18th “ 
Not given 2 1 1 Not given 
11 2 9 
The seat of the calculus in the fatal cases was 
the ileo-csecal region in four, the jejunum in 
three, the ileum in three, the small intestine in 
two, and the duodenum in one case. 
Since all the operative measures after the seventh 
day terminated fatally, and five cases recovered after 
this date under medical treatment alone, the condi- 
tion of the patient must determine the treatment 
to be followed. 
In faecal obstruction pain at the outset was rare. 
It was present in six cases only, one-third of the Intestinal Obstruction. 
43 
whole number, and was absent on the fifth day in 
one instance, on the fifteenth in two, and on the 
twentieth in one. It was seated in the right iliac 
fossa, in the region of the stomach and liver, and 
in the left iliac fossa each in one case. 
Xauseaor vomiting was present in nine cases and 
absent in ten. It was of late occurrence, the date 
being stated in only three cases, in these on the fifth, 
fourteenth, and nineteenth days. It was faecal in 
but three cases and in these the only date assigned 
was the twentieth day. 
Tympany was present in rather more than a third 
of the cases, and usually at a late date, after the 
first week. The abdomen of a child measured 
thirty-one inches, of an adult forty-three inches in 
circumference. 
An abdominal tumor was noted in about one-half 
of the cases of obstruction from faeces. It occupied 
the entire abdomen in three instances, was situated 
in the left lumbar region in two, in the left hypo- 
chondrium, the left iliac fossa, the right side and 
right iliac fossa each in one case. The tumor was 
described as elongated, rounded, nodular, slightly 
movable, hard, dull. Scybala were occasionally 
to be felt in the rectum. 
The temperature was rarely above the normal. 
The urine was scanty on the fifteenth and twentieth 
days in two cases of faecal obstruction. 
The seat of the obstruction was the large intes- 
tine, and its lower part was more often involved 
than the upper. This evidence is in favor of the 
view that the faecal tumor in so-called stercoral 
typhlitis is rather the result of an inflamed appendix 
than the cause of an inflamed caecum. 44 
Intestinal Obstruction. 
There were fifteen recoveries and four deaths 
among these cases. In one the death was due to 
perforation of the bowels, in another it was attribu- 
ted to pulmonary congestion, and in two there was 
no obvious anatomical cause. 
In the cases which recovered the obstruction 
lasted from two to three weeks in three cases, from 
three to four, four to five, five to six weeks, one 
in each period, and in one case it lasted for four 
months. 
The medical treatment consisted of large enemata, 
irrigations, electricity, and various purgatives. Lap- 
arotomy, colotomy, and division of the anus were 
each performed in one instance. 
It is obvious from the above consideration that 
obstruction from faeces may be excluded from the 
series of acute, internal, mechanical obstructions, 
because abdominal pain, tympany, and faecal vomit 
were rare and late, while nausea or vomiting was 
also of late occurrence. A tumor was present in 
half the cases, and was characteristically faecal. 
Fever was absent. Furthermore, rectal injections 
are likely, at once, to give positive evidence of faecal 
obstruction. 
The rarity of obstructing intestinal calculi was 
such that they may practically be disregarded. 1 f 
present, their significance is that of gall-stones. 
STRICTURES AND TUMORS. 
Malignant disease and strictures of the intes- 
tine, and abdominal tumors outside the intestine, are 
sometimes the cause of symptoms of acute obstruc- 
tion, and the former may require consideration 
in differential diagnosis. Intestinal Obstruction. 
45 
There have been fifteen cases of such strictures 
and tumors of the intestine since 1880, of which 
ten occurred among females and five among males. 
The age of these patients was as follows:— 
Years of age. Number of oases. 
From 20—30 ‘2 
30—40 1 
40—50 3 
50—00 4 
00—70 5 
15 
Four-fifths of the cases thus occurred after the age 
of forty, and three-fifths after the age of fifty years. 
In two-thirds of the patients antecedent symp- 
toms of abdominal disturbance were present as 
follows:— 
Chronic abdominal pain in 3 cases 
Constipation “ 3 “ 
Irregular and bloody discharges “ 1 “ 
Rectal uneasiness “ 1 “ 
Previous attacks “ I “ 
Hernia “ 1 “ 
10 
The date and relative frequency of the important 
symptoms of intestinal obstruction from stric- 
tures and tumors is shown in the following state- 
ment :— 
Date. 
Pain. 
Nausea or 
Vomit. 
Tympany. 
Tumor. 
1st day 
8 
i 
2nd “ 
1 
1 
3rd “ 
O 
1 
4th “ 
1 
1 
5th “ 
1 
1 
6th “ 
3 
Later or 
not given — 
6 
9 
12 
10 
‘ 46 
Intestinal Obstruction. 
Although pain was the first symptom in one* 
half of the cases, in two the attacks began with 
constipation. The pain was seated in the lower 
abdomen in three instances. 
The vomit became faecal in five cases; the earliest 
date was the third day. The tympany might be 
enormous on the third day, or moderate on the 
sixth day. 
A tumor was perceptible by rectal examination 
in two cases, and by palpation in the iliac fossae 
each in one case. In three instances there were 
visible intestinal coils. 
The temperature was not elevated before the 
sixth day, was never higher than 102.2° F., and 
then not till the tenth day. 
The lesion and its seat were as follows:— 
Cancer of the sigmoid flexure in 5 eases, 
“ “ rectum “ “ 
“ “ colon “ 4 “ 
“ “ caecum “ 1 “ 
Stricture of the ileum “ 1 “ 
“ “ caecum “ 1 “ 
“ “ colon “ l “ 
“ “ rectum 1 “ 
15 
The obstruction was thus of the large intestine 
in fourteen cases, and of the small intestine in but 
one instance. It was situated in the left iliac fossa 
or pelvis in nine cases, nearly two-thirds of the whole 
number, and in the right iliac fossa in two cases- 
The seat was thus in the lower abdomen in nearly 
four-fifths of all the cases of acute obstruction 
from strictures and tumors. 
Of the fifteen cases eleven died and four recovered 
from the immediate symptoms of obstruction. The 
nature of the lesions is such that surgical treat- Intestinal Obstruction. 
47 
ment alone offers hope. In eight cases where death 
occurred without surgical treatment, it took place on 
the fourth, fifth, eight, twelfth, eighteenth, and 
fifty-fourth days each in one case, and on the seven- 
teenth in two cases. 
Surgical treatment was employed in seven cases, 
with the following immediate result:— 
Date of operation. Number of cases. Recovery. Date of death. 
5th day 1 1 0 
7th “ 1 1 0 
8th “ 1 0 1, after 9 weeks. 
9th “ 2 2 0 
14th “ 1 0 1, 17th day. 
Not given 1 0 1, same day. 
7 4 3 
As a result of the foregoing analysis the symp- 
toms, apart from stoppage of the bowels, upon the 
presence of which the physician must rely to estab- 
lish a diagnosis of acute, internal obstruction, are 
abdominal pain, nausea or vomiting, abdominal 
tympany, and abdominal tumor. The presence of 
fever, the occurrence of hiccough or jaundice, ab- 
normal conditions of the urine, are all occasional 
and subordinate. 
The cardinal symptoms are, then, pain, vomiting, 
tympany, and tumor. The vomit may become faecal, 
and the tumor may be simulated by visible intestinal 
coils. The relative frequency, in percentages, of 
the occurrence of these symptoms in the main var- 
ieties of acute, intestinal obstruction, as occurring 
since 1880, is here shown: — 48 
Intestinal Obstruction. 
Strangu- 
lation. 
Intussus 
ception. 
Twist. 
Gall- 
Stones. 
Stricture oi 
Tumor. 
Pain 
82 
70 
60 
S3 
60 
Nausea or) 
vomiting j 
09 
75 
37 
74 
SO 
Fecal vomiting. 
47 
13 
15 
61 
33 
Tympany 
56 
33 
55 
56 
66 
Tumor 
10 
69 
13 
27 
Visible coils 
11 
7 
20 
But the presence of these cardinal symptoms is 
evidence of other disease than acute, internal, me- 
chanical obstruction of the bowels. They may re- 
sult from external causes of obstruction, and the 
various hernise are to be excluded. They may be 
the symptoms of a peritonitis in the absence of 
mechanical, intestinal obstruction. The various 
causes of peritonitis are therefore to be excluded. 
These include those arising from the gastrointes- 
tinal, genital, and urinary tracts, the biliary passages, 
suppurating or necrotic lymph-glands, embolism 
of the abdominal arteries, and from the continu- 
ance of inflammatory processes through the thoracic 
and abdominal walls. 
The diagnosis of acute, internal obstruction is 
then made, in the first instance, by exclusion. 
The second question relates to the part of the 
bowel which is the seat of the obstruction. It 
appears from the above analysis that the chief 
varieties of obstruction were situated as follows:— 
Large intestine. Small intestine. 
Strangulation 8 GO 
Intussusception 57 8 
Twist 34 5 
Gall-stone 4 9 
Stricture anil tumor 14 1 
117=57 per cent. 89= 43 per cent Intestinal Obstruction. 
49 
It is obvious that obstructing gall-stones in the 
large intestine are not of much consequence from 
their seat in that part of the bowel, as they have 
usually produced their important symptoms before 
reaching the colon. 
The obstruction, therefore, is likely to be either 
in the small or in the large bowel in not far from 
equal proportion. In order to determine which is 
affected, the patency and capacity of the large in- 
testine must be ascertained as thoroughly as pos- 
sible. 
Rectal examination by the finger alone may make 
the diagnosis clear, as in certain cases of intussus- 
ception, stricture, and obstruction from abnormal 
contents.. The limits of this method, however, 
are easily reached. Exploration by the introduction 
of the entire hand into the rectum may then sug- 
gest itself as a means of determining the seat of 
the obstruction. The cases are but a few where 
such a method has been used in intestinal obstruc- 
tion with success. They are so few and the evi- 
dence thus to be obtained is so indefinite, that this 
method of exploration may be placed among the 
possibilities in any given case, but as of doubtful 
expediency. 
There remains the introduction of the rectal 
sound or tube. These have the advantage in 
length over the finger or hand; they have the dis- 
advantage of giving rise to errors of judgment. The 
information to be furnished by the rectal sound is 
limited to the determination of the length and 
calibre of the rectum and sigmoid flexure, at the 
most as far as the junction of the two legs of the 50 
Intestinal Obstruction. 
bowel which form the loop. This may lie at the 
navel, as in a case recently examined by me after 
death. It has been my experience to fail to pass 
either the rigid or the flexible tube beyond the 
sigmoid flexure in numerous attempts both on the 
living and dead. After repeatedly introducing the 
flexible tube its entire length, it has been found 
compactly coiled within the rectum on passing the 
finger through the anus. In these respects my 
experience corresponds with that of Treves 10 and 
others. 
The use of the rigid tube is not without danger. 
I have known it, in the hand of a skilful and ex- 
perienced surgeon, to perforate the intestinal wall 
above a stricture of the rectum. 
The capacity of the large intestine, beyond the 
reach of the finger or a short tube, is best deter- 
mined by an attempt to distend the bowel with air, 
gas, or water, under a certain degree of pressure. 
Air may be introduced by connecting the end of an 
inserted rectal tube with the nozzle of a syringe or 
a pair of bellows. 
Air or gas may be allowed to escape from a 
siphon of aerated or carbonated water. Ziemssen 11 
recommends that the intestine be charged, alter- 
nately and in small quantities, with solutions of bi- 
carbonate of soda and tartaric acid, — twenty 
grammes (five drachms) of the former and eighteen 
grammes (four and a half drachms) of the latter. 
The simplest and best agent, however, is warm 
water. It is easily procured, and the quantity 
used can be simply and accurately measured. 
10 Treves, op. cit., 398. 
11 Ziemsser., Arch. f. klin. Med., 1883, xxxiii. 236. Intestinal Obstruction. 
51 
Some arrangement is necessary by means of 
which the injected fluid shall be prevented from 
escaping from the anus. Forcible compression of 
the buttocks against the rectal tube suffices for 
moderate degrees of pressure. But the column of 
fluid may be under considerable, even extreme, 
pressure, especially when this diagnostic procedure 
becomes a remedial measure, as in cases of intus- 
susception. 
Lund 12 figures and describes an apparatus for 
this purpose, consisting essentially of an annular 
air-cushion through which passes a tightly fitting 
rectal tube. The latter is connected with the in- 
jecting syringe. A similar apparatus was impro- 
vised by Forest,18 who wound a roller bandage tightly 
around a glass vaginal syringe from which the 
piston was removed. The mouth of the syringe 
was closed with a perforated cork. A glass tube 
was pushed through this and was connected with 
the injecting syringe. This latter is most con- 
veniently a fountain-syringe or a funnel and rubber 
tube. These may be elevated gradually to any 
desired height above the patient’s level, and will 
permit an accurate measure of the pressure used 
and the quantity injected. 
The force necessary to distend the large intestine 
sufficiently to determine its calibre may be slight. 
But the physician should be prepared to increase it 
sufficiently, within safe limits, to make it clear that 
the large intestine is or is not obstructed. These 
limits are determined by the time which has elapsed 
12 Lund. Lancet, 1883, i. 588. 
13 Forest. Am. J. Obst., 1886, xix. 673 52 
Intestinal Obstruction. 
since the obstruction became apparent, the age of 
the patient, and the quantity of fluid injected. 
Thomas14 records a case where, on the third day, 
an enema, under light pressure, was followed by death 
in an hour and a half. The case proved to be one 
of intussusception; a rent was found in the sheath 
and a half tumblerful of water in the pelvis. The 
earlier, therefore, this method of exploration is 
employed the better, especially in the case of sus- 
pected intussusception. 
The age of the patient is important, since obstruc- 
tion in children is most likely to be from intussus- 
ception. Lower degrees of pressure will produce 
rupture in them than in the adult, and the capa- 
city of the large intestine is less. 
The quantity of fluid admitted is as important as 
the force necessary for its injection. For diagnostic 
purposes all that is necessary is that a certain quan- 
tity of fluid should or should not be admitted into 
the bowel. The quantity which the large intestine 
of the adult will hold with safety may be stated at 
six quarts. In a case of catarrhal enteritis recently 
under my charge, nearly five quarts were gradually 
injected, without discomfort, by means of a bulb- 
syringe and rectal tube. Six quarts of fluid re- 
turned through the tube after removal of the 
syringe. Larrabee15 states that six quarts were 
injected into the intestine, and retained, in a case of 
obstruction of the ileum. The quantity which the 
large intestine of the infant may safely receive has 
been less exactly determined than the degree of 
n Thomas. Lancet, 1888, ii. 1219. 
« Larrabee. Louisville Med. News, 1881, xi. 3. Intestinal Obstruction. 
53 
pressure which can be applied without causing 
rupture. 
The limits of safety as defined by the above con- 
ditions will permit the elevation of the fountain- 
syringe to a height considerably less than that 
found necessary, by experiments, to rupture the 
bowel. Recent investigations on this point have 
been made by Rotch,16 who found that more than 
seventeen feet of pressure were necessary to tear 
the bowel of an infant, removed from the body. 
Forest17 found that the colon of an infant would 
bear, without rupture, from twenty to twenty-two 
feet of pressure. He also found that the colon of 
an adult would bear, with a like result, from thirty 
to thirty-seven feet. Young 18 inserted a rectal tube 
into the bowel of a patient suffering from obstruc- 
tion and connected it, on several occasions, with 
the waste-pipe of a tank which was elevated thirty 
feet. The patient eventually recovered from the 
immediate symptoms. Within safe limits will, 
therefore, be below ten feet in the infant, and 
twenty feet in the adult. 
It should be remembered that, for diagnostic pur- 
poses, the indication is to distend the large intestine 
if possible, and without increasing the patient’s 
danger. Anaesthesia should be employed; the 
patient should be inverted or placed on the right 
side, that the fluid may more readily pass up the 
bowel. 
The objections which have been raised to the 
value of injections in determining the seat of the 
16 Kotch. Boston Med. & S. J., 1882, cvi. 322. 
17 Forest, loc. cit., 091. 
18 Young. British Med. Journal, 1884, ii. 706. 54 
Intestinal Obstruction. 
obstruction are based upon the condition of the 
patient and the negative value of the experiments 
made. It is asserted that the patient’s voluntary 
muscles may resist the admission of the fluid; that 
a part of his intestine may be contracted and the 
rest tympanitic, with a resulting increase of the 
intra-abdominal pressure. The rectum may be filled 
with faeces, thus obstructing the entrance of fluid, 
or so distensible as to take in so large a quantity as 
to give rise to error of judgment. Again, a strictured 
bowel may be passable from below, but closed from 
above by a projecting fold of tissue. Finally, the 
experiments concerning the capacity of the large 
intestine are regarded as useless, since they are 
made on relaxed tissues. 
These objections have a value within certain lim- 
its. If the injection is made late in the course of 
the disease, under slight degrees of pressure, and 
without anaesthesia, it may prove of no diagnostic 
value. If the question to be decided by injection 
depended upon the difference of a few ounces in 
the quantity of fluid admitted, the experiments on 
the corpse would be useless. But the diagnostic 
value of the injection is dependent upon a sufficient 
degree of pressure to overcome muscular resistance 
within the limits of safety, under anaesthesia. If 
the tympany is extreme enough to produce a doubt- 
ful result, the stomach and upper bowel may be 
emptied of their contents by siphonage. The quan- 
tity of fluid to be forced into the large intestine of 
the adult is one of several quarts or of a few pints. 
Since Treves 19 cites the case where the rectum held 
»9 Treves, op. cit., 397. Intestinal Obstruction. 
55 
three pints, it is evident that, when only this quan- 
tity of fluid can be forced in, the obstruction may 
be at the sigmoid flexure, and that a larger quantity 
must be injected to ensure that the intestine above 
this point is passable. With these precautions and 
with these limitations the exploration of the large 
intestine by means of forced injections seems likely 
to prove in the future, as has been claimed in the 
past, a valuable, diagnostic measure. 
It may, possibly, become unnecessary for the 
determination of the patency of the large intestine 
to use the higher degrees of pressure and the larger 
quantities of fluid. Treves20 claims that by auscul- 
tation of the csecal region it is possible to obtain 
pretty conclusive evidence of the arrival of injected 
fluid at that point. The colon must be entirely 
clear and the enemata quickly introduced, in an 
intermittent manner, without any admixture of air. 
The variety of abdominal sounds to be heard in 
cases of intestinal obstruction is so considerable 
that especial training in abdominal auscultation, 
and particularly in this affection, is regarded as 
necessary that this method of examination may 
prove of value. 
Although, in general, fsecal vomiting is more 
likely to occur in obstruction of the small intestine 
than in that of the large, this relation is of no im- 
portance in determining the part of the bowel 
affected. It occurred in forty-seven cases of stran- 
gulation, fourteen of gall-stones, twelve of intus- 
susception, and five of malignant disease or strict- 
ure. It was present in four cases of stricture or 
29 Treves, op. cit., 398, 56 
Intestinal Obstruction. 
tumor when the obstruction was at or below the 
caecum. It was noted in four cases of intussus- 
ception in the same region, below the caecum, in two 
of twist of the large intestine, and in one of strangu- 
lation of this part of the bowel. Thus, in more than 
one-eighth of the cases of faecal vomit, the obstruc- 
tion was of the large intestine. 
The physician having determined, with more or 
less success, the patency and capacity of the large 
intestine, the question which next demands consid- 
eration relates to the special variety of obstruction 
which may be present. 
This question is best answered by an appreciation 
of the relative frequency of the several varieties, 
the knowledge of the age of the patient, the ante- 
cedent and immediate symptoms. 
The published experience of the past eight years 
shows that for all practical purposes the following 
is the relative proportion of the varieties of intes- 
tinal obstruction likely to be concerned in any indi- 
vidual case:— 
Strangulation 101 cases=37 per cent 
Intussusception 93 “ =34 “ 
Twist 40 “ =15 “ 
Gall-stones 23 “ =8 “ 
Stricture or tumor 15 “ =6 “ 
272 100 
These varieties of obstruction were seated as 
follows: — 
Large intestine. Small intestine. 
Strangulation 7 per cent 72 per cent. 
Intussusception 51 “ 8 “ 
Twist . 30 “ 5 
Gall-stones 0 “ 14 “ 
Stricture and tumor 12 “ 1 “ 
100 100 Intestinal Obstruction. 
57 
Since obstruction of the large intestine was in- 
tussusception or twist in four-fifths of the cases 
the differential diagnosis of these varieties is of 
especial importance. Etiology afforded no aid. The 
relative frequency among the sexes was the same. 
If the patient is under thirty years of age the 
case is one rather of intussusception than of twist. 
Rectal tenesmus, bloody stools, and an abdominal 
or rectal tumor are significant of intussusception; 
they are not to be expected in twist. The greater 
the capacity of the large intestine the more likely 
is the presence of intussusception than twist, for 
the latter was found near the sigmoid flexure in 50% 
of the cases, while the former was found near the 
caecum in 75%. 
Finally, if the obstruction is not relieved by dis- 
tention of the bowel and massage, with anaesthesia, 
there is probably an irreducible intussusception or 
a twist, each of which demands surgical treatment. 
If the person is over thirty years of age, and there 
is neither tenesmus, bloody stools, nor a tumor 
characteristic of intussusception, the case is prob- 
ably one of twist, tumor or stricture, or of stran- 
gulation. Twist was more than four times as 
common as strangulation, and more than twice as 
frequent as tumor or stricture. The latter was 
nearly twice as common as strangulation. The last 
is likely to be above the sigmoid flexure, while twist, 
cancer, and stricture are more likely to be at or below 
this point. Cancer and stricture are not infre- 
quently within reach of the finger, hand, or sound. 
They often have the antecedents of chronic pain, 
irregular and bloody discharges, and rectal uneasi- 
ness. 58 
Intestinal Obstruction. 
If the obstruction was seated in the small intes- 
tine, it was due to strangulation or gall-stone in 
more than four-fifths of the cases. The diagnosis 
of gall-stone was to be determined by its occurrence 
after the age of fifty years in six-sevenths of the 
cases, by previous symptoms attributed to this 
cause in one-half of the cases, by the usual late 
occurrence of the tympany on or after the fourth 
day, and by the occasional presence of a small, 
hard tumor. 
Intussusception is to be differentiated from stran- 
gulation bv its greater frequency in early youth, and 
the fact that a tumor is more often found. A twist 
of the small intestine is only to be differentiated 
by its extreme rarity. 
What may be the immediate cause of the stran- 
gulation has but little practical value. At the best 
there is little else than numerical frequency to in- 
fluence the opinion. It is desirable to remember 
that nine-tenths of the cases were due to adhesion, 
vitelline remains, or vermiform appendix, in the 
proportion of 63% : 21% : 6%. It is still more 
important to remember that, in the presence of 
urgent symptoms of acute obstruction, the source 
was to have been found in the lower abdomen in 
more than four-fifths of the cases. 
The question, what is to be done by the physician, 
has already been partly answered. He is to re- 
member that in the light of exact knowledge 
nearly all cases of acute, mechanical, intestinal 
obstruction die, unless relieved by surgical inter- 
ference. That curative, medical treatment has 
proven of sure avail only in a limited number of 
cases of intussusception, possibly in a few of twist Intestinal Obstructwn. 
59 
in the large intestine, and in certain cases of gall- 
stones in the small intestine. That his first duty, 
after relieving pain, is to determine the capacity 
of the large intestine. That this is best accom- 
plished during the first two days following the 
initial pain, before tympany makes the task more 
difficult, and pathological changes cause it to be 
more dangerous. Finally, that the means employed 
for this purpose represent the most efficient cura- 
tive agent in his control. 
In case a diagnosis of intussusception is estab- 
lished, the possible benefits of medical treatment 
at an early stage result from the reduction of the 
displaced bowel. In fourteen cases where the 
condition of the bowel during the first five days 
was noted, it was found that in five, more than 
one-third, the bowel was irreducible on the third 
day. This fact should not necessarily deter the 
physician from an attempt at reduction at a later 
date. Wilson21 withdrew an intussusception after 
seventeen days of obstructive symptoms, and 
the patient recovered. On the other hand, although 
this possibility may be admitted, sloughs of the 
intestine may be evacuated on the ninth day. 
Notwithstanding 31% of the cases recovered 
without any operative treatment, it does not follow 
that such a recovery is to be anticipated with favor, 
especially if it is to be associated with the evacua- 
tion of a slough. In this class of cases event- 
ual death from annular stenosis of the intestine 
is to be feared, if earlier death from peritonitis 
does not occur, or strangulation may take place 
21 Wilson. Transylvania J. M., 1S35, viii. 4S6 60 
Intestinal Obstruction. 
under adhesive hands between the diseased bowel 
and neighboring coils. It is even possible that so 
much of the bowel may be detached as a slough 
that an insufficient quantity remains to serve for 
the necessary absorption of nutriment. Lanceus,22 
for example, reports a slough of three feet of the 
ileum. 
The medical treatment of intussusception con- 
sists essentially in the use of mechanical measures 
for the reduction of the displaced portion of bowel. 
The beneficial effect of such measures is all the 
more possible since it is evident that spontaneous 
reduction may occur. Senn28 observed this fact in 
his experiments, and Langmaid24 records a striking 
illustration. His patient was an infant of five 
months, who, on the first day, suffered from rest- 
lessness, vomiting, and bloody dejections. On the 
third day a tumor, with a central indentation like 
the neck of the uterus, was to be felt per rectum. 
A cylindrical tumor was also to be recognized in 
the region of the descending colon. After a few 
hours the invaginated bowel descended to the 
anus. In the interval between two visits the 
tumor disappeared. The patient had two natural 
dejections on the sixth day, and recovered without 
further disturbance. 
The mechanical treatment consists of rectal 
injection or inflation, preferably the former, and 
replacement by a repositor. Almost indispensable 
advantage is to be derived from the associated use 
22 Lanceus (Rev. Med. Quir. Buenos Ayres). Canada Lancet, 
1880-81, xiii. 200. 
a3 Seim, op. cit. 
2* Langinaid. Boston Med. anil Sury. Journal, 1882, cvii. 33. Intestinal Obstruction. 
61 
of anaesthesia. Massage of the tumor and inver- 
sion of the body are important adjuncts. 
The use of electricity is to be condemned as 
irrational where intestinal contractions induce and 
promote the disturbance. Large doses of quick- 
silver have been employed within the past few 
years as well as in more remote times. Gronau26 
reports a case, in which, on the seventh day, one 
hundred and twenty grammes were given in two 
doses. The immediate effect was to check vomit- 
ing, although the pains persisted. A week later 
two copious dejections were noted, and on the 
following day eleven inches of ileum were dis- 
charged. The quicksilver did not appear till forty- 
four days after its administration. 
The reduction of the displaced bowel by means 
of a probang or bougie, well padded at the end, 
seems useless, from reasons already stated, in any 
case of intussusception where the seat is above the 
sigmoid flexure. Even below this point inflation 
or injection have proven equally serviceable, and 
are to be preferred as freer from risk. The earlier 
they are employed the better, and their use is to 
be avoided when there is reason to suppose that 
gangrene is present at the neck of the tumor, or 
that the latter is irreducible. It has already been 
stated that the tumor may be irreducible on the 
third day, and that a slough may be passed on the 
ninth day. It remains to be shown what were the 
limits of the successful employment of injections and 
inflations since 1880. 
*s Gronau. Berl. Kl. Woch., 18S2, xix. 514. 62 
Intestinal Obstruction. 
Recoveries from intussusception after inflation 
or injection: — 
Diagnosis certain. 
Diagnosis probable. 
Date. 
Water. 
Gas. 
Air. 
Total 
Water. 
Gas. 
Air. 
Total 
1st day 
]1 
3 
4 
2 
4 
6 
2nd “ 
1 
1 
2 
1 
3 
0 
3rd “ 
1 
1 
2 
1 
3 
4th “ ...... 
i 
1 
Not given.... 
4 
1 
5 
3 
3 
0 
4 
1 
6 
ii 
10 
1 
11 
22 
Deaths from intussusception after inflation or 
injection: — 
1 
Diagnosis certain. 
Diagnosis probable. 
Date. 
Water 
Gas. 
Air. 
I’otal 
Water. 
Gas. 
Air. 
Total 
1st day 
1 
1 
1 
1 
2nd “ 
1 
2 
3 
3rd “ 
3 
1 
4 
4th “ 
1 
1 
5th “ 
1 
1 
5 
1 
4 
10 
1 
1 
It thus appears that there were thirty-three 
cases of recovery after injection or inflation for 
certain or probable intussusception. In seventeen 
cases air was inflated, in fourteen water was 
injected, and in two gas introduced from a siphon- 
reservoir. It is further evident that the remedy Intestinal Obstruction. 
63 
was used on the first day in ten cases, on the 
second day in seven, on the third in four, on 
the fourth in one, and on a date not given in 
eleven cases. The inference from these figures is 
that the successful use of inflation or injection may 
take place on the fourth day, but is most likely 
to occur during the first two days. 
The unsuccessful use of the above treatment 
resulted, in eleven cases : in two on the first day, 
three on the second, four on the third, and in one 
on the fourth and fifth days respectively. Certain 
of these failures are due to an insufficient pressure, 
for after death, in these, the intussusception was 
easily reduced. In other cases the tumors returned, 
or the symptoms were not relieved. In such the 
tumors may not have been wholly reduced at the 
time of treatment. The inference is direct from 
the consideration of these tables showing the effect 
of medical treatment, that if the latter does not 
overcome the obstruction within the first two, 
possibly three, days, aid should be sought from the 
surgeon. 
Relief, by injection or inflation, from obstruction 
due to a twist is of very unlikely occurrence. 
There is no exact evidence on this point. As in 
intussusception so in twist: if no relief follows 
inflation or injection on the second or third day, 
the aid of the surgeon should be sought. 
The surgeon’s knife offers the only hope of cure 
from strangulation. 
In the medical treatment of obstruction from 
gall-stones, it is to be remembered that in the 
cases here collected a fatal result followed all 64 
Intestinal Obstruction. 
surgical treatment after the first week, and that 
five cases recovered under medical treatment after 
this date. The condition of the patient alone must 
determine the nature and duration of the treatment. 
Opiates, cathartics, and electricity have all been 
used in cases ending with recovery. 
In the light of the published experience of the 
past eight years, the medical treatment of acute 
obstruction is limited to the use of injections 
during the first three days, under sufficient degrees 
of pressure, within fixed limits, to determine the 
patency of the large intestine. If it proves im- 
passable the case is no longer medical, but surgical. 
If the large intestine is readily distended, and a 
diagnosis of gall-stones is admissible, and the con- 
dition of the patient is not urgent, opium is to be 
given; laxatives and electricity may be tried, but 
they are of doubtful expediency. If medical treat- 
ment is of no avail, and surgical treatment is 
refused, the efforts of the physician are restricted 
to the relief of pain and distress by narcotics, 
intestinal punctures, and gastric siphonage. 
In conclusion, acute, intestinal obstruction is 
diagnosticated by exclusion. Its seat is fixed by 
injection. Its variety is determined by its seat, 
the age, antecedents, and symptoms of the patient. 
Its treatment is surgical, on or after the third day, 
if the symptoms are urgent and forced injections 
fail to relieve. 
THE END. 
PRINTED BY CUPPLE8 * HURD, THE ALGONQUIN PRESS, BOSTON.