Read by title before I.H.A., Bureau of Surgery, June 19, 1940.
K. A. MCLAREN, M.D.
Intestinal obstruction in elderly patients is frequently met with. It may be caused by trauma, by peritonitis as from an appendix, by strangulated herniae, volvulus, adhesions, impacted faeces, and by new growths. The cause in many cases is obvious, and where necessary surgery should be resorted to at once as delay only causes further damage to the intestine and renders less likely the chance of favorable culmination.
In cases of impacted faeces frequently manual relief has to be resorted to as well as enemeta. It is in cases of partial obstruction or of seeming complete blockage, which after an enema or two are completely relieved, that we must further investigate and that at once. These cases are in great part due to the presence of a new growth, generally carcinoma in the colon or rectum. The figures given are as follows: 80 percent of intestinal carcinoma originate in the rectum, 15 percent in the colon, and 5 percent in the small intestine.
Carcinoma in these parts is usually of slower growth than in other localities, and if removed early sometimes does not return, or if it does it may be much slower in doing so than in other localities. If, however, the growth is not discovered early it will have spread by means of metastasis to the liver, and directly to the lymphatics of the abdomen. Operation then cannot hope to be curative, and will consist of a colostomy to prolong life only. How many times in our practice have we met patients who have lived for years following a colostomy? It is not probable that had they been operated very early in the course of their illness the growth could have been removed, and these years of inconvenience been saved?.
Again there are numerous instances of colostomy operations being performed in a rush because of complete obstruction, where had the correct diagnosis been made before the obstruction reached such a stage the operation would have been much safer.
Many of these patients survive but a few days. The bowel has been too greatly injured by distension and infection for them to survive. It is therefore necessary for the physician to be ever on the watch for possible early symptoms of new growth in these regions. When a patient comes to report increasing constipation or diarrhoea or bleeding haemorrhoids he should be thoroughly investigated.
Small intestine growths can rarely be palpated, and one usually must rely upon x-ray examination for help, but as pointed out these constitute only about 5 percent of the cases met with.
Rectal growth usually can be located by digital examination. Every physician should carry a number of rubber finger cots in his bag and should use them. Rectal growths are usually not annular, and are to be found on the posterior surface of the bowel high up near the promontory of the sacrum. They feel hard and irregular, and are painful to touch. Upon the discovery of such a mass a surgeon should be consulted at once. The stools o such a patient may be pencil shaped, or flattened on one side, or may be small with jelly-like mucus and blood streaked according to the presence of ulceration or not. A proctoscopic examination will reveal much more than the examining finger, and should be resorted to.
There are cases which occur farther up, which are not palpable, and which are yet too small to be felt through the abdomen. Here is a barium enema and x-ray will show an annular growth in the sigmoid, in the splenic flexure, or in the transverse colon. These cases when discovered early offer the most brilliant surgical results. They cause slight increasing weakness, pallor, steadily increasing constipation, and vague abdominal pains.
Obstruction occurs very suddenly as a rule, and the first time will usually be relieved by different and frequent enemeta. It may be that this attack is the first time the patient has found it necessary to call in his physician, and it is the duty of the physician to insist upon further and full investigation following the relief of the obstruction, for this is the time when his life may be saved or prolonged for some years if the diagnosis is established and he is operated upon at once.
If this is not done the obstruction will return within a few days to a few months, and enemeta will not succeed, and operation under adverse circumstances will have to be undertaken. This is poor surgery upon the physicians part.
I leave to the surgeon the selection of the operation. He has to be guided by what he finds upon opening the abdomen. It is our duty to get these cases to the surgeon at the earliest possible moment that they may derive the greatest good.
Now there are those where, because of previous grave abdominal conditions, obstruction may occur, and when it is impossible to operate again. These cases then are terminal, and we must resort to the use of topical application of heat, different enemeta, and to our remedies.
I have had three such patients during the last two years, and have been able to test the use of the homoeopathic remedies on them. Our repertories contain paragraphs relating to remedies useful in these cases, and just because a case appears to be hopeless is no reason for withholding a prescription. Nux vomica and Opium prescribed according to their indications gave marked relief. Flatus passed from time to time in small amounts with some relief. Faecal vomiting was present, but in the main they suffered very little, became semicomatose, and died.