CHAPTER XVI

FUNCTIONAL OBSTRUCTIONS (Continued)

VARIETIES OF FUNCTIONAL OBSTRUCTIONS

PARALYTIC TYPE. In considering the cIinica1 aspects of

functiona obstructions of the paraIytic type, the cases faII

naturaIIy into the two groups aheady discussed from the experimenta point of view in the preceding chapter: nameIy,

disturbances of motihty resuIting from IocaI, intra-abdomina1

pathoIogy; and reflex disturbances resuIting from distant

Iesions,

The more important disturbances among the first group

are those that arise as a compIication of peritonitis, those that

foIIow operative procedures or other forms of mechanica

trauma, and those occurring as a comphcation of mechanica

obstruction. The most frequentIy encountered and most

serious cases are those accompanying peritonitis.

Functional Obstruction from Peritonitis. Disturbances of

intestina1 motiIity may be caused by acute peritonea1 infection

in two ways: mechanicaIIy, by the production of adhesions;

and functionaIIy, by causing paraIysis and atony of the

intestina1 cana as a resuIt of injury to the neuromuscuIar

structure of the gut, as discussed in the preceding chapter.*

FrequentIy the obstruction is found to come about as a resuIt

of both these conditions, and there is present in the same case a

mechanica and a functiona eIement.

The foIIowing case is ihustrative of the functiona dis-

turbances of motihty associated with diffuse peritonitis; there

was apparentIy no mechanical eIement in the obstruction:

* On the basis of the work described in the preceding chapter it must be admitted that even in cases where IocaI damage to the gut is the outstanding factor there may at times be some reflex eIement in the inhibition of motility.

823 Book Page 185

824 FUNCTIONAL OBSTRUCTIONS

CASE XXVII. Functional obstruction associated witb peritonitis. No. 256152, M. G. H. Male, aged fifty-three, entered the HospitaI with

a typical history and physica findings of acute appendicitis. He appeared

to be acuteIy ill; temperature IOI’F., white bIood count 26,000.

The patient was operated upon and a ruptured appendix with abscess

formation was found. The abscess was partiaIIy waIIed off; aIthough the

notes state that there was considerabIe free fluid in the genera1 peritonea1 cavity.

FoIIowing the operation the patient had a stormy convaIescence.

Marked distention of the abdomen was present, and there was some dis-

comfort from this source, but no coIicky or cramp-Iike pains suggesting

mechanica obstruction. Enemas, pouhices and recta1 tube were tried, but IittIe gas was expeIIed and the distention was not reIieved. The patient

showed very IittIe eIevation of temperature (usuaIIy from 100’ to IOI’F.).

On the ninth day postoperative, the patient’s genera1 condition was

said to be worse, the most outstanding symptom being the persistent

distention. An enterostomy was decided upon, and an iIeostomy, under

novacaine anesthesia and without any expIoratory operation, was carried

out according to the WitseI method; a catheter was inserted into a dis-

tended Ioop of gut and the omentum was sutured around the point where the

catheter emerged from the gut. There was no reIief of distention foIIowing

the operation; there was very IittIe drainage from the catheter. The patient died the next day. At necropsy a genera1 fibropuruIent peritonitis was found.

Comment: Sepsis was undoubtedIy the chief factor in this patient’s

death, the symptoms of obstruction being due to a generaIized atonic

condition of the intestina1 tract and no improvement foIIowing the drainage

of a distended coi1. It wiI1 be noticed in the postoperative notes that foIIow- ing the first operation there was no evidence of colicky pains or other signs of

increased peristaIsis such as is usuaIIy associated with mechanica obstruction.

The foregoing case seems to be an exampIe of pure func- tiona1 obstruction. As has already been stated, it is not uncom- mon in connection with peritonitis to have both a mechanica and a functiona eIement present in the same case. This is iIIustrated by the foIIowing history:

CASE XXVIII. Obstruction complicating peritonitis and having botb a mechanical and a junctional element.

No. 287917, M. G. H. FemaIe, aged thirty-one. The first operation con- sisted in drainage of a tubo-ovarian abscess. FoIIowing the operation the patient had a somewhat stormy convaIescence, with a temperature range between 102’ and 103’~. There was a profuse drainage from the abdomina1

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ACUTE INTESTINAL OBSTRUCTION

wound. The cuIture of the pus from the wound showed a hemoIytic strep-

tococeus. AbdominaI distention was persistent, but was somewhat reduced

by enemas. On the fifteenth day postoperative, the operative notes state that the

abdomina1 distention was more marked and the patient was compIaining

of severe, cramp-Iike, coIicky pains. The drainage from the wound was stiI1

profuse. It was decided that intestina1 obstruction was present, and opera-

tion was advised. Operation (under novacaine anesthesia) consisted in the insertion of a

catheter into a diIated coi1 of smaI1 intestine. There was immediate reIief

of a11 symptoms of obstruction foIIowing the enterostomy, and the patient

was eventuaIIy discharged in good condition. Comment: In this case there was probabIy atony of the Ioops of smaI1

intestine in the region of the peIvic abscess, due to inflammation and

infection. Kinking of the intestines by recent inflammatory adhesions

doubtIess added a mechanica eIement. The severe, cramp-like pains showed

that there was no genera1 atony, cIearIy indicating that vigorous peristaIsis in the upper bowe1 was attempting to push the intestina1 contents beyond a

point of obstruction.

There was a twofoId reason why at the time the enterostomy was

performed it was deemed unwise to carry out any extensive exploration.

In the first pIace, the expIoration wouId have been IikeIy to disseminate the

peritonitis which now was IocaIized in the region of the abscess. Inthe

second pIace, it is known from experience that these obstructions coming

on earIy after operation and caused by Iight adhesions combined with functiona atony of certain coiIs do very we11 if the bowe1 above is drained,

without any attempt to find the exact point of obstruction. There was no bIoody ffuid in the peritonea1 cavity; and whiIe this does not ruIe out the

possibiIity of stranguIation it makes it seem unIikeIy.

WhiIe undoubtedIy the patient had some toxic absorption from the

IocaIized peritonitis, the outstanding feature of this case at the time of the

second operation was the intestina1 obstruction.

Functional Disturbance as a Complication of Mechanical

Obstruction. The Iate stages of most cases of mechanica obstruction are compIicated by functiona disturbances of the motiIity of that portion of the bowe1 Iying above the obstruc- tion. It is not infrequentIy found that when patients are operated upon Iate in the disease the bowe1 does not regain its motility even when the mechanica di ffIcuIty has been reIieved, the norma tone and peristakis having been compIeteIy

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826 FUNCTIONAL OBSTRUCTIONS

abolished by the Iong-continued distention and resuItant injury to the capiIIary circulation of the intestina1 waI1. Perhaps, aIso, the toxic contents of the obstructed bowe1 pIays a rBIe. Administration of ether to these Iate cases is IikeIy to enhance this functiona disturbance. The atony may not invoIve to an equa1 degree the whole intestina1 tract Iying above the obstruction, but may be IargeIy confined to some par- ticuIar Ioop immediateIy reIated to the mechanica obstruction,

Functional Disturbances after Operative Procedures. Minor degrees of functiona disturbance are among the most common compIications that foIIow abdomina1 operations,l even when no peritonitis is present; for, as shown experimentaIIy (see preceding chapter), handIing of the intestines is capabIe of producing inhibition of motiIity. This disturbance usuaIIy amounts to no more than sIight distention; there are cases in the Iiterature, however, where the symptoms have progressed to the point of rea1 functiona obstruction, expIoratory operation or autopsy showing a genera1 atonic diIatation of the intestina1 cana but no mechanica obstruction. CIinicaIIy, this group is of minor importance, since practicaIIy a11 the true obstructions that come on earIy after operation have a mechan- ica1 basis or occur as a compIication of peritonitis.

In connection with these functiona disturbances due to IocaI trauma, Richards, Fraser and WaIIace2 have pointed out that resections and anastomoses for gunshot wounds of the intestines are often foIIowed by functiona obstruction, the segment above the anastomosis becoming distended and paraIyzed. This resuIt may foIIow even though the operation take pIace reIativeIy soon after the injury. AIthough IocaIized peritonitis frequentIy pIays a part in this picture, these authors consider that the functiona eIement due to trauma to the gut

is an important factor. Reflex Disturbances from Distant Pathological Processes.

Functiona disturbances aIso occur where there is no intra- abdominaI Iesion, the inhibition of intestina1 movements being caused by some pathoIogica1 process in a distant part of the

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ACUTE INTESTINAL OBSTRUCTION 827

body and the peritonea1 cavity itseIf being unaffected. The reflex mechanism which brings this about has been discussed in the preceding chapter. CIinicaIIy these cases are rare, and therefore from a practica1 point of view reIativeIy unimportant; yet they are occasionaIIy encountered, and represent such an interesting probIem in the functiona pathoIogy of the gastro- enteroIogica1 tract that considerabIy more space in the Iitera- ture is given to them than they deserve on the basis of their

frequency. Functional disturbances caused by distant Iesions have

been reported as occurring most frequentIy in connection with renaI pathology (tumors, infections, operations or coIic). They have aIso been observed foIIowing retroperitonea1 hemorrhage or infection. 3 Eisendrath4 stresses the intimate reIationship between the spIanchnic nerve suppIy to the kid- neys and to the intestines. Tixier and CIave15 have aIso discussed the reflex mechanism whereby pathoIogica1 processes in the kidneys or retroperitonea1 tissue produce serious gastro- intestina1 disturbances. (See Fig. 44.)

The foIIowing case iIIustrates the condition in which an infectious process of the kidney resuIted in reflex inhibition of intestina1 motiIity of such severity as to bring the patient to operation under the diagnosis of intestina1 obstruction :

CASE XXIX. Functional obstruction following infection of tbe kidney. No. 2sIoxg, M. G. H. MaIe, aged sixty-eight. Three days before

admission the patient was taken with sudden, severe abdomina1 pain.

There has been some IocaIization of the pain in the right lumbar region; the pain has been of suflicient severity to require morphia. The bowels have

not moved since the onset of the symptoms. There has been constant nausea

and regurgitation of “watery materia1.” There have been no urinary symptoms.

PhysicaI examination showed the abdomen greatIy distended and

tympanitic. There was generaIized tenderness, even to the sIightest pressure.

The patient was operated upon under IocaI anesthesia. The distention

of the intestines was so great that an expIoratory operation couId not be

carried out. The cecum was found to be distended, and a tube was inserted into this organ.

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828 FUNCTIONAL OBSTRUCTIONS

The patient died five hours after operation. At necropsy the abdomina1

examination was negative except for great distention of a11 the intestina1

tract. There was pyonephrosis of the Ieft kidney, with stones.

Functiona obstruction foIIowing fractured ribs has aIso been reported. Adams6 observed 2 such cases, RaIph2 one. The foIIowing is a brief abstract of Adams’ first case:

CASE xxx. Functional obstruction following fractured ribs. MaIe, aged sixty-six. Three days before admission the patient feI1 and

fractured severa ribs on the right side. The affected side was strapped.

The boweIs had been reguIar before the accident; afterwards they did not move even with enemas. The patient became markedIy distended, and

vomited profuseIy.

An expIoratory Iaparotomy was carried out, but no organic obstruction

was found. The patient deveIoped severe shock and died. Autopsy was

essentiaIIy negative, except for great intestina1 distention.

Adams’ second case recovered foIIowing an iIeostomy. IntestinaI motihty is inffuenced by the genera1 bodiIy

state. Marked inhibition of intestina1 motiIity wiI1 occasionaIIy occur in the course of acute infections, notabIy pneumonias, the resuItant abdomina1 distention being at times a serious compIication. Symptoms suggestive of true intestina1 obstruc- tion may aIso deveIop at times in the course of uremic states and present a difEcuIt probIem in diagnosis. Not infrequentIy disturbances of intestina1 motiIity of sufficient severity to be cIassed as functiona obstructions are observed in the very aged and in young infants. The cIinica1 syndrome may be that of obstruction and yet no organic cause be demonstrabIe at operation or at autopsy. During the ten-year period 191 S-1927

at the Massachusetts Genera1 HospitaI g such cases were admitted to the surgica1 wards: 6 of these were patients over seventy years of age, 2 were infants under one month. ProbabIy these functiona disturbances of intestina1 motiIity were due to the poor constitutiona state of the patients; they may be diffIcuIt to distinguish from mechanica obstructions. The foIIowing histories iIIustrate these conditions :

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ACUTE INTESTINAL OBSTRUCTION

CASE XXXI. Functional obstruction in an aged person. No. 254687, M. G. H. MaIe, aged seventy-three. For the past two weeks

the patient had felt poorIy, but had worked until thirty-three hours before

admission to the hospita1. At that time he was’taken with abdomina1 pain

and vomiting. The vomitus was said to be dark in coIor. He had vomited a

number of times since the onset of the attack; there had been one bowe1

movement during that time. During most of this time the patient had been

troubled by hiccough.

On physica examination the abdomen was found greatIy distended and

tympanitic throughout. It was tender on paIpation.

A diagnosis of intestina1 obstruction was made and the abdomen was expIored under ether anesthesia. There was no free fluid in the peritonea1

cavity. The intestines were generaIIy distended and of dark coIor due to

interference with the circuIation by distention. No cause for the obstruction couId be found. During the cIosure of the abdomen the patient vomited

and aspirated a considerabIe quantity of vomitus, and died immediateIy.

Autopsy was carried out, but no organic cause for the obstruction was

found.

Comment: There is not sufficient data at hand to give an adequate

expIanation of the functiona obstruction in this aged patient. The danger of aspiration of vomitus whiIe under a genera1 anesthetic and the methods

of avoiding this compIication are discussed in a Iater chapter.

CASE XXXII. Functional obstruction in an infant. No. 270780, M. G. H. An infant, five weeks oId. The baby had been

Iosing weight and vomiting for four days. During this time the boweIs had

moved onIy twice and in very smaI1 amount. The baby had cried out

constantIy and been very restIess. An enema had faiIed to produce either gas or feces.

Genera1 physica examination was negative except for an extreme

degree of emaciation and marked abdomina1 distention. The abdomen was

tympanitic a11 over. The most probabIe diagnosis seemed to be intestina1

obstruction, and an enterostomy was decided upon.

Under IocaI anesthesia a catheter was inserted into a distended Ioop of

smaI1 intestine. The baby died four days Iater. Autopsy was essentiaIIy

negative, except for distention of the smaI1 intestine, and emaciation.

SPASTIC OCCLUSIONS. So far, onIy those functiona obstruc- tions of the bowe1 brought about by intestina1 atony have been considered; there are aIso obstructions caused by IocaIized spasms of the intestina1 muscuIature. PeristaIsis is a comphcated process, depending upon a high degree of co6rdi-

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830 FUNCTIONAL OBSTRUCTIONS

nation of the different parts in order to bring about a purposefu1 movement. If there exist areas of IocaIized spasm that are out of time with the wave of peristaIsis, the progress of the con- tents is bIocked. WhiIe moderate degrees of intestina1 spasm* are probabIy very common, contractions of sufficient intensity and duration to bring about the symptoms of true obstruction are rare. Authentic cases, however, have been reported, much more attention having been paid to the condition in the Ger- man Iiterature than eLsewhere.

Our knowIedge as to either the frequency or the mechanism of this type of disturbance is vague. NageP reported 2 cases from his cIinic, together with 49 coIIected from the Iiterature. The spasms have been reported as occurring under diverse circumstances; a number have occurred in neurasthenic or hysterica individuaIs, who seem particuIarIy predisposed to these spasms of intestina1 muscuIature. The condition-may be recurrent: Jacobsen9 operated on the same patient twice during one hospita1 admission. Most of the cases have foIIowed abdomina1 operations on the stomach, intestines or peIvic organs (Green et aI.,lO Meyer,ll NageI,8 and SteindI12). In 1925, Reimer13 reported 3 cases where obstruction due to IocaIized spasm foIIowed intraperitonea1 hemorrhage. F. CoI- mers14 reports 3 cases in which spastic obstruction came on in association with “grippe,” the symptoms being so severe that the patients were operated upon and nothing but spasmodic contractions of the smaI1 or Iarge intestine were found; 2 of these cases afterwards showed signs of disturbance of the centra1 nervous system.

The views expressed by most of the authors as to the etioIogy are not concIusive, and the evidence on which they base their specuIations is vague. SteindI12 says that spastic occIusion can come about in several ways: as the resuIt of injury to the peritonea1 nerve pIexuses; from causes directIy affecting the intestina1 tract; from irritation of intestina1

* The gas pains after operation probabty represent, at Ieast in part, IocaIized spasm

of the gut.

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ACUTE INTESTINAL OBSTRUCTION 831

contents; as a resuIt of hysteria; and from causes unknown. This author thinks that considerabIe importance shouId be attached to changes in the autonomic nervous system. He reports the finding at autopsy of changes in the meduIIa in the region of the vagus center, which he reIates to the intestina1 spasm. These changes, due to narcosis or absorption of toxins, consisted of perivascuIar infYtration and Iymphocytosis. Reimer l3 considered that changes in the centra1 nervous system are important. Riess15 considers that spasm of the intestina1 muscuIature is the important factor.

LocaI injury to the muscIe or nerve pIexuses is at Ieast probabIy an important factor in the production of the spasm around foreign bodies in the intestina1 Iumen, the spasm converting an incompIete bIockage by the foreign body into a compIete obstruction. For exampIe, there is good reason for beIieving that a spasmodic contraction often occurs around a gaIIstone that has lodged in the intestina1 tract and that might have passed through without producing an obstruction had it not been for the tonic contraction incited by its presence. Tonic contractions have been reported around coIIections of intestina1 parasites, particuIarIy ascarides, of sufficient per- sistence to produce the syndrome of obstruction. The spasm in this instance is supposedIy due to a toxin secreted by the worms (see March installment, p. 592).

The pains of Iead coIic are probabIy associated with areas of IocaI spasm and at times may be of sufficient severity to present a probIem in differentia1 diagnosis. Murphy’s16 case in which an operation was performed in a case of Iead coIic under the diagnosis of intestina1 obstruction is iIIuminating; an actua1 area of spasm of the intestina1 muscuIature was found. His articIe carries an iIIustration of this condition.

REFERENCES TO CHAPTER XVI

I. MCIVER, M. A., BENEDICT, E. B. and CLINE, J. W. JR. Postoperative gaseous dis-

tention of intestine; experimental and clinical study. Arch. Surg., 13: 588-604, 1926.

2. RICHARDS, 0.. FRASER, J. and WALLACE, C. Paralysis of intestine after resection for gunshot injuries. Brit. M. J., 2: g-1 I, 1916.

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FUNCTIONAL OBSTRUCTIONS

3. JOYCE, J. L. SubperitoneaI effusions simuIating acute intraperitonea1 disease. Brit. J. Surg., 12: 547-553, 1925.

4. EISENDRATH, D. N. ReAex iIeus of renal origin.Surg., Gynec., Obst., 22:698-701, ,916. 5. TIXIER, L., and CLAVEL, C. RetroperitoneaI syndrome and reIation between

kidney and gastro-intestina1 reffexes. Surg., Gynec., Oh., 54: 505-510, 1932.

6. ADAMS, J. E. ParaIytic iIeus as seque1 of fractured ribs. Ann. Surg., 5 I : 102-1 IO, 1910.

7. RALPHS, F. G. IIeus foIIowing fractured ribs. &it. J. Surg., 13: 559-561, 1926. 8. NAGEL. Spastic iIeus. Beitr. z. klin. Cbir., 124: 139-156, 1921; ab. J. A. M. A.,78:

254, 1922. g. JACOBSEN, H. Spastic iIeus. Hospitalstid., 65: 753-758, 1922; ab. J. A. M. A., 80:

‘50, 1923. IO. GREEN, R. M., KELLOGG, F. S., and HARVIE, P. L. Spastic paralytic ileus. Boston

M. +Y S. J., 168: 580-582, 19x3. I I. MEYER, W. IntestinaI obstruction due to iIiac spasm. Ann. Surg., 61: I 13-114, 1915.

12. STEINDL, H. Enterospasm. Arcb.f. klin. Cbir., 139: 245-318, 1926; ab. J. A. M. A.,

86: 1667, 1926.

13. REIMER, H. Spastic intestina1 occIusion in intraperitonea1 hemorrhage. Arch. f. klin. Cbir., 135: 520-541, 1925; ab. J. A. M. A., 85: 156, 1925.

14. COLMERS, F. Spastic iIeus in inffuenza. Zentralbl. j. Cbir., 49: 193x-32, 1922; ab.

J. A. M. A., 80: 735, ‘923. 15. RIESS, P. EtioIogy of spastic ileus. Zentralbl. f. Cbir., 52: 2758-2760, 1925. 16. MURPHY, J. B. IIeus. J. A. M. A., 26: 15-22; 72-76, 1896.

REFERENCES TO CHAPTER XIV*

15. CANNON, W. B., and MURPHY, F. T. Movements of stomach and intestines in some surgical conditions. Ann. Surg., 43: 512-536, Igo6.

16. HOMANS, J. Textbook of Surgery. Bait., Thomas, 1931, p. g3r. 17. FOSTER, W. C., and HAUSLER, R. W. Studies on acute intestina1 obstruction; acute

stranguIation. Arch. Znt. Med., 34: 697-713, Igzq. 18. MCIVER, M. A., WHITE, J. C., and LAWSON, G. M. RBIe of BaciIIus weIchii in acute

intestina1 obstruction; with Iigation of veins to obstructed loop. Ann. Surg., 89:

647-657, 1929. Ig. BRINTON, W. Intestinal Obstruction. PhiIa., Lippincott, 1867, p. 29. 20. HATCHER, R. A., and WEISS, S. Studies on vomiting. J. Pbarmacol. @ Exper. Tberap.,

22: 139-193, 1924.

21. Quoted by Brinton, W.,‘a p. 7. 22. SYDENHAM, T. The Works of Thomas Sydenham. Ed. 3, trans. John Swan, London,

1753, P. 43. 23. BRINTON, W.,rs p. 12. 24. ALVAREZ, W. C. Syndrome of miId reverse peristalsis. J. A. M. A., 69: 2018-2024,

1917. 25. ALVAREZ, W. C. The Mechanics of the Digestive Tract; Introduction to Gastro-

enteroIogy. Ed. 2, N. Y., Hoeber, 1928.

26. NOTHNAGEL, H.,r p. 384. 27. MENDEL, L. B. Pjlugers Arch., 63: 425, 1896. 28. FALLOISE, A. Origine &crCtoire du Iiquide obtenu per enervation dune anse intes-

tinale. Arch. internal. de pbysiol., I : 261-277, 1904.

[Continued on p. 839.1

* Continued from p. 822.

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