The treatment comprises the management of the disease during the intervals and during the attacks. During the intervals the following rules are of importance: The diet should exclude all substances which give large residue of fecal matter or which are of an irritating character. Thus green vegetables, salads, fruits, vinegar, mustard, pepper, must be strictly forbidden. Milk and milk soups, eggs, tender meats without too much fat and without tendons, butter, toasted bread or plain white bread well baked, farina, rice and sago, well cooked, are permissible. The patients should eat frequently and not too much at a time. Cold drinks should be avoided. Attention must be paid to the patient's taking a sufficient quantity of food.

The bowels must be kept in working order. It is absolutely necessary to secure one evacuation daily. Massage, electricity, and the usual mild cathartics (like magnesia sulphate, rhubarb, cascara sagrada, syrup of figs) may be used. Injections of water or oil into the bowel are also of benefit. When diarrhoea is present it should not be checked unless the patient is greatly debilitated. Even then only mild astringent remedies are permissible. Often even during periods of diarrhoea, when not very large evacuations take place, a mild cathartic (like castor oil or Carlsbad salts) must be employed in order to assure a thorough cleansing of the bowel.

During the attack of intestinal colic warm fomentations over the abdomen should be applied. If these be insufficient, the narcotic remedies are in place. Opium alone or opium with belladonna may be given either by the mouth or in suppositories. Here also it is necessary to produce a sufficient evacuation of the bowel, which is best done by rectal injections. If there are great distention of the abdomen and vomiting, gastric lavage is beneficial. Cocaine in doses of one-third to one-half grain, or menthol one grain three times daily, will allay the vomiting. If there is a real attack of acute obstruction this must be treated in the same manner as primary acute intestinal obstruction, described above.

If the stenosis involves the upper portion of the small intestine, lavage will play an important part in allaying the symptoms temporarily.. Chronic fecal impaction requires the application of massage and also of electricity, as described in the chapter on constipation. Sometimes the hardened scybala will have to be removed from the rectum by artificial means. For this purpose the sphincter is first dilated and the fecal masses are removed with the fingers or with a spoon-shaped instrument. If there is a blocking of the passage higher up in the colon, strong cathartics (croton oil) may be administered. Metallic mercury has also been advantageously used in these instances.

Strictures of the rectum, excepting those of a cancerous nature, can first be treated by dilating them gradually with bougies of various size. The rectal bougie of Crede best answers this purpose. It is advisable to leave the bougie within the stricture for at least fifteen minutes and to insert it once every two to three days. If the stricture is of a very high degree this method of treatment may be inefficient, and then surgical measures will have to be undertaken.

Operative Intervention

All types of chronic intestinal obstruction, with the exclusion of those caused by fecal accumulation and strictures of the rectum, gradually grow worse. The above-described modes of treatment are only of a palliative nature. For this reason it must be considered as a decided advance that surgical means have been found fully to remove the obstacle and restore the patient to complete health. The procedures which are resorted to are various and depend upon the anatomical lesion underlying the obstruction.

Malignant growths must be extirpated as early as possible and an end-to-end anastomosis of the bowel established. A circular stricture of the bowel (of benign type) can be removed by enteroplasty in a similar way as pyloroplasty, namely, by splitting the gut parallel to its axis or vertically to the stricture and uniting the edges of the incision transversely. Pean1 has successfully performed such operations. Several simple strictures of the bowel can be treated in the same way, if they are not too close together. If the stricture is of a tubular form or if it is of too high a degree, excision of the involved part followed by exact coaptation of the divided ends by sutures is best done. This operation is greatly facilitated by Murphy's button, which makes it possible to unite the two ends of the severed bowel rapidly without losing too much time in the suturing.

In cases in which the stricture cannot be excised nor otherwise remedied, or in any other form of obstruction of the bowel which cannot be removed, the bowel just above the stricture is united to the bowel below it and a short circuit thus established. This is likewise best accomplished by Murphy's button.

1 Pean . Bulletin de l'Academie de Medecine, 1890, p. 856.

In some strictures of the colon in patients who are already quite prostrated, a complete operation of excision or even of the formation of a new circuit cannot be performed without too great risk of life. Here colotomy is indicated, being later supplemented by a more radical procedure when the patient is stronger and in better condition.

Adhesions should be severed and tumors compressing the bowel treated by radical removal. Surgical treatment of the intestinal stenosis, affording as it does radical relief, should be resorted to in every case as soon as the diagnosis is positive. The only excuse for subjecting the patients to non-operative measures as long as they get along in comparative comfort, is the high mortality which surgical intervention still furnishes. According to Treves,1 the mortality fluctuates between twelve and twenty per cent. It is to be hoped, however, that owing to our advanced knowledge of this subject the diagnosis of intestinal stenosis will be made quite early, and that the patients by being operated upon at an early period will show a smaller percentage of mortality.

1 Loc. cit., p. 560.