the lesion. They are gradually developed, and in this respect are
unlike the symptoms of internal strangulation or of intussusception,
which are generally acute and rapid in their course. When the
obstruction in stricture is complete, progress toward death is
comparatively slow. If the stricture is seated in the small intestine,
the symptoms are often so obscure that for a long time the presence of
the contraction may not be suspected; the contents of the small bowel
are usually fluid, and in this state readily pass through the
constricted part. The more solid the contents of the bowel, the greater
the difficulty in passing a contracted and narrow orifice, and the more
conclusive and characteristic the assemblage of symptoms of obstruction
from stricture.
The history of a case of intestinal obstruction from stricture is often
instructive. For weeks or months there have been colicky pains and
intestinal disorder; possibly, in the early stages, diarrhoea, but
later marked constipation, and probably previous attacks where
constipation was for a time insuperable and death from obstruction
imminent. Hemorrhage, except in cancer or when complicated with piles,
is rare. The attack may come on suddenly, or constipation become more
and more difficult to overcome; violent peristalsis presents itself,
accompanied by pain and abdominal distension, and followed by nausea
and vomiting, the latter often being stercoraceous. During the throes
of pain--for it is paroxysmal--the outline of the distended gut can be
felt and seen through the abdominal walls if they are thin and free
from fat. Unless the stricture is relieved the patient gradually dies
from asthenia. Inflammation is often absent throughout, but enteritis
or peritonitis may come on, or perforation and peritoneal extravasation
ensue and hasten the fatal termination.
When the obstruction is in the rectum it can be felt with the finger;
if in the sigmoid flexure, it may be felt with a gum bougie or probe,
but the use of the former is unreliable, and the latter, unless
carefully employed, dangerous. Obstruction at this point, however, is
attended with marked distension of the descending and transverse colon.
If seated in the small bowel, the large intestine is flaccid and
collapsed. Careful manual exploration often enables the practitioner to
determine the site of the contraction. Weight, pain, dulness, and
fulness are usually found about the stricture, but these signs may be
of little value when the abdominal wall is thick and unyielding, or
peritonitis or tumor is present, or the contracted portion of bowel is
compressed or drawn out of its proper site. Brinton suggests that the
site of stricture may be determined by the quantity of water which can
be injected through the anus into the bowel. Such an estimation must
often be erroneous, as stricture {857} is rarely ever complete and
fluid may be forced through the constricted part. Indeed, Battey of
Georgia has demonstrated upon dead and living subjects that fluid may
be made to pass through the entire canal from the anus to the stomach.
Obstruction due to cancer of the rectum can be determined by digital
examination. When seated in the small intestine or higher up in the
large bowel, the presence of a painful tumor, preceded for weeks by
evidences of impaired nutrition, emaciation, and followed by
lancinating pain, cancerous cachexia, etc., will indicate the character
of the trouble.
Compression and Contraction of the Bowel.
Obstruction of the bowel is sometimes occasioned by compression or
traction exerted on the intestine by abdominal tumors or cysts. Fibrous
tumors of the uterus, ovarian cysts, hydatid growths, or indeed any
form of abdominal tumor, may by pressure on some part of the intestinal
track produce fatal obstruction. Several inches of bowel may thus be
compressed and rendered impervious, or if traction is exerted by the
tumor, which is often adherent to the bowel, the tube may be sharply
bent or twisted and its action interfered with. A case is reported of
compression of the bowel from a great accumulation of fat about the
colon. Adhesions of intestinal coils from chronic peritoneal
inflammatory changes constitute a large and important class of cases of
intestinal obstruction. This condition is known as contraction of the
bowels: 23 of the 124 cases reported by Bryant were of this character.
The usual site of stricture is the large bowel: contraction is far more
frequently seen in the small intestine, and is caused by an effusion of
lymph following simple peritonitis or the inflammation attending the
formation of cancer or tubercle of the peritoneum. Coils of intestine
are matted together or to neighboring parts in this way by bands of
lymph or false membranes, and the action of the bowel interfered with
or obstructed. Constriction of a length of bowel may be found after
death, or a sharp, angular bend by which complete obstruction has been
produced.
Circumscribed peritonitis may produce adhesion of a portion of bowel by
bands of lymph to the uterus or its appendages, or to some part of the
large intestine, or to the abdominal wall, and the action of the bowel
become embarrassed by traction, constriction, or bending. In
consequence of the irritation following this condition, spasmodic
contraction may follow and add to the difficulty, or enteritis may
ensue; and this will especially be the case if the circulation of the
part is interfered with, and render complete what before was a partial
obstruction. Distension and fulness of the bowel above the obstruction,
with contraction and emptiness of the portion of the gut below, are
found after death in cases of contraction, just as we see in fatal
cases of stricture. The history of the case and presence of a tumor
will generally enable the practitioner to determine when obstruction is
due to the presence of some adventitious growth. When contraction is
complicated with the presence of tubercle or cancer, symptoms attending
these conditions will be present.
Obstruction of the intestines from contraction generally comes on {858}
insidiously. The patient may date the beginning of his trouble from an
old attack of circumscribed peritonitis which probably took place weeks
or months before. He has attacks of colicky pains, indigestion, and
constipation. The last is difficult to overcome, continuing for hours
before it is relieved by medicine or the efforts of nature. During the
attack of almost insurmountable constipation violent peristaltic
movement of the bowel above the impediment may be noticed. The patient
may gradually become more and more feeble from suffering and
interference with nutrition, and die from exhaustion, or fits of
obstinate constipation may continue to recur, until finally one of them
becomes insuperable and fatal.
The symptoms of contraction closely resemble those of stricture, but it
is important to distinguish one from the other, as the treatment,
especially if surgical interference is demanded, is very different. A
rigid analysis of all of the signs will usually, but not invariably,
enable the practitioner to make the distinction.
There is an important difference between the constipation of stricture
and that of contraction. In the former the difficulty is in defecation,
emptying the large bowel, the usual site of stricture; in the latter
the difficulty is in the passage of the contents of the gut along the
narrowed and contracted small intestine, the common site of
contraction. In stricture the calibre of the bowel is diminished by
some sharply-defined mechanical impediment seated in the cavity or in
the walls of the tube; in contraction the bowel is bent or kinked by
adhesions, or coils of intestine are matted and glued together and
peristalsis interfered with. In stricture defecation is difficult and
painful; in contraction the alvine discharges are painless. In the
former blood and mucus are not unfrequently seen in the feces; in the
latter the motions are healthy. In stricture constipation alternates
with diarrhoea; in contraction looseness of the bowels is rarely seen.
In stricture distension of the abdomen is lumbar and epigastric; in
contraction the distension is less and is central and hypogastric. In
both conditions violent distinct peristaltic action is seen during a
fit of constipation, and in both the bowel above the constriction is
distended and hypertrophied. In contraction the powerful, writhing
peristalsis involves the small intestine above the impediment, and in
stricture the large bowel above the obstruction. In both stricture and
contraction inflammation of the bowel and peritoneum may supervene. In
contraction, when inflammation sets in or when enteritis and
peritonitis are absent and the attack of constipation is
insurmountable, I have noticed that the symptoms are more urgent and
rapid in their course, and danger of death from collapse greater, than
when these conditions exist in stricture.
DIFFERENTIAL DIAGNOSIS.--In every case of intestinal obstruction a
careful examination should be made for external strangulated hernia.
All of the regions of the abdomen in which hernia may occur should be
thoroughly inspected, as the symptoms of the two conditions are
identical. A small or incomplete external strangulated hernia may
easily be overlooked. An individual with an old hernia may suddenly
have symptoms of intestinal obstruction, and it may be doubtful whether
the obstruction is due to internal constriction or to the external
hernia. Diagnosis is especially difficult when the chronic hernia is
irreducible in character. If the cause {859} of the impermeability is
internal and below the external hernia, that portion of intestine in
the hernial tumor becomes swollen, tense, and hard, and closely
resembles the local symptoms of strangulated hernia. If the external
hernia is reducible, reduction en masse may take place and a
retro-peritoneal hernia be formed. When the case is doubtful and
urgent, an operation for strangulated hernia should be performed.
Functional obstruction of the bowel is sometimes seen, closely
simulating obstruction from one of the structural changes mentioned.
Cases of functional obstruction are seen usually in hysterical or
nervous women, and are generally recognized by the history, course, and
termination of the malady. The fact that local enteritis, peritonitis,
or typhlitis, by paralyzing a portion of the bowel, may produce all the
signs of acute and complete obstruction, should not be lost sight of.
In cases of congenital stricture or malformation, or the presence of
foreign bodies in the intestine, or acute internal strangulation, or
twisting of a length of bowel, and generally in intussusception,
symptoms of acute obstruction are present. The individual may have been
in perfect health, and suddenly symptoms of the gravest character set
in. Intense pain, referred to some special part of the belly, is the
first sign of trouble. Nausea soon follows, and with it great
prostration; the depression of vital power approaches, and sometimes
reaches, syncope; the patient rolls and tosses in agony; his mental
distress is equally great, and if old enough he is conscious of his
danger and is anxious and despondent. Vomiting succeeds the nausea: at
first the contents of the stomach, and then those of the small
intestines, are thrown up; after a time the vomiting is stercoraceous.
The belly becomes swollen, tympanitic, and exquisitely tender; the
weight of the bed-clothes or the slightest touch of the finger upon his
abdomen is intolerable; he keeps his head and shoulders raised and his
lower limbs retracted to avoid pressure of the abdominal muscles.
Constipation is complete and insuperable. If the abdominal wall is
thin, the violent motion of the intestines can be seen and felt through
it. These painful peristaltic movements of the bowel are paroxysmal and
attended by loud rumbling or gurgling noises. The pain gradually
increases; the patient is very restless and complains of great thirst;
his pulse is small, hard, and frequent, his extremities cool and
features pinched. If not soon relieved, exhaustion comes on; he has
muttering delirium, cold clammy perspiration, hiccough, twitching of
the tendons, and death soon follows from collapse or from peritonitis
or gangrene, or from both. The average period of death is from six to
eight days. It may occur in thirty-six or forty-eight hours, or the
patient may last for two weeks.
In congenital occlusion and malformation the history of the case, the
age of the patient, and the fact that the deformity in such cases is
almost always confined to the anus and rectum, usually render the
diagnosis sufficiently easy.
Obstruction caused by foreign bodies impacted in the intestines can
generally be diagnosed. The history of the case may show that foreign
bodies have been swallowed or that the patient has been subjected to
some of the conditions which cause the formation of enteroliths. These
stony concretions are usually found in the cæcum or colon, and
frequently give rise for days and weeks to symptoms of indigestion,
emaciation, {860} constipation, and other evidences of bad health
before complete occlusion of the intestine takes place. Not
unfrequently, before the sudden attack of impermeability of the bowel
the patient has had repeated attacks of typhlitis, and has been
conscious for a long time of the presence of a tumor in the region of
the cæcum or colon. Possibly he has passed on some former occasion
pieces of the stony concretion.
Diagnosis of obstruction by gall-stones is often aided by the fact that
the patient has recently suffered characteristic pains of hepatic colic
and by the icterous condition of the skin. Possibly the individual has
suffered repeated attacks of hepatic trouble and has previously passed
a gall-stone. Obstruction from this cause is seen four times as often
in women as in men, and always after the middle period of life.
In obstruction occasioned by internal hernia or the presence of
membranous bands, loops, mesenteric pouches, the symptoms are often
such as to baffle all attempts at accurate and certain diagnosis. The
onset of the symptoms is sudden and the course of the disease rapid;
prostration of vital power is extreme, sometimes amounting to syncope;
vomiting incessant and persistent; pain constant and fixed. The most
characteristic symptom of internal strangulation is the very great and
prolonged depression of vital power; it occurs generally in early adult
life.
Erichsen states that in twisting of the bowel the abdomen is unevenly
distended, it being tympanitic on one side and flattened on the other.
This condition of the bowel is usually seen after middle age. In
intussusception the principal signs are, usually, the early age of the
patient--obstruction from other causes in children being rare--the
suddenness of the onset of symptoms, the frequent desire to go to
stool, the tenesmus, and the characteristic bloody mucus discharges. By
abdominal palpation frequently the sausage-like tumor can be
recognized, and very often the intussuscepted part can be felt in the
rectum or seen protruding through the anus. When invagination involves
the upper part of the small intestine, diagnosis of the cause of
occlusion is almost impracticable.
In obstruction of the bowel from fecal accumulation, inflamed and
thickened intestine, stricture, compression and traction, and
contraction of the gut from cancerous deposit, the symptoms are
gradually presented and chronic in character. They are unlike the signs
of acute obstruction, which occur in persons apparently in perfect
health and are sudden and violent from the beginning. In chronic
obstruction of the intestine the patient has probably been complaining
for some time, with symptoms of abdominal trouble. He has been unwell
for weeks, his appetite poor, digestion disordered, strength
diminished, and bowels constipated. The last symptom is the most
distressing of all. Purgatives do not give the relief ordinarily
obtained, but add to the griping, colicky pains, nausea, and general
depression. When his bowels do act, the stool is sometimes liquid,
sometimes very hard (scybalous), or the form of the matter passed is
tape-like or pipe-like. Sometimes, in his frequent attempts at stool,
the only discharge is blood and mucus or pus. Attacks of eructation and
vomiting often take place during the progress of the disease.
Stercoraceous vomiting is, however, rare, and only seen in the later
period of the attack. Abdominal distension is slow in making its
appearance, but after a time is well marked, and due more to tympanitis
than to {861} constipation; the tympanitic distension is accompanied by
loud rumbling and gurgling noises in the bowels. After a period which
varies much in different cases, inflammation, suddenly or gradually, is
set up, and all the symptoms of acute obstruction are presented,
grafted on signs of chronic occlusion. We have pain, nausea, vomiting,
great distension and tenderness of the abdomen, peristalsis plainly
seen and felt if the abdominal wall is thin, the small, frequent, wiry
pulse, clammy perspiration, prostration with hiccough, tendinous
twitchings, and death, very like that following a case of external
strangulated hernia.
Obstruction due to fecal accumulation generally happens in persons who
have passed middle age, and can often be diagnosed by digital rectal
examination and palpation of the abdomen, by the presence of fecal
tumors, and the history of long-existing constipation with its manifold
consequences; previous attacks of impermeability, and relief by
discharge of enormous masses of feces.
Obstruction caused by the presence of some abdominal tumor is generally
known by the history of the case, the fact of the existence of the
tumor being known to the patient or discovered by the physician by an
examination through the abdominal walls or through the vagina or
rectum. The progress of such cases is essentially chronic, but acute
symptoms may at any time come on. Diagnosis of obstruction due to
stricture is frequently made by examination of the rectum and sigmoid
flexure, the usual sites of constriction from this cause. Complete
occlusion from stricture is almost always preceded by well-marked
premonitory symptoms.
When the obstruction is situated in the lower part of the colon and
rectum, its precise seat can be determined by digital or manual
examination or the use of a bougie or tube. When the site of
obstruction is above the sigmoid flexure, it is difficult, and
occasionally impossible, to determine its exact locality. As a rule,
when the constriction is in the small intestine the symptoms are acute
and urgent; pain is intense, vomiting comes on soon, and prostration is
early and extreme. When the large intestine is involved, except in
volvulus, the symptoms are generally chronic. In twisting of the gut
the symptoms are rapid and uncommonly severe. The higher up the
obstruction, the earlier stercoraceous vomiting begins. Above the
constriction the bowel is distended and tympanitic; below the
constriction it is generally collapsed. In obstruction of the large
intestine the outline of the tympanitic and distended gut may be traced
with the eye and hand. In constriction of the small intestine the
secretion of urine, as has been shown by Hilton, G. Bird, and Barlow,
is less than where obstruction is seated in the large bowel. Besides
rectal and vaginal examinations, which should never be neglected in any
case of intestinal obstruction, abdominal palpation may also aid in
determining the site of constriction. It should not be forgotten,
however, when a tumor is found--as, for instance, in invagination--that
the bowel may be displaced; a distended cæcum may be pushed into and
occupy the left side of the belly. Cases are not uncommon where the
symptoms are so combined and uncertain as to render accurate diagnosis
of the site of obstruction impracticable.
Very little light is thrown upon the diagnosis by pain, constipation,
or vomiting when these symptoms are considered separately. Pain is
common to many diseases of the abdomen; obstinate constipation, lasting
for {862} days and weeks, is often seen where there is no mechanical
obstruction; and vomiting attends many morbid conditions of the body.
But when these symptoms are combined and examined along with the
history of the case and mode of invasion, they are often characteristic
of constriction of the intestine. Pain in acute obstruction is fixed,
umbilical, and intermittent; in chronic cases it is more diffused and
increases with the distension. In acute cases constipation is complete
and insuperable; in chronic cases this symptom gradually increases; in
intussusception we have frequent discharges of a dysenteric character,
and hemorrhage, sometimes copious, when the small bowel is involved.
The bowel below the seat of complete constriction may be full of fecal
matter, and the discharge of this spontaneously or by the aid of
enemata may induce the attendant not to regard the case as one of
occlusion. Stercoraceous vomiting, as a rule, comes on early in acute
and late in chronic cases of complete occlusion of the gut; in
spasmodic ileus or impermeability not due to mechanical occlusion
feculent vomiting is only occasionally seen.
The duration of life in acute intestinal obstruction varies very much
in different cases: death may ensue in a few hours or not for ten or
twelve days; the average period is six days. The duration depends upon
the site of the constriction and the mechanical injury to the bowel;
the nearer to the pylorus the constriction, the more rapid the
progress. In volvulus involving the sigmoid flexure, when injury to the
bowel is great, the symptoms are acute in the extreme. After
peritonitis or enteritis begins, progress toward a fatal issue is very
rapid, the patient rarely living more than three or four days. In
occlusion from stricture, compression, fecal impaction, and chronic
intussusception the patient may live for weeks or even months.
The statistics of Leichtenstern show that from 5 to 10 fatal cases of
intestinal obstruction occur every year among every 100,000
inhabitants; and according to the mortuary records of England an
average of 1 death from this cause is seen in every 260 deaths. Brinton
reports 1 death from intestinal obstruction in every 280 deaths; his
statement is based upon 12,000 promiscuous autopsies. The first author
states that the statistical reports of the general hospital of Vienna
inform us that out of 60 cases of ileus, 6 or 10 per cent. recovered.
This report, however, is too meagre to be of much value. From Brinton's
statistics of 500 deaths from obstruction we find that out of 100
cases, 43 are intussusception, 17 stricture, 4.8 impaction of
gall-stones, 27.2 internal strangulation, and 8 torsion.