Previous history of the case will shed much light on the probable existence of intestinal stricture. Thus a history of typhoid, of dysentery, of tuberculosis, or of syphilis will be most suggestive, for in any of these diseases there may be numerous intestinal ulcers. A history of hernia, reduced or operated, or of injury, is also of importance, as also is one of operation upon other viscera, especially within the pelvis, the lower bowel being often involved in a disease process within this cavity which may have left its marks.
PLATE L
Enterolith with Gallstone for a Nucleus; Removed by Enterotomy. (Richardson.)
This patient was a man of sixty-nine, with symptoms of complete intestinal obstruction. There was no previous history whatever of gallstone. The impaction was high up in the small intestine. The gallstone was removed by a small linear cut which was satisfactorily sutured. The patient died in the course of twenty-four hours.
Stricture may be recognized by the gradual course of the case and by a history of increasing difficulty or of increasing constipation. A stricture as such is not formed within an hour, and in this sense is the result of a previous more or less active disease. This is true, also, of cancerous stricture.
6. Intrinsic Neoplasms.
—The possibility of both innocent and malignant tumors occurring within the intestinal structures has already been considered. It is obvious that any such growth will cause gradual obstruction by the usual process, or may precipitate by its presence the occurrence of intussusception, of volvulus, or of some kinking by which obstruction is suddenly produced.
7. Extrinsic Neoplasms.
—What has been said above applies equally well to growths not primarily involving the intestine, but encroaching upon it. Thus obstruction may gradually result from retroperitoneal growths, or from the impaction of a growing uterine myoma pressing upon the rectum and finally occluding it. Also cancers growing in various locations encroach upon and finally involve the bowel in conditions which nevertheless were originally quite external to it.