11 Reynolds's System of Medicine.
Stricture of the intestine often follows dysentery or tubercular and syphilitic ulceration of the bowel. Follicular or hemorrhoidal ulceration is sometimes the beginning of a stenosis which ends in stricture of the rectum. Stercoral ulcers of the colon are not unfrequently the starting-point of cicatricial contraction of the calibre of the bowel. Sometimes, but rarely, ulcers of typhoid fever end in constriction of the intestinal tube. The diameter of the gut is also contracted by the effects of caustic substances, by ulceration following the lodgment of foreign bodies, and by effusion of lymph or thickening attendant upon long-standing hernia. Very often after death it is impossible to determine what particular kind of inflammation and ulceration caused the stricture. Generally, the cause which provokes the ulceration sets up chronic peritonitis, which materially aids in producing the obstruction. Spasm of the circular muscular fibres usually accompanies these lesions, and materially contributes in many cases to fatal intestinal obstruction. Some authors assert that spasm without organic change can produce acute obstruction: such an occurrence, except possibly in the rectum, must be very rare, if indeed it ever happens.
The most common cause of stricture is cancer. This disease may originate in the bowel itself, or, beginning in some neighboring organ or tissue, gradually spreads and involves the gut. It may extend around the bowel or be infiltrated along the sides of the canal for several inches, and may be scirrhous, medullary, or epithelial in character. Eighty per cent. of the cases of cancer of the bowel are situated in the rectum. Usually, but not invariably, cancerous deposits are found in persons who have passed middle age.
An impediment to the passage of fecal matter is invariably produced in constriction of the intestine from the above causes, and it frequently continues until fatal occlusion occurs. The contents of the bowel accumulate above the block, producing distension of the gut and thickening of the muscular coats above the stricture, with contraction and atrophy of the portion of intestine below. Dilatation of the bowel above the seat of lesion is sometimes great enough to cause rupture and peritoneal extravasation, or distension and stretching of the coats of the canal may be sufficient to interfere with its circulation, and ulceration ensue.
Occasionally cases of stricture or well-marked circumscribed contraction of the bowel are seen which give rise to no marked symptoms of constriction during life. Such was the case in the instance related by Bristowe and referred to above. These instances are, however, exceptional in the large intestine.
Symptoms of stricture vary according to the site, cause, and extent of 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 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.