A system of practical medicine. By American authors. Vol. 2

by Unknown

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 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 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.