CHAPTER XXXVIII DIAGNOSIS OF CASES OF INTESTINAL (Part 1)

CHAPTER XXXVIII DIAGNOSIS OF CASES OF INTESTINAL OBSTRUCTION Cases of intestinal obstmction fall into two dis- tinct groups : (1) those in wliicli a sudden cessation of the passage of faeces and flatus is the main symp- tom, and (2) those in which the difficidty in obtainiiig a satisfactory emjjtying of the bowel is of a clironic and progressive character. The first class of case is given the name of acute, the second is known as ^diroiiic. In a number of the acute cases, the history makes it clear that the final acute stage is but the culmination of a chronic affection, and to these the designation of acyte obstruction upon chronic is sometimes given. As the discharge of fseces and flatus depends upon the action of the intestinal muscle, it can be arrested either by failure of peristalsis or by mechanical obstruction. The clinical term " intestinal obstruction should be limited to the latter class of cases, and will be so used here. Cases of intestinal paresis from jieri- tonitis, or of congenital dilatation of the colon (Hirschsprung's disease), arc not included. A Acute iiilesliiial ohsliiielion. - This condi- tion will be recognized by the combiiiationof four symp- toms—(1) complete cessation of tlie normal mtestnial (lischar-e of forces and Hatus, (2) dislei.su.n of coils o[ -mt 'ubove llie point of obstruction, (3) seven- colicky pain, (I) regnrgit;uit vonutmg. As a result 550 INTESTINAL OBSTRUCTION 551 of the absorption of the retained intestinal con- tents and their excretion by the kidneys, the urine becomes heavily charged with indican, and turns black upon the addition of a strong mineral acid. There may be more or less well-marked shock, due to the irritation of the nerves, especially their tight compressio]!, symptoms of toxtemia and, if vomiting is severe, of collapse from loss of fluid, and the patient may show the effects of a chronic dis- ease which has culminated in intestinal obstruction, e.g. cancer of the colon or rectum. The constipa- tion of obstruction is what is known as "absolute constipation " : neither motion nor flatus is passed spontaneously, the bowel does not react to a pur- gative, and an enema fails to bring away anything beyond, at times, just a very little flatus, or tiny portions of motion which have been lying in the bowel below the obstruction. Reguigitiint vomiting is recognized by the absence of nausea and of great straining effort — the stomach ajjpeai's to empty itself quite easily. The first vomit consists, as in all cases, of the usual contents of tlie stomach ; in intestinal obstruction the vomited nuitter ([uickly becomes alkaline and definitely intestinal, and later it may become fsecal. As a rule, gTcat urgency of vomiting and but limited distension indicate ob- struction high up in the bowel. Having arrived at the conclusion that the patient is suffering from acute obstruction, the next step in the diagnosis is to determine whether there is any external hernia. The usual and also the unusual seats of hernia must each and all be carefully ex- amined ; and if 'a tumour is found, which is fixed to the belly- wall, tense, and dull on percussion it is to be regarded as a slrangulaied hernia. Should the surgeon be in doubt as to whether a given 552 SURGICAL DIAGNOSIS [chap. swelling is a heruia or not, when there are symp- toms of acute obstruction, he should explore the sweUing by operation. If no hernial tumour is detected, inquiry should be made as to whether the patient is the subject of a hernia wliich has been reduced, and, if so, what relation as regards time the onset of the symptoms of obstruction had to the reduction of the hernia, and whether the reduction ofiered any difl&culty. It must be remem- bered that a patient may himself accomplish a reduction en bloc of a hernia, and without noticing any difficulty whatever in the taxis. When, then, it is known that the patient is the subject of a reducible hernia, the ring and hernial canal should be very carefully examined, and it may even be justifiable to endeavour to get the rupture to de- scend to make certain that it is not the seat of the obstruction. If the surgeon is able to exclude altogether ex- ternal hernia, the problem then is to distinguish between the various forms of internal strangulation. In a large number of cases it is impossible to deter- mine the exact cause of the strangulation without actual exploration of the abdominal cavity ; _ intus- susception is capable of more certain diagnosis than any other form of acute internal strangulation. When, early in the case, the collapse is very marked, the pulse being small and feeble, and the skin cold and bathed in sweat, it indicates tight strangulation. When vomiting sets in early, is frequently repeated, and quickly becomes intestinal, and the belly is uniformly and only moderately distended, and tlic excretion of urine is small, the obstruction is known to be seated in the small intestine, and tlie higher up tlie strangulation the more marked are these distingiiisliing features. When, on the other hand. xxxviii] INTESTINAL OBSTRUCTION 553 the abdomen is greatly distended, and the vomiting is less urgent, and a longer interval elapses before it becomes intestinal, it indicates that the obstruc- tion is in the large inlestine. In these cases it may be possible to see or to mark out by percussion the caecum and colon, and when the obstruction is in or near the transverse colon the right loin may be much more distended than the left. The following forms of internal strangidation are to be distinguished, viz. intussuscejition, internal hernia, and volvulus. In cases of acute intestinal obstruction there is no advantage for purposes of diagnosis to be derived from the administration of copious or repeated ene- mata, or from attempts to pass a long rectal tube. If an elongated tumour is felt in the position of the ca3cum, or in the course of the colon, and if there is frequent tenesmus, with a discharge from the anus of bloody mucus or even of pure blood, intussusception is to be diagnosed. The tumour will be noticed to become alternately more and less firm and apparent, its periods of firmness being accom- panied by griping pains and tenesmus. This periodic hardening of the tumour is due to strong peristalsis, and is an evidence of the muscularity of the swell- ing. In some cases the lower end of the strangled bowel may be felt in the rectum, or it may even be extruded beyond the anus. If the patient has been suddenly seized with localized pain in the belly which has rapidly become greatly distended, and a rounded tense swelling or tumour can be detected in either iliac fossa or flank, the obstruction may be diagnosed as a volvulus. Vomiting may be slight or absent in obstruction due to this cause. This condition is met with more fre- quently in the large than in the small bowel, and par- S* 554 SURGICAL DIAGNOSIS [chap. ticularlv in the CEecum or in the sigmoid flexure, and the twisted part may be enormously distended and be visible throusih tlie abdominal walls. When there is but moderate distension of the abdomen, and no tumour or swelling or seat of special resistance can be detected, and, further, when the vomiting sets in early and _ quickly becomes intestinal, the case may be diagnosed as one of internal hernia, or of strangulation of the bowel by a hand. If there is an old hernia, or a history of some previous attack of peri- tonitis or oit an intraperitoneal operation such as ovariotomy, it would point to the presence of a hand If the patient has been subject to attacks of colic, and if there is ill-defined local resistance or fullness, especially in either iliac fossa, it pomis to internal hernia. . If a patient who has been suffering from jaundice, pain m the hepatic region, sickness, and other symp- toms of gall-stones suddenly exhibits signs of acute intestinal obstruction, the condition may be attrib- uted to impaction of a gall-stone in the howel. The diagnosis of these causes of acute intestinal obstruction is also considered in Chapter XXXMl. B Cluonie intestinal obstruction is most frequent m the large, intestine, and, particularly, near its lower end. r f it Chronic intestinal obstruction must be hrst ot all distinguished from chronic constipation, m winch, at Ion" and irregular intervals, full-sized and often very large and hard fa3cal masses are passed, icvad impaction is another condition not to be confused with chronic obstruction ; it may occur at any part of the colon, but particularly in the cfecum, at either of the flexures, or in the pelvic colon ; m the worst cases the whole of the large bowel may be choked xxxviii] INTESTINAL OBSTRUCTION 555 with fseces. In the abdominal colon fascal masses are felt as rounded or uneven lumps, which may be indented by the fingers, are often resonant on per- cussion and slightly tender, and under treatment can be traced moving along the colon, or gradually melting away. The finger in the rectum at once detects faecal masses in the pelvic bowel. A case of chronic intestinal obstruction should be investigated as follows : First of all a careful history of the case should be obtained, attention being paid particularly to the character and fre- quency of the motions — to the size, shape, and amount of the f cecal matter pa.ssed, and to the admixture with mucus and blood. The size of the motion is an index of the lumen of the lower part of the large bowel ; if a stricture is higli up in the colon the faecal matter that passes through it may be re-formed into larger masses in the lower colon before it is discharged. The progressive diminution of the size of the motion is an important sign of increasing contraction in the lumen of the bowel. The presence of mucus in the motion is an indica- tion of hypersemia and irritation of the mucous membrane, and the presence of blood is the result of more intense congestion or of ulceration of the mucous membrane. When the mucous discharge is abundant it may be passed frequently and give the patient the impression that he is suffering from diarrhoea. In some cases of very vascular growths of, or penetrating into, the colon, the discharge of mucus is extraordinarily copious. The irregularity of faecal discharge should be noted ; the arrest of all discharge for some days, followed by the frequent passage of very loose or soft and small motions, is a significant sign of organic obstruction ; this is spoken of as alternating constipation and diarrhoea. Tlie 556 SURaiCAL DIAGNOSIS [chap. passage of several unsatisfactory motions in tlie early hours of the day— " morning diarrhcea followed by quiescence of the bowel for the rest of the day, is frequently observed in the earlier stages of cancer of the lower bowel. A history of colicky pains with gargling in the bowel is an indication oi vio-orous but ineffectual contractions of the bowel above an obstruction. Any history of previous operation or attacks of peritonitis should, of course, be carefully noted. After obtaining the history of the case the sur- geon should carefully examine' the patient and specially note the following points : 1. Distension. — This may be general, involvmg - both large and small bowel, or partial. It is par- ticularly important to determine whether distension involves the large intestine and all the abdominal part of it ; the fullness of each flank must be noted, and by careful percussion the outline of the colon must be made out. Distension is evidence that the obstruction, though chronic, has become com- plete, and the extent of bowel involved m it shows the seat of the obstruction. Even when the obstruc- tion is low down, the caecum is the part of the colon to be distended first, and its condition should m all cases be specially noted. . 2. Accumulation o£ f^ces.-When the obstruction in the colon is chronic but not complete, faecal matter may be held back above it, and be felt m the colon, particularly in the sigmoid colon above disease in the rectum, and in the caecum. Ihe detection o frecal masses in the colon is important evidence oi the presence of chronic obstruction. .3 Visible and audible peristalsis, commg on sponta ncously or when the al.dot.ien is exposed, or oxciled l.y palpation, is a proof of mechanical obstruction XXXVIII INTESTINAL OBSTRUCTION 557 rendering the peristalsis ineffective, and also causing hyjiertropliy and distension of the bowel above. It may be attended with loud gurgling sounds and with griping pain. It is generally easy to determine whether the peristalsis is in the small or the large bowel. 4. Tenderness. — It is important to notice any tenderness in the bowel, particularly in the cascum or sigmoid colon. In these situations stercoral ulceration is liable to occur, and tenderness is the only local sign which gives warning of its presence. 5. Tumour. — If any tumour can be felt, its exact seat, size, fixity or mobibty, and consistence must be noted. 6. The liver must be examined for evidence of enlargement and for hardness or irregularities of its surface, such as may be caused by secondary malignant disease. For the same reason the skin and conjunctiva and the urine will be examined for evidence of jaundice. 7. The abdominal wall. — In cancer of the inteslii.e, as well as of the stomach, secondary growths are liable to occur at the umbilicus in the form of film discoidal nodules, and the detection of such a lump is important iu any case of obstruction as showing its nature and the occurrence of metastasis. 8. The inguinal glands should be examined for the same reason, and any enlai-gement carefully noted. 9. All the seats of hernia must be examined. 10. Rectal examination.— Having completed the ex- amination of the abdomen, the surgeon should himself, if possible, see one or more of the stools, noting the points in them to which reference has already been made, and then he should explore the rectum. This should be done first of all with the finger properly gloved and lubricated, and llien, if necessary, with the 558 SURGICAL DIAGNOSIS [chap. proctoscope or sigmoidoscope. The iiiiger will notice the resistance or flaccidity of the sphincter ani, and the smoothness and softness of the anal canal, or any induration or unevenness of its walls. The finger then explores the rectum proper, noticing its lumen, whether contracted (stricture), distended (balloon- ing), or enlarged by ulceration ; whether empty or occupied by faical masses or a foreign body, a pro- lapsed growth, or an intussusception. The finger then feels the rectal wall, whether thickened or hardened at any part, and whether the bowel is. fixed or mov- . able, or displaced and compressed by a growth outside it. With a well-illuminated proctoscope the mucous lining of the rectum can be seen, and with a sigmoidoscope the rectum and lower pelvic colon can be explored, and changes in its mucous membrane and in its dilatability can be studied with a pre- cision not otherwise attainable. If the patient has vomited, the vomited matter should be examined, and in particular its odom-, , colour, and reaction to litmus-paper noted, to deter- : mine whether it is ordinary stomach contents, or this with the addition of bile only and green in colour, or whether it is regurgitant vomit from the small intestine, or even fsecal matter from the colon. 1 Lastly, the surgeon must take note of the patient's general condition, particularly of emaciation, pallor, and the signs of asthenia. If the patient is otherwise in good health, but passes a hard motion at long intervals, the motion being dark in colour and of normal size, and the rectum is found healthy and empty, the belly not greatly distended nor containing a tumour, and particularly if the patient is an aiur>mic young woman, it may be con.sidercd a case of at^ony of the bowel. xxxviii] INTESTINAL OBSTRUCTION 559 If with symptoms like the above the rectum i. found full of hardened fteces, or similar f«cal masses can be felt in the colon, it is usually spoken of as a case of faecal impaction. The two conditions have very much in common. In fcecal impaction the patient may pass, even daily, small hard lumps of fseces, or be troubled with tenesmus and a frequent evacuation of mucus stained with faeces. This con- dition is often met with in elderly people. If with the signs of chronic obstruction an elon- gated tumour is felt in the belly, and the patient discharges mucus with a small amount of fa3cal matter from the rectum, and complains of irregular colicky pains and tenesmus, chronic intussusception is to be diagnosed. The end of the intussuscepted length of bowel may be felt in the rectum. For the diagnosis of simple and malignant stricture of the rectum, see p. 615. If these causes can be excluded, the surgeon must attempt to determine by the amount and character of the abdominal distension whether the obstruction is seated in the large intestine or in the small bowel. Malignant disease is much more frequent in the large than in the small bowel, while chronic peri- tonitis or adhesions or traction most often afiect the small intestine. If a tumour can be detected through the abdominal wall it is of great value in the diagnosis. If the signs point to obstruction in the small intestine, and there is a history of previous peritonitis, or of pelvic inflammation or tumour, and the constipation is not absolute, the condition may be attributed to chronic peritonitis, or some similar cause, dragging upon or binding down the intestine and impeding its peristalsis. When, how- ever, the