If the diagnosis of acute obstruction of the bowels is not always easy, the recognition of the special anatomical lesion underlying it is still more difficult. In many instances an exact anatomical diagnosis will not be possible and we will have to be satisfied with a probable conjecture. In some cases, however, the exact determination of the etiological factor underlying the obstruction will be possible. The following groups of acute obstruction of the bowels can be clinically differentiated:

1. Acute Incarceration of the bowels in hernias (also internal hernias, in slits of the omentum, mesentery, or diverticula), in strangulation by bands or twists of the bowel, is most frequent between the ages of twenty and forty. It occurs more often in males than in females. There is often a previous history of peritonitis, of hernia, or of accidents (contusions). The onset of the disease is sudden. The pains are severe. Vomiting is present from the start, becoming stercoraceous later on. Collapse is marked. Tenesmus is absent. Physical examination of the abdomen gives, as a rule, negative results.

2. Volvulus most often involves the sigmoid flexure and can then be easily recognized. Volvulus of the small intestine, which occurs very rarely, cannot be differentiated clinically from incarceration. The rotation of the bowel around its axis is either complete (360°) or incomplete (half rotation, 180°). In the first instance there is total occlusion, while in the latter the intestinal lumen is at first partially pervious. Volvulus is more common in males than in females in the proportion of four to one, and occurs principally late in life, usually between forty and sixty.

There is usually an antecedent history of chronic constipation. The onset of the disease is sudden. The pain ordinarily is intermittent. Vomiting may be absent at first and later on occurs intermittently. Constipation is almost absolute and grows worse after the use of aperients. There is pronounced meteorism. The sigmoid flexure can occasionally be felt as a tumor. Only moderate amounts of water can be injected into the rectum.

3. Intussusception Occurs Very Frequently In Early Childhood

The onset is sudden, the pains appear early, are colicky in character and come in paroxysms. There are marked tenesmus and bloody evacuations. The collapse is not pronounced. The invaginated coil may be accessible to palpation and then appears in the form of a tumor of egg-size or somewhat larger, this occurring in about fifty per cent of the cases. Meteorism develops in conjunction with peritonitis.

4. Obturation Of The Intestine By Gall Stones, Enteroliths, Or Foreign Bodies

Obstruction by gall stones occurs chiefly in women and is more frequent at an advanced age. A previous history of gall stones or a preceding attack of jaundice, pains in the region of the liver, and swelling of this organ are points which aid in the diagnosis. Obstruction by gall stones usually occurs in the small intestine; the symptoms, as a rule, are less severe than in other forms of ileus. The collapse is not pronounced or may be entirely absent. Flatus may occasionally be passed, copious vomiting of bile may be present. If the gall stone is situated in the lower portion of the ileum the vomiting may later become stercoraceous. Occasionally the stones can be palpated through the abdomen and felt as a hard mass. Meteorism is generally not highly developed. In some instances there is diarrhoea with admixture of blood, the latter being due to abrasions of the intestinal mucosa produced by friction of rough gall stones.

The recognition of an enterolith as the cause of obstruction is very difficult and possible only when small fragments of a fecal calculus have previously been found in the dejecta. The seat of obstruction is as a rule then in the large bowel, the latter being the place where enteroliths develop.

Obstruction by foreign bodies will be recognized by the previous history; often also, especially if they are of a metallic nature, by a Roentgen picture. An accumulation of cherry pits or plum stones may also cause an obstruction and will likewise be recognized by the previous history and by the presence of some of them in the dejecta.

Hardened fecal matter will very rarely give the picture of obstruction. This will occur only in very weakened individuals and in persons with spinal trouble. In these cases the rectum and colon will be found filled with greatly hardened scybala. If a stricture or a tumor exists within the intestine and narrows its lumen, an accumulation of fecal matter above the stricture gives rise to acute obstruction.

5. Dynamic Ileus

Obstruction due to paralysis of a segment of the bowel can be recognized only with great difficulty. Often there has been a preceding laparotomy or some operation on the genital organs in the female or a history of a replaced hernia.

With regard to the recognition of the different forms of intestinal obstruction the following table, which gives the frequency of the principal symptoms in the various forms of obstruction, may be of assistance.

Among two hundred and ninety-five cases of acute obstruction of the bowels collected in literature and minutely examined by R. Fitz 1 of Boston, the symptoms were as follows with regard to the different groups of obstruction:

Strangulation. Per Cent.

Intussusception. Per Cent.

Twist. Per Cent.

Gall

Stones.

Per Cent.

Stricture or Tumor. Per Cent.

Pain.....

82

70

60

83

60

Nausea and vomiting.....

69

75

37

74

80

Fecal vomiting....

47

13

15

61

33

Tympanites........

56

33

55

56

66

Tumor.......

10

69

13

27

Visible coils........

11

..

7

..

20

Prognosis

The prognosis of acute obstruction of the bowel is very serious. According to Curschmann,2 only thirty to thirty-five patients out of one hundred recover from this disease. As a rule ileus caused by coprostasis or by obturation with gall stones and foreign bodies gives the best prognosis. Then come volvulus and intussusception, while incarceration gives the worst prognosis. If in the course of ileus deglutition pneumonia or diffuse peritonitis or perforation of the bowel develops, then the case is well-nigh hopeless. Operative intervention, especially in cases in which the seat of the intestinal occlusion is known, improves the prognosis considerably, but only if it is resorted to early. Later, when the complications just mentioned arise, not much can be expected from an operation.