The symptoms of acute intestinal obstruction appear either suddenly or after slight disturbances have existed for a few days, as for instance diarrhoea, constipation, feeling of uneasiness. In some instances the history of an exciting cause is given. Thus a severe blow on the abdomen, violent bodily exertion, a cold, a too copious meal, or a strong laxative.

The patients are first seized with violent abdominal pains, sometimes of a crampy character. The pain may be felt at first at a certain definite spot within the abdomen, while later it becomes more diffuse. In other instances the patient is unable to localize the pains distinctly. Occasionally the area around the navel is given as the seat of the pains, while in other cases they are referred to the entire abdomen. The pain usually exists uninterruptedly, though it may show exacerbations from time to time. Soon after the occurrence of these colicky pains eructations of gas and then vomiting appear. At the beginning gastric contents are ejected, later bile, and finally offensive feculent material is brought up. The latter usually has a yellowish-brown color, is liquid, and contains only very fine, small, solid particles suspended in the fluid. At this period the eructated gases have a fetid odor and hiccough almost constantly distresses the patient. After the act of vomiting the patient may feel somewhat relieved for a short while, but soon there is a return of the severe symptoms.

Almost simultaneously with vomiting, meteorism of the abdomen ensues. The passage from the rectum is entirely stopped and there is no evacuation either of fecal matter or of flatus. The meteorism may involve either a certain region of the abdomen or the entire cavity. The tympanites gradually increases and a feeling of tension becomes more and more pronounced. The diaphragm is soon pushed upward by intestinal coils filled with gas in such a manner that the liver dulness may be absent from the entire right thoracic cavity. Dyspnoea supervenes; the breathing becomes accelerated and superficial, assuming the thoracic type. The pulse is small and frequent. The extremities are cold, the skin is covered with perspiration, the face is pale, bearing the expression of utmost anguish, the eyes are sunken, dryness of the throat and extreme thirst exist, and the patient is barely able to use his voice. These extremely painful and tormenting symptoms persist and the patient succumbs - unless there is a change in the course of the disease - remaining conscious until the end.

After having given a general description of the clinical picture of ileus it will not be amiss to discuss each symptom separately.

1. Pains

Pain, the most constant and conspicuous symptom of intestinal obstruction, depends upon several conditions. It is usually due, first, to the injury inflicted on the peritoneum and the intestinal walls in consequence of the strangulation; secondly, especially at a somewhat later period, to the tumultuous and increased irregular peristaltic movement of the intestines. These movements above the site of obstruction are of a very intense character and produce "colic" as well as exacerbations of the pains which occur at certain intervals. The intensity of the pain depends upon the degree of excitability of the individual, upon the state of the sensorium, upon the extent of the intestine and peritoneum involved, and upon the severity of the occluding lesion and the rapidity of its occurrence. Later on the pain is influenced by the distention of the gut and by the presence or absence of peritonitis.

At the commencement of the disease the pain is frequently not aggravated and sometimes relieved by pressure. Later, however, the pain is considerably increased by even slight pressure, the cause of this being the presence of peritonitis.

According to Treves,1 the pain is constant, although liable to periodical exacerbations in cases of complete obstruction. In cases in which the obstruction is but partial the pain is distinctly intermittent, and the patient experiences intervals between attacks of pains during which he is free from suffering. The pain as a rule grows more intense with the progress of the disease. There may be, however, a diminution in the severity of the pain for a short period before a fatal issue, caused by a collapse, paralysis of the intestine, rupture or perforation of the bowel, or by a diminished activity of the sensorium.

Treves has pointed out that no matter in what part of the small intestine the obstruction is situated, the pain arising therefrom is usually referred to the region of the umbilicus.

1 F. Treves: "Intestinal Obstruction," Philadelphia, 1884.

If the obstruction is localized in the large bowel, then the pain may be experienced, especially at the beginning of the disease, at the seat of the lesion.; later, however, the pain may assume a more diffused character or may be felt at other regions of the abdomen. This is the reason why only the initial pain is of some diagnostic significance with regard to the seat of the lesion.

2. Vomiting

Vomiting is almost always present. At the beginning of the disease it is of reflex origin due to the irritation of the peritoneum; later on it must be ascribed principally to the irregular, strong, peristaltic contractions of the intestines. The appearance of fecal vomiting was believed by the old writers to be a sign that the obstruction was situated in the large bowel. Nowadays, however, it is generally known that this symptom is often present in cases in which the obstruction is situated in the ileum or even in the jejunum. The reason of absence of putrefactive processes in the intestinal contents normally is the rapidity with which they are moved farther on along the canal until they reach the large bowel. In obstruction, however, the peristaltic contractions are much slower and thus putrefactive processes develop even in the small bowel.

In order to explain the mechanism of stercoraceous vomiting a reversed peristaltic or antiperistaltic motion of the intestines was formerly assumed. Of late, however, the mechanism of fecal vomiting as expounded by Haguenot 1 as early as 1713, is now generally accepted. According to this author, stercoraceous vomiting takes place in the following manner: Above the occluded intestine there is an accumulation of more or less liquid intestinal contents in considerable quantity; the bowels being distended with large amounts of gas are under constant pressure, which is increased after each inspiration and especially after energetic contraction of the abdominal muscles, occurring for instance during the act of vomiting. Under the influence of pressure the stagnant liquid contents are regurgitated from above the occluded spot into places in which there is less resistance and thus reach the duodenum and the stomach. Here they irritate the mucous membrane and cause vomiting.

1 Haguenot: "Memoire sur les Mouvernents des lntestins dans la Passion Iliaque. " Histoire de l'Academie Royale des Sciences, Paris, 1713.

This theory is perfectly in accord with the circumstance that in stercoraceous vomiting mostly liquid or sometimes semi-liquid contents are evacuated, but never solid fecal matter; for even in obstruction of the colon the fluid will be moved farther upward while solid particles will remain in the lower portion of the bowel. Vomiting of formed fecal matter is a very rare occurrence, and must be ascribed to an existing fistulous opening between the colon and stomach.