These symptoms, however, may be developed without the pre vious existence of anything resembling colic; tenderness may exist from the first, and the inflammation may have arisen with out the intervention of any obstructing cause; and then it has probably travelled from without, beginning in partial, local peri tonitis, and obstruction only occurring as a consequence of the inflammation of the bowel. In both classes, the existence of the inflammation is shown by the permanence of pain, the presence of tenderness, and the febrile action ; the question as to what was the exciting cause is one of minor importance. Indeed, any history which seems to point to obstruction, and the prominent symptom of inaction of the bowels, are both very, apt to lead us away from the important fact of enteritis being really present.
§ 3. lleus and Intusauseeption.—Physicians of the largest expe rience and most comprehensive judgment have failed to deduce from the symptoms indications which can be regarded wholly trustworthy as to the nature of this disease. Its commencement is very analogous to the first form of enteritis just spoken of: the colic is more severe : there is usually complete remission of pain for a while, which again returns with increased violence. In contrast to simple colic, the spasm is more regular in its recur rence, there is less sensation of twisting and grinding, and more of a continued paroxysm, caused by the violent and energetic action of the muscular fibre to overcome the obstruction: the large coils of intestine may sometimes be felt rolling and turning over in the abdomen during its continuance. In the progress of the disease, when the bowel is inverted, paralysis of fibre induced by inflammation, acts as a further impediment, but primarily the obstacle is mechanical.
As in enteritis, the cause of its occurrence may be the presence of some solid mass in the intestine : the symptoms of the two affections are. therefore, often intermingled together, and the suc cess of treatment may depend on a discrimination of their coex istence. In the first-mentioned form of enteritis, for example, a very limited amount of inflammation in the immediate proximity of the solid substance may give rise to manifest and characteristic evidence of some form of obstruction ; and yet, on the fact of the practitioner recognizing and obviating the slighter and less marked condition of local inflammation, may entirely rest the safety of his patient.
Closely resembling intussusception are those cases in which the bowel is inclosed in a band of adhesion when at first there is no inflammation : the history may be simply that the bowels have not acted, that medicine has been taken without effect, that sickness has come on, and finally, that paroxysms of pain have recurred at intervals : or the order may be inverted, violent pain having first occurred, accompanied by vomiting from the com mencement ; and it is only discovered at a later period that the bowel will not act : or, again, the vomiting may be absent in either case for a considerable period. In all of them there is ulti mately more or less of inflammation set up ; and if the patient be not seen till then, hope may for a short time linger over the pos sibility of relief following on the use of antiphlogistic measures, which is only dissipated by the utter futility of the most judicious treatment.
§ 4. Obstruction.—The rules of diagnosis are so obscure, that a large number of cases must be classed under this head, of which the only fact known is that the bowels obstinately refuse to act : but as in enteritis we found that very generally the attack com menced either with colic or tenderness on pressure, in ileus that the stoppage occurred suddenly without previous derangement of bowels, so we find in this class that long-continued constipation has usually preceded the obstruction. Here we have clearly two possible states—a gradually diminishing calibre of the bowel, or a condition of extreme distension from long-standing accumula tion and impaction—which are both quite different from those already referred to ; but the mere fact of habitual constipation, although of great importance, does not necessarily indicate either condition; the habit may exist without the evil effect. In cases of obstruction we have the additional fact of the bowels being loaded with feculent matter: when no organic disease exists, this always occupies the lower end of the colon; when pressure from without is the cause of obstruction, the accumulation will also generally be found where the bowel is fixed near its outlet : stric ture usually affects the rectum or the lower part of the colon. In some rare cases it happens that the narrowed portion is found high up, and then large accumulation cannot take place: in such instances, there is a great resemblance to ileus.