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CLINICAL MANUALS 
 
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 Practitioners and Students 
 OF Medicine. 
 
Intestinal Obstruction: 
 
 ITS YAEIETIES. 
 
 WITH 
 
 THEIK PATHOLOGY, DIAGNOSIS, AND TREATMENT. 
 
 The Jaclisonian Prize Essay of the Royal College 
 of Surgeons of England, 1883. 
 
 BY 
 
 FREBEEICK TREVES, F.R.C.S., 
 
 SURGEON TO AND LECTURER ON ANATOMY AT THE LONDON HOSPITAL; 
 
 HUNTERIAN PROFESSOR OF ANATOMY AT THE ROYAL 
 
 COLLEGE OF SURGEONS OF ENGLAND. 
 
 WITH 60 ILLUSTRATIONS. 
 
 FHILABELPEIA : 
 HENPtY C. LEA'S SON & 00. 
 
 1884. 
 
JOHN STRTJTHERS, Esq., M.D., 
 
 PROFESSOR OF ANATOMY AT THE UNIVERSITY OF ABERDEEN, 
 
 AS A TOKEN OF RESPECT 
 
 FOR HIS POSITION AS .^' ANATOMIST, 
 
 AND AS A 
 
 SLIGHT ACKNOWLEDGMENT OF JIANY ACTS OF KINDNESS. 
 
PEEFACE. 
 
 The importance of the subject of Intestinal Obstruc- 
 tion may be, in one way, estimated by the circum- 
 stance that over two thousand individuals die every 
 year in England alone from various forms of obstruc- 
 tion of the bowels, exclusive of hernia. 
 
 In the foUowino- work I have based the classifica- 
 tion of the different varieties of Intestinal Obstruction 
 upon pathological grounds rather than upon clinical 
 distinctions. Tliis has been done for two reasons. 
 In the hrst place, the knowledge of the morbid 
 anatomy of Intestinal Obstruction is much more 
 extensive and precise than is the knowledge of its 
 clinical history; and, secondly, the arrangement is 
 more convenient, inasmuch as it avoids much repe- 
 tition which would otherwise be necessary. A classi- 
 fication, however, based upon purely clinical grounds 
 is extremely desirable, and this classification I have 
 attempted in the chapters upon diagnosis. 
 
 In the consideration of the A^arious forms of the 
 present afi'ection I have dealt first with the patho- 
 logical aspect of the case, then with the symptoms, 
 and finally with the prognosis. The general diagnosis 
 of Intestinal Obstruction, as a whole, is reserved for 
 some special chapters, and the same method has 
 
viii Intestinal Obstruction, 
 
 been adopted with regard to the whole subject of 
 treatment. 
 
 The drawings are, with a very few exceptions, 
 original, and I am indebted to the artist, Mr. R. E. 
 Holding, for the care he has expended upon them. 
 
 The work is in substance the Essay to which the 
 Jacksonian Prize was awarded by the College of 
 Surgeons in 1884. The Essay was completed in 
 December, 1883. It has been entirely revised, some 
 parts have been re-Avritten, and such new matter lias 
 been introduced as was required to bring the work up 
 to date. 
 
 My thanks are due to the Council of the College 
 of Surgeons for permission to publish the Essay and 
 certain of the plates that illustrate it. 
 
 FREDERICK TREVES. 
 
 18, Gordon Square, W.C. 
 
 iSejjtember, 1884. 
 
CONTENTS. 
 
 CHAPTER PAGE 
 
 I.— The Classification of Intestinal Obstkuction 1 
 
 n.— Some Especial Features in the Etiology of 
 
 Intestinal Obstruction S 
 
 ni.— Strangulation by Bands or through Aper- 
 tures— Hernia-like Strangulation of the 
 Bowel IS 
 
 rv.— Strangulation by Bands or throlgh Aper- 
 tures— Symptoms 62 
 
 v.— Strangulation by Bands or through Apek- 
 
 TURES— Course and Prognosis .... 91 
 
 VI.— Anomalous Forms of Obstruction due to 
 
 Isolated Bands and to Adhesions ... 96 
 
 YII.— Volvulus 134 
 
 Vni.— Intussusception— Pathology 166 
 
 IX.— The Etiology of Intussusception . . . .202 
 
 X.— The Symptoms op Intussusception . . .215 
 
 XI.— The Course and Prognosis of Intussusception 212 
 
 Xn.— Stricture of the Intestine— Pathology . . 252 
 
 Xm.— The Symptoms and Prognosis of Stricture of 
 
 THE Intestine 285 
 
 XIV.— Obstruction of the Intestine by Neoplasms . 309 
 
 XV.— Compression of the Intestine by Tumours, etc., 
 
 external to the Bowel 315 
 
 XVI.— Obstruction of the Intestine by Foreign 
 
 Bodies 319 
 
■X Intestinal Obstruction. 
 
 CHAPTEK, PAGE 
 
 XVn.— Obstruction op the Intestine by Gall Stones 323 
 
 XVIII.— Obstruction by Intestinal Stones . . . 33G 
 
 XIX.— Obstruction of the Intestine by F^cal Masses 
 
 —Chronic Constipation— Ileus Paralyticus 3U 
 
 XX.— The Diagnosis— The General Significance of 
 
 the Leading Symptoms 355 
 
 XXI.— The Diagnosis of the different Forms of 
 
 Intestinal Obstruction 371 
 
 XXII.— The Symptoms as modified by the Position of 
 
 THE Obstruction 391 
 
 XXIII— The various Affections that have been most 
 
 FREQUENTLY CONFUSED WITH CaSES OF OB- 
 STRUCTION OF THE Bowels 100 
 
 XXIV.— The Treatment— Non-Operative Measures . 115 
 
 XXV.— The Treatment— Operative Measures . . 415 
 
 XXVI.— The Special Treatment of Individual Forms 
 
 of Obstruction 193 
 
 Index . 509 
 
toTESTiNAL Obstruction. 
 
 CHAPTER I. 
 
 THE CLASSIFICATION OF INTESTINAL OBSTRUCTION. 
 
 There are several cliiFerent plans upon wliicli a 
 classification of the various forms of intestinal ob- 
 struction niaj be based. 
 
 Bj one method they may be divided into the two 
 great classes of the congenital and the acquired, 
 according to whether the conditions that produced 
 the obstruction existed at birth, or had been subse- 
 quently produced. Among the former may be placed 
 such examples as depend upon congenital stenosis, 
 upon certain congenital deformities, upon Meckel's 
 diverticulum, upon peritoneal bands the result of 
 intra-uterine peritonitis, and the like. Among the 
 latter would be grouped cases of stricture following 
 ulceration, intussusception, volvulus, strangulation by 
 bands produced by peritonitis, cases of obstruction by 
 foreign bodies, and indeed all the principal examples 
 of intestinal occlusion. 
 
 By another method the classification is founded 
 upon a discrimination of the different mechanical 
 conditions that produce the narrowing or closure of 
 the lumen of the bowel. Thus in one set of cases the 
 lumen of the canal is obliterated by j^'^^ssiore froin 
 without. This division would include all cases of 
 strangulation by bands and through apertures, and all 
 examples of obstruction by the pressure of a tumour 
 B— 12 
 
2 Intestinal Obstruction. [Chap. i. 
 
 outside the bowel. In another set of cases the intes- 
 tine is occluded in consequence of an alteration in its 
 normal outline and in the relation that its walls bear 
 the one to the other. Under this headins: would be 
 classed examples of volvulus, of occlusion by kinking 
 and bending, and the important series of cases known 
 as intussusceptions. In a third variety of case the 
 lumen of tlie howel is blocked by some substance such 
 as a foreign body that has been swallowed, a gall 
 stone, an enterolith, a mass of ftecal matter, or a 
 neoplasm growing from the intestinal wall. In a 
 still further series of cases the obstruction depends 
 upon changes arising in the wall of the gut itself 
 and under this heading we meet with stenoses and 
 strictures of all kinds, including both those that are 
 simple and those that are cancerous. 
 
 By a third method of classification all cases are 
 divided according to their clinical character and are 
 grouped into acute and subacute cases, into chronic 
 cases and into chronic cases that end acutely. This 
 division of the subject has been adopted in that part 
 of the present volume which deals Avith the general 
 subject of diagnosis. 
 
 Lastly there is a method of classification based 
 upon 2J(ithological anatomy. This is the method that 
 has been followed in the body of the present work. 
 
 This plan consists in grouping together instances 
 of intestinal obstruction tliat are pathologically alike. 
 It consists of such an arrangement and grouping as 
 would probably be adopted if all the specimens of 
 intestinal obstruction in anv larcje museum were 
 taken, and an attempt then made to arrange them in 
 some definite and coherent order. The classification 
 that is founded upon this basis is the following : 
 
 Strangulation by bands, etc., or through apertures. 
 
 Volvulus. 
 
 Intussusception. 
 
Chap. II.] Etiology. 
 
 Stricture. 
 
 Obstruction by neoplasms. 
 
 Compression by tumours, etc., external to the bowel. 
 
 Obstruction by gall stones and foreign bodies. 
 
 Obstruction by enteroliths. 
 
 Obstruction by fsecal masses. 
 
 CHAPTEE IT. 
 
 SOME ESPECIAL FEATUKES IN THE ETIOLOGY OF 
 INTESTINAL OBSTRUCTION. 
 
 Into the very wide and complicated subject of the 
 general etiology of intestinal obstruction I do not 
 propose to enter in this place, since the more impor- 
 tant features in the causation of the various forms of 
 stoppage of the bowels are detailed in the account 
 given of those diflerent forms when considered 
 individually. 
 
 There are, however, certain phases of the matter 
 that are well worthy of a separate consideration upon 
 special grounds, and among these may be taken the 
 influence of the following affections in producing 
 intestinal obstruction, viz.: 
 
 Peritonitis. 
 Sti-angulated hernia. 
 IMescnteric gland disease. 
 
 The important subject of the influence of ulcera- 
 tion of the intestine in producing occlusion is fully 
 considered in the chapter on stricture. 
 
 Peritonitis. — It is well known that in this 
 affection, and especially in what is known as the 
 adhesive form, a fibrinous exudation appears upon 
 the surface of the inflamed membrane. Any two 
 surfaces so affected may, through the medium of the 
 
4 Intestinal Obstruction. [Chap. ii. 
 
 exudation, become adherent if they be brought into 
 contact with one another. 
 
 The adhesion may be over a very extensive sur- 
 face, or may involve only a few isolated points. As 
 the inflammation subsides there is no doubt that a 
 good deal of this exudation is in time absorbed. 
 Such as remains becomes organised into fibrous tissue, 
 and so are produced " adhesions," " bands," " perito- 
 neal false ligaments," and the like. 
 
 Some of these adhesions may be extremely loose 
 and delicate, while others are composed of a more 
 callous material. It would appear that many of the 
 more flimsy of these uniting structures in time disap- 
 pear, even after they have become organised into 
 definite connective tissue. It is much to be regretted 
 that so little is known of the circumstances that 
 favour the absorption of adhesions after peritonitis, 
 and so an important element in the prognosis of that 
 affection is lackino;. One circumstance that has 
 distinct influence in this direction is certainly the 
 movement of the adhering pai-ts. As an illustration 
 of this might be taken adhesions that involve the 
 small intestine, and that are connected with that 
 bowel either by both of their points of attachment or 
 by one. 
 
 During the progress of peritonitis the intes- 
 tines are relatively still. They are, moreover, more 
 or less distended from some paralysis of their walls. 
 As a result of this distension coils of bowel may 
 be brought together that were hitherto far apart, or a 
 certain loop may be placed in association with a com- 
 paratively distant point on the parietes. When the 
 inflammation has subsided the parts return, as far 
 as possiljle, to the status quo ante, peristaltic move- 
 ments spread through the intestine, coils that were 
 close together tend, as a result of those movements, 
 to become separated, and adhesions that attach the 
 
Chap. II.] Etiology. 5 
 
 intestine to points upon the parietes are persistently 
 dragged upon. It follows from tliis almost constant 
 tension that the still soft adhesion yields, becomes 
 elongated and thinned, ultimately gives way and is 
 absorbed. 
 
 Movement also has great influence upon the 
 future physical characters of the adhesion. Most of 
 the adhesions assume primarily a membranous cha- 
 racter, and this they may retain throughout their 
 existence. It is not uncommon to find some coils of 
 intestine matted together by an extensive series of 
 false membranes, which appear sometimes as wide 
 expansions, at other times as thin but broad ribbon- 
 like bandsj of all dimensions and of various lengths 
 (Figs. 1 and 24). If two distant coils of small intes- 
 tine have been brought together during peritonitis, 
 and have become attached to one another by means of 
 the exudation, or if a like attachment has taken place 
 between the intestine and the parietes, then, as move- 
 ment is restored in the bowel, the adhesions, which 
 may be quite membranous, are dragged upon, and 
 as a result become elongated. As they increase in 
 length so must they become attenuated in width and 
 thickness. The constant tension, moreover, probably 
 interferes with their already feeble nutrition, and 
 induces a further wasting. 
 
 The wide membranous adhesion may thus become 
 narrowed and ribbon-like. 
 
 It may, however, undergo a still further change. 
 This adhesion, subjected to the rolling movements of 
 the intestines over one another, and subjected to fre- 
 quent tortion, now in one direction and now in the 
 other, tends to become rounded and cord-like, and 
 the more that it is stretched the more completely is 
 this transformation favoured. Thus are formed 
 " peritoneal false ligaments " and the bands that are 
 so common a cause of strangulation of the bowel. 
 
6 Intestinal Obstruction. [Chap. ii. 
 
 The moulding of the mass of adhesion-tissue into 
 a cord by the movements active within the abdomen 
 is illustrated by the changes that are effected by 
 those movements in the omentum when it becomes 
 adherent. This structure may become attached by 
 its free extremity, and in the course of time, if the 
 abdomen be opened, it will be found to be changed 
 into a cord-like mass. The intestines in their move- 
 ments have rolled over and under and about the 
 adherent membrane, and at last they have moulded 
 it almost as a piece of clay may be moulded when 
 rubbed betweeli the palms. This change is best 
 brought about when the situation of the adhesion is 
 such as to keep the membrane on the stretch. 
 
 A like metamorphosis may be effected in any 
 smaller part of the great omentum that may have 
 become adherent to a distant point. 
 
 By a combination of these various circumstances, 
 by a stretching of the adhesion on the one hand, by 
 its consequent attenuation on the other, and its 
 subjection to the moulding influences of moving 
 intestines for the third part, it happens that cords 
 and bands of great length are often produced as a 
 result of peritonitis. Many instances may be given, 
 but one of the most striking is afforded by a case 
 reported by Mr. Obre."^ In this example a cord-like 
 band was found to pass from a coil of small intestine 
 situated near the xiphoid cartilage to the parietal 
 peritoneum about the inguinal canal. The false 
 ligament measured seventeen and a half inches. The 
 patient had had a strangulated inguinal hernia, and 
 there was clear evidence to show that the herniated 
 bowel had been that to which the cord was attached. 
 Subsequent changes in the abdomen, which were asso- 
 ciated with much violent peristaltic movement and 
 much distension, had carried the involved coil so far 
 * Path. Soc. Trans., vol. iii., page 95. 
 
Chap. II.] Etiology. 7 
 
 away from its original point of adhesion as to produce 
 the band described. 
 
 It must be remembered that not only may these 
 Ijands form arcades beneath which coils of intestine 
 may become strangulated, but the longer of them 
 may become separated at one of their points of 
 attachment, and so form floating cords that may lead 
 to strangulation of a loop by " knotting." 
 
 Adhesions of all kinds, but especially those 
 attached to parts not susceptible of much movement, 
 may undergo considerable contraction. In cases of 
 extensive peritonitis this contraction may produce 
 great deformity. The mesentery may become so 
 shrunken as to produce obstruction in the intestine to 
 which it is attached. The most severe form of this 
 condition is that known as peritonitis deformans. 
 
 Adhesions upon the surface of a fixed part of the 
 intestine may, as a result of their contraction, pro- 
 duce great narrowing of the bowel by compressing it. 
 This condition is not infrequently met with in the 
 colon, and especially in the hepatic and splenic 
 flexures (Fig. 22). In parts of the tube where the gut 
 cannot be compressed against an unyielding surface 
 the contraction of peritoneal adhesions may still 
 produce some obstruction by causing an extensive 
 puckering of the intestinal walls. 
 
 Some of the adhesions formed after inflammation 
 oJt the serous membrane are exceedingly complicated, 
 while others are found to unite parts that are usually 
 far separated from one another. Thus I find in- 
 stances of adhesion between the ascending colon and 
 the ovary, between the transverse colon and the 
 csecum in one case, and the mesentery over the lower 
 lumbar region ii^ another, between the arch of the 
 colon and a part of the parietes not far above the 
 symphysis. Then again the sigmoid flexure has been 
 found connected by adhesions to the bladder, the 
 
8 Intestinal Obstruction. [Chap. ii. 
 
 uterus, the rectum, the peritoneum in the right iliac 
 fossa, and the csecum. In all these cases I tliink that 
 the unusual connection of parts may be explained by 
 displacement from distension, the distension occurring 
 duiing the development of the peritonitis. Thus the 
 transverse colon when distended is apt to become 
 bent uj^on itself, and by such bending to reach the 
 lower parts of the abdomen. In the same way the 
 distended sigmoid flexure may turn down into the 
 pelvis, or extend across to the right iliac region, or 
 even mount up in the abdomen and reach the liver. 
 
 In addition to the causes of obstruction already 
 alluded to, peritonitis may be the means of bringing 
 about an occlusion in the intestine by other and very 
 difterent methods. 
 
 The adhesions may form a part of the bowel into 
 a rigid loop, they may bend it so acutely as to greatly 
 narrow or even entirely obstruct its lumen, they may 
 lead to obstruction by kinking, or they may bring 
 about an arrangement of certain coils of small intes- 
 tine or of the loop of the sigmoid flexure that 
 especially favours the production of a volvulus. 
 
 In another series of cases as a result of local 
 peritonitis, the omentum or the tip of the appendix 
 vermiformis has become adherent at one point, and 
 beneath the arcade so formed coils of intestine have 
 been strangulated. Similar arcades have been 
 formed by the adhesion of the point of a free 
 Meckel's diverticulum, and of the outer extremity of 
 the Fallopian tube. 
 
 In still another variety of case a loop of bowel 
 has been strangulated through a slit in a membranous 
 adhesion, or through an aperture formed by adhesions 
 between adjacent viscera, or through the gap left 
 between two parallel adhesions. 
 
 With regard to the forms of peritonitis that may 
 lead to adhesions capable of producing obstruction, 
 
Chap. II.] Etiology. 9 
 
 it can be briefly said that any variety of peritoneal 
 inflammation from wliicli a patient recovers may 
 become indirectly a cause of intestinal occlusion. In 
 the great majority of cases, therefore, it will be found 
 to have been a very localised peritonitis. The prin- 
 cipal examples are furnished by the circumscribed 
 pelvic peritonitis that is comparatively so common in 
 women, by that attending typhlitis or perityphlitis, 
 by that depending upon injury, or upon an ulceration 
 of the stomach or intestine that has not quite ad- 
 vanced to perforation. Another common form has 
 followed upon strangulated hernia. Another has 
 been induced by gall stones, and has led probably to 
 adhesion between the gall bladder and the colon. 
 Another has been set up by faecal accumulations, or 
 by the impaction of some foreign substance in the 
 bowel. 
 
 It must be remembered also that peritonitis may 
 occur during intra-uterine life. Dohrn, indeed, rei^oits 
 a case of obstruction in a child eight days old that 
 ended fatally, and was found to be due to adhesions 
 formed evidently before birth. ''^ 
 
 There is also a form of peritonitis that may occur 
 shortly after birth, and that appears to be due to 
 extension of inflammation from the divided umbilical 
 cord. 
 
 The variety of peritonitis known as " infantile," 
 and which is distinct from the localised form just 
 mentioned, is with very rare exceptions always fatal, 
 and in the newly born would appear to be without 
 exception fatal. 
 
 Acute diflfused peritonitis is so very seldom re- 
 covered from that it can have little concern in the 
 etiology of obstruction. In puerperal peritonitis, 
 according to Bauer, "an absolutely fatal prognosis 
 
 * Quoted by Bauer ; Ziemsson's Cyclopaedia of Medicine, vol. 
 viii., page 288. 
 
lo Intestinal Obstruction. [Chap. ii. 
 
 must be made," and the same gloomy prognosis 
 applies to the j^eritonitis depending upon carcinoma. 
 
 With regard to tubercular peritonitis, it leads in 
 time to a certain death ; but its coui-se is usually 
 chronic, and during its progress it is apt to produce 
 very numerous and extensive adhesions, which are 
 frequently the cause of intestinal obstruction. Indeed, 
 certain writers have included chronic tubercular peri- 
 tonitis among the varieties of chronic occlusion of 
 the bowels. 
 
 StraiigTilatcd hernia.— There is, I think, a 
 fairly common impression that when a strangulated 
 hernia has been reduced and the patient has recovered 
 from the operation, no further evils will result beyond 
 a possible return of the hernia, and with it a risk of 
 a second strangulation. A piece of bowel, however, 
 that has been strangulated in an external hernia and 
 has then been reduced into the abdomen may be the 
 cause of one of many different forms of intestinal 
 obstruction. I do not allude to results immediately 
 following the reduction of the hernia, but to results 
 that are comparatively remote. Among the former, 
 as is well known, it is not infrequent for the once 
 strangulated loop to remain so entirely paralysed 
 after reduction as to continue the symptoms of ob- 
 struction until death ensues, and that, too, without 
 either becoming gangi-enous or causing peritonitis.* 
 
 The conditions Avith which I propose to deal 
 briefly are remote, and are subsequent to the more or 
 less complete recovery of the patient from the opera- 
 tion. 
 
 1. The peritonitis about the reduced loop of bowel 
 may lead to adhesions, and these may cause obstruction 
 
 * See cases by Mr. Pitts, St. Thomas's Hosp. Repoi-ts, 1882, 
 page 75 ; and Hemot (Pseudo-etranglements, page 4G). For a 
 general consideration of the immediate effects that may follow 
 reduction, sec " Les Accidents consecutifs a la Reduction de 
 I'Euteroc^le <^trangl^e," by Jules Ferret. Th6se. Paris, 1879. 
 
Chap. II. J Etiology. ii 
 
 by kinking or bending of the gut. On the otlier 
 liiind, the oincntnin or a free coil of intestine may 
 become adherent to the inflamed serous surface, and 
 thus a condition be produced that may lead to ob- 
 struction."*^ 
 
 2. The reduced loop may adhere to the abdominal 
 parietes and become obstructed by bending and by 
 the changes known as " traction effects." Examples 
 of this form of obstruction are given in chapter vi. 
 
 3. The ad hesions about the reduced and adherent 
 loop may be extensive, and may so contract as to 
 narrow the lumen of the gut by compression. 
 
 4. The herniated coil may be retained in the 
 form of a permanent loop by means of adliesions, and 
 this loop, whether an " open " or a " closed " one, may 
 lead to obstruction of the intestine, as is fully ex- 
 plained in a subsequent part of this work. 
 
 In one instance at least a fistula bimucosa was 
 formed between the extremities of the loop. 
 
 5. Stricture may follow as a result of damage to 
 the walls of the bowel, ulceration of the mucous 
 membrane, and the like. Several illustrations of this 
 condition will be found in the chapter upon cicatricial 
 strictuVe. 
 
 C. The great lengthening of the mesentery that 
 is usually found in large hernia? favours especially 
 the formation of volvulus of the small intestine. The 
 connection between these two conditions is well 
 shown in a case reported by Dr. J. K. Fowler, where 
 tliere is little doubt but that a fatal volvulus of the 
 ileum depended upon an unduly long mesentery re- 
 sulting from hernia, t 
 
 * Bull, (le la Soc. Anat., 1804, page 252 ; M. Besnier. See 
 also Patli. Soc, Trans., vol. vii., ])age 11)8 ; Mr. Obro. 
 
 i' For a further account of this matter sec a paper by the 
 author on "The Forms of Intestinal Obstruction that may follow 
 after Hernia " [Lancet^ Juno 7, 1884). 
 
T2 Intestinal Obstruction. [Chap. ii. 
 
 Mesenteric g:l»iid disease.— Mesenteric gland 
 disease may indirectly lead to obstruction in several 
 different ways. 
 
 1. The little local peritonitis excited in tlie serous 
 membrane covering the glands may lead to the adhe- 
 sion of a free diverticulum, or of the free end of the 
 omentum, or may encourage the development of 
 bands which may in turn prove a cause of intestinal 
 stranojulation. * 
 
 2. The local peritonitis may lead to adhesions 
 being formed between two remote parts of the intes- 
 tinal tube. Thus, in a case recorded by Dr. Hilton 
 Fagge the sigmoid flexure was found attached to the 
 ileum, and in the angle between these two adherent 
 portions of gut was a caseous gland. + 
 
 3. The ileum about the seat of a diseased gland in 
 the mesentery may become sharply bent upon itself ; 
 and between the two limbs of the loop so formed, and 
 fusing them together, as it were, will usually be found 
 an old and degenerate gland. 
 
 Or the bending may be very limited and well 
 localised, so that a fold of the bowel is turned in and 
 forms a sjoecies of diaphragm. This condition is 
 shown in the remarkable, and, I think, unique, case 
 depicted in Fig. 49. 
 
 4. In several instances the shrinking of the 
 mesentery after extensive gland disease has been so 
 considerable, and has produced so much distortion, as 
 to lead to a fatal obstruction of that part of the bowel 
 connected with the diseased area.;}; 
 
 5. Dr. Leared has reported a case of fatal stran- 
 
 * Bee specimens, Guy's Hosp. Museum, No. 1,819 (36) ; and 
 St. Bart.'s Hosp. Museum, No. 2,105 ; also cases by M. Briclieteau 
 (Bull, de la Soc. Anat., 1861, page 118), and by Mr. B. Hill {Lancet, 
 vol. i., 1876, page 773). 
 
 f Path. Soc. Trans., vol. xxvii., page 1.57. 
 
 j See Path. Soc. Trans., vol. xxi., page 187 ; and cases by 
 Dr. Fagge, Guy's Hosj). lleports, vol. xiv., page 272. 
 
Chap. III.] Strangulation BY Bands. 13 
 
 gulation of tlie small intestine through a hole in the 
 mesentery. It was considered that this aperture was 
 probably caused by the breaking down of a mesen- 
 teric gland. The patient was a lad aged 14."^ 
 
 CHAPTER III. 
 
 STKANGULATION BY BANDS OK THROUGH APERTURES 
 
 HERNIA-LIKE STRANGULATION OF THE BOWEL. 
 
 Under this variety of intestinal obstruction may 
 be included : 
 
 1. Strangulation by isolated peritoneal adhesions, 
 
 2. Strangulation by cords formed from tbe omentum. 
 
 3. Strangulation by Meckel's diverticulum. 
 
 4. Strangulation by normal structures abnormally attached 
 
 (such, as by an adherent vermiform appendix or Fallo- 
 pian tube, or by a fixed mesentery) , including strangu- 
 lation by the pedicle of an ovarian tumour and the 
 hke. 
 
 5. Strangulation through slits and apertures in the mesen- 
 
 tery or omentum, or in certain peritoneal Hgaments, 
 or through membranous adhesions. 
 
 These various forms may be conveniently con- 
 sidered together, for although in each case the 
 anatomical cause of the obstruction is different, yet 
 the effects upon the gut are in all instances practi- 
 cally identical. In each the segment of bowel in- 
 volved is, almost without exception, the small 
 intestine. In each the mechanism of the obstruction 
 is practically the same. In each the symptoms that 
 arise are, with some minute exceptions, so nearly 
 identical that they may be studied as a whole. In 
 each the course and issue of the malady are such that 
 
 * Path. See. Trans., vol. xiv., page 156. 
 
1 4 InTES TINA L ObS TR UC TION. [Chap. 1 1 1 . 
 
 these various forms may be said to share a common 
 prognosis. Between them all, moreover, there is a 
 close bond of union in the fact that they are adapted 
 for the same form of treatment, and may be relieved 
 by the same operative procedures. 
 
 Considered as a whole this form may be taken as 
 the type of acute intestinal obstruction, and as such 
 it assumes a position of considerable importance. It 
 is the strangulated hernia of the interior of the 
 abdomen. It obstructs the gut as a hernia obstructs. 
 It involves the small intestine with about the same 
 frequency as does an external rupture. It is indeed 
 as rare to find a portion of the large intestine stran- 
 gulated by any of the methods above named, as it is 
 to discover colon in a femoral or inguinal hernia. 
 The symptoms that attend this variety of intestinal 
 obstruction are, in all main points, the symptoms of 
 strangulated hernia, and the prognosis of the two 
 affections depends rather upon the situation of the 
 constricting agent than upon any other factor. It is 
 for many reasons a matter of moment to note that 
 strangulated hernia and the different forms of 
 internal obstruction above described are but varieties 
 of a single malady, that they differ from one another 
 solely on anatomical grounds, that in their pathology 
 and in the broader lines of their clinical history they 
 are the same, and that, excluding the taxis, they are 
 amenable to the same general form of surgical treat- 
 ment. 
 
 It will be convenient to consider the pathological 
 anatomy of these five varieties of obstruction separ- 
 ately, and then their symptoms and the elements of 
 their prognosis collectively. 
 
 PATHOLOGICAL ANATOMY. 
 
 1. Strangulation by isolated peritoneal 
 adhesions.— Those isolated adhesions (known com- 
 
Chap. III.] Strangulation BY Bands. 15 
 
 monly as "bands," "solitary bands," or "peritoneal 
 false ligaments ") are the results or residues of some 
 form of peritonitis. Owing to tlie high mortality of 
 acute diffused peritonitis on the one hand, and the 
 very general and extensive adhesions produced by 
 chronic diffused peritonitis on the other, it follows that 
 these isolated bands are usually due to moderate, 
 chronic, and well localised forms of peritoneal inflam- 
 mation. It would appear, as has been already pointed 
 out, that in some cases they may be congenital, and 
 due then to intra-uterine peritonitis. The mode of 
 formation of these bands, and the methods whereby 
 they become elongated and cord-like have already 
 been described (chapter ii.). 
 
 Their appearance in cases where they have caused 
 obstruction varies greatly. 
 
 Most commonly the " band '' takes the form of a 
 firm fibrous cord about the size of a No. 4 or No. 6 
 catheter. It may be still more slender, and appear 
 as a tough, rigid thread. On the other hand, it may 
 be of comparatively large size ; thus M. Terrier has 
 reported a case of internal strangulation, for which 
 he performed laparotomy, where the constricting 
 band had nearly the dimensions of the little finger.* 
 The cord-like " band " is usually described as being 
 dense and fibrous, and in one or two instances as 
 being of almost cartilaginous hardness. Less fre- 
 quently the constricting agent has the appearance of 
 an actual l)and, and in such cases is found as a tough 
 ribbon-like membrane, with a width of half an inch or 
 even more. A band of this character is well shown 
 in Fig. 1. 1 
 
 The " false ligament " is usually single, and hence 
 the name bestowed upon it by Mr. Gay of "the 
 
 * Bull, ct Mem de la Soc. dc Chir. de Taris, vol. iv., 1879, 
 page 5G4. 
 
 t London Hosp. Museum, No. Ad. 78. 
 
1 6 Intestinal Obstruction. [Chap. hi. 
 
 solitary band." It must not be assumed, however, 
 tliat such a band commonly exists as the solitary 
 adhesion in any given case. It most probably will be 
 the only isolated adhesion, and the only one so 
 modified as to be capable of strangulating the bowel. 
 But in cases where this isolated adhesion is met with 
 other adhesions will very usually be found. This is 
 
 Fig. 1.— Strangulation by a broad Pei-itoueal Baud passing between two 
 adjacent Coils of Ileum. 
 
 especially the case when the band is due, as it often 
 is, to pelvic peritonitis. The same ajiplies, although 
 in a less degree, to the local peritonitis set up by 
 inflammation in or about the caecum. Here, in addi- 
 tion to any adhesion that may have become isolated, 
 elongated, and cord-like, there will very probably be 
 some matting together of parts in the immediate 
 vicinity of the caput coli. ^lany cases, however, are 
 reported wliere the only relics of a typhlitis have 
 assumed the form of one solitary band, A single 
 false ligament, the representative of a single adhesion, 
 
Chap. III.] Strangulation BY Bands. 17 
 
 may be produced by the very localised peritonitis that 
 is sometimes associated with caseous degeneration of 
 a mesenteric gland. I have met with several re- 
 ported cases, and not a few specimens, that illustrate 
 this circumstance. A single adhesion may readily 
 follow upon the little speck of peritonitis that often 
 attends an intestinal ulcer (Fig, 20). As the ulcer 
 deepens it excites an inflammation over a very 
 limited area of the serous surface. This inflamed 
 spot adheres to some other point on the peritoneum ; 
 a single adhesion forms, which, becoming elongated by 
 the method already described, forms an example of 
 the solitary band. A great many of the cases of 
 " solitary band " described are evidently instances of 
 strangulation by Meckel's diverticulum, or by a diver- 
 ticular ligament. 
 
 In some few cases there have been two or more 
 false ligaments found in the abdominal cavity. , Some- 
 times these would a})pear to have been produced by 
 the thrusting of a coil of intestine through a broad 
 peritoneal adhesion so as to divide it into two seg- 
 ments. In other instances the bands are inde])endent 
 of one another. Mr. Berkeley Hill reports a case of 
 acute intestinal obstruction where two bands existed, 
 both of which constricted knuckles of small intestine. 
 One constriction was, however, comparatively slight, 
 the other was severe. Laparotomy was performed, 
 and unfortunately the band found and divided was 
 that associated with the minor obstruction. The 
 more serious strangulation was overlooked and the 
 child died. The adhesions in this case appear to have 
 been due to mesenteric gland disease.* 
 
 The false ligament, although single, may have a 
 complicated arrangement, and lead to extraordinary 
 forms of constriction of the bowel. Thus in the 
 
 * Lancet, vol. i., 1876, page 773. 
 1 ^ 
 
 -1 A< 
 
i8 
 
 Intestina l Obs tr uc tion. 
 
 [Chap. III. 
 
 specimen shown in Fig. 2 "^ there was one isolated adhe- 
 sion. It was, however, broad and Y-shaped ; one end 
 of the Y was attached to the uterus, while the two 
 other ends were connected with points on the small 
 
 Fig. 2.— strangulation of the Ileum by a Y-sliaped Band attached to the 
 
 Fundus of the Uterus. 
 
 The Uterus is shown at the lower part of the figure. 
 
 intestine about one and a half inches apart. Tliere 
 were many adhesions about the pelvic viscera. In 
 Fig. 3 t it will be seen that an adhesion connecting the 
 
 * St. Bart.'s Hosp. l\Iuseum, No. 2,164. 
 t Guy's Hosp. Museum, No, 2,507 (50). 
 
Chap. III.] Strangulation by Bands, 
 
 19 
 
 Fig. 3.— Strangulation of tbe Ileum by complicated Bands passing be- 
 tween the Uterus and Ovary. 
 
 uterus, ovary, and mesentery leads to a complicated 
 form of strangulation and to a double constriction 
 of the bowel. 
 
20 Intestinal Obstruction. [Chap. iii. 
 
 In many cases of strangulation by a false liga- 
 ment the circumstances of the obstruction are com- 
 plicated by simple adhesions of the same age, and due 
 to the same cause, as the so-called ligament. These 
 adhesions may have matted together into a knuckle 
 the very segment of the bowel that has become 
 strangulated, or may have so attached themselves to 
 the involved intestine as to encourage a volvulus of 
 it wlien beneath the constricting band. 
 
 The attachments of these peritoneal false liga- 
 ments exhibit the greatest possible variety. To be 
 capable of producing a strangulation of the intestine 
 the band must have at least two points of attach- 
 ment, and there is scarcely any conceivable combina- 
 tion of connected points that is not illustrated in the 
 history of these adhesions. 
 
 Most commonly the strangulating band is con- 
 nected by one end with the mesentery. In one very 
 frequent variety the band is attached by both its 
 extremities to the mesentery, the points of attach- 
 ment being at a variable distance apart. This 
 disposition of the band is illustrated by Fig. 4,* and 
 it would ajDpear to be very frequently, if not most 
 frequently, due to a limited peritonitis incident upon 
 mesenteric gland disease.t In that very large series 
 of cases where the isolated adhesion is due to pelvic 
 peritonitis, it may be found to be attached by one 
 end to some pelvic viscus, and by the other to a 
 neighbouring part. Thus bands are found passing 
 from the uterus, or ovary, or bladder, to the parietal 
 peritoneum of the pelvis or abdomen ; or, starting 
 from the same source, they may attach themselves to 
 the csecum or sigmoid flexure, or with much greater 
 frequency to some part of the lower ileum or its 
 
 * University Coll. Museum, No. 1,164. 
 
 t See specimens St. Bart.'s Hosp. Museum, No. 2,165 ; and 
 Lend. Hosp. Museum, No. Ad. 79. 
 
Chap. III.] Strangulation BY Bands. 
 
 21 
 
 mesentery. In several instances tlie constricting 
 band has merely passed from one point on the pelvic 
 wall to another. When the band has been caused by 
 
 Pig. 4.— Strangulation of small Intestine by a solitary Band attached at 
 either end to the Mesentery. 
 
 some local peritonitis in connection with hernia, one 
 of its extremities may be found attached to the 
 vicinity of the femoral or inguinal rings, while the 
 other end may be fixed to the intestine, the mesentery, 
 
22 Intestinal Obstruction. [Chap. hi. 
 
 or the posterior parietal peritoneum. When the 
 band has followed after typhlitis (one of the common 
 caiises of false ligaments), both ends of it may be 
 found connected with the csecum, as is apparently the 
 case in a specimen in the College of Surgeons 
 Museum ; "^ or it may pass between the caecum and 
 the peritoneum lining the iliac fossa, or attach itself 
 to the ileum or to its mesentery, or become connected 
 with the lining of the anterior abdominal wall. In 
 some cases, and I think this especially occurs after 
 very localised peritonitis due to intestinal ulcer, a 
 single band passes between two neighbouring coils of 
 intestine. The early stage of such a band is well 
 shown in Fig. 20. Perhaps from the same cause the 
 false ligament may pass from the surface of the bowel 
 to be attached to the mesentery of the piece of intes- 
 tine involved, or to the mesentery of another and 
 possibly distant segment of the gut. 
 
 Whatever their origin, it must be owned that these 
 last-mentioned forms of band are not uncommon. 
 
 Among the less usual attachments of these bands 
 may be mentioned the following : Between the 
 descending colon and the mesentery, f Between the 
 mesentery near the caecum, and the anterior surface 
 of the rectum. I Between the transverse colon and 
 the ciecum § (the band in this case occurred in con- 
 nection with extensive adhesions due to peritonitis 
 after ulcer of the stomach). Between the omentum 
 and the mesentery. || Between the ascending and de- 
 scending colon.^ Between the colon and the ovary.** 
 
 * No. 1,360a. 
 
 t St. Thomas's Hosp. Museum, No. R 15. 
 t Mr. A7ard; Path. Soc. Trans., 1852, page 302. 
 fDr. Hilton Fagge ; Guy's Hosp. Reports, vol. xiv., 18G9, 
 page 272. 
 
 II Dr. Hilton Fagge, loc. cit. 
 
 11 Seerig. Rust's Magazin fur Heilkunde, band xlvi. 
 
 ** Rokii'.ansky ; Brit, and For. Med.-Chir. Keview, vol. iii. 
 
Chap. III.] Strangulation BY Bands. 23 
 
 In not a few cases isolated cords of adhesion are 
 described as passing between the sigmoid fle.xure and 
 distant parts. In this way the flexure has been 
 connected -vs-ith the ccecum, with the mesentery near 
 the ca?ciim, and with the parietal peritoneum in the 
 right iliac fossa. Rokitansky * reports a case of 
 adhesion between the sigmoid flexure and a coil of 
 small intestine in the right hypochondriac region. 
 It is well known that the distended sigmoid flexure 
 may reach the right iliac fossa, or even the right 
 hypochondriac district, and cases like the above may 
 be explained on the assumption that the flexure 
 became greatly distended during the time that the 
 peritonitis was active from which the adhesions were 
 derived. Such distension may readily attend the 
 constipation and intestinal paralysis of peritoneal 
 inflammation. 
 
 Jlethods of strangukition. — When a portion of 
 the intestine is strangiilated by an isolated peritoneal 
 adhesion the gut will be found to be constricted by 
 one of two ways, 1. It may be strangailated beneath 
 the band as beneath a shallow and narrow arch. 2. 
 It may be snared and constricted by a noose or knot 
 formed by the false ligament itself. 
 
 1. Strang-ulation beneath a band can only occur 
 when the band is coDiparatively short, and when it is 
 stretched along a Arm surface. From an examina- 
 tion of some fifteen cases, where the constricting cord 
 is well described, it would appear that its average 
 length in this form of strangulation is about one and 
 a half to two inches. The arch beneath which the 
 implicated bowel passes is variously described as 
 large enough to admit one, two, or three fingers. 
 Larger arches have been formed permitting much 
 intestine to pass beneath them, but these great aper- 
 tures ai^e exceptional in acute cases. Since the cord 
 * Manual of Path. Anatomy (Syd. Soc), vol. ii., 1850. 
 
24 Intestinal Obstruction. [Chap. iii. 
 
 must be stretched along a firm surface it happens 
 that this form of stransjulation is much more com- 
 monly found about the posterior abdominal parietes 
 than elsewhere. It is often met with about the iliac 
 fossse, especially that of the right side, and about the 
 brim of the true pelvis. When a band passes be- 
 tween two points on the mesentery a coil of small 
 intestine may readily be strangulated beneath it, the 
 resisting pai'ts between which the bowel is com- 
 pressed being the false ligament on the one hand, and 
 the mesentery on the other. It will be readily 
 understood also that a knuckle of the small intestine 
 may be strangulated with little difficulty when it 
 passes between a band and a solid viscus like the 
 uterus. In some few cases the firm basis required 
 for this form of obstruction appears to have been 
 provided by a rigid mass of adhesions, across which 
 the false ligament has been stretched. 
 
 2. Strangulation by a noose or knot requires a 
 lonir false liiiament which must lie loose and free in 
 the abdominal cavity, being attached only by its two 
 ends. 
 
 The snaring of a coil of small intestine by this 
 means must be a matter of some difficulty, and must 
 be almost impossible in cases where the bowel is per- 
 fectly normal. As Leichtenstern has well pointed 
 out, the gvit in these cases will usually be found to 
 have been in an abnormal condition previous to the 
 occurrence of the strangulation. A knuckle of gut 
 
 may be rendered so adherent 
 that it could not slip out 
 of the way by peristaltic 
 movement when it had be- 
 come involved in the noose 
 or knot. It is probably a 
 still more common circumstance for two ends of a 
 loop of intestine to be matted together by a little 
 
Chap. III.] Strangulation BY Bands. 25 
 
 mesenterial peritonitis, so that if a noose should slip 
 over such a loop, the constricting cord will find at the 
 
 Fig. 6. — Strangulation by a Band. (Astlty Cooper.) 
 a, anterior al)clonilnal parietes ; h, hand passing from a lu'vnial sac to surround the 
 intestine ; c, band returning to the hernial sac ; d, loop or noose fonned by 
 the band ; e, intestine strangulated by the noose d ; /, intestine strauguhvted 
 iu a less degree by the portions of the band h and c. 
 
 base of tJie loop a narrowed neck around which it 
 may take good hold. The most common method 
 whereby a coil of intestine may be snared is when the 
 lax band forms a ring or spiral between its fixed 
 
26 
 
 InTES TINA L ObS TR UCTION. 
 
 [Chap. III. 
 
 points a and h (Fig. 5). Through this ring a 
 loop of the small intestine slips, or over an abnor- 
 mally fixed coil of that part of the bowel the noose 
 passes. For an excellent illustration of this method 
 see Fig. 6.* 
 
 Strangulation by the formation of a knot is some- 
 what different from the process of snaring just 
 described. The mechanism of this variety of obstruc- 
 tion is thus described by Leich- 
 tenstern : " There are several 
 kinds of this knotting. The 
 most frequent is the following : 
 The long and loose ligament is 
 fastened at one end to a loop of 
 the small intestine, and hangs in 
 the form of a simple coil (Fig. 7). 
 If the top of the intestinal loop 
 passes directly through the coil c, 
 a simple knot is formed about 
 the piece of the intestine, as is 
 shown in Fig. 8. It is evident that the same result 
 can be produced by the coil being thrown over the 
 top of and around the intestinal 
 loop. 
 
 " An(;>ther and rarc^r form of 
 knot is made as follows : a long 
 and perfectly loose fcdse ligament 
 forms a simple coil, like that shown 
 in Fig. 5, between its points of 
 attachment a and h. If now one 
 leg of the so-formed primary noose 
 passes tlirough it we have a knot 
 like that shown in Fig. 9, and if 
 now the intestinal loop passes directly through c 
 (Fig. 9), it becomes firmly caught and strangulated. 
 
 * From Sir Astloy Cooper's Treatise on Abdominal Hernia, 
 plate xxvi., Figs. 2 and 3. 
 
 Fig. 7. 
 
Chap. III.] Strangulation by Bands. 27 
 
 . . . . A common characteristic of all described 
 
 knots is, that when the strangulated intestine is 
 freed tlie ligament can immediately be drawn out 
 straight.""^ 
 
 With regard to the relative frequency of these 
 two forms of strangulation by band, viz. strangula- 
 tion under the false ligament, and strangulation by a 
 noose or knot, my own collection of cases gives the 
 proportion of the two as about six 
 to one. Leichtenstem, however, 
 who deals with a larger series of 
 instances, has tabulated fifty-six 
 cases of strangulation under the 
 band, and twenty-six by means of 
 knots and snaring. 
 
 With regard to the amount of 
 intestine that may be involved in a ■^^^* ^* 
 
 noose or knot, it must be remembered that the 
 false ligament may, under certain circumstances, 
 attain a considerable length. Thus, in Mr. Obre's 
 case already alluded to (page 6), the false ligament 
 was VI \ inches long. 
 
 Into the precise physical conditions that underlie 
 the production of strangulation in these and in 
 analogous forms of strangulation it is not necessary to 
 enter. Many theories exist upon the subject, and the 
 matter is one rather of pure physics. 
 
 An excellent account of the mechanism of stran- 
 gulation as applied to hernia has been given by 
 Schmidt,! and an able account of the various theories 
 that exist upon the question has been furnished by 
 Hueier.J To the works of these authors the reader 
 is referred. 
 
 * Loc. cit., page 528. 
 
 t Die Unterleibsbriiche, Handb. der Allgem. und Speciel, 
 Chirurgie, Yon Pitlia imd Billroth, 1882, page 146. 
 
 X Grundriss der Chirurgie, page 248. Leipzig, 1883. 
 
2$ Intestinal Obstruction. [Chap. hi. 
 
 2. 8traiig:ulatioii by cords formed from 
 the oiiientiim.— These cords are in all cases due to 
 an adhesion or adhesions formed between the omen- 
 tum and some other peritoneal surface as a conse- 
 quence of peritonitis. 
 
 The form and arrangement of these omental cords 
 show very considerable variety. Sometimes the 
 lower border of the omentum, and probably the 
 central part of that border, becomes adherent at 
 some one sj^ot. As a result the inferior part 
 of the membrane is rolled up into a round solid 
 band, and the whole structure assumes a fan-shaped 
 outline. The base of the fan is at the transverse 
 colon, while its apex or narrowed part is represented 
 ]jy the cord-like extremity of the adherent epiploon. 
 A case of this character is reported by Dr. Hare, the 
 point of adhesion being at the anterior abdominal 
 parictes below the umbilicus."* In a somewhat 
 similar case described by Mr. Avery the extremity of 
 the omentum was twisted into a cord about the size 
 of the little finger, and attached to the mesentery in 
 the right iliac region, f 
 
 In other cases, especially where one of the lateral 
 borders of the epiploon has become adherent, the 
 attached portion separates as a cord, which becomes 
 in time dense and fibrous. If the omentum has 
 formed extensive adhesions, its whole substance may 
 be changed into a series of cords passing between the 
 transverse colon and various other parts of the 
 abdominal cavity. Such Avas the condition of things, 
 for example, in a case of Dr. Fagge's, the many false 
 ligaments that had formed being attached to the 
 abdominal parietes and small intestines in many 
 
 * Piitli. Soc. Trans., vol. rii., 1851, page 111. 
 
 t IVjtd., vol. iv., page 150. A case of a like character will be 
 foiind in a paper by M. Berger, in Bull, et M^m. de la Soc. de 
 Chir. de Paris, tome vi., 1880, page 601. 
 
Chap. III.] Omental Cords. 29 
 
 places.* In any case the omentum from which a 
 band is dorivcul is often found much altered in struc- 
 ture, having become tliin and reticulate. 
 
 One of the most curious modes of forming 
 omental bands is met with in a case described by 
 Dr. K. Fowler. Here the epii)loon was divided into 
 two lateral cords, which, coming off from either side 
 of the transverse colon passcnl down behind or among 
 the intestines, and were found to be united togetlier 
 near the pelvis. All the patient's troubles dated 
 from a kick received upon tlie abdomen. It is 
 probabh; tliat in this case a rent had formed in tlie 
 omentum, through which the great bulk of the small 
 intestines had proti'uded. The lateral jxirts of the 
 omentum, i.e. the parts on either side of the rent, 
 had then shrunken into cord-like masses, which would 
 be more or less hidden by the bowels. Dr. Hilton 
 Fagge has put upon record an almost similar case in 
 his monograph in the Guy's Hospital Keports. 
 
 When once a portion of the epiploon has become 
 adherent the development of the attached part into a 
 ligamentous cord is to be explained by the same 
 process that fashions a broad ribbon-like adhesion into 
 a fibrous thread. The segment of the adherent 
 omentum is continually being dragged upon, espe- 
 cially when attached to a movable viscus ; it tends to 
 become elongated, while the rolling movements of the 
 bowels around it help to mould it into a rounded 
 cord-like ligament. {See page G.) 
 
 As a rule the omental cords are much coarser and 
 thicker than are the bands resulting from peritoneal 
 adhesions. Many are nearly as thick as the finger, 
 while only a few are described as being very fine. In 
 the matter of length they usually have an advantage 
 over the simple band, as may be expected from the 
 dimensions and relations of the great omentum. 
 * Guy's Hosp. Keports, loc. cit. 
 
30 Intestinal Obstruction. [Chap. iii. 
 
 The point of attachment of the epiploic band will 
 obviously depend upon the situation of the peritonitis 
 that renders it adherent. Such adhesion may follow 
 after any form of peritoneal inflammation from which 
 a patient recovers. 
 
 It may be due to a limited peritonitis following 
 injury, as in Mr. Avery's case mentioned above, 
 where the attachment was close to a slit in the 
 mesentery, the result of violence. Pelvic peritonitis 
 may lead to adhesions in and about the pelvis, and 
 from this cause the omentum has been found con- 
 nected with the uterus or the ovaries. In like 
 manner typhlitis has led to attachments to the csecum 
 and to the peritoneum in the iliac fossa. In other 
 and less well defined instances the abnormal attach- 
 ment has been found upon the mesentery and upon 
 the free surface of the small intestine. Undoubtedly, 
 however, the most common cause of omental adhesion is 
 some peritonitis set up about a hernia, and espe- 
 cially about a femoral hernia."* The frequency with 
 which omentum is found in the latter form of rupture 
 is well known, as is also its disposition to become 
 adherent when once so herniated. Thus it happens 
 that the most frequent point for the attachment of an 
 omental band is in the vicinity of the femoral ring. 
 Since the omentum lies more to the left than to the 
 right side of the abdomen, omental hemise are more 
 common upon the left side, and it is therefore 
 about the hernial orifices to the left of the middle line 
 that the omental cords are more usually attached. 
 
 One of the least common aspects of the epiploic 
 cord is shown in a specimen in St. Thomas's Hospital 
 Museum, in which it will be seen that the cord passes 
 merely from one part of the great omentum to 
 another. 
 
 * Portions of omentum attached to umbilical herniae rarely, if 
 ever, form actual cords. 
 
Chap. III.] Meckel^ s Diverticulum. 31 
 
 While, as above stated, only one peritoneal false 
 ligament is usually found in a given instance, the 
 omental adhesions may be met with in the form of 
 two or even more cords. In the case of epiploic 
 adhesions also two cords may Ije found apparently 
 constricting the bowel at different points, and in per- 
 forming laparotomy for the relief of such obstruction 
 the wrong band may be divided. This circumstance 
 happened to Mr. Bryant. He had divided an omental 
 band attached to the left ovary that appeared to be 
 obstructing the gut, but at the autopsy a second cord 
 was found connected with the uterus, beneath which 
 was a coil of ileum tightly strangulated.* 
 
 The modes of strangulation by omental cords are 
 identical with those described in connection with 
 peritoneal bands, although it would appear that the 
 proportion of cases of strangulation by a noose or 
 knot is greater in the former than in the latter class 
 of adhesion. This circumstance is no doubt due to 
 the greater average length, and the greater mobility 
 of the omental false ligament, f 
 
 3. Strangrulation by Meckel's diverticii- 
 lum. — The true or Meckel's diverticulum is due to 
 the persistence or incomplete obliteration of the vitel- 
 line duct. When met with in its most perfect condi- 
 tion it exists as a tube, having a structure similar to 
 that of the small intestine itself, that extends between 
 the lower part of the ileum and the umbilicus. The 
 abdominal end of the tube opens into the lumen of 
 the lesser bowel, while the umbilical extremity may 
 be closed, or may open upon the surface and permit 
 of the discharge of fsecal matter. I have myself met 
 with two cases where such discharge took place. 
 Once in a lad, aged seventeen, who had been troubled 
 since birth with the occasional escape of fseces from a 
 
 * St. Thomas's Hosp. Museum, No. E, 14. 
 t LoMcet, vol. ii., 1873, page 773. 
 
32 Intestinal Obstruction. [Chap. hi. 
 
 sinus at the navel, and once in a male infant a few 
 weeks old, wliere a like condition existed, and upon 
 whom I successfully performed a plastic operation for 
 the closure of the abnormal passage. 
 
 This condition, however, of the diverticle is com- 
 paratively rare. Most commonly it exists as a blind 
 tube coming oft' from the ileum. The length of this 
 tube is on an average three inches, and in the great 
 majority of the examples the measurement extends 
 between one inch and four. Sometimes it exists only 
 as a nipple-like projection.* On the other hand cases 
 are recorded where the diverticle, in the form of a 
 free tube, attained the length of ten inches. As a 
 rule the abnormal tube is cylindrical in shape, with a 
 conical extremity. In nearly every instance the 
 intestinal end of the diverticulum is larger than its 
 opposite extremity. In no case, as far as T am aware, 
 has it been seen to assume a polypoid form, and 
 present a comparatively narrow attachment. In 
 diameter its base is usually less than that of the gut 
 from whence it arises, although sometimes the dia- 
 meters of the two tubes may be nearly identical.! It 
 may retain the same width throughout, and thus 
 resemble a glove finger. Much more frequently, how- 
 ever, its free extremity is considerably narrower 
 than its base. 
 
 In structure the diverticulum is composed of all 
 the layers of normal small intestine. Its mucous 
 membrane is smooth, and possesses Lieberkiihn's 
 follicles. It often presents also a Peyer's patch 
 (Cazin). The muscular coat is sometimes deficient at 
 the apex of the diverticle, and at this spot, therefore, 
 hernial protiusions of the mucous membrane under 
 the serous coat are not infrequently met with. 
 
 * Guy's Hosp. Museum, No. 1,819 (45). 
 
 t For an instance of a very wide diverticulum sec specimen 
 No. 1.819 (50), in Guy's Hosp. Museum. 
 
Chap. III.] Meckel's Djverticulu.u. 33 
 
 When this occurs the extremity of the abnormal tube 
 presents an ampulla of globular shape, and the process 
 is said to be " clubbed." In one dried j)roparation in 
 the London Hospital Museum the ampulla at the end 
 of a diverticulum has so peculiar an outline that the 
 whole process, which is of no great length, looks 
 hammer-shaped. The clubbed extremity of the 
 diverticulum, when it exists, takes an important part 
 in the production of strangulation by knotting. In 
 cases where the diverticulum appears as a compara- 
 tively immense pouch there is little doubt but that 
 the process has been exposed to a considerable degree of 
 distension. Cazin figures a case where a species of valve 
 or diaphragm existed between the diverticulum and the 
 intestine."^ Meckel alludes to a similar arrangement. 
 
 The diverticulum is always single, and arises from 
 the ileum from one to three feet above the ileo-ca3cal 
 valve. It is extremely rare for the process to take 
 origin beyond these limits. Cazin, however, alludes 
 to a case where it is said to have arisen from the 
 ileum, twenty lines from the cascum. In a specimen 
 in Guy's Hospital Museum f the process is described as 
 springing from the middle of the ileum. 
 
 The process may come off at an acute angle with 
 the long axis of the bowel, but more usually the 
 angle formed is a right angle. 
 
 It is sometimes provided with a scanty mesentery, 
 as is shown in a drawing by Sandifort. 
 
 The end of the diverticulum is, in the majority of 
 cases, free. Very often, however, it is continued in 
 the form of a solid cord. This cord should be 
 attached to the umbilicus or to the abdominal parietes 
 immediately below that cicatrix. | This attachment 
 
 * Etude sur les Diverticules de I'lntestin. Paris, 1862. 
 t No. 1,819 (50). 
 
 + St. Bart.'s Hosp. Museum, No. 2,168, and many other speci- 
 mens. 
 
 D— 12 
 
34 Intestinal Obstruction. [Chap. hi. 
 
 is, indeed, very frequently met with. Often tlie cord 
 is pervious for a little way, and presents a minute 
 canal into which a bristle may be inserted. This 
 diverticular ligament may break from its attachment 
 to the parietes and may float free within the ab- 
 dominal cavity. Under such circumstances, however, 
 it is much more usual for it to acquire fresh adhesions 
 to some point of the peritoneal surface. 
 
 These secondary adhesions of a free diverticulum, 
 or of a diverticular cord at the extremity of one of 
 the processes, are of considerable importance in the 
 etiology of strangulation of the intestine. It is by 
 the diverticulum that has acquired a fresh point of 
 attachment that constriction of the bowel is most 
 often effected. It is, in the great majority of cases, 
 to the mesentery that the tube or the cord continued 
 from it is adherent."^ This adhesion may be found 
 on a portion of the mesentery above the origin of the 
 diverticulum, but somewhat more frequently it is on 
 the mesentery of tlie ileum between the point of origin 
 of the process and the caecum. 
 
 The loop formed by such an adhesion presents the 
 greatest possible variety. When the diverticulum is 
 very small and short, the ring that it forms is quite 
 insignificant, and incapable of engaging more than a 
 slight portion of the intestine. f When, however, the 
 
 * In twenty-three cases collected by Cazin the points of 
 attachment of the diverticulum were as follows • 
 
 To colon 1 
 
 To mesentery ... ... 10 
 
 23 
 
 Near umbilicus ... ... 3 
 
 Near inguinal ring ... ... 1 
 
 To small gut G 
 
 To caecum ... ... ... 2 
 
 In nineteen additional cases collected by myself the attach 
 ments were as follows : 
 
 Near umbilicus ... ... 7 
 
 To femoral rin^ ... ... 1 
 
 To small gut 3 
 
 To caecum 1 
 
 t Guy's Hosp. Museum, No. 1,819 (36) 
 
 To mesentery ... ... 7 
 
 19 
 
Chap. III.] Meckel's Diverticulum. 35 
 
 process is long, and especially when it ends in an 
 elongated cord or ligament, a loop of considerable size 
 may be formed, and nooses and knots may be developed 
 capable of snaring many coils of the bowel.* 
 
 In other cases the diverticle or diverticular cord 
 is attached to some other part of the small intestine 
 or to the omentum, or to some point on the ab- 
 dominal parietes other than the immediate vicinity 
 of the umbilicus. In many instances it is evident 
 that the site of the adhesion has been influenced by 
 some definite form of localised peritonitis. Thus the 
 extremity of the diverticulum has been found 
 attached to the pelvic viscera or pelvic parietes after 
 peritoneal inflammation in that region, to the caecum 
 or peritoneum about the right iliac fossa after typh- 
 litis, and to the vicinity of the femoral and inguinal 
 canals after hernia. In some specimens the peri- 
 tonitis causing the adhesion has evidently been set 
 up by mesenteric gland inflammation. 
 
 In another series of cases the diverticulum does 
 not exist as such, but is replaced in its entire length 
 by a fibrous cord identical in aspect with the band 
 so often seen attached to the apex of the tubular pro- 
 cess. These cords may be found to extend between 
 the parietes in the vicinity of the umbilicus and 
 that part of the ileum from which the more familiar 
 diverticle takes origin. They may be considered to 
 represent an entirely obliterated diverticulum, or may 
 be the remains of persisting omphalo-mesenteric 
 vessels.! A case belonging to the latter category 
 has been placed on record by I)r. Mahomed. In this 
 instance a fibrous band extended from tbe middle of 
 the anterior abdominal wall (midway between the pubes 
 and the umbilicus) to the right iliac fossa. The 
 
 *Patli. Soc. Traus., vol. xxi., page 185. 
 
 ^ See an exhaustive paper on Persistent Omphalo-Mes. Ra 
 mains, by Dr. Fitz ; Amer. J. of Med. Sc, July, 1884. 
 
36 Intestinal Obstruction. [Chap. hi. 
 
 deeper extremity of the cord had snared in a noose 
 a large portion of ileum. It then attached itself to 
 the mesentery, some three feet from the ileo-csecal 
 valve, and was found to be continuous with a branch 
 of the ileo-colic artery. The more superficial ex- 
 tremity of the band divided, one part ascending to 
 the navel with the obliterated hypogastric artery, the 
 other descending to form the left superior vesical 
 artery. The cord was quite impervious to injection.* 
 
 These diverticular ligaments may break loose from 
 their connections at the umbilicus, and may, like the 
 tubular processes, either remain free in the abdominal 
 cavity, or form secondary adhesions at almost any spot. 
 
 To still further complicate this matter, the cord 
 may retain its attachment to the anterior abdominal 
 wall, and separate from its connection with the intestine. 
 It may then either form no other attachment, or may 
 adhere to a point somewhere within the abdomen, f 
 
 Finally, a cord may be found to stretch from the 
 root of the mesentery to be attached to the margin 
 of the ileum (close to its mesentery) opposite the 
 spot from which the diverticle most commonly arises. 
 Leichtenstem believes that such bands rejiresent that 
 part of tho omphalo-mesenteric vessels that extends 
 between the bowel and the main blood-vessels at the 
 root of the mesentery. He gives a figure to show the 
 continuation of this band with an ordinary diverticu- 
 lum which is attached by a cord to the umbilicus. A 
 false ligament described by Dr. David King may 
 possibly have been of this nature. This band, which 
 was an eighth of an inch in diameter, passed from 
 the upper part of the root of the mesentery to a point 
 on the small intestine. Beneath it a piece of bowel 
 liad become strangulated, t 
 
 * Path. Soc. Trans., vol. xxvi., page 47. 
 
 t Spangenberg, Arch. f. Phys. v., Sleckel, b. v., s. 87. 
 
 + St. Bart.'s Hosp. Reports, vol. xvii., 1881, page 277. 
 
Chap. Ill] Meckei^s Diverticulum. 37 
 
 Tliere can be little doubt but that these strangely 
 attached diverticular ligaments have often been 
 mistaken for isolated peritoneal adhesions ; and, in 
 any case, where a " solitary band " exists without a 
 trace of ancient peritonitis, there are some prima- 
 facie grounds for suspecting the cord to be of con- 
 genital origin. 
 
 The diverticulum, as already stated, is always 
 single. The same remark applies, with but few 
 exceptions, to the diverticular ligaments. In a few 
 instances the cord seems to have divided, so that an 
 appearance as of two bands has been produced. Such 
 is apparently the case in a specimen in one of the 
 museums,* in which one ligament encircles a loop of 
 bowel and strangulates it, while the other goes to be 
 attached to the vicinity of the femoral ring. 
 
 It may be here mentioned that a free true diver- 
 ticulum has in several instances been found in an 
 external hernia. One of the earliest cases of this 
 kind is described by Littre. f In this case a diverticle 
 four inches in length was found in a scrotal hernia 
 in a man aged 48. It is evident that Littre was 
 unaware of the nature of the intestinal pouch. | 
 Cazin gives a drawing to show a Meckel's diverticu- 
 lum in a scrotal hernia from a case dissected by 
 himself § 
 
 Methods of 'producing strangulation. — 1. A coil of 
 small intestine may be strangulated beneath an 
 adherent diverticulum precisely in the same manner 
 as it would be when beneath a peritoneal adhesion. 
 
 * St. Bart.'s Hosp. Museum, No. 2,173. 
 
 t Mem. de I'Acad. dee Sciences, 1700, page 300, ''Observat. 
 sur una nouvelle Espece de Hernie. " 
 
 + A full account of the relation of the diverticulum to hernia 
 will be found in " Du Pincement Herniare de I'lntestin," by M. 
 Loviot. Paris, 1879. 
 
 § Loc. cit., Fig. 14. See also case by Busch, Central, fiir 
 Chirurg., 1884, No. 23, page 69. 
 
38 Intestinal Obstruction. [Chap. in. 
 
 An illustration of this mode of constricting the bowel 
 is shown in Fig. 10, from a case reported by M. 
 Rayer.^ It is scarcely possible to conceive that this 
 method of producing obstruction can occur when the 
 diverticulum simply extends between the ileum and 
 the anterior abdominal wall. 
 
 fYet several cases are recorded 
 ^ where the diverticulum ha,d these 
 attachments, and where it is 
 vaguely stated that beneath the 
 process some bowel was strangu- 
 lated. In the absence of clearer 
 evidence these cases must be 
 accepted with some little doubt. 
 '^'^W'an adt'^DWez- Certainly, in nearly all reported 
 tide. (Kayer.) instances of Strangulation under 
 
 "'"end'oTgiuf^^J'ionrrf'; ^ diverticulum, the process has 
 stonguiatud'ioop.^' ^^"^ been adherent to a point other 
 than the vicinity of the um- 
 bilicus. When the adhesion is to the mesentery, 
 as is so frequently the case, it will be readily under- 
 stood that beneath the arcade so formed a loop of 
 intestine may be with great ease engaged and com- 
 pressed. This condition of the parts is often met 
 with. 
 
 2. A diverticular ligament, whetlier attached to 
 the extremity of a pouch-like process, or (in the 
 absence of such process) connected directly with the 
 gut, may form precisely the same kinds of noose and 
 knot as are formed by isolated adhesions. The length 
 and looseness of the congenital ligament render it well 
 able to snare the bowel, provided that the position 
 and circumstances of the bowel render it capable of 
 being snared. 
 
 The strangulation of a loop of intestine by the 
 simple noose or spiral, depicted on page 24, would 
 * Archiv. Gen , do Med. , tome v. , page 68. 
 
Chap. III.] 
 
 Meckel^ s Diver tic ul um. 
 
 39 
 
 appear to be fairly common in the case of diverticular 
 cords. The numerous specimens found in museums, 
 where these cords are seen to have made one and a 
 half or two turns round the involved bowel, are 
 
 Fig. 11.— Strangulation by Meckel's Diverticulum. 
 
 a, point of origin of diverticle. The distal end is attached to the mesentery. The 
 
 loop involved measured 12 inches. 
 
 probably of this character. An example of this 
 variety of strangulation in its simplest form is 
 depicted in Fig. 11."^ In some instances the band 
 will be seen to have passed twice round the bowel at 
 the point of constriction.! Iii other specimens one 
 
 * Lond. Hosp. Museum, No. Ag. 2. 
 
 t For specimens see St. Bart.'s Hosp. Museum, No. 2,172, and 
 University Coll. Museum, No. 1,167. 
 
40 Intestinal Csstruction. [Chap. hi. 
 
 and a half turns are made. A reference to the 
 drawing taken from Sir Astley Cooper's work 
 (Fig. G), will show the manner whereby the gut is 
 snared in these nooses, and will also explain how in 
 constriction by a simple spiral an appearance is pro- 
 duced as of a cord passing one and a half or two 
 times round the bowel. Very often the strangulation 
 by a noose is a little more complicated. In a case 
 reported by Dr. Bristowe, * the spiral, although 
 simple in itself, was yet so arranged around the 
 intestinal coils as to compress them in four different 
 places. In a case recorded by Moscati,t the diver- 
 ticular band formed a definite figure of 8 loop in 
 which the intestinal coils were so involved as to be 
 constricted in three places. What mechanism is 
 involved in producing these extraordinary forms of 
 obstruction, and what movements of the bowel and 
 what arrangement of the band are requisite, must be 
 at present a matter of pure speculation. 
 
 The relative frequency of the two forms of 
 strangulation already described, viz. under the band 
 and by the noose or knot, is represented by Leichten- 
 stern, by the figures 40 and 14 in a total of 54 cases. 
 These figures are a little difficult to understand, if 
 taken in connection with the experience gained by an 
 examination of all the specimens to be found in the 
 various museums of London. These specimens cer- 
 tainly appear to show that strangulation by snaring 
 is by no means uncommon, and that this form of ob- 
 struction does not bear to the constrictions under the 
 band so wide a proportion as 1 to 4. If one could 
 judge from an inspection of museum specimens only, it 
 would seem that stranijulation under the diverticular 
 band is only about twice as frequent as is the more 
 comj)licated method of obstruction. According to 
 
 * Path. Soc. Trans., vol. xxi., page 185. 
 
 t Mem. de I'Acad. de Chiiurg., tome iii., page 468. 
 
Chap. III.] Meckel's Diverticulum. 41 
 
 Leichtens tern's figures, strangulation by the noose is 
 relatively more frequent in the case of the peritoneal 
 adhesion than it is in the case of the congenital band. 
 This fact also is in direct opposition to the conclusions 
 derived from the museum sj)ecimens, and I am strongly 
 inclined to believe that obstruction by snaring is 
 relatively more frequent when the diverticulum is 
 concerned than when the trouble is brought about by 
 the false ligament. This latter conclusion is one that 
 would be anticipated if the gi*eater average length and 
 the greater mobility of the diverticular ligament be 
 borne in mind. 
 
 3. Strangulation hy knots formed hy a free diver- 
 ticulum. — These remarkable knots and the methods 
 of their formation have been very exhaustively studied 
 by M. Parise.* To produce these knots it is neces- 
 sary that the diverticulum should be of good length, 
 should be quite free (save only for its intestinal 
 attachment), and should possess an ampulla at its 
 extremity. The importance of the ampulla is para- 
 mount, and French writers are in the habit of speaking 
 of it as la clef de Vetranglement. Three varieties 
 of knot may be described : 
 
 a. The diverticle forms a ring into which its own 
 free end projects (Fig. 12). A loop of intestine 
 entering the centre of that ring will 
 push the clubbed end of the process 
 before it and so tie the knot by which 
 the coil becomes obstructed. 
 
 h. The diverticulum surrounds the 
 pedicle of an intestinal loop in such a 
 way as to encii'cle it with a simple knot. 
 The mode of formation of the noose is Fig. 12. 
 
 shown in Fig. 13, Of this variety 
 M. E,egnault gave many years ago an excellent 
 example. The diverticle was in this case six inches in 
 *Bull. cle I'Acad. de Med., tome xvi., page 373k 
 
42 
 
 Intestinal Obstruction. [Chap. in. 
 
 length, and by its means one and a half feet of 
 intestine were strangulated. 
 
 c. In this form two loops of the bowel are involved 
 (Fig. 14), one above, a, and the other below, 6, 
 the origin of the diverticulum, d. One of the loops 
 
 Fig. 13.— One mode of Strangulation by the Diverticulum. (Kegnault- 
 
 B^clard.) 
 
 fl, origin of diverticle ; 6, its clubbed extremity. 
 
 enters the knot by a preliminary rotation (" anse 
 rotatoire "), e, the other, is noosed by the diver- 
 ticulum, as in the simple knot (" anse nodale ") c. 
 There appears to have been only one case recorded of 
 this species of knot.* The commonest form of knot 
 is undoubtedly the second of the three now given. 
 
 Diverticula and diverticular ligaments may lead to 
 other forms of obstruction which do not, however, 
 
 * " Observat. d'une nouvelle Forme d'Etrang. dite par Noeud 
 iutestinab" by Dr. M. Levy ; Gazette Medicale, 1845, page 129. 
 
Chap. III.] Meckel's Diverticulum. 43 
 
 come under the present category. These forms may 
 be enumerated here for the sake of completeness, and 
 will be dealt with in detail in subsequent paragraphs. 
 4. Strangulation over a divei'ticular hand. — In this 
 form a loop of intestine is thrown over a tightly drawn 
 diverticular band as a shawl is 
 thrown over the arm. Under 
 certain conditions, which need 
 not be here detailed, an obstruc- 
 tion follows in the bowel so 
 displaced. The occlusion is some- 
 what similar to that that would 
 take place in a coil of thin india- 
 rubber tubing, if thrown across a a 
 tense wire cord and allowed to Fig. 14. — strangi^lation 
 
 ■ITT, by tlie Diverticulum 
 
 become dependent. ^ \,y a double Kuot. 
 
 6. Strangulation hy kinking. 
 — If, under certain circumstances, much traction be 
 brought to bear on a diverticular ligament, the gut, 
 without undergoing any structural alteration, may 
 l)ecome so acutely bent at the point of origin of the 
 abnormal band or process as to be occluded. It has 
 been shown also that a free diverticulum, when of good 
 size, and coming off at about a right angle with the 
 bowel, may cause such bending of the bowel, when 
 the pouch is much distended, as to cause obstruc- 
 tion. 
 
 6. Strangulation hy the effects of traction. — In 
 these cases the bowel at the point of origin of the 
 diverticle undergoes certain gross structural changes 
 which may, in time, bring about intestinal obstruction. 
 There is evidence to show that these changes result 
 from long continued traction upon the bowel, brought 
 about by means of an adherent diverticular process. 
 
 It may be noted that foreign bodies that have been 
 swallowed, and intestinal concretions of various kinds, 
 may lodge within the pouch-like diverticula, and excite 
 
44 Intestinal Obstruction. [Chap, in, 
 
 in them ai\ inflammation of like character and like 
 tendencies to that set up in the vermiform appendix 
 by identical substances. 
 
 One effect of the true diverticulum in producing 
 intestinal obstruction is illustrated by a specimen in 
 Guy's Hospital Museum, that is, so far as I am 
 aware, unique. In this case a short finger-like 
 diverticulum had become inverted, had projected into 
 the lumen of the intestine and had led to the forma- 
 tion of an intussusception."^ 
 
 In order of frequency the various methods of 
 producing obstruction by the diverticulum may bo 
 arranged as follows : (1) By strangulation under the 
 diverticulum'; (2) by loops or nooses; (3) by diverticular 
 knots. Ijeiclitenstern's figures for these three varieties 
 are 40. 1 4, and 1 2. Strangulation over a band or by 
 kinking, and obstruction from the effects of long- 
 continued traction, are all comparatively rare. 
 
 False diverticula. — It will be convenient to 
 take note here of certain acquired diverticula that 
 may. under some circumstances, be possibly confused 
 with the congenital variety. 
 
 In all essential points, in structure, in position, 
 and in nimiber, these diverticula differ entirely from 
 Meckel's process. 
 
 They are simply hernial protrusions of the mucous 
 membrane of the bowel through the muscular coat, 
 and hence the common name " distension diverticula." 
 In structure they are composed simply of mucous 
 membrane and peritoneum. They present in their 
 walls no muscular fibres. The lining mucous mem- 
 brane in the smaller pouches is quite normal, but in 
 the larger diverticula that membrane becomes atro- 
 phied and its glandular structures tend to disappear. 
 They may be met with in any part of the bowel, but 
 are somewhat more often found in the large than in 
 * Guy's Hosp. Museum, No. 1,819 (45). 
 
Chap. III.] False Dij'erticula. 45 
 
 the small intestine. They have been seen in the 
 duodenum, are comparatively common in the jejunum, 
 and are encountered with still greater frequency in 
 the ileum. They may appear in any part of the 
 colon, but are most common in the sigmoid flexure 
 and rectum. 
 
 In the matter of numbers they show the greatest 
 variety, and are far more frequently multiple than 
 smgle. The chief examples of midtiple diverticula 
 are met with in the large intestine. Alibert couuted 
 two hundred in one colon. In the museum of St. 
 Thomas's Hospital is a sigmoid flexure, the whole 
 surface of which is studded with a multitude of little 
 hernial pouches, varying in size from a pin's head to a 
 marble. Pig. 15, from Sir Astley Cooper's work on 
 hernia, shows a jejunum, along the mesenteric border 
 of which distension diverticula 
 are crowded almost as closely as 
 they can lie. 
 
 The chief examples of single 
 pouches are met with in the 
 lesser bowel. Thus Dr. Bristowe 
 has reported an instance of a 
 single diverticulum no larger than j^io. 15^ 
 
 a horse-bean, situated in the ileum 
 
 just above the ileo-caecal valve."^ In other cases only 
 two pouches were found in the small intestine, as in 
 an instance noted by Dr. Hilton Fagge, where the 
 abnormal sacs were both in the jejunum. f 
 
 In size, the false diverticulum may also show any 
 dimensions between that of a pin's head and that of a 
 large apple. In sha]>e they are usually globular, 
 especially when small. | When of larger size they 
 may become lobulated, as is the case with one of the 
 
 *Path. Soc Trans., vol. vi., page 191. 
 
 t Ibid. , vol. xxvii. , page 147. 
 
 j Guy's Hosp. Museum, No. 1,819 (69). 
 
46 Intestinal Obstruction. [Chap. in. 
 
 Fig. 16.— False Diverticula. 
 
Chap. III.] False Diverticula, 47 
 
 diverticula shown in Fig. 16.* It is extremely rare 
 for them to assume the conical shape or finger-] ike 
 outline so commonly met with in Meckel's diverticula. 
 They are usually narrower at the attached extremity 
 than at the fundus, and are apt, when of good size, to 
 assume a polypoid outline. 
 
 As regards the relation of these hernial pouches to 
 the intestinal wall, it will be found that in the lesser 
 bowel they invariably appear along the mesenteric 
 border of the gut, and force their way, as they en- 
 large, between the two layers of the mesentery. In 
 the colon they are usually met with on those parts of 
 the intestine to which the appendices epiploicae are 
 attached, and into the substance of these appendages 
 the pouch will, as a rule, be found to have projected. 
 This relation of the diverticulum to the appendices 
 was admirably shown in the case reported by Dr. 
 Bristowe. 
 
 It is probable that all these pouches are due to 
 distension, and may be regarded as hernise of the 
 mucous membrane through the muscular coat. They 
 occur, with but few exceptions, in old people ; and 
 those of the colon are usually associated with a his- 
 tory of chronic constipation. In the small intestine, 
 also, the diverticula are as a rule attended with con- 
 ditions bringing about great distension of the bowel. 
 In Sir Astley Cooper's case the pouches were in the 
 jejunum, while in the ileum was an obstruction of 
 slio-ht character, that had no doiibt encouragfed a Ions:- 
 continued distension of the intestine. In several 
 other instances the protrusions were met with in 
 patients who had sufiered from hernia, the diverticula 
 being situated in a part of the bowel above that in- 
 volved in the rupture. Of the exact pathology of 
 these little pouches it must be confessed that very 
 little is known. If they are due to distension it is 
 * Coll. of Surgeons Museum, No. 1,177. 
 
48 Intestinal Obstruction. [Chap. hi. 
 
 difficult to understand why they are not met with 
 more frequently in cases of acute and chronic intes- 
 tinal obstruction. In such cases they are indeed, 
 with the exceptions above named, practically un- 
 known. The formation of one diverticulum as a 
 result of localised distension is not difficult to under- 
 stand, but in those cases in which several continuous 
 feet of the bowel present these pouches, conditions are 
 involved that have certainly not yet been interpreted. 
 Over and over again the gut is found at an autopsy 
 enormously distended, sometimes in its entire length, 
 sometimes in a limited segment, and yet no diver- 
 ticula are present, although the distension may have 
 been so extreme as to rupture the serous coat. 
 
 I have only been able to find one reported case of 
 a false diverticulum in a child. The case ^ reported 
 by Dr. Piatt, "^ and presents some extraordinary 
 features. The patient was a little girl aged nine. 
 The autopsy showed that she had a stricture of the 
 small intestine, due probably to the contraction of a 
 tubercular ulcer. This stricture had become plugged 
 by a hard faecal mass, and the child presented the 
 symptoms of acute obstruction. On examination by 
 the rectum a soft elastic tumour was felt pressing 
 upon the anterior wall of the bowel. At its lower 
 extremity was an orifice like an os uteri, into which 
 the finger could be introduced. This was supposed to 
 be the orifice of an invaginated piece of bowel, and 
 the case was presumed to be one of intussusception. 
 The autopsy showed that there was no invagination 
 of any part of the gut, and the tumour proved to be 
 a false diverticulum of the rectum, into the orifice of 
 which the finger had been introdiiced in the rectal 
 examination. 
 
 In no case, I believe, has the distension diverticu- 
 lum caused an intestinal obstruction. A specimen in 
 * Lancet, vol. i., 1873, page 42. 
 
Chap. III.] False Diverticula. 49 
 
 the Guy's Hospital Museum* shows an intussuscep- 
 tion in the immediate vicinity of such a pouch, and 
 from the condition of the parts there is every reason 
 to believe that the diverticulum was antecedent to 
 the obstruction. The connection, however, between 
 the two might have been purely accidental. 
 
 These pouches, and especially those of the colon, 
 are apt to lodge little faecal masses and foreign 
 matters of various kinds. Inflammation of the pouch 
 may be induced by such lodgment, and peritonitis 
 from perforation result, just as occurs in the appendix 
 vermiformis. Notice has already been drawn to the 
 fact that the colic diverticula are apt to project into 
 appendices epiploicae ; and it is quite probable that in 
 those cases where such an appendix has caused an 
 isolated adhesion a pouch might have formed in the 
 appendage, have lodged a foreign substance of some 
 kind, and have been, in consequence, the seat of a limited 
 peritonitis. Thus, Mr. Hulke records a case where an 
 epiploic appendage was adherent to the pelvic perito- 
 neum near the right sciatic notch. Beneath the 
 arcade so formed a loop of bowel had been strangu- 
 lated. The appendix was on the sigmoid flexure, 
 which extended in an angular loop across the pelvis. f 
 In a specimen in the College of Surgeons Museum it 
 will be seen that an appendix has become adherent to 
 the omentum in such a way as to cause stenosis of 
 the part of the colon from which it arose. In this 
 case tlie comparatively large size of the involved 
 appendix is conspicuous. | 
 
 I have found two cases on record where a false 
 diverticulum in the sigmoid flexure communicated 
 witli the interior of the bladder by an ulcerated open- 
 ing. Here also it is probable that inflammation was 
 
 * Guy's Hosp. Museum, No. 1,849 (10). 
 
 "^ Medical Times and Gazette, vol. iL, 1872, page 482. 
 
 + O0II. of Surgeons Museum, No. 1,362. 
 
 E— 12 
 
5© Intestinal Obstruction. [Chap. hi. 
 
 excited in the pouch by the lodgment of a fsecal 
 mass ; by the peritonitis set up the process became 
 adherent to the bladder, and by the extension of 
 ulceration from the diverticulum the bladder was 
 perforated. * One of the patients passed faecal matter 
 by the urethra, while the other f seems to have been 
 more troubled by the escape of urine into the rectum. 
 
 4. Strangrulatioii by normal structures 
 abnormally attached. 
 
 A. The vermiform appendix may become adherent 
 to some point on the neighbouring peritoneum, and so 
 form a band or arch beneath which a loop of intestine 
 may be strangulated. The process is very commonly 
 adherent to the mesentery of the lower ileum. J Less 
 frequently it is adherent to the ileum itself,§ or to 
 the caecum, or to the peritoneum about bhe right iliac 
 fossa and margin of the pelvis. In one instance, 
 reported by Sir Risdon Bennet, the appendix was 
 adherent to an enlarged ovary on the right side, and 
 beneath the cord so formed a loop of the ileum and a 
 part of the ascending colon were constricted. || 
 
 In some rare cases the appendix has been 
 described as wound in the form of a close spiral, or 
 of a ring into which a loop of intestine has entered 
 and has become strangulated. In other instances, 
 equally uncommon, the appendix is said to have tied 
 itself into an actual knot of a character similar to 
 those sometimes formed by the true diverticulum. 
 By such a knot the bowel has been constricted. 
 
 It must be confessed that this last-mentioned 
 form of obstruction is a little difficult to credit. The 
 
 ♦Path. Soc. Trans., vol. x., page 131 ; Mr. Sydney Jones. 
 
 + Ibid. , vol. X. , page 208 ; Mr. Charles Hawkins. 
 
 t Guy's Hosp. Museum, No. 2,508 (50). 
 
 % See a good case by Mr. Gay; Path. Soc. Trans., vol. iii., 
 page 101. 
 
 II Path. Soc. Trans., vol. iv., page 146. The specimen is now 
 in St. Thomas's Hosp. Museum, No. R 17. 
 
Chap. III.] Fixed Mesentery. 5.1 
 
 average length of the appendix is three inches. It is 
 often four or five inches, and has been found to reach 
 and even exceed the length of eight inches. 
 
 B. In several instances the Fallopian tube has be- 
 come adherent to some part of the neighbouring 
 peritoneum, to that, for example, lining one of the 
 iliac fossae, and beneath the arcade so formed a portion 
 of the small intestine has been strangulated.* 
 
 0. A few cases are reported where a loop of 
 bowel has been strangulated beneath a band formed 
 by a fixed portion of the 'mesentery. In these ex- 
 amples some coils of the small intestine become fixed 
 at a distant spot. They may be involved in a large 
 irreducible hernia, or may have hung down into the 
 pelvis, and acquired adhesions when in that position. 
 Under such circumstances the corresponding part of 
 the mesentery may become tightly stretched across 
 the posterior wall of the abdomen or the pelvic brira, 
 and a bridge be thus formed beneath which some of 
 the lesser bowel may become strangulated, f Du- 
 chaussoy appears to be of opinion, that when a large 
 coil of the ileum simply hangs down into the pelvis, 
 the arch then formed by the mesentery may be of 
 such a character that intestine can be obstructed 
 beneath it. Such a circumstance, however, must be 
 extremely exceptional, in the absence of any adhesions 
 holding the dependent bowel in place. In cases of 
 acute obstruction it is common enough to find all the 
 coils of small intestine below the point of strangula- 
 tion hanging in a bunch empty and collapsed into the 
 pelvis. If we except these cases, however, there 
 must be very few conditions met with where large 
 
 *For cases see Bull. Soc. Anat, de Paris, 1841, page 209, by 
 M. Gaubric ; and Archiv. Gen. de Med., 1829, by M. Rostun. 
 
 ^ See case by Dr. Hilton Fagge (Guy's Hosp. Reports, vol. 
 xiv,), where the Heiim was adherent to a tumour formed by an 
 extra uterine fcetation, while beneath its tensely drawn mesentery 
 some jejunum was strangulated. 
 
52 Intestinal Obstruction. [Chap. hi. 
 
 coils of the bowel hang listlessly in the pelvis, and 
 so form from the mesentery a band sufficiently long 
 abiding to allow gut to be compressed beneath it. 
 When such dependent coils are fixed or adherent the 
 mechanism of the obstruction is quite intelligible. 
 
 D. To the bands formed by adherent appendices 
 epiploicce allusion has already been made (page 49). 
 
 E. Dr. Hilton Fagge has recorded the case of a 
 woman aged seventy-four, who died vdth symptoms 
 of acute intestinal obstruction that had lasted for six 
 days. The autopsy revealed a portion of the ileum 
 strangulated by the pedicle of a large ovarian cyst. 
 On moving the tumour a little the obstructed bowel 
 was easily reduced.* 
 
 5. StrangnlatJon throug'h slits and aper- 
 tures. 
 
 A. Slits and apertures in the mesentery. — Through 
 holes formed in this membrane portions of intestine have 
 frequently been strangulated. The holes are usually 
 slit-like, and are most common in the mesentery of the 
 lower ileum. In other parts they are rare. In many 
 cases these slits can be more or less distinctly traced 
 to an injury, and several specimens in the museums of 
 London show that a limited rent of the mesentery 
 may be the only visible lesion after violence applied 
 to the abdomen. In other cases there is every reason 
 to believe that the abnormal aperture is congenital. 
 The edges in such instances are smooth, rounded, and 
 regular ; there is no history of injury and no trace of 
 any previous peritonitis. In one case the upper 
 margin of the slit appieared as a dense and distinct 
 band containing in its substance a large branch from 
 the superior mesenteric artery, f 
 
 The hole is usually situated near to the intestine. 
 
 * Guy's Hosp. Eeports, vol. xiv. 
 
 t Contrib. a I'fitude de I'Occlusion Intest., by M. Le Moyne. 
 Paris, 1878. 
 
Chap. III.] Omental Apertures. 53 
 
 In size it shows great variation. It may be no larger 
 than a sixpenny piece,"^ or it may be extensive enough 
 to admit four fingers, f In the last-mentioned in- 
 stance the portion of bowel involved was the sigmoid 
 flexure, and so far as I can ascertain this is the only 
 case on record where colon has found its way into 
 the slit. Mr. Partridge has recorded a case, which 
 is probably unique, of strangulation of a knuckle 
 of ileum through an aperture in the mesentery of 
 the vermiform appendix. \ In a few instances 
 the strangulation has occurred through slits in the 
 transverse and descending meso-colon. 
 
 B. Slits and apertures in the omentum. — An 
 example of this form of obstruction is shown in 
 Fig. 17. § These slits may be due to congenital 
 defect, but in many instances they can be distinctly 
 traced to an injury. M. Le Fort reports the case of a 
 young man who developed symptoms of intestinal 
 obstruction some little while after having received a 
 kick on the abdomen from a horse. The autopsy 
 showed two hernise of portions of the small intestine 
 through two slits in the great omentum. || In speaking 
 of omental bands allusion has already been made to 
 the circumstance that as a result of violence a mass 
 of intestines may protrude through an immense rent 
 in the omentum, and the two divisions of the 
 membrane thus formed may develop into omental 
 bands. 
 
 C Less common forms of slit. — Mr. Holmes has 
 placed on record a remarkable case, where a loop of 
 
 *Dr. Leared ; Path. Soc. Trans., vol. xiv., page 156. 
 
 + M. Tr^lat ; Bull, et Mem. de la Soc. de CMr. de Paris, 
 tome vi , 1880, page 594. 
 
 tPath. Soc. Trans., vol. xii., page 110. 
 
 §University Coll. Museum, No. 1,161. See also specimen in 
 St. Bai-t.'s Hosp. Museum, No. 2,177. 
 
 II Bull, et Mem. de la Soc. de Chir. de Paris, tome v., 1869, 
 page 635. 
 
54 
 
 InTES TINA L ObS TR UC TION, 
 
 [Chap. III. 
 
 the lower ileum was strangulated througli a hole 
 apparently formed in an appendix epiploica. The 
 appendix in question was attached to the sigmoid 
 flexure and formed a fatty fibrous ring through which 
 the loop had passed. There were several large and 
 
 Fig. 17. — Strangulation of small Intestine tLrough a Hole in the Great 
 
 Omentum. 
 
 broad appendices upon the same segment of the colon, 
 some of which were perforated near their bases, as if 
 they also were capable of developing into rings.* It 
 may be that the appearance of a ring had been 
 brought about by two adjacent appendices becoming 
 adherent at their extremities. Dr. Quain describes 
 
 * Path. See. Trans., vol. xii., page 3. 
 
Chap. III.] Sl/ts and Aperturrs. 55 
 
 an autopsy where forty inches of the ileum wen^ 
 found to have passed through a slit in the broad 
 ligament of the uterus. In this case, however, the 
 gut was also held down by a band of old adhesions.* 
 Barth reports a case of strangulation of the intestine 
 in a slit in the suspensory ligament of the liver, f 
 The small intestine has not infrequently been found 
 to have passed through the foramen of Winslow, and 
 Leichtenstern has collected three cases where the gut 
 so placed became strangulated by the margins of the 
 aperture. 
 
 In by no means a few instances a coil of intestine 
 has been contracted by passing through a slit formed 
 in a broad membranous adhesion. In other cases the 
 bowel has protruded between two cord-like adhesions 
 placed close together and parallel with one another. 
 Mr. Hutchinson mentions an instance where the slit 
 was formed between a false ligament and the edge of 
 the broad ligament of the uterus, by the side of which 
 the adhesion ran. \ In some cases rings and slits 
 have been formed between intestinal loops that have 
 become matted together, and through these apertures 
 a non-adherent coil has passed and become constricted. 
 In one case, briefly mentioned by Sir Astley Cooper, 
 it was found that " two folds of intestine had adhered 
 at one point only (as may be represented by bringing 
 the points of the thumb and finger in contact) ; through 
 the noose thus formed, another fold of intestine was 
 passed and had become strangulated." § The occa- 
 sional gaps and slits that may be formed between 
 adherent intestines, and the viscus or parietes to which 
 they are attached, may serve as holes through which a 
 coil of bowel may pass and be constricted. 
 
 *Patli. Soc. Trans., vol. xii., page 103. 
 t Schmidt's Jalirb., b. 96, s. 207. 
 % Med. Times and Gazette, 1858. 
 § Abdominal Hernia, chap. xxs.v. 
 
56 Intestinal Obstruction. [Chap. hi. 
 
 Into the complicated subject of internal hernise 
 there is no occasion to enter in this work. Of the 
 numerous varieties described, one only is at all 
 common, the diaphragmatic form ; and diaphragmatic 
 hernia, it must be owned, has little to do either 
 clinically or pathologically with intestinal obstruction. 
 
 Of the other varieties, such as the hernia meso- 
 colica, the hernia intrailiaca, the hernia intersigmoidea, 
 and the like, it need only be said that they are very 
 rare, that they become the seat of a strangulation 
 still more rarely, and that whether strangulated or 
 not strangulated, they cannot be diagnosed during life. 
 Should the portion of intestine that they contain 
 become constricted, the symptoms induced would be 
 similar to those of strangulation under a band, while 
 the treatment of the two cases would be practically 
 identical. 
 
 RELATIVE FREQUENCY OF THE VARIOUS FORMS OF 
 STRANGULATION DEPENDING UPON BANDS, APER- 
 TURES, ETC. 
 
 The seven most common forms met with under 
 this heading may be arranged in the following order 
 of frequency : 
 
 1. Strangulation under isolated peritoneal adhesions = 60 
 
 2. Strangulation under diverticula and diverticular bands =1 40 
 
 3. Strangulation by knots and nooses formed by^ 
 "bands " 
 
 4. Strangulation by knots and nooses formed byy=:25 
 diverticula 
 
 5. Strangulation under an adherent appendix J 
 
 6. Strangulation through slits in the omentum ^ 20 
 
 7. Strangulation under omental ligaments = 15 
 
 The figures may be taken as representing the probable relative 
 frequency of the various forms. 
 
 THE PORTION OF INTESTINE INVOLVED. 
 
 In the form of intestinal obstruction now under 
 consideration, although many very different methods 
 
Clap. III.] Strangulation BY Bands. 57 
 
 are concerned in the production of that obstruction, 
 the part of the alimentary tube involved is, with 
 scarcely an exception, the same, viz. the small in- 
 testine. 
 
 A case has already been incidentally alluded to 
 where a part of the ascending colon was found com- 
 pressed beneath an adherent vermiform appendix, and 
 another where a loop of the sigmoid flexure was 
 strangulated through a rent in the mesentery. 
 
 Instances may be given where a part of the colon 
 has been obstructed beneath a tightly drawn mesen- 
 tery (Duchaussoy), together with a few other isolated 
 observations of the same character. So extremely 
 rare, however, is it, for any part of the colon to be 
 involved in the present variety of intestinal obstruc- 
 tion, that, so far as the general bearings of the whole 
 subject are concerned, the few reported cases may be 
 regarded as pathological curiosities. If it be borne in 
 mind that the hernia-like strangulation of the bowel 
 requires that the gut to be involved should be quite 
 free and movable, and that it should be capable also 
 of readily forming a knuckle or loop, it will be seen 
 that no part of the normal colon, if we except, 
 perhaps, the sigmoid flexure, has a disposition that 
 will allow it to share in this form of obstruction. 
 
 In the great majority of all cases the segment of 
 small intestine involved is the lower part of the 
 ileum. In a fair number of instances the middle and 
 upper portions of the ileum have been involved, but 
 the examples of strangulation of the jejunum by the 
 methods now under consideration are comparatively 
 rare. Indeed, it may be said that, as one follows the 
 small gut from the csecum to the pylorus, every foot 
 of the distance renders the probability of strangula- 
 tion more and more unlikely. I believe that there 
 is no recorded instance of implication of the duodenum 
 in this form of obstruction ; and, indeed, it would be 
 
58 Intestinal Obstruction. [Chap. hi. 
 
 anatomically impossible for the " third part " of that 
 segment of the bowel to be involved. 
 
 The frequency with which the last few feet of the 
 ileum are involved is very intelligible. The coils of 
 the lower ileum are the parts of the small intestine 
 most apt to be found in the pelvis, and to be thus 
 ensnared by those many adhesions that may result 
 from pelvic peritonitis. They are, moreover, in the 
 closest association with the csecum and appendix, and 
 are most likely, therefore, to be strangulated by 
 adhesions that may follow upon typhlitis, and by the 
 cord formed by the vermiform appendix when it 
 becomes adherent. Then, again, the true diverticulum 
 arises from the lower ileum, and, as may be expected, 
 the obstructions that it causes have, with compara- 
 tively few exceptions, their seat in the last few feet of 
 the lesser bowel* In strangulation due to this 
 process the part of the ileum involved may be either 
 that above or that below the origin of the abnormal 
 appendage. In most cases that portion of the bowel 
 is engaged that lies between the diverticulum and the 
 csecum. It must also be noted that abnormal apertures 
 in the mesentery, or such at least as are supposed to 
 be of congenital origin, are most often found in 
 that part of the membrane that is connected with the 
 lower ileum. This part of the bowel, moreover, is 
 often involved in hernise of the right side, and may 
 suffer in any trouble due to bands of adhesion follow- 
 ing upon complicated ruptures. Lastly, it is to be 
 observed, that while any coil of small intestine taken 
 from the upper ileum or jejunum would be equally 
 movable at both ends, one end of the terminal part 
 
 * I have not been able to find any case where a part of the 
 small intestine has been involved in obstruction due to the diver- 
 ticulum other than the ileum. The obstructed coil may not have 
 been always a 'part of the last few feet of the gut, but it has still 
 always been well within the limits of the ileum. 
 
Chap. III.] Strangulation BY Bands. 50 
 
 of the ileum, on the other hand, is more or less fixed 
 by its connection with the caecum. 
 
 As to the aviount of small intestine that may be 
 involved in a strangulation, the greatest variety exists. 
 The involved piece, on the one hand, may be so small 
 that only one half of the circumference of the gut is 
 nipped,"^ while on the other hand it may measure 
 four feet. Every possible variety exists between these 
 two extremes. Taking an average of forty -five cases 
 where the amount of bowel involved is stated, I find 
 that it reaches 15 '5 inches. The amount involved 
 depends a great deal more upon the mechanism of the 
 strangulation than upon the anatomical cause of it. 
 "When the obstruction is due to strangulation under a 
 band or through a slit the average amount of bowel 
 involved is small, often a mere knuckle. When, on 
 the other hand, the strangulation is brought about by 
 knots and nooses, it is usually found that large coils 
 are involved, it being impossible, under ordinary 
 circumstances, for a little loop of bowel to be so 
 strangulated. 
 
 To these general observations there are, of course, 
 many exceptions. For example, one of the cases in 
 which an unusually large amount of intestine was 
 strangulated was a case of strangulation under an 
 adherent vermiform appendix, in which instance four 
 feet of ileum were found to be implicated, f Exam- 
 ples, also, of strangulation of two and even three feet 
 of bowel beneath a band are, although exceptional, by 
 no means uncommon. 
 
 THE MECHANISM OF THE OBSTRUCTION. 
 
 The actual mechanism of the obstruction varies a 
 little in different cases. In many instances, no doubt, 
 
 * Case of strangulation under an omental band, by Dr. J. 
 Boeckel ; Bvill. et M^m. de la Soc. de CMr., tome iv., 1880, page 339. 
 t Dr. Hilton Fagge ; Guy's Hosp. Reports, vol. xiv. 
 
6o Intestinal Obstruction. rchap. hi. 
 
 a knuckle or coil of gut is driven with such sudden and 
 severe force beneath a band or through an aperture 
 as to become practically strangulated at once, just as 
 is the case in strangulated hernia, when the symp- 
 toms appear abniptly during some unwonted exertion. 
 No force of equal magnitude being brought to bear 
 upon the part so as to eifect its reduction, it remains 
 firmly gripped. When a comparatively large mass of 
 intestine is involved, the strangulation need not be 
 present from the first. But the band pressing upon 
 the mesenteric vessels produces a congestion in the 
 involved coils until at last the engorgement, aided by 
 increasing distension of the loop itseK, leads to a 
 complete strangulation. 
 
 It must be observed also that engorgement of the 
 veins, and a diminution in the arterial blood supply 
 of the gut, with consequent deficiency of oxygen and 
 excess of carbonic acid in such blood as occupies the 
 intestinal walls, induces inordinate activity of the 
 peristaltic movements. It is probable that these 
 violent movements materially aid in producing a 
 strangulation. 
 
 Many cases are on record, from the accounts of 
 which it is to be inferred that vascular distension has 
 been a conspicuous factor in completing the obstruc- 
 tion ; cases where much gut is involved, where the 
 mesentery is extensively compressed, and where a 
 bloody fluid in the peritoneum, or many "haemorrhages 
 beneath the serous coat, point to the severity of the 
 congestion that preceded actual stopping of the circu- 
 lation. Increasing distension, moreover, of the 
 implicated bowel must always be an important 
 feature. This distension is due not only to matters 
 passed into the partly occluded intestine from above, 
 but also to gas developed within the strangulated and 
 paralysed loop. Certain simple experiments throw 
 some light upon the matter. M. Le Moyne opened 
 
Chap. 111.] Strangulation BY Bands. 6i 
 
 the abdomen in the cadaver, and having drawn a 
 little loop of the small intestine through a slit made 
 in the mesentery, replaced the gut so arranged and 
 closed the abdominal wound. He then made a 
 second incision into the belly at a remote spot, and 
 injected water or semi-fluid matter into the small 
 intestine above the seat of the obstruction. The first 
 matter that reached the loop in the mesentery passed 
 through it, but as more was injected the little coil 
 became rapidly distended, and was ultimately closed 
 and entirely obstructed,* M. Anger, experimenting 
 in another direction, drew a loop of gut out of the 
 abdomen, and put a ligament lightly around its two 
 ends. The ligature was loose enough to allow the 
 gut to slide about within it, and to allow the tip of 
 the little finger to be introduced into each end of the 
 bowel. He then made a hole at the bend of the loop, 
 at the part most remote from the ligature, and intro- 
 duced a tube, through which air was blown. As the 
 gut distended some air escaped, but the more swollen 
 it became the more tightly was it gripped, until when 
 fully distended it was found to be hermetically sealed ; 
 and, what is more interesting, more gut had been 
 drawn into the loop from the abdomen.^ 
 
 In a great many cases the final cause of the stran- 
 gulation is a twisting of the involved coil of bowel. 
 This is well shown in several museum specimens. 
 Here the band would not have been of itself sufficient 
 to produce a strangulation provided that the bowel 
 had not become twisted beneath it. On the other 
 hand, it is equally obvious that the volvulus could not 
 have been produced without the band. The twist is 
 given to the bowel partly by distension, partly by its 
 
 * Contrib. a I'E^ude de I'Occlusion Intestinale, by M. Lo 
 Moyne. These de Paris, 1878. 
 
 fDe i'Etranglemeut Intestinale, by M. Benjamin Anger. 
 These de Paris, 1865. 
 
62 Intestinal Obstruction. [Chap. it. 
 
 own movements, partly by the dragging of the mesen- 
 tery. In some cases, adhesions already existing above 
 the implicated coil may have favoured the volvulus. 
 There must be cases also, similar to that illustrated in 
 Fig. 2, where the arrangement of the band is such, that 
 it could never strangulate the bowel luitil the bowel 
 itself had become twisted. 
 
 There are instances also where the arrangement 
 of the band and of the mesentery are such, that the 
 engaged loop as it becomes distended is soon so 
 acutely bent over the band by the dragging of the 
 mesentery that it becomes obstructed (in one end of 
 the loop at least) before it is very tightly gi'ipped. 
 
 CHAPTER TV. 
 
 STRANGULATION BY BANDS OR THROUGH APERTURES. 
 
 SYMPTOMS. 
 
 Frequency. — The cases that come under this 
 category form no less than one fourth of the total 
 number of cases of intestinal obstruction from all 
 causes.* 
 
 The high proportion here indicated depends partly 
 upon the fact that several distinct anatomical con- 
 ditions are comprised under one general heading, and 
 partly upon the circumstance that a comparatively 
 common ailment (local peritonitis) takes an im- 
 portant part in the production of the different 
 forms of the obstructing agent. 
 
 Sex. — This variety of obstruction of the bowels is 
 more common in males than in females in the pro- 
 portion of 180 to 118. The distribution of these 
 
 * From this enumeration are excluded hernise and affections 
 of the rectum, both congenital and acquired. 
 
Males. 
 
 Females, 
 
 52 
 
 59 
 
 43 
 
 15 
 
 52 
 
 14 
 
 21 
 
 13 
 
 Chap. IV.] Strangulation BY Bands. 63 
 
 figures among the different sub-varieties is shown 
 in tiie following table from Leichtenstern : 
 
 Strangulation hy false ligaments . 
 ,, by the omentum 
 
 „ by the diverticle 
 
 „ by the appendix vermifonnis . 
 
 „ .'throug-h sKts in the mesentery 
 
 and in other parts, occluding the omentum 12 17 
 
 180 118 
 
 It will be seen that strangulation by peritoneal 
 adhesions occurs with about equal frequency in the 
 two sexes. The balance, however, is very strangely 
 struck. THe two forms of peritonitis that are an- 
 swerable for the bulk of the adhesions that cause 
 strangulation are pelvic peritonitis, and the peritoneal 
 inflammation associated with typhlitis. Pelvic peri- 
 tonitis is practically limited to women, and in the 
 matter of strangulations due to pelvic adhesions 
 females are of course enormously ahead of the males. 
 Typhlitis, on the other hand, is much more common 
 in males than in females, the ratio being, according to 
 Bamberger, twenty-six to four. The cases, however, 
 of false ligaments due to pelvic inflammation out- 
 number those due to inflammation of the caecum, and 
 the balance between the two sexes is made nearly 
 even by the increased frequency of hernia in the male, 
 and by the greater liability to peritonitis from violence 
 in members of that sex. 
 
 The disproportion in the number of the cases 
 among males and females due to strangulation by the 
 omentum is readily explained. Owing to its limited 
 length the omentum can contract adhesions about the 
 right iliac fossa (typhlitis) with somewhat greater 
 ease than about the pelvis. This circumstance would 
 render omental adhesions a little more frequent in 
 men. A more influential factor, however, is concerned. 
 
64 Intestinal Obstruction. [Chap. iv. 
 
 The omental adhesions are very commonly, perhaps 
 most commonly, brought about by external hernise, 
 and Mr. Kingdon's tables show that for all ages 
 and all varieties, rupture is twice as common among 
 males as it is among females. The formation of 
 omental cords after injury must also be taken into 
 consideration. 
 
 With regard to the diverticula, it is simply a 
 matter of anatomical observation that they occur with 
 much greater frequency in the male than in the 
 female sex. Their situation about the csecal region 
 would also render the shorter of them more liable to 
 form adhesions after typlilitis than after pelvic 
 peritonitis. 
 
 The gi'eater frequency of strangulation by the 
 appendix vermiformis in males is explained by the 
 ease with which that process becomes adherent after 
 typhlitis, typhlitis being certainly the most common 
 cause of adherent appendix. 
 
 The distribution of the few cases of strangulation 
 through mesenteric and other slits and apertures calls 
 for little comment. The slightly increased frequency 
 in the female sex may possibly be due to the cir- 
 cumstance that obstruction through slits in broad 
 adhesions has been met with most often in the pelvis 
 among the results of peritonitis in that region. 
 
 Age. — Strangulation by false ligaments, by the 
 omentum, by the appendix, and through abnormal 
 slits and apertures occurs most frequently in persons 
 between the ages of twenty and forty. This circum- 
 stance obviously depends upon the fact that the forms 
 of peritonitis, with which these affections are so 
 intimately associated, are most common between these 
 ages. Typhlitis falls within this period of life."* 
 
 » " Typhlitis occurs most frequently between the ages of 16 
 and 35." Bauer; Ziemssen's Cyclopaedia of Medicine, vol. viii., 
 page 317. 
 
Chap. IV.] Strangulation BY Bands. 65 
 
 Pelvic peritonitis occurs, with comparatively few 
 exceptions, during the period of child-bearing, and as 
 a rule early in that period, being frequent in primi- 
 parse. Mr. Kingdon's tables show that the gi'eatest 
 number of cases of hernia appear for the first time 
 during the twenty years in question. During the 
 same period also strangulation of hernise is common, 
 and perhaps at no other period of life are injuries of 
 a severe character more frequent. 
 
 Many cases are met with after forty.* Forms of 
 peritonitis that may be recovered from, and that lead 
 to adhesions, may occur after that age, and, moreover, 
 strangulation of the bowel may not occur for many 
 years after the peritonitis that renders it possible 
 has passed away. 
 
 Before twenty these varieties of obstruction are 
 comparatively uncommon, and before ten they are 
 very rare. In one or two cases of incarceration by a 
 false ligament in young children, the formation of the 
 adhesion has probably depended upon an intra-uterine 
 inflammation. Children are not liable to those forms 
 of peritonitis that can be recovered from. In such 
 subjects typhlitis is quite rare and pelvic peritonitis 
 practically unknown. Infantile peritonitis and the 
 tubercular form of the disease are uniformly fatal; 
 although during the course of the more chronic forms 
 of the latter affection strangulation may occur. Thus 
 M. Larguier des Bancels reports the case of a boy, 
 aged eight, who during the progress of tubercular 
 peritonitis developed symptoms of acute obstruction, 
 of which he soon died. The autopsy revealed a coil 
 of the lower ileum strangulated by a band, one of the 
 many resulting from the disease of the serous 
 
 * The oldest patient of whom I can find record is a woman 
 aged 80, who died of acute obstruction due to an omental band 
 after hernia. Lucas-Champoinniere ; Bull, et Mem. de la Soc. de 
 Chir. de Paris, tome v., 1879, page 645. 
 F— 12 
 
66 Intestinal Obstruction. [Chap. iv. 
 
 membrane."^ When, therefore, strangulation due to 
 adhesions is met with in the young, it is usually found 
 that the adhesions have followed injury, or the slight 
 peritonitis that may attend caseous degeneration of 
 the mesenteric glands. The main number, however, 
 of the cases of incarceration coming under the present 
 general category are such as depend upon congenital 
 abnormalities. 
 
 Strangulation by means of the true diverticulum oc- 
 curs most frequently during the twenty years between 
 10 and 30. Of the two decades the latter presents 
 the greater number of cases. Leichtenstern found 
 the average age in seventy cases to be 2.5 years. He 
 notes eight cases between the ages of 2 and 10 years, 
 and Trier has recorded a case in an infant of 8 
 months.! Above the age of 40 strangulations due to 
 the diverticulum are extremely rare. Incarceration 
 by this process is to a great extent independent of 
 peritonitis, since it can occur without the aid of 
 acquired adhesions. Moreover, when a free process 
 does acquire an attachment it seems to be capable of 
 doing so without inducing a peritonitis of appreciable 
 magnitude. A diverticular pouch or ligament, once 
 free, is often found adherent to some spot on the 
 serous membrane, while about that spot no trace of a 
 previous inflammation will be found. 
 
 [The account of the symptoms that follows is 
 founded mainly upon an analysis of fifty recorded 
 cases of this form of obstruction. These fifty cases 
 were selected from a larger number, upon the sole 
 ground that the accounts of them were more or less 
 complete, both clinically and pathologically. Im- 
 perfectly reported cases are, when not simply useless, 
 actually misleading.] 
 
 * Sur le Diagnostic et le Traitement Chirurgical des Etranglc- 
 ments Internes. These de Paris, 1870. 
 tPfaff's Mittheil., Jahrg. iii., Heft 9. 
 
Chap. IV.] Strangulation BY Bands, 67 
 
 The previous history. — This is a matter of 
 some importance in tlie diagnosis, and may be con- 
 sidered under two heads : 1. History of previous 
 peritonitis, injury, etc., i.e. of circumstances that 
 may have rendered an obstruction possible : 2. 
 History of previous attacks of abdominal disturbance, 
 i.e. of symptoms such as may have been produced by 
 the same cause that brought about the final strangula- 
 tion. 
 
 1. Out of the fifty cases above alluded to, there 
 was in thirty-four instances (68 per cent.) a history of 
 such previous trouble as may have produced causes 
 for obstruction. In seventeen cases (34 per cent.) 
 there was a history of peritonitis ; in eleven (22 per 
 cent.) a history of hernia; in six (12 per cent.) a 
 history of accident. In sixteen cases (32 per cent.) 
 there was nothing in the previous history to note 
 under this heading. These sixteen cases included 
 several examples of the diverticulum, some in- 
 stances of slit in the mesentery, and a few patients 
 in whom adhesions had been found without any 
 circumstances in their previous history to call atten- 
 tion to the occurrence. 
 
 As to the interval of time that may have elapsed 
 between the causative afiection and the actual strangu- 
 lation, the greatest variety exists. The shortest period 
 I have noticed is in a case where only five weeks 
 elapsed between the peritonitis, that presumedly 
 formed the band, and the strangulation of the bowel. 
 The longest period was met with in a female aged 52, 
 who died of strangulation of the ileum by a band 
 connected with the pelvic peritoneum. Twenty-one 
 years before she had had "inflammation of the womb" 
 following labour."^ In two cases, next to this in point 
 of time, seven years had elapsed. Omitting the 
 twenty-one years' case, the average duration of the 
 * Guy's Hospital Keports, vol. xiv., page 272. 
 
68 Intestinal Obstruction. [Chap. iv. 
 
 interval between the causative peritonitis and the ob- 
 struction was three years. 
 
 With regard to internal strangulations, due directly 
 to hernia, they were in all cases observed in connec- 
 tion with ruptures of many years' standing. In one 
 patient aged 80, who died of incarceration of the 
 bowel by an omental band, the hernia with which 
 that band was associated had existed for sixty years. 
 
 In the twelve cases where an accident is credited 
 with being the existmg cause of a strangulation, the 
 interval between the lesion and the intestinal trouble 
 was in all cases short, and in two instances the 
 development of strangulation was immediate. 
 
 2. Some of the patients who had died of obstruc- 
 tion had complained of previous intestinal troubles, 
 such as severe indigestion, ''spasms," bilious attacks 
 and persistent pains in the abdomen. The number of 
 individuals in whom such symptoms had been noticed 
 was comparatively few, and it is questionable whether 
 such symptoms were, or were not, dependent upon 
 the same cause that ultimately brought about the 
 obstruction. It can only be surmised that when 
 adhesions are attached to the bowel itself they may, 
 from traction or other causes, embarrass at times the 
 peristaltic movement of the intestine and hinder the 
 progress of its contents. 
 
 In six individuals (12 per cent.) there was a 
 history of previous obstruction. These attacks were 
 marked by the onset of a sudden and severe pain of 
 a colicky character, associated with vomiting and con- 
 stipation. Their duration was, as a rule, quite short, 
 varying from one to three days. Usually there had 
 been only one such attack previous to the final one. 
 In rarer instances there had been two or three. In 
 some examples these previous attacks had been very 
 severe. Mr. Gay has given details of the case of a 
 man aged 42, who died from strangulation of a coil of 
 
Chap. IV.] Strangulation BY Bands. 69 
 
 ileum beneath an adherent appendix. Durmg the 
 four years that preceded his death, the patient had had 
 no less than thirty attacks of severe pain, associated 
 with vomiting and absolute constipation. This case, 
 however, was complicated by a stricture of the small 
 intestine, to the occasional plugging of which these 
 thirty attacks were probably due."^ The rarity of 
 previous attacks in this form of intestinal obstruction 
 compares strikingly with the great frequency of such 
 occurrences in many of the more chronic forms of 
 obstruction. 
 
 The mode of onset.— The attack, as a rule, 
 begins suddenly with very severe abdominal pain, 
 followed rapidly by vomiting and symptoms of consti- 
 tutional depression. On analysing fifty cases, I find 
 that in thirty-five instances (70 per cent.) the mode 
 of onset was more or less distinctly sudden. In thir- 
 teen cases it was comparatively gradual, and in the 
 remainino- two observations the commencement of the 
 attack is not described. 
 
 A study of the pathology of this form of obstruc- 
 tion would lead one to infer that its onset would be 
 sudden. A loop or knuckle of gTit is, in a moment, 
 thrust beneath a band, or through an aperture, or is 
 snared by a free noose or knot, and symptoms of 
 strangrdation follow almost directly. An examination 
 of the cases of gradual onset often reveals some cir- 
 cumstance that may account for this somewhat 
 unusual mode of commencement. In some instances 
 the symptoms of absolute obstruction followed upon 
 prolonged constipation, and the condition of the parts 
 involved seems then to have borne the same relation 
 to the conditions of acute strangulation that an " ob- 
 structed hernia " bears to a strano-ulated one. In 
 one case the intestines were so matted together by 
 numerous adhesions, that partial obstruction may 
 * Path. Soc. Ti-ans., vol. iii., page 101. 
 
70 Intestinal Obstruction. [Chap. iv. 
 
 have taken place at many points at once, so that the 
 final incarceration would be, in a sense, cumuliitive. 
 In another instance of gradual onset, a loop of the 
 ileum and a part of the ascending colon were beneath 
 the band, the large bowel apparently affording some 
 temporary protection to the small. In other cases it 
 would appear that a large quantity of intestine had 
 passed beneath a band, but had not been at first 
 tightly nipped by it. In such examples complete 
 strangulation would follow slowly upon the gradual 
 distension and engorgement of the compressed coils. 
 
 In the instances where the onset has been gradual, 
 the patient has usually had some slight pain, often of 
 an intermittent character, with trifling vomiting, and 
 a constipation that has frequently not been absolute. 
 Very soon, however, the symptoms increase in severity 
 and assume all the characters of those of acute strangu- 
 lation. The transition from subacute symptoms to 
 acute is often coincident with the administration of 
 strong aperients. 
 
 Evidence of any immediate exciting^ cause 
 is very commonly absent. In probably about two- 
 thirds of the cases the attack seems to have come on 
 when the patient was in good health, or at least free 
 from any abdominal disturbance. In three cases (out 
 of fifty), it set in suddenly during the night while the 
 patient was asleep. In about one-third of the cases 
 some circumstances have immediately preceded the 
 symptoms of strangulation that may have taken an 
 active part in producing the obstruction. The fallacy, 
 however, of the argument, " post hoc propter hoc," may 
 enter into many of these relations, or the supposed 
 exciting cause may have been really a part of the 
 symptoms of the final malady. This would, perhaps, 
 apply to those instances where strangulation has fol- 
 lowed upon a " bilious attack " or upon severe " indi- 
 gestion." Putting these cases aside, however, we find 
 
Chap. IV.] Strangulation by Bands. 71 
 
 that the obstruction has several times appeared after 
 a hearty meal, and especially a meal of indigestible 
 food, such, for example, as beans. In connection 
 with hernia, it has come on when the rupture was 
 down or giving trouble. In two instances it appeared 
 while straining at stool. In one or two cases it came 
 on after the administration of a purge. It has followed 
 also upon a sharp attack of diarrhoea. In quite a fair 
 number of patients the symptoms of strangulation 
 have made their appearance either during or imme- 
 diately after unusual exertion. In one instance a 
 peculiar position of the body seems to have had some 
 influence, as illustrated by the case, reported by Dr. 
 Quain, where a coil of ileum was found strangulated 
 through a slit in the broad ligament of the uterus. 
 Here the attack came on suddenly while the patient 
 was bending to unlace her boots. In a remarkable 
 case reported by Mr. Bryant, a distended bladder was 
 the immediate cause of a strangulation being pro- 
 duced. In this instance a coil of bowel was involved 
 beneath a band that passed from the bladder to the 
 lumbar spine. The patient had been out for a drive 
 and had been compelled to retain her urine for some 
 hours. Shortly after emptying her bladder, symptoms 
 of acute obstruction set in. Here there is little doubt 
 but that the distended viscus so raised the band out 
 of the pelvis as to allow a loop of gut to pass beneath 
 it.* 
 
 The pain. — The pain attending these cases of 
 Ltitestinal obstruction is among the most conspicuous 
 and most constant of the symptoms. 
 
 It is usually the first manifestation of the attack. 
 
 It is generally at the commencement of great 
 
 severity, and is of a griping or colicky character. In 
 
 several instances the patients are spoken of as being 
 
 bent double with the pain, or even as rolling on the 
 
 * Med. Times and Gazette^ vol. i. , 1872, page 304. 
 
72 Intestinal Obstruction, [Chap. iv. 
 
 floor ill agony. Often it appears to have been mode- 
 rate, but ill no case could it be described as trivial. 
 
 As to the situation of this early pain, Mr. Gay, in 
 his well-known essay on "The Solitary Band," observes, 
 " the localisation of the pain is ever at first due to the 
 constricting agent, and marks its seat." In other 
 works similar observations occur. With these state- 
 ments I might be permitted to disagree. In examin- 
 ing into the clinical history of the fifty cases that form 
 the basis of the present remarks, I find that in many 
 instances the initial pain was distinctly referred to a 
 spot that subsequent post-mortem examination proved 
 to have corresponded to the seat of obstruction. But 
 in a still greater number of the cases this pain is 
 described as being located in a point more or less re- 
 mote from the seat of strangulation. The proportion 
 of the latter class of case to the former is nearly that 
 of two to one. Taking all the cases together, it is 
 seen that in the majority of them the pain is referred 
 to the immediate vicinity of the umbilicus. In some 
 of these examples the obstructed coil was, it is true, 
 found to be placed near to the umbilicus, and in other 
 cases the strangulating band had an attachment close to 
 that cicatrix. But in still other and more numerous in- 
 stances the situation of the intestinal lesion was found 
 to be remote from the umbilicus, was located in the 
 right iliac fossa, or deep in the pelvis, or close to a 
 hernia] opening about the groin. Still more marked 
 examples of this lack of relationship may be given. 
 A few of them are the following. The pain was on 
 the right side just below the liver ; the obstruction was 
 in the ileum eighteen inches from the csecum.* The 
 pain was on the left side, and on a level with the 
 navel, and in one case where it was so placed a coil of 
 ileum had passed through a rent in the right broad 
 
 * Med. Times and Gazette, vol. ii., 1876, jiage 651. 
 
Chap. IV.] Strangulation by Bands. 73 
 
 ligament,'^ while in another the strangulation was deep 
 in the right iliac fossa, f The pain was near the gall 
 bladder ; the obstruction was in the ileum. \ The pain 
 was in the epigastrium, and the trouble that caused it 
 was due to a band passing between the urinary bladder 
 and the lumbar spine. § 
 
 In speaking of the situation of the pain in intesti- 
 nal obstruction in a subsequent chapter, I have pointed 
 out the physiological improbability that a painful spot 
 among a series of complicated and moving coils, like 
 those of the smaller bowel, would be accurately 
 localised. The pain in intestinal strangulation would 
 often seem to be a referred pain, and it is needless to 
 point out that in affections of other abdominal viscera, 
 discomfort is often felt at a distant point. From the 
 frequency with which the pain is referred to the 
 vicinity of the umbilicus, it might be gathered that it 
 has been conducted to the great abdominal nervous 
 centres. It is complained of, with strange frequency, 
 as being about the middle line. The solai' plexus, 
 through which the small intestine is supplied, is 
 situated about four inches above the umbilicus, while 
 the superior mesenteric plexus commences still nearer 
 to the navel, and runs for some little distance almost 
 directly in the middle line. Pain conducted along the 
 latter plexus would probably be most definitely felt 
 near the middle line, and about the umbilicus. It may 
 be noted that the pain to which reference is now being 
 made is a pain due to compression of a limited part of 
 the gut, and not one depending upon disordered peri- 
 staltic movement. The pain caused by such move- 
 ments could not well be localised, since its very occur- 
 rence involves a constant changing of position. From 
 
 *Path. Soc. Trans., vol. xii,, page 103. 
 
 t Union Medicale, 1860, page 97. 
 
 t British Med. Journ., vol. i., 1883, page 999. 
 
 ^BuU. de la Soc. Anat., 1843. 
 
74 Intestinal Obstruction. [Chap, i v. 
 
 the facts themselves, however, I would maiiitain that 
 the position of the pain, in this form of internal 
 strangulation is of no diagnostic value as a guide to 
 the seat of the lesion ; that it is more often complained 
 of about the umbilicus than elsewhere, and that as a 
 means of ascertaining the locality of the trouble it is 
 actually misleading. 
 
 The pain that is so conspicuous a feature at the 
 commencement of these cases persists throughout the 
 course of them. It does not, however, retain its 
 original intensity. It soon becomes less severe, and 
 often undergoes considerable abatement. In some of 
 the more acute cases, however, it has persisted with 
 all its original intensity until deadened by the col- 
 lajDse that supervenes. 
 
 The pain often ceases shortly before death. This 
 circumstance, however, is of no significance ; it is 
 usually coincident with a profounder collapse, or with 
 gangrene of the bowel involved, or with advanced 
 narcotism. 
 
 One or two cases have been recorded where the 
 pain has been almost an insignificant feature, and 
 of these extremely rare cases no satisfactory explana- 
 tion can be given. The most striking one that I 
 have met with is reported by Mr. Hulke."* The 
 patient was a man, aged thirty-two, who, after a 
 hearty meal, was seized with sudden abdominal pain 
 and vomiting. The pain soon passed ofif, but the 
 vomiting persisted and became very severe. Neither 
 faeces nor flatus were passed by the rectum. On the 
 tenth day the vomiting was feculent, but the patient 
 still complained of little or no pain. Such pain as 
 there was was about the umbilicus. Laparotomy was 
 performed, and the man survived the operation fifty- 
 three hours. The autopsy revealed a coil of the 
 lower ileum strangulated beneath a band formed by 
 * Medical Times and Gazette, vol. ii., 1877, page 482. 
 
Chap. IV.] Strangulation BY Bands. 75 
 
 an epiploic appendix of the sigmoid flexure that had 
 become adherent to the peritoneum near the right 
 sciatic notch. 
 
 The pain in the hernia-like strangulation of the 
 bowel is continuous. It presents slight exacerbations, 
 as do all " colicky " pains. It does not, however, 
 intermit at any time, nor are there any intervals of 
 calm between definite paroxysms. 
 
 I shall later on have occasion to draw attention 
 to the fact that, speaking generally, paroxysmal pains 
 indicate an incomplete occlusion of the bowel."^ 
 When the obstruction is absolute the pain becomes 
 practically continuous. In the present form of in- 
 carceration the lumen of the gut becomes entirely 
 obliterated, and the pain in consequence presents no 
 paroxysmal character. To this statement there are 
 but few exceptions to be made, and such as there are 
 are probably susceptible of explanation. In Mr. 
 Gay's monograph, already quoted, he states that he 
 met with only six examples of paroxysmal pain 
 among forty-one cases where the nature of the pain 
 was indicated. Among my fifty cases I find eight 
 instances of intermittent pain. The circumstances of 
 these eight examples are worthy of brief notice. 
 
 1. Female, aged 53. Pain appears to have been only 
 paroxysmal at the commencement. Case of strangailation 
 beneath a band ; laparotomy with cure on sixth day.t 
 
 2. Female, aged 23. Here only a single fine of gut was 
 found beneath a band, not a knuckle or loop ; the obliteration 
 of the canal was therefore apparently incomplete. The pain 
 is merely said to have " persisted on and off." J 
 
 3. Female, aged 26. Case of strangulation beneath a band. 
 Here the strangulation does not appear to have been severe 
 at fii'st, and laparotomy was not considered necessary until 
 the eleventh day.§ 
 
 * See chapter xx. 
 
 t British Medical Journal, 1883, page 999. 
 
 X St. Bart.'s Hosp. Reports, vol. xvii,, page 277. 
 
 § Bull, et Mem. de la Soc. do Chir. de Paris, 1879, page 632. 
 
76 Intestinal Obstruction. [Chap. iv. 
 
 4. Female, aged 21. Strangulation beneath a band. The 
 incarceration was not severe, and when laparotomy vras per- 
 formed on the fourth day the involved coil was found in 
 good condition. The patient recovered.* 
 
 5. Male, aged 42. In this case, already alluded to, there 
 was, besides the incarceration, a strictui-e of the intestine, to 
 which the paroxysmal pain was probably to no small degree 
 due. 
 
 6. " A boy." Case of strangulation beneath a band.f 
 
 7. Female, aged 26. Mr, Bryant's case of band arising from 
 the bladder. Each paroxysm was attended with stranguary, 
 and the " play " allowed to the band by its mobile point of 
 attachment probably prevented the obstruction from being very 
 complete. 
 
 8. Female, aged 45. Paroxysms every half -hour. Two 
 bands were found to hold down two portions of bowel. 
 Neither band compressed the gut greatly, and the upper of the 
 two involved coils was but veiy slightly pressed upon by the 
 band. I 
 
 In the majority of these cases, therefore, there is some 
 reason to suspect that the occlusion of the bowel was not so 
 complete as it may have been, nor so perfect as it commonly 
 is. 
 
 During the early stages of the malady, before any 
 abdominal tenderness exists, the pain is often described 
 as being relieved by pressure. 
 
 There is a direct connection, more or less con- 
 stantly observed, between the severity of the pain 
 and the urgency of the vomiting, and especially be- 
 tween the pain and the degree of constitutional 
 disturbance. 
 
 Tenderness of the abdomen.— This symp- 
 tom, as demonstrated by pressure upon the abdomen, 
 is, as a rule, entirely absent at first. It may never 
 appear, especially in cases pursuing a rapid course. 
 In a few cases of a less acute character it has been of 
 trifling degree, or not sufficiently marked to attract 
 
 * Bull et Mem. de la See. de Chir. de Paris, 1879, page .564. 
 t Sur le Diagnostic et Traitement des Etranglement Internes. 
 Thfese de Paris, 1870. 
 
 X Lancet^ vol. ii., 1873, page 773. 
 
Chap. IV] Strangulation BY Bands. 77 
 
 notice. In the majority of cases, however, some part 
 of the abdomen becomes tender during the course of 
 the disease. This tenderness may be limited in 
 extent, or diffused. Limited tenderness usually ap- 
 pears about the second or third day. It is a symp- 
 tom that, when well marked, is of considerable 
 diagnostic value, since it appears to be always 
 restricted to the actual seat of the lesion. It depends, 
 no doubt, upon congestion or inflammation of the in- 
 volved coils, or upon some slight peritonitis excited 
 in their serous coat. As a factor in diagnosis, there- 
 fore, it is of much more value than is the simple 
 spontaneous pain always observed in these maladies. 
 
 A diffused tenderness of a marked nature indi- 
 cates the onset of a peritonitis, and is also a symptom 
 of much clinical value. When peritoneal inflam- 
 mation has become diffused a general tenderness is 
 practically constant, unless modified or concealed by 
 profound collapse or narcotism. 
 
 In several cases, after the symptoms have lasted for 
 a few days and the pain has been severe, the abdo- 
 men has exhibited a general but slightly marked 
 tenderness on pressure. This is probably the result 
 of violent peristaltic movements. In such move- 
 ments the muscular coat of the bowel is practically in 
 a state of cramp, and there is no reason why the in- 
 volved gut should not become as tender after a pro- 
 longed attack of cramp as does the calf of the leg 
 after it has been the seat of a like disturbance. This 
 cause of tenderness may perhaps contribute to the 
 production of the local " \)wii on pressure," but I 
 presume that it would in no ordinary case attain to 
 the marked character of the tenderness due to perito- 
 nitis. It is obvious that any fine distinctions on this 
 Bcore are impossible. 
 
 In several cases of localised tenderness pressure 
 over the affected spot has caused an increase in the 
 
78 Intestinal Obstruction. [Chap. iv. 
 
 colicky pains, and has induced an immediate attack 
 of vomiting. 
 
 Toiiiitiiig. — Vomiting is a conspicuous and con- 
 stant symptom. In an isolated case or so it has been 
 the earliest manifestation of the obstruction. In the 
 great majority of cases it comes on immediately after 
 the appearance of the pain or within a few hours of 
 that event. I have met with two instances where the 
 vomiting did not appear until twenty-four hours after 
 the onset of the pain.* It soon, however, became 
 stercoraceous, and the patient died on the eighth day 
 in one case, and was cured by laparotomy on the fifth 
 day in the other. In both instances the initial pain 
 had been sudden and severe. 
 
 As regards its character the ejected material con- 
 sists jBrst of the contents of the stomach and then 
 usually of bilious matters. In its next stage it may 
 be thin and of a brownish colour, or be comparable to 
 pea-soup, or be of a yellow tint like the yolk of egg. 
 Vomited matters with these characters are often 
 described as possessing an " intestinal odour." Lastly, 
 the vomit may become stercoraceous. 
 
 Stercoraceous vomit is common in this form of 
 obstruction. In five of my fifty cases the character of 
 the ejecta is not clearly described, but in the remaining 
 forty-five cases the vomit became stercoraceous in 
 twenty-eight instances, and remained non-stercoraceous 
 in seventeen. These figures very closely correspond 
 with those given by Mr. Gay. That surgeon found 
 that the vomited material became stercoraceous in 
 twenty-six cases out of thirty-seven. 
 
 The period in the attack at which the vomit 
 assumed a feculent character varied from the 
 second to the ninth day. An average taken from 
 
 * Dr. Hilton Fagge ; Guy's Hosp. Reports, vol. xiv. : Dr. 
 Bocckel ; Bull, et Mem. de la Soc. de Chir., tome vi., 1880, 
 page 339. 
 
Chap. IV.] Strangulation BY Bands. 79 
 
 the twenty-eight cases gave the fifth clay as the 
 mean. 
 
 An examination of the seventeen cases where the 
 vomit remained non-feculent revealed a striking fact. 
 The cases separated into two categories : in one, death 
 had taken place before the usual period for the onset of 
 stercoraceous vomiting had been reached ; in the other, 
 the course of the attack had been less acute than 
 usual, and the patient's life prolonged beyond the 
 average duration. Thus feculent vomiting was absent 
 in some of the most acute and in some of the least acute 
 cases. In nine of the seventeen examples the patient 
 had died within two and a half days of the commence- 
 ment of the attack. In the remaining eight cases life 
 had been prolonged on an average to the eighth day. 
 In one instance the patient had died on the fourth 
 day, but the matters vomited had not become sterco- 
 raceous. On an average, life was prolonged for three 
 days after the onset of feculent vomiting. 
 
 Cazin observes that stercoraceous vomit is rare in 
 cases of strangulation by the diverticulum. This is, 
 to a certain extent, true, since these cases very com- 
 monly assume a rapid course, and end in death before 
 the usual time for the occurrence of such vomiting has 
 been reached. 
 
 I have only met with one instance where the 
 vomit distinctly contained blood. It was in a case of 
 acute strangulation of the lower ileum by a diverticu- 
 lum. The patient lived two and a half days. The 
 vomited matter was never feculent."^ 
 
 When once it has set in the vomiting will persist 
 until the termination of the attack. It is one of the 
 most distressing of the symptoms. Everything swal- 
 lowed is immediately ejected, and even when nothing 
 is taken by the mouth the vomiting will continue 
 
 * British Med. Journal, vol. ii,, 1882, page 785; by Dr. J. 
 Cockle. 
 
8o INTESTINAL OBSTRUCTION. [Chap. IV. 
 
 incessantly. Often a little movement or a little pres- 
 sure upon the abdomen will excite an attack. When 
 not actually sick the patient will commonly complain 
 of a most distressing nausea and will be troubled by 
 eructations of flatus. It is worthy of note that the 
 patient is in no way relieved by the attacks of vomit- 
 ing, as may be the case in other maladies associated 
 with this symptom, and as is sometimes the case in 
 other forms of intestinal obstruction. 
 
 With few exceptions, the longer the obstruction 
 lasts the more violent and distressins: do the attacks 
 of vomiting become. Sometimes they may cease 
 entirely a few hours before death, just as the pain 
 may abate under the same circumstances. In other 
 cases, however, there has been a sudden and profuse 
 gush of vomit either just before death or in the act of 
 dying, the fluid pouring, without effbi-t, from the 
 mouth and throus^h the nostrils. This is observed 
 also in other forms of obstruction and sometimes in 
 death from peritonitis. 
 
 In a few isolated cases, where the obstruction does 
 not appear to have been very complete at first, the 
 vomiting has undergone distinct abatement after the 
 violent attack marking the onset of the trouble has 
 passed away. 
 
 Opium has often a very decided effect upon the 
 vomiting. When the patient is well under the in- 
 fluence of the drug the symptoms of intestinal ob- 
 struction may be more or less efiiciently masked. The 
 pain abates, the pulse imj^roves, the amount of urine, 
 if lessened, increases, and the vomiting becomes less 
 troublesome or ceases for a while. Under the in- 
 fluence of opium, stercoraceous vomiting even may 
 cease, and on the reappearance of the symptom the 
 ejected matters may be non-feculent. This is well 
 illustrated by a case recorded by JMr. Berkeley Hill. 
 The patient was a child aged ten, and the obstruction 
 
Chap, iv.i Strangulation by Bands. 8i 
 
 was due to strangulation of the ileum under a band. 
 By the tliird day of the attack the vomiting was 
 severe and feculent. Opium was given. For four 
 hours the vomiting ceased entirely, and when it re- 
 turned was much less distressing, was less frequent, 
 and was non-stercoraceous. Although laparotomy 
 was not performed until the seventh day the vomited 
 matter appears never to have again become feculent, 
 except on one occasion.'* 
 
 In this and like cases it is probable that the drug 
 stills the peristaltic movement of the intestine, so that 
 what is ejected is merely the contents of the stomach 
 and of the highest part of the smaller bowel. 
 
 Peritonitis, presumedly by the paralysing effect it 
 has upon the intestine, seems to have some influence 
 upon the production of feculent vomiting. 
 
 When acute peritonitis sets in early there is cer- 
 tainly a much less tendency for the ejected matter to 
 become stercoraceous. In some cases this has been 
 very marked. The same may be said, perhaps, of 
 chronic peritonitis. In one case where acute strangu- 
 lation of the bowel occurred during the progress of 
 a chronic peritonitis, the vomiting, although severe, 
 never became stercoraceous. Yet the patient lived 
 six days.! 
 
 In nearly every instance the act of vomiting is 
 associated with much retching and distress. In one 
 case, however (that of Mr. Hulke's, quoted on 
 page 74), where the patient had little or no pain, the 
 vomited matter appears to have gushed passively from 
 the mouth with little trouble to the patient. The 
 vomiting was in this instance copious, and in time 
 feculent. 
 
 Constipation. — Constipation is, as a rule, abso- 
 lute from the first, and continuous. Neither faecal 
 
 * Lancet, vol. i. , 1876, page 773. 
 
 t Case by M. Larguier dea Bancels, loc. cit., page 64, 
 
 G— 12 
 
82 Intestinal Obstruction. tchap. iv. 
 
 matter nor flatus is passed after the onset of the 
 attack. It would seem as if all the bowel below 
 the seat of the obstruction became instantaneously 
 paralysed, since it would be absurd to assume that in 
 every case the colon is quite empty at the time that 
 the strangulation occurs. 
 
 The exceptions to this condition of things are very 
 rare. In two or three instances a motion has been 
 passed during or immediately after the occurrence 
 of the initial symptoms, and was probably derived 
 from the intestine below the site of the strangulation. 
 Enemata administered almost at any time after the 
 commencement of the attack may possibly bring away 
 scybala from the colon, and in one case such scybala 
 came away repeatedly. Flatus generated in the large 
 intestine may also be passed, but the circumstance is 
 quite exceptional. 
 
 I have met with two recorded instances where 
 blood is said to have been passed. In one case, in a 
 man aged 53, a coil of the lower ileum, eighteen 
 inches in length, was strangulated beneath a band. 
 The patient died, after laparotomy, on the sixth day. 
 Constipation was absolute throughout, but the patient 
 is said to have passed a little blood. It is not stated 
 if the man had piles.* In the other case (the case by 
 Mr. Berkeley Hill, alluded to on page 80) enemata 
 on two occasions brought away scybala and blood. 
 The patient was a child aged ten, and there is no 
 evidence to show that the blood was derived from the 
 seat of strangulation. It may have been produced 
 accidentally by the enema tube. At autopsies blood is 
 frequently found in the engaged coil and in the intes- 
 tine above it, but not, so far as I am aware, in the 
 bowel below the obstruction. 
 
 Out of my fifty cases, I have met with six 
 
 ^Dr. Fincliam ; Med, Times and Gazette, vol. ii., 1876, page 
 Cil, 
 
Chap. IV.] Strangulation by Bands, 83 
 
 instances where a more or less copious motion or mo- 
 tions passed during the course of the disease. In all 
 instances the event occurred shortly before death. In 
 two of the examples the stool must have been derived 
 from the bowel below the obstruction (which was 
 found to be complete at the autopsy), and I believe 
 that its evacuation was coincident with the appearance 
 of general peritonitis. In both of these cases a single 
 stool was passed on the day before death. In both 
 there had been absolute obstruction for more than 
 seven days. In both the peritonitis was very recent, 
 and was not due to perforation.* It is not difficult to 
 imagine that the onset of so grave a change as general 
 peritonitis may produce such effect upon the abdomi- 
 nal nervous centres as to excite the passive bowel 
 below the obstruction, although of the nature of that 
 influence we may have no knowledge. The four 
 remaining cases are more intelligible, and in each of 
 them the unusual motion may have come from the 
 bowel above the obstruction. 
 
 In two there was perforation, and in two there was 
 volvulus. The first of these cases, in a man aged twenty- one, 
 had assumed a subacute course, the patient dpng on the 
 thirteenth day. Constipation had heen absolute throughout, 
 but shortly before his death the patient passed a copious black 
 liquid stool into the bed. The autopsy showed that eight 
 inches of the lower ileum had become strangulated beneath a 
 band passing fi-om the transverse colon to the caecum. An 
 ulcer of the stomach was found to have perforated, and the 
 reHef thus given to the distended bowel had allowed the incar- 
 cerated knuckle to become partly withdrawn from under the 
 band. In fact, the obstruction at the last moment had ceased 
 to be complete, t 
 
 In the second case, an aperient given shortly before death 
 led to some greenish loose motions being passed. The obstruc- 
 tion had been complete for nine days. The autopsy showed a 
 perforation of the bowel above a coil of ileum engaged beneath 
 
 * Maunoury. These de Paris, 1819. 
 
 t Dr. Hilton Fagge ; Guy's Hospital Eeports, vol. xiv., page 
 «<2i 
 
84 Intestinal Obstruction, [Chap. iv. 
 
 a band. The mecliaiiism of the relief was probably the same 
 in this case as in the preceding. * 
 
 In the two remaining cases, although the gut was in each 
 instance beneath a band, yet the main cause of the obstruction 
 was a volvulus of the engaged coil. Without the volvulus the 
 obstruction would have been but partial. It will be shown in 
 speaking of twist of the small intestine, that the constipation 
 in such cases is commonly not complete, and to that variety of 
 obstruction these two examples more properly belong. In one 
 of the examples the patient, a man aged twenty-one, lived 
 forty-three hours, and passed two liquid motions not long 
 before death, f In the other case, that of a child aged foui-, 
 constipation had been complete, and all the symptoms of in- 
 carceration were marked up to the foui'th day, when a dose of 
 croton oil produced a copious evacuation. The child lived 
 until the tenth day.;}; 
 
 GENERAL CONSTITUTIONAL SYMPTOMS. 
 
 Rig'or. — In only one case among fifty can I find 
 any mention of a rigor associated with the appearance 
 of strangulation. In this solitary instance there can 
 be little doubt that the rigors (for the patient had 
 several) were connected with a circumscribed perito- 
 nitis which was developing at the time of the onset 
 of the incarceration, and that they had no direct con- 
 nection with the strangulation. § 
 
 Prostration. — Usually coincident with the onset 
 of the attack the patient exhibits evidences of gi'eat 
 prostration, and in severe cases this soon deepens into 
 profound and even fatal collapse. 
 
 There is great muscular weakness, the face is 
 drawn with pain and has an aspect of horrible 
 anxiety, the features become pinched, the eyes sunken 
 and surrounded by bluish rings, and the voice weak 
 
 * Bull, de la See. Anat. de Paris, 1861, page 118 ; by M. 
 Brichetau. , 
 
 t M. Le Moyne ; Contrib. a I'Etude de rOcclusion Intestinale. 
 These de Paris, 1878. 
 
 4: Dr. Kemot; Path. See. Trans., vol. xv., page 101. 
 
 § M. Terrier ; Bull, et Mdm. de la Soc. de Chir. de Paris, 1879, 
 page 564f 
 
Chap. IV.] Strangulation BY Bands. 85 
 
 and muffled. A cold sweat breaks out upon the sur- 
 face, and in extreme cases the limbs become cyanosed 
 and the complexion livid. The patient at last sinks, 
 retaining his intelligence, as a rule, to the last. 
 
 The pulse is small, often becoming thready, as in 
 23eritonitis, and of increased frequency. It commonly 
 rises to 120, 130, or 140. It may become much modi- 
 fied when opium is freely given. 
 
 The tempei'atiu'e is commonly throughout the 
 whole case subnormal, being the temperature of 
 collapse. Even when peritonitis sets in it may still 
 remain subnormal. In acute cases it may be found 
 to sink gradually, almost hour by hour, as the symp- 
 toms advance, and it may even continue to sink when 
 peritonitis has set in. A gradual increase in the 
 frequency of the pulse is often associated with this 
 depression of the bodily heat. As a rule, however, 
 the occiuTence of acute peritonitis has an appreciable 
 effect upon the temperature, provided that it has not 
 been set up by perforation, and may cause it to rise 
 from below normal to normal, and to reach 99° or 99 '6°, 
 or even 100°. When perforation occurs at the end of 
 a case of intestinal obstruction a profounder state of 
 collapse is as a rule at once induced, and upon the 
 sinking temperature the inflammation has no in- 
 fluence. 
 
 A rise of temperature above the normal in a case 
 of acute strangulation of the bowel may be said to, in 
 all cases, indicate the appearance of peritonitis. 
 
 The respii'atiojis are increased in frequency, 
 are superficial, and are often of a supracostal type. 
 In this form of obstruction the embarrassment to the 
 respiration caused by intense distension of the abdo- 
 men is very rarely met with. 
 
 The tongpiie is usually coated, being at first white 
 and then becoming diy and brown. It exhibits, how- 
 ever, some few exceptions to this rule, as, for example, 
 
86 Intestinal Obstruction. [Chap. iv. 
 
 in a case in which the tongue on the tenth day of the 
 symptoms is described as being moist, white, and but 
 slightly coated. 
 
 There is usually a very offensive taste in the 
 mouth, especially after the vomited matters have be- 
 come stercoraceous. 
 
 Intense thirst is usually complained of, espe- 
 cially in cases where vomiting has been very profuse. 
 In one or two instances the occurrence of hiccup 
 throughout the progress of the case has been noted. 
 
 Urine. — The quantity of the urine is very com- 
 monly diminished, and in the most acute cases may 
 be entirely suppressed, the bladder being found 
 empty. As will be subsequently explained (chapter 
 XX.), the effect of internal strangulation upon the 
 renal excretion is brought about mainly through the 
 nervous symptom. A diminution, therefore, in the 
 amount of the urine is most marked in the most acute 
 cases, and in those attended by intense pain and 
 much collapse. In many instances the excretion of 
 the urine has been immediately increased on the 
 patient coming under the influence of opium. The 
 position of the obstruction in the small intestine has 
 no effect upon this symptom. It may be absent 
 when the strangulation concerns the jejunum, and 
 present when it involves the ileum. The significance 
 of this symptom is more fully dealt with in the chap- 
 ter just alluded to. 
 
 In only two cases was stranguary noticed. In 
 one of these the obstructing band was attached to the 
 bladder. In the other, so large a mass of empty coils 
 hung down into the pelvis that it may possibly have 
 pressed upon the bladder. The patient was a girl 
 aged ten, and the mass was found, during life, to 
 press upon the rectum. 
 
 In not a solitary case was tenesmus complained 
 of. 
 
Chap. IV.] Strangulation BY Bands. 87 
 
 In a single instance the patient became delirious 
 before death. He was a young man, the symptoms 
 were very acute, and death ensued in less than two 
 days. 
 
 In three cases out of the fifty the patients suffered 
 from cramps. In two of these the cramps were com- 
 plained of in the lower limbs, in the remaining case 
 in the jaws and hands. In all three examples the 
 symptoms of strangulation were very severe, and the 
 progress of the case rapid. The subject of muscular 
 spasm in connection with strangulation of the bowel 
 has been fully investigated by M. Berger."^ He finds 
 that the cramping pains are usually in the feet and 
 calves, that the symptom is limited to cases of severe 
 strangTilation, and is most common in adults. He 
 has collected fourteen cases where this feature was 
 noted. Eleven were cases of strangulated hernia, 
 two of strangulation by a band, and one of obstruc- 
 tion by a diverticle. 
 
 It is in a case of this kind, associated with cramps 
 in the limbs, attended by profound collapse, with a 
 cold skin and cyanosed extremities that the mistake 
 of diagnosing intestinal obstruction for cholera has 
 occurred. This error may well be made when the 
 strangulation has been preceded by an attack of 
 diarrhoea, t 
 
 There is a case reported by Dr. Peacock that is, I 
 should imagine, unique. It concerns a man, aged sixty- 
 five, who died collapsed, and in whose abdomen a small 
 knuckle of the ileum was found strangulated by a 
 band. The involved gut was gangTenous. The 
 patient is said to have been ill six days with constipa- 
 tion, but to have worked up to the morning of his 
 death. 
 
 *Bull. et Mem. de la Soc. de Chir. de Paris, vol. ii., 1876, 
 page 698. 
 
 t Bee case by M. Le Moyne, loc. cit. 
 
88 Intestinal Obstruction. [Chap. iv. 
 
 THE CONDITION OF THE ABDOMEN. 
 
 The abdominal walls remain flaccid, or in 
 their normal condition until such time as local ten- 
 derness becomes marked, or general peritonitis sets 
 in, or distension reaches a considerable degree. Even 
 in some cases where peritonitis was found after death, 
 the parietes appear to have retained their normal sup- 
 pleness to the end. 
 
 Meteorisni.— Distension of the abdomen is in 
 this form of obstruction comparatively slight. It 
 usually appears about the third day. In no case 
 could it be spoken of as excessive. The most extreme 
 instance of distension of which I find a record was 
 met with in a patient who was attacked with stran- 
 gulation of the bowel when suffering from chronic 
 tubercular peritonitis. It never approaches to the 
 excessive degree of distension met with in cases of 
 volvulus of the sigmoid flexure. It appears to be 
 least marked in the rapid cases, and especially in 
 cases attended by active peristaltic movements in the 
 bowels and extreme vomiting. Meteorism to attain 
 great magnitude requires the intestinal walls to be 
 paralysed, and the presence of colicky pains serves to 
 indicate that that paralysis has not yet supervened. 
 Excessive vomiting also must tend to keep the intes- 
 tine empty. 
 
 When peritonitis sets in the meteorism undergoes 
 a considerable increase. 
 
 The swelling is usually first noticed in the epigas- 
 tric and umbilical regions, and may form a very 
 distinct elevation of the parietes in those districts. 
 The regions of the colon remain flat, the meteorism 
 being, of course, limited to the lesser bowel. When, 
 however, the distension has reached any magnitude 
 it practically occupies the entire abdomen. In one case 
 there was very visible distension of the transverse 
 
Chap. IV.] Strangulation BY Bands. 89 
 
 colon, but in this instance the great omentum had 
 been much dragged upon. The connection between 
 these two circumstances is discussed elsewhere (chapter 
 vi.). 
 
 On percussion the abdomen is found to be equally 
 resonant all over, although early in the case there 
 may be less marked resonance or absence of resonance 
 in the region of the colon. That part of the bowel 
 must soon, however, become overlapped by the dis- 
 tended small intestine. 
 
 A careful examination of the abdomen toy 
 palpation usually reveals nothing, and a digital ex- 
 ploration of the rectum gives equally negative results. 
 
 There are, however, some remarkable and rare 
 exceptions to these latter statements. (1) Some local 
 dullness may be discovered in the otherwise tympanitic 
 abdomen ; (2) a tumour or swelling may be detected 
 through the parietes ; and (3) something may be re- 
 vealed by an examination of the rectum. 
 
 It may be conceived that a localised area of dull- 
 ness on percussion may possibly be due to one of 
 three things : to an extravasation into the peritoneal 
 cavity ; to large coils of gut involved in the strangu- 
 lation ; or to the empty loops of bowel that may lie 
 below the point of obstruction. With regard to a 
 definite swelling or tumour, it will be reasonable to 
 conclude that it could depend upon the second only 
 of these possible causes. It must be no matter of 
 surprise that both these phenomena (the dullness on 
 percussion and the swelling) are very rare. Much 
 effusion of fluid in the peritoneal cavity is very un- 
 common in these cases and has not the least tendency 
 to become localised in any way. Extravasations of 
 blood do take place, but never, I believe, attain such 
 magnitude as to be the cause of dullness on percus- 
 sion. In the second place the involved bowel is often 
 a mere knuckle, and is very commonly found against 
 
90 Intestinal Obstruction. [Chap. iv. 
 
 the posterior abdominal wall or within the pelvis. 
 In any case it is very apt to be covered over by the 
 distended coils above the obstruction. In the third 
 place the empty coils of intestine below the site of 
 the incarceration are found, with comparatively few 
 exceptions, to hang down into the pelvic cavity, and 
 to be thus removed from examination. 
 
 (1) Localised dullness on 2)e7'cussio7i, and (2) a 
 tumour felt through the parietes. — In my fifty cases 
 I find only seven examples of the first phenome- 
 non and four of the second. With one exception, 
 the dullness was localised in the right iliac region, 
 the rest of the abdomen being tympanitic. In 
 every instance it corresponded to the site of some 
 tenderness on pressure. In one case it was due to 
 the matting together of the ileum and caecum by 
 adhesions. In all the other examples it was caused 
 by the engorged coil involved in the strangulation. 
 This coil was always large, varying from eight inches 
 in one case to two metres in another. In the excep- 
 tion above alluded to the patch of dullness was just 
 to the right of the right rectus muscle. It was 
 caused by a loop of strangulated jejunum. 
 
 The tumour detected through the parieties was 
 in each case caused by large loops of the intestine 
 engorged by strangulation. In one example the 
 incarcerated coil was filled with blood. In three cases 
 the swelling was felt in the right iliac fossa. In the 
 fourth case it was in the middle line and extended 
 from near the navel almost to the pubes ; it was not 
 observed until after the general distension had been re- 
 lieved by the trochar, and was caused by a large coil of 
 bowel strangulated by a diverticulum adherent to the 
 umbilicus. The swelling seems to have been, in each 
 example, ill-defined, dull, tender, and about the size of 
 the fist. It is remarkable that in every instance the 
 mass was not felt until towards the end of the case. 
 
Chap, v.] Strangulation BY Bands. 91 
 
 or was discovered rather towards its conclusion than 
 its commencement. 
 
 (3) A tumour felt through the rectum. — Although 
 extensive coils of empty and flaccid intestine are often 
 found hanging inertly into the pelvis, I know of only 
 one instance where they were felt during life. This 
 occurred in Mr. Hill's case already quoted (page 82). 
 Here a soft round mass was felt through the rectum, 
 and was found to press upon its anterior wall. 
 
 In only three cases out of fifty were any coils of 
 intestine visible through the anterior ahdoviiiuil 
 parietes. One was a case of acute obstruction 
 associated with a remarkable paroxysmal pain and 
 demanding laparotomy on the third day. The other 
 cases pursued a chronic course, death ensuing on the 
 thirteenth and fourteenth days respectively. The 
 movement of the intestinal coils were visible in both 
 of these examples, in the former case on the tenth 
 day, in the latter on the seventh. One of the patients 
 is described as being much emaciated. 
 
 These cases form but a feeble exception to the rule " 
 that visible peristaltic movements are met with only 
 in cases of chronic obstruction. 
 
 CHAPTER Y. 
 
 STRANGULATION BY BANDS OR THROUGH APERTURES 
 
 COURSE AND PROGNOSIS. 
 
 The coiu^se pursued by this form of obstruction is 
 always more or less acute and, so far as is at present 
 known, every case, unless relieved, ends in death. 
 
 The duration of any given case depends, I think, 
 neither upon the age of the patient nor the situation 
 of the obstruction in the lesser bowel, but upon the 
 
92 Intestinal Obstruction. [Chap. v. 
 
 tightness of the strangulation and the amount of 
 bowel involved. The most rapidly fatal cases are 
 those in which a considerable quantity of intestine has 
 been severely strangulated. The two conditions must be 
 combined ; for in some of the least acute cases large 
 coils have been found to have been involved, but only 
 moderately compressed. As a solitary factor, the rigour 
 of the incarceration is the most important in bringing 
 about a rapidly fatal termination. The larger the coil 
 so involved the more severe the manifestations. 
 
 A sudden onset of symptoms need not mean a 
 very rapid course. Some of the examples of abrupt 
 onset sliow^ a period of ten to thirteen days before death 
 ensued. As a rule, however, the more gradual the 
 development of the symptoms the longer is the 
 probable duration of the case. 
 
 Since in snaring by loops or knots larger coils are, 
 on an average, involved than in the case of strangula- 
 tion under a band, it follows that the progress of the 
 malady is more rapid in the former variety of 
 strangulation than in the latter. In the former class 
 of case, moreover, the incarceration is usually more 
 complete and more rigorous. Thus the average dura- 
 tion until death, in a case of strangulation under a 
 band or through an aperture, is six days. The 
 average duration in a case of snaring, whether by 
 a false ligament or by a diverticle, is four days. 
 Some of the most acute cases led to death in ten, 
 seventeen, and twenty-four hours, while in the least 
 severe instances life was prolonged to the thirteentli, 
 fourteenth, and fifteenth day. Opium, if given 
 in large doses, has, as already stated, a considerable 
 effect upon, the progress of any given case. Under 
 its use the pain and vomiting have greatly diminished, 
 the pulse has improved, the temperature has risen, 
 and the patient has been placed apparently in a much 
 more favourable condition. 
 
Chap, v.] Strangulation by Bands. 93 
 
 Many of the patients die simply of collapse, others 
 die later of exhaustion brought al^out l)y the intensity 
 of the pain, the severe vomiting, etc. ; others die of 
 acute peritonitis. 
 
 Peritonitis is not very commonly found in this 
 form of strangulation of the bowel. It is met with 
 in a little more than one half of the cases. The period 
 of its onset and the conditions under which it ap- 
 pears vary greatly. It has been recorded as present 
 in a patient who died in seventeen hours after the 
 commencement of the obstructive attack, while it 
 has been found to be entirely absent in another case 
 where the individual lived fourteen days. The average 
 time for its appearance is about the fifth day. 
 
 Perforation of the bowel above the seat of obstruc- 
 tion is quite nncommon, and would not appear to 
 occur in more than 10 or 12 per cent, of all the cases. 
 It has caused death as early as the fifth day. 
 
 In speculating as to tlic possibility of spon- 
 taneous recovery in cases of this form of strangula- 
 tion of the bowel, one cannot fail to note that patients 
 who have ultimately died of acute obstruction have 
 sometimes had previous attacks that, so long as they 
 lasted, were as severe as the final one. It would not be 
 unreasonable to assume that these previous disturbances 
 were, in some cases at least, brought about by the same 
 mechanism that caused at last the fatal attack. If so, 
 they may prove to be instances of spontaneous relief 
 of an acute obstruction. Then, again, an isolated case 
 or so has been recorded where patients were attacked 
 with symptoms of intestinal incarceration that could 
 not be diagnosed from like attacks known to be due 
 to " bands." These patients, after being almost in 
 articulo mortis, after vomiting feculent matter for 
 days, after presenting the phenomena of absolute 
 obstruction, have at last recovered. So far as I am 
 aware, no autopsy at a subsequent date has made clear 
 
94 Intestinal Obstruction. [Chap. v. 
 
 the nature of such cases, and therefore that they 
 may have been cases of strangulation by bands must 
 be a matter of pure conjecture. 
 
 In the face of instances like these it is well to 
 observe what light the post-mortem examination of 
 fatal cases can throw upon this question of spon- 
 taneous relief. There is not the least reason for 
 supposing that the bowel, when it has been strangu- 
 lated for a certain length of time, has the least power 
 of removing itself from the constricting agent. What 
 we know of strangulated hernia would support this 
 impression. There is a circumstance, however, under 
 which sjDontaneous reduction may occur in cases of 
 incarceration of recent standing. It is when a loop of 
 gut has passed beneath a band and has then become 
 so twisted as to have its lumen closed. In such a 
 case sudden and severe symptoms may appear and 
 yet the band without the volvulus may not suffice to 
 strangulate the gut. As the muscular vigour of the 
 gut becomes impaired, or is rendered feebler by the 
 action of opium, it is possible to conceive that the 
 volvulus may untwist and the coil escape from the 
 band that never held it other than slightly. This 
 may be the explanation of some of the " previous 
 attacks " noted in cases of fatal strangulation. 
 
 AVhen the strangulation is well advanced recovery 
 by this means must be practically impossible. I have 
 alluded to two cases where the involved gut was found 
 to be partially reduced after death ; but in these cases 
 the reduction had been effected by the sudden relief to 
 distension caused by a perforation. The very cause 
 that brought the relief but served to hasten the 
 appearance of death. 
 
 One possible factor in spontaneous recovery may 
 be the giving way, from gangrene, of the constricting 
 band. Post-mortem examinations afford some support 
 to any theory based upon this circumstance. Many 
 
Chap, v.] Strangulation- bv Bands. 95 
 
 of the bands that cause obstruction are very thin, and 
 have but a poor blood supply. They must be greatly 
 compressed when they produce incarceration, and yet 
 experience shows that they usually outlive the too 
 vascular bowel. There are, however, cases where the 
 patient seems to have been very near a prospect of 
 spontaneous recovery when death occurred. Among 
 these are the following : In one case of lapar- 
 otomy performed on the third day of the acuter 
 symptoms, the band on being handled was found 
 to be so slender that it broke as it was being 
 lifted up."^ In two other cases a diverticulum that had 
 caused obstruction was found to be so softened that it 
 was partly torn away from its point of origin, f In 
 another case of laparotomy, that ended in cure, the 
 diverticulum was more livid than the gut that it was 
 compressing; and lastly,! Dr. Servier quotes an 
 instance where the constricting band was gangrenous 
 and on the point of rupturing. § 
 
 In connection with the question of diverticula 
 becoming gangrenous, it must be borne in mind that 
 such an event may, instead of leading to cure, lead to 
 death by perforation should the gangrenous part of 
 the process be pervious. Indeed, the tearing away of 
 the diverticle has caused fatal peritonitis, and Cazin 
 notes a case where, througli the rent so formed, some 
 metallic mercury that had been administered found its 
 way into the peritoneal cavity. 
 
 A specimen in St. Thomas's Hospital Museum j| 
 shows another possible means of escape, although a 
 very remote one. The specimen consists of a part of 
 the small intestine of a dog, around a knuckle of which 
 
 * Bull, et Mem. de la Soc. de Cliir. de Paris, 1879, page 564. 
 + Dr. Hilton Fagge, loc. cit. ; and Dr. Wilks, Path. Soc. Trans., 
 vol. xvi., page 126. 
 
 t Bull, et Mem. de la Soc. de Chir. de Paris, 1881, page 210. 
 § De rOcclvision Intestiuale, page -12. Liege, 1871, 
 II No. Q 7. 
 
96 Intestinal Obstruction. [Chap. vi. 
 
 Mr. Travel's had, during life, firmly tied a ligature. 
 The animal died on the third day. The ligatured part 
 had separated and was found in a kind of cyst formed 
 by lymph from the peritoneum. Into this cyst the 
 two ends of the bowel opened so that the integrity of 
 the tube was practically restored. It is conceivable 
 that such a circumstance may occur in a young human 
 subject when only a small knuckle of gut or a part of 
 the circumference of the gut is very tightly strangu- 
 lated. 
 
 It is not impossible that in a favourable case the 
 canal of the intestine may be completed after ob- 
 struction by the formation of a " fistula bimucosa " 
 such as has been formed in some cases of strangulated 
 hernia. 
 
 From the above speculations the conclusion may 
 safely be drawn, that while spontaneous relief in acute 
 obstruction may not be impossible, it must at least be 
 excessively rare. 
 
 CHAPTER YI. 
 
 ANOMALOUS FORMS OF OBSTRUCTION DUE TO ISOLATED 
 BANDS AND TO ADHESIONS. 
 
 Under tins headiiig may be grouped a remarkable 
 series of cases, all more or less infrequent, in which 
 an obstruction has been brought about by means of an 
 adherent diverticulum, or by an isolated band, or by 
 more extensive adhesions, but where the mechanism 
 of the occlusion is unlike that involved in the class 
 just described. 
 
 These cases are united by a common pathological 
 bond, while clinically they present conspicuous differ- 
 ences. Unlike the form of obstruction just discussed, 
 
Chap. VI.] Strangulation over a Band. 97 
 
 they involve the large bowel with almost as great a 
 frequency as they involve the small. 
 
 These anomalous cases may be classified under the 
 following headings : 
 
 1. Strangulation over a "band. 
 
 2. Gcclusion brouglit about by acute "kinldng due to traction 
 
 upon an isolated band or an adherent diverticulum. 
 
 3. Occlusion effected by udliesiuns which retain the bowel 
 
 in a bent posiiion. 
 
 4. Obstruction by means of adhesions that compress the gut. 
 
 5. Obstruction by the matting toffcther of several coils of 
 
 intestine. 
 
 6. Obstruction by changes effected in the intestinal walls 
 
 due to simple traction. 
 
 7. Narrowing of the bowel from shriiilctng of the mesentery 
 
 after inflammation. 
 
 1. StraiigiilatioiA over a band. — If several 
 coils of a thin indiarubber J)ipe, through which water 
 was flowing, were thrown over a tightly drawn wire, 
 the lumen of the tube would become more or less 
 completely occluded at the spot where the wire was 
 crossed. It is conceivable that a similar circumstance 
 may be met with in the abdomen when a long loop of 
 intestine is thro^vn across a more or less rigid band. 
 Here the weight of the dependent loops would act as 
 a compressing agent, and the interference with the 
 circulation in the mesenteric vessels would induce an 
 engorgement of the involved bowel. It is difficult, 
 however, to understand how such a form of obstruction 
 could occur in the living subject without some 
 arrangement of parts that would permit the dependent 
 coils to retain their position. One would imagine 
 that a little vigorous peristaltic movement would 
 soon overcome the occlusion, on the one hand, and 
 withdraw the intestine from its abnoimal situation, on 
 the other ; although it is more than probable that the 
 intestinal contents could enter the involved loop with 
 much more readiness than they could leave it. I have 
 H— 12 
 
98 Intestinal Obstruction. [Chap. vi. 
 
 found records of four cases where this form of ob- 
 struction seems to have taken phice, and in one only 
 is the mechanism of the occlusion uncomplicated. In 
 the simplest case a diverticular band passed from the 
 ileum to the umbilicus, and over it a coil of ileum 
 from two to three feet in length was found to have 
 been flung and to be hanging suspended. This coil 
 was intensely congested, and numerous extravasations 
 had taken place beneath its serous coat. Symptoms 
 of obstruction appeared suddenly during perfect health, 
 and the patient only lived ten hours.* In two other 
 instances an extensive loop of the lower ileum 
 had passed through a hole in the omentum. The 
 loops were black with congestion, and were hanging 
 down into the pelvis. In one case the coil was fixed 
 in this position by recent adhesions. In neither of 
 the cases was the obstruction effected by the aperture 
 itself, the gut being very readily withdrawn at the 
 autopsy. As the author of one of the cases (Dr. Fagge) 
 observes, the strangulation was not due to the narrow- 
 ness of the aperture, but to the hanging of the gait 
 over its lower edge. In both cases the symptoms 
 appeared suddenly ; in both acute peritonitis was 
 found at the post-mortem ; in both the patient lived 
 five days.f In the fourth case a diverticulum passed 
 to be attached to the umbilicus, and over it two loops 
 of the ileum, black with congestion, were suspended. 
 They w^ere found to be twisted upon themselves, and 
 it is impossible to say which was the primary and 
 most essential j^henomenon, the volvulus or the hang- 
 ing of the gut over the cord. The symptoms appeared 
 suddenly, acute peritonitis set in on the sixth day, and 
 the patient died on the ninth. \ 
 
 * De rOcchision Intestinale, by Dr. Lusseau. Paris, 1870. 
 t Bull, de la Soc. Anat., page 252; Paris, 1864; case by 
 M. Besnicr. And Guj-'sHosp. llcports, vol. xiv.; Dr. Hilton Fagge. 
 ; Path. 80c. Trans., vol. vii., page 205 ; case by I\Ir. AVurd. 
 
Chap. VI.] Acute Kinking. ^9 
 
 In a drawing of a case of strangulation by an 
 adherent diverticulum, given by Bouvier, it would 
 appear as if this form of obstruction had had great 
 influence in producing the fatal result.* 
 
 The four cases all occurred in males. The ages 
 were respectively 22, 45, and ^'b^ the fourth case being 
 met with in " a boy." 
 
 So far as can be judged from these few cases, the 
 symptoms resemble those of hernia-like strangulation, 
 a sudden onset, severe pain, excessive vomiting (be- 
 coming stercoraceous in at least one instance), and 
 absolute constipation. In the case fatal in ten hours 
 there was diarrhoea and profound collapse. The main 
 points of difference between these cases and those of 
 incarceration under a band would appear to consist in 
 the less continuous character of the pain and in the 
 fact that the symptoms all advance with varying 
 intensity. These features are intelligible in the light 
 of the fact that the obstruction in these cases must 
 be comparatively incomplete, while the interference 
 with the blood circulation in the bowel would be 
 of a character to excite inordinate peristaltic move- 
 ments. 
 
 2. Occlusion by acute kiiLkiug due to 
 traction, — In these cases a band attached to the 
 bowel so drags upon its point of attachment that the 
 gut becomes acutely bent at this spot, and is ulti- 
 mately occluded by a process akin to the kinking that 
 may close an indiarubber tube (Fig. 1 8). This condition 
 is usually met with in the case of a diverticulum or 
 diverticular ligament attached to the umbilicus, or in 
 instances where an isolated adhesion is connected with 
 the ileum on the one hand and some more fixed and 
 distant point on the other. The shortness of the 
 mesentery of the lower ileum favours the formation of 
 a kink in that part of the bowel. 
 
 *Bull. lie rAcad. de Med., tome xvi., page 083, 18-51. 
 
loo Intestinal Obstruction. [Chap. vi. 
 
 Dr. Reignier has shown that it is possible for an 
 unattached diverticle to cause obstruction by kinking, 
 if the process become much distended. He found 
 in the body of an infant a free diverticulum 7 centi- 
 metres long. On injecting 
 water into the gut above the 
 process, he found that when 
 the pressure was moderate the 
 diverticle simply became filled 
 and that the fluid passed 
 readily by it. When, however, 
 Fig. 18. the pressure was much in- 
 
 creased the process dilated 
 enormously, and so pressed upon the gut below its point 
 of origin as to bend the intestine tranversely and finally 
 occlude its lumen. "^^ He gi^'es a case in the j^erson of 
 a man, aged 22, that illustrates this experiment in 
 practice. This patient died after exhibiting for ten 
 days tlie symptoms of acute intestinal obstruction. The 
 autopsy showed a free diverticulum much dilated by 
 liquid faeces, and which had so acutely bent the gut 
 from w^hich it arose, that the lumen of the intestine 
 M-as quite closed. On lifting the divei-ticle and gently 
 pressing it the obstruction was at once overcome. 
 
 In cases of kinking by adherent diverticula and 
 bands it is probable that distension of the bowel may 
 be active in brinirinj; the obstruction about. ^Moreover, 
 distended coils of intestine may press upon the liga- 
 ment itself and so cause it to be stretched. 
 
 The following are examples of kinking produced 
 by isolated adhesions : In a case by Louis, a band 
 was found to pass between an o\arian cyst and the 
 lower ileum. When the cyst was emptied by the 
 trochar the band was stretched and so dragged upon 
 the bowel that it was closed, and symptoms of intes- 
 tinal obstruction developed. Heller reports a case 
 * Bull, (le la Soc. Anat., page 279. Paris, 1879. 
 
Chap. VI.] Acute Kinking. loi 
 
 where a loop of the lesser bowel was adherent to a 
 gravid uterus. After delivery the traction upon the 
 intestine was such that it became acutely bent and 
 occluded. " Warren saw a pedunculated subperitoneal 
 fibroid of the uterus so wedged in, in consequence of a 
 sudden change of position, between the wall of the 
 pelvis and a false ligament stretched from the lowest 
 part of the ileum to the uterus, that the former was 
 bent and occluded by the traction of the band attached 
 to it." * Dr. Hilton Fagge records the case of a little 
 girl, aged 9, in whose abdomen at the autopsy many 
 old adhesions were found resulting from a local 
 peritonitis set up by caseous degeneration of the 
 mesenteric glands. Some adhesions passed between 
 the sigmoid flexure and the ileum, others between the 
 latter bowel and the omentum ; while the mesentery 
 was so much shrunken as to bind the small intestine 
 closer to the spine. The immediate cause of obstruction 
 seems to have been due to a band that fixed the small 
 intestine to the liver, and that caused great angular 
 bending of the bowel. At this bend the empty and 
 the distended coils met, while above that point was a 
 perforation in the jejunum, f 
 
 One of the best examples of obstruction by kink- 
 ing due to an adherent diverticle is given by Dr. 
 Wilks. The process in this case was attached to the 
 umbilicus and had been so stretched, probably by the 
 meteoristic state of the gut, that it had become torn 
 and so had induced peritonitis. % The gut was normal at 
 the seat of the acute bend, as indeed it appears to 
 have been in all the cases belonging to this category. 
 In Dr. Wilks' case the dragging of the empty and 
 pendulous coils below the attachment of the diverticle 
 appears to have helped in maintaining the obstruction. 
 
 * Leichtenstern, loc. cit., page 530. 
 tPath. Soc. Trans., vol. xxvii., page 157. 
 X Ibid., vol. xvi., page 126. 
 
102 Intestinal Obstruction. [Chap. vi. 
 
 Dr. Quain* reports the following case iii a woman 
 aged 53: A large perinephritic abscess had been 
 opened, to the wall of which the descending colon 
 was adherent. The patient died with symptoms of 
 obstruction lasting twelve days. The adlierent colon 
 was found to have been so bent by the collapse of the 
 al)scess wall as to have become occluded. 
 
 So far as can be judged from the few cases pub- 
 lished, the sijmjjtoms due to kinking of the bowel 
 are very nearly identical with those of strangulation 
 under a band. 
 
 The onset is usually less abrupt and the progress 
 of the case less acute, patients living eleven, fifteen, 
 and twenty days in some instances. The sym^Dtoms 
 also are such as would suggest that the occlusion is 
 not absolute. Thus the pain, although severe, will 
 present very unequal degrees of intensity ; the -somit- 
 ing, although often incessant and distressing and 
 stercoraceous, may abate ; the meteorism, even in 
 cases of long duration, may be quite slight. The 
 constipation, moreover, although usually complete, 
 may yield a little, and the bowels be 0})ened by an 
 aperient even when the symptoms of obstruction 
 have lasted eight days, as in Dr. Fagge's case. 
 
 3. Occlusions by adhesions that retain 
 the boAvei in a bent position.— In these cases, 
 which concern both the large and the small intestine, 
 the gut is found to have become adherent to some 
 fixed point in such a way that a more or less acute 
 bend is produced. The site of the adhesion is on 
 the abdominal or pelvic parietes or the pelvic 
 viscera. It may be on the liver. The usual cause of 
 the adhesion is either pelvic peritonitis or hernia. In 
 the case of the rupture, the part of bowel adherent 
 is the same that occupied the hernia. The condition 
 is met witli, tlierefore, only after enteroceles, and only 
 " I'atli. Soc. Trans., vol, v., ^lage 179. 
 
Chap, vi.i Bending of the Bowel. 103 
 
 after such as have been stranguhited or inflamed. 
 The })o\v('l, presenting in any case some inflammation 
 of its serous coat, is reduced into the abdomen, and 
 instead of remaining free in that cavity, contracts 
 adhesions by means of its inflamed surface with some 
 otlier part of the 2)eritoneum. 
 
 In every case of this kind, so far as I am aware, 
 the adhesion of the bowel has been to the parietes 
 in the vicinity of the hernial orifice. 
 
 The bowel, having been recently herniated, usually 
 acquires an adhesion in a bent position, and when 
 so fixed often leads to further intestinal troubles, 
 in cases where strangulated or inflamed hernire have 
 been successfully reduced. 
 
 The condition usually occurs after femoral ruptures, 
 inasmuch as such hernia? are peculiarly prone to 
 become incarcerated or inflamed, while the com- 
 paratively small amount of gut they usually contain 
 favours the formation of these particular adliesions. 
 Among other, and less frequent, causes of these 
 attachments may be noticed peritoneal cancer, and, 
 so far as attachments to the liver are concerned, the 
 local trouble excited by gall stones. It is a singular 
 coincidence that pelvic peritonitis, femoral hernia, 
 peritoneal cancer, and gall stones are all much more 
 common in women than in men, and this serves to 
 explain the fact that the present form of intestinal 
 obstruction is practically limited to females. Out 
 of the fifteen cases that I have collected there is 
 one instance only in a male. In this isolated example 
 the adhesions had followed upon some local mischief 
 excited by tapping tlie bladder above the pubes.* All 
 the cases occurred in adults, the youngest patient 
 l)eing a woman of thirty (pelvic peritonitis), the oldest 
 M woman of fifty-nine (omental cancer). 
 
 * Dr. Briddoii ; Ncu- York Med. Jour., vol. xxxii., 1SS2, pasi-e 
 UG. 
 
104 Intestinal Obstruction. [Chnp. vi. 
 
 The involved gut is usually adherent at one 
 isolated spot only, and a single and simple angular 
 bend is thus produced. This is the condition met 
 with in those cases that depend upon hernia. In 
 other instances the attachment may he more extensive, 
 as in a case of Dr. Fagge's, where one foot of the 
 lower ileum was found adherent to the anterior 
 abdominal parietes as a result of omental cancer. 
 Moreover, the bends formed in the bowel may be 
 by no means simple. There may be several angular 
 bends, the loops being adherent at more points than 
 one, and made to assume the outline of the letter \^* 
 This arrangement may be still further complicated 
 by the matting together of the three bars of the 
 intestinal N, whereby the false position is perpetuated. 
 In one case where N-like bends were produced only 
 four inches of bowel were involved, so that the angles 
 formed were very acute and abrupt, f 
 
 A few examples may be given to illustrate the 
 varieties assumed l>y this form of intestinal obstruc- 
 tion. The convexity of the ascending colon may 
 become adherent to the o\'ary, and the gut be so 
 narrowed at the bend as barely to admit a crow-quill. \ 
 The transverse colon may become adherent to the 
 fundus uteri. § The rectum may attach itself to a 
 cancerous ovary, and present in consequence a very 
 angular bend. || The sigmoid flexure may adhere to 
 a uterus the seat of a malignant disease, and present 
 so abrupt a bend that fatal obstruction with symptoms 
 like those of volvulus may ensue.** 
 
 * Case by ^I. Cossy, quoted by M. Nouet ; De rOcchision 
 Intestinale dans ses Rapports avec les Inflammations pdri-uterines 
 chroniques. Paris, 1874. 
 
 t Louis ; Archiv. Gen. de Med., l^^ Serie, tom^e xiv., page 193. 
 
 i Ducliaussoy, M^m. sur I'Anat. Path, des Etrang. Internes, 
 1860. 
 
 ^ Dr. Hilton Fagge, loc. cit. 
 
 Ij Path. Boc. Trans., vol. xvi., page 197. 
 
 ** M. Cossy ; i\I<'m. de la Soc. d'Observat, 185*), tome iii. 
 
Chap, vi.j Bending of the Bowel. 105 
 
 The period of time that may intervene between 
 the formation of the adhesion and the occurrence 
 of symptoms of intestinal obstruction varies greatly. 
 In the case following aspiration of the bladder just 
 alluded to, evidences of ol)struction appeared within a 
 few days of the original lesion. In the great majority 
 of cases the intestinal symptoms do not make their 
 appearance until months after the initial peritonitis. 
 I think tliat in the cases due to hernia a somewhat 
 earlier appearance is usual, a matter in most instances 
 of weeks rather than of months. Sometimes years 
 have elapsed between the causative inflammation 
 and the symptoms of obstruction, such examples 
 being most usual in the large intestine. Many of the 
 patients have been the victims of chronic constipation 
 for years before the final occlusion occurred. At the 
 same time it must be noted that adhesions of the same 
 character as those now under consideration have been 
 met with in the autopsies of patients who presented 
 no marked intestinal symptoms during life. 
 
 The mechanism of the obstruction in these cases 
 varies, and may be conveniently considered under 
 three categories, taken in order of severity. 
 
 1. The gut at the adherent point may become 
 so bent that occlusion by kinking is produced. This 
 is, as a rule, met with in the lowest part of the colon. 
 The symptoms induced are severe and sudden in their 
 onset. Their abrupt development possibly depends upon 
 sudden occlusion at the bend, brought about by some 
 distension of the bowel, or some change in its position. 
 
 2. The bowel (a portion always of the small 
 intestine) is adherent over a small area, and symptoms 
 of obstruction follow from certain effects of traction 
 without conspicuous occlusion of the lumen of the 
 tube. It is certain that, so far as the lesser bowel 
 is concerned, mere adhesion over a limited district 
 tends to cause an impediment to the passage of matter. 
 
io6 Intestinal Obstruction. [Chap. vi. 
 
 The gut at the adherent spot cannot exercise its 
 peristaltic function. It becomes a more or less inert 
 segment in an active tube. If a little acute mischief 
 be excited about the seat of the adhesions, symptoms 
 of an acute or subacute character may arise, the 
 exact pathogenesis of which is a little obscure. That 
 form of rupture known as Littre's hernia throws 
 some light upon these cases. In this hernia the gut 
 is tightly held down, a part only of its circumference 
 is nipjDed, and yet symptoms of acute mtestinal 
 obstruction follow, the greater part of the lumen 
 of the bowel being at the time often quite unoccluded. 
 Supposing a patient to have a loop of intestine 
 adherent to the parietes, and that some little inflam- 
 matory trouble is excited about the adherent knuckle, 
 it would seem as if symptoms of subacute obstruction 
 could arise somewhat upon parallel lines to those that 
 produce the manifestations in Littre's hernia. In the 
 case following asi:>iration of the bladder some local ]ieri- 
 tonitis kejit up after the gut had become adherent was 
 apparently suflicient to lead, in combination with the 
 bent bowel, to rather acute evidences of obstruction. 
 In other instances violent peristaltic movements, such 
 as may occur during colic or diarrhoea, may cause a 
 rough dragging upon the attached intestine, and 
 so add, as it were, the fuse to a train already laid 
 and prepared. The effect of a little local peritonitis 
 in rendering a peritoneal obstruction an actual one 
 is often illustrated. As one example I might cite the 
 following : An old man was admitted into the London 
 Hospital under the care of my colleague Mr. Rivington. 
 The patient had received a blow upon the abdomen. 
 A few days after admission he developed symptoms 
 of acute obstruction, of which he died in less than two 
 days. At the autopsy the transverse colon was 
 found to be bent upon itself and retained in that 
 position by old adhesions. In no place was the lumen 
 
Chap. VI.] Bending of the Bowel. 107 
 
 of the bowel occluded. The peritoneum was healthy 
 save at one spot over the liver where there was a 
 little local peritonitis."^ 
 
 As regards the cases now under notice, it can only 
 be said that patients may die of more or less acute 
 obstruction, and exhibit at the autopsy an adherent 
 and bent intestine about which some little peritoneal 
 mischief is evident, while the lumen of the bowel is 
 at no point wholly or even nearly occluded. 
 
 3. The adherent bowel may offer a more or less 
 definite mechanical obstacle to the passage of its 
 contents. A part of the colon may present so sharp 
 and rigid a bend as to give to the involved intestine 
 the properties of a stricture. This condition is well 
 illustrated by a case reported by Dr. Owen Eees, 
 where the rectum was so involved.! In other 
 instances the bowel, and particularly the lesser bowel, 
 is adherent over a wide area, and the mere inertness 
 of the attached portion constitutes an obstruction. 
 This is well seen in those cases Avhere the bowel is 
 adherent,' in a contorted position, as when it assumes 
 an N-like outline and the limbs of the N are bound 
 together, or when sevei-al inches of it are blended in a 
 straight line with the parietes, as in Dr. Fagge's case 
 quoted above. Here the bowel above the diseased part 
 has not only to pass its own contents along, but has 
 to force them also through \h^ inert and adherent 
 segment. The longer this segment the more marked 
 the obstruction. When closely bound down, the 
 involved gut must be practically incapable of peri- 
 staltic movement, and must be to the rest of the bowel 
 as a piece of thin indiarubber tubing. Pathological 
 reports and museum specimens well illustrate this. 
 The adherent bowel is either of normal aspect or is 
 abnormally thin, while the intestine above it shows a 
 
 *ror an account of this case see par. 5 of this chapter. 
 \Mcd. Times and Gazette, vol, i., 1869, page 436. 
 
io8 Intestinal Obstruction. [Chap. vi. 
 
 hypertrophy of its walls that may, in some instances, 
 be extreme."^ The gut, moreover, just above the 
 inert part often shows some ulceration of the mucous 
 membrane, due presumedly to the imtation of accumu- 
 lated matters. The hypertrophy is all in the muscular 
 coat and compares conspicuously with the thin walls 
 of the inert and adherent segment. Moreover, when 
 there is much angular bending of the gut the contents 
 of the bowel have to be not only forced through an 
 inert tube, but have to take a devious course and 
 encounter certain definite obstructions. 
 
 The symptoms associated with this form of ob- 
 struction will obviously show great variation. They 
 may assume an acute, or a subacute or a chronic 
 aspect, and may differ somewhat, according to whether 
 the occlusion is situate in the larcre or the small 
 intestine. 
 
 A. In the colon. — If the obstruction be due to a 
 sudden closure of the gut by kinking at the already 
 bent and adherent part the symptoms may be of a 
 very acute character. This condition appears to 
 most usually occur in connection with the sigmoid 
 flexure or rectum, and the manifestations produced 
 are identical with and cannot be distinguished from 
 volvulus of the former segment of the bowel. I 
 might give one illustration. A woman, aged forty-four, 
 was admitted into the London Hospital under my care 
 suffering from symptoms of acute obstruction. These 
 symptoms had appeared suddenly after taking an 
 aperient. They were precisely the symptoms of 
 volvulus of the sigmoid flexure. The patient had 
 been the subject of some constipation for years, and 
 had had attacks of colic occasionally. In twenty- four 
 hours after the onset the woman was in a precarious 
 condition. I performed laparotomy, but she died twelve 
 hours afterwards. The rectum was adherent to one 
 * See case by Louis quoted above. 
 
Chap. Vi.] Sending of the Bowel. 109 
 
 point of the pelvic wall in a bent position. The bend 
 here had become so extreme that the gut was entirely 
 occluded. The colon above was enormously distended, 
 and the sigmoid flexure reached to the right of and 
 above the umbilicus. On emptying the colon by 
 puncture, and breaking through the adhesions, the 
 passage in the bowel was soon restored. The cause of 
 the adhesion w^as a trifling stricture, which had helped 
 to make the sudden closure by kinking more complete. 
 
 The symptoms may be subacute, as in a case 
 reported by M. Cossy, where the sigmoid flexure was 
 adherent to a cancerous ovary. Here the final attack 
 lasted some eight or nine days, and was marked by 
 paroxysmal pain with idsible peristalsis, by slight non- 
 stercoraceous vomiting, and by constipation reKeved 
 by an occasional stool. In other instances the mani- 
 festations may be quite chronic, and may resemble in 
 all points those due to stricture of the rectum. A 
 case of this character has been reported by Mr. Heath. 
 He performed lumbar colotomy on the twentieth day 
 of the constipation. The rectum was adherent to the 
 uterus and ovary (which was the seat of cancer), and 
 was bent into a sharp sigmoid form."* 
 
 B. In the small intestine. — The symptoms when 
 the obstruction is in this part of the bowel may be 
 acute or chronic. A more or less typical example of 
 each form may be given. I saw, in consultation with 
 Dr. Towne of Kingsland, a woman, aged 58, who 
 three months previously had had some inflammation 
 about a small femoral hernia. The bowel was reduced 
 at the time, and, to her surprise, had never come down 
 again, nor given her any trouble. She was, when 
 seen, sufiering from intestinal obstruction; the onset 
 had not been sudden. She had much pain of a 
 markedly paroxysmal character. She vomited at first 
 at long intervals, bringing up large quantities of 
 *Patli. Soc, Trans., vol. xvi., page 197. 
 
i I O InTES TINA L ObS TR UC TION. [Chap. VI . 
 
 matter. As the case progressed the vomiting became 
 more frequent (every two or three hours) and 
 feculent. She had constipation that was absolute but 
 for one slight liquid motion passed during the first few 
 days of the attack. I performed laparotomy on the 
 seventh day, and found a coil of greatly distended ileum 
 adherent in a bent position to the vicinity of the 
 femoral ring. The adhesions retaining it were readily 
 broken down and the abdomen then closed. She 
 never vomited after the operation; a very copious 
 motion was passed on the fourth day and the patient 
 made a perfect recovery. 
 
 In Dr. Fagge's case, quoted above, where a foot of 
 the ileum was adherent to the parietes, the symptoms 
 lasted some five months. There was constipation that 
 alternated with diarrhoea, vomiting that appeared late 
 in the case, and that came on once or twice in the 
 twenty-four hours, the patient bringing up immense 
 quantities each time, and pain of a very marked 
 paroxysmal character. There was a dragging pain 
 about the lower part of the abdomen. The vomited 
 matters became stercoraceous six days before death. 
 
 It will be seen that in both cases there are 
 evidences of incomplete obstruction. The constipation 
 alternates with an occasional motion. In some of the 
 other less acute cases the patient, when not al>solutely 
 constipated, passed many scanty and very liquid stools. 
 The vomiting is not severe at first, and occurs at long 
 intervals. The abdominal pain is paroxysmal. There 
 is a dragging pain about the part to w^iicli the gut 
 is adherent. There is not much distension of the 
 abdomen. In the chronic cases the movements of 
 the intestinal coils are visible. 
 
 In one instance, where the ileum was adherent to 
 the ovary and formed many angular bends, an 
 irritable diarrhoea took the place of the more usual 
 constipation, and the patient only vomited twice 
 
fciiap. vi.i Compression by Adhesions. tii 
 
 during the month that immediately preceded her 
 death. Such a case hardly comes clinically under the 
 category of intestinal obstruction. 
 
 4. Obstructions t>y means of adhesions tliat 
 compress the g^ut.— Peritoneal adhesions, when 
 favourably placed, may undergo considerable contrac- 
 tion. When placed upon the bowel these false 
 membranes may, by their shrinking, so compress the 
 intestine as to seriously narrow its lumen. Exjoeri- 
 ence demonstrates a fact that might have been anti- 
 cipated, viz. that this form of constriction is most 
 usually met with about the most fixed segments of 
 the intestine, that is to say, about the ascending and 
 descending colon, and the hepatic and splenic flexures. 
 The process involved in certain of these cases where 
 the colon is concerned is intelligible enough. Thus, 
 says Leichtenstern, " A circumscribed, chronic, con- 
 stricting peritonitis is sometimes found at the flexures 
 of the colon. As the results of atony of the muscu- 
 lar coat repeated fsecal accumulations are found espe- 
 cially at the flexures, the points where the obstacles 
 to the advance of the fseces are greater. TJie 
 frequently repeated irritation of the peritoneum pro- 
 duced thereby excites chronic peritonitis, which may 
 result in constriction. In other cases the chronic 
 peritonitis starts from the concavity of the liver and 
 extends to the flexura hepatica ; it is set up at the 
 former point by gall stones, neoplasms, etc., or is the 
 continuation of a cirrhotic process in the liver, or of 
 a portal periphlebitis. In the left hypochondrium 
 we sometimes find, together with numerous splenic 
 adhesions and fibrous perisplenitis, the splenic flexure 
 adherent and constricted by chronic fibrous perito- 
 nitis."* In other instances the cause of the con- 
 stricting peritonitis is not so evident. An example of 
 such cases is afforded by a specimen in the London 
 * Loc. cit. , page 632. 
 
1 12 IntestiN'al Obstruction. [Chap. vi. 
 
 Hospital * (Fig. 22). Here the ascending colon just 
 above the csecum is narrowed by an isolated patch of 
 contracting adhesions so as to produce considerable 
 stenosis. It is probable that in this case, and in 
 others like it, the limited peritoneal inflammation has 
 been induced by an ulcer of the mucous membrane, 
 although the evidence of this in the present specimen 
 is not clear. The association of cicatricial strictures 
 of the bowel with a constricting peritonitis is well 
 known, and is illustrated by a vast number of recorded 
 cases and museum specimens. A specimen in Guy's 
 Hospital affords a good example of a constriction at 
 the splenic flexure due to adhesions, f In some of 
 these instances the patient has given a history of a 
 previous attack of enteritis. 
 
 The extent to which the bowel is naiTow^ed in 
 these cases is often considerable. In some the aftected 
 colon would barely admit the tip of the little finger. 
 In others it would only admit a crow-quill. 
 
 In a singular specimen from the College of 
 Surgeons Museum, one of the appendices epiploicae 
 has contracted such an adhesion to the attached 
 omentum as to cause constriction of the bowel. | 
 
 I have found but few examples of this form of 
 obstruction in the small intestine. In every instance 
 there has been some complication in the case. The 
 affected bowel is always adherent to the parietes or 
 to the pelvic viscera. In two cases reported by Dr. 
 Fagge (in one of which the ileum was involved and 
 in the other the jejunum) adhesions existed elsewhere, 
 and the final obstruction was complicated by angular 
 bending of the intestine about the point of its at- 
 tachment.§ Mr. Gay has reported a case where eight 
 
 * London Hospital Museum, No. Ae. 84. 
 t Guy's Hosp. Museum, No. 1,852. 
 t Coll. of Surgeons Museum, No. 1,302. 
 f Loc. cit. 
 
Chap, vf.] Matting of the Bowels. 
 
 ^^3 
 
 inches of tlie ileum were adherent to the fundus of a 
 uterus '' in a state of scirrhous degeneration." The 
 intestine so involved was so narrowed as to barely 
 admit a goose-quill.* It is doubtful if this case would 
 fall under the present category. 
 
 As regards the symptoms incident to this vaiiety 
 of obstruction, it can only be said that they more or 
 less completely resemble those due to stricture of the 
 bowel. In the case of the colon this assertion may be 
 made without reservation. In the case of the small 
 intestine the manifestations of the disease appear to 
 exhibit a more rapid development than is usual in 
 stricture, the permanent stenosis being complicated by 
 the effects of angular bending. 
 
 5. Obstriictioii hy tlie iiiattiiBs; to^ethor of 
 intestinal eoils.— The many cases that can be 
 classed under this category present a protean aspc-ct. 
 
 1. The small intestine. — The coils 
 of the lesser bowel may be matted together 
 in many different ways. In one set of 
 cases a small segment of the gut is so 
 adherent as to form a permanent and un- 
 changing loop. In another set of cases, 
 many coils, involving often a considerable 
 tract of the intestine, are matted together 
 so as to form more or less complicated 
 masses. In both instances the involved 
 coils are usually quite free from adhesions 
 to the parietes or to other viscera. 
 
 In the Ji7'st set of cases a simple per- 
 manent loop is formed in the bowel. This 
 loop may be open, the walls of tlie gut 
 being adherent only at the extremities of 
 the loop (Fig. 19a and Fig. 20), f or it 
 may be closed, the walls of the involved bowel being 
 
 *Path. Soc. Trans., vol. iii., page 108. 
 
 t Guy's HosiJ. Museum Eeports, 183G, page 21. 
 
 1—12 
 
114 Intestinal Obstruction. [Chap. vi. 
 
 adherent in their entire extent (Fig. 19 b). The latter 
 variety involves a much smaller amount of intestine 
 
 Fig. 20. — Adhesions forming the Bowel into a Loop. 
 A probe Is introduced into a perforation in tbc intestine. 
 
 i-han does the former.* There are several distinct condi- 
 tions under which these distortions of the bowel may be 
 produced. Many are the results of hemise. If a coil 
 of good size be involved in a rupture and much 
 
 *For specimens of these loops see St. Bart.'s Hosp. Miiseum, 
 No. 2,100 ; Path Soc. Trans,, vol. x., case by Mr. Birkett ; and 
 St. Thomas's Hosp. Museum, Q No. 128. 
 
Chap. VI.] 
 
 Intestinal Loops. 
 
 ^'5 
 
 compressed by the hernial orifice, adhesions may form 
 at the point compressed, and a permanent open loop be 
 formed after the gut has been reduced. If the her- 
 niated coil be small (a mere knuckle) a closed loop 
 m^j result from the adhesions produced l^y inflamma- 
 tion of the serous coat. 
 
 Then again an ulcer of the mucons membrane may, 
 by inducing a limited peritonitis, lead to the forma- 
 tion of a loop. If the adhesions are scanty and iso- 
 lated, an open loop is produced as in Fig. 20 ; if 
 extensive, a closed loop as in the si^ecimen (N^o. Q 
 1 28) in St. Thomas's Hospital Museum. 
 
 In other cases the loop-prodncing adhesions are 
 the result of mesenteric gland disease, and I have seen 
 two preparations where a broken down or caseous 
 gland has occupied the angle formed by the two limbs 
 of the loop. 
 
 Sometimes a fistulous passage connects the cavities 
 of the two portions of bowel 
 at the root or narrow part 
 of the loop. Such a passage 
 is known as a fistula biniu- 
 cosa. They most frequently 
 result from idiopathic ulcers 
 of the intestine, but may 
 follow also from the destructive 
 processes induced by compres- 
 sion."^ 
 
 One of the most remarkable 
 cases of fistula bimucosa is 
 aftbrded by a report of Dr. Bris- 
 towe's in the Pathological So- 
 ciety's Transactions t (Fig. 21). 
 Here the transverse colon communicated with the ileum 
 at two points through a cavity whose walls were formed 
 
 *Path. Soc. Trans., vol. x. ; Mr. Birkett's case, 
 t Vol. xiv., 1863, page 201. 
 
 Fig. 21. — Fistula Bimucosa, 
 with formation of a Loop 
 in tlie Ileum. 
 
ii6 Intestinal Obstruction. [Chap. vi. 
 
 Fig. 22.— Stenosis of ascendingr Colon from the contraction of Peritoneal 
 
 Adhesions. 
 
Chap. VI.] Intestinal Loops. ii7 
 
 by firm adhesions. The patient died with symptoms 
 of phthisis and dysenteric diarrhoea, and there is 
 little doubt but that the primary mischief was caused 
 by a perforating ulcer of the transverse colon. 
 
 It does not appear that the open loop ever of itself 
 leads to definite obstruction. In cases where a fistula 
 bimucosa exists a fatal perforatioi). may form in the 
 gut above the seat of the sinus. This may be due to 
 fresh ulceration of the bowel formed independently of 
 any obstruction effects. In Mr. Birkett's example of 
 a fistula bimucosa following a strangulated rupture, a 
 like termination to the case ensued, although the 
 cause of the perforation in this instance was not evi- 
 dent. The open loop may become twisted, and so 
 cause obstruction, while it forms an excellent point 
 d'appui around which a normal coil may become in- 
 volved in a volvulus. Sir Astley Cooper, in his 
 treatise on hernia, mentions a case where " two folds 
 of intestine had adhered at one point only (as may be 
 represented by bringing the points of the thumb and 
 finger in contact). Through the noose thus formed 
 another fold of intestine had passed, and had become 
 strangulated." 
 
 The closed loop very usually leads to obstruction 
 of the intestine. Here the adherent bowel is so 
 acutely bent that a fold of mucous membrane projects 
 into the lumen of the intestine, and offers a valve-like 
 impediment to the passage of matters (Fig. 23 a). 
 The gut above the bend in time enlarges from disten- 
 sion until it forms an actual ampulla (Fig. 23 b) and 
 so renders the passage of the contents of the bowel 
 still more difficult. A remarkable case fully reported 
 by M. Nicaise "^ affords an example of this, and from 
 his case Fio^. 23 b is taken. In this case the 
 ampulla was so large that the lower segment of the 
 
 *Bull. et Mem. de la Soc. de Chir. de Paris, tome vi., 1880, 
 page 582. 
 
ii8 
 
 Intestinal Obstruction. 
 
 [Chap. VI. 
 
 these 
 with 
 upon 
 
 bowel appeared to issue fiom the side of it rather than 
 from the end. The parts are compared by M. Nicaise 
 to the c?ecum and the entering ileum. The aperture 
 was valve-like, and just admitted the tip of the index 
 finger. The patient, a man aged twenty -five, had 
 
 been operated upon for a 
 strangulated inguinal hernia 
 five years before the fatal 
 obstruction came on. 
 The symptoms in 
 cases may be classed 
 those that depend 
 stricture of the lesser bowel^ 
 although they are perhaps 
 liable to more acute modes 
 of termination."^ In M. 
 Nicaise's case the patient 
 had been troubled during 
 the five years that followed 
 the reduction of his hernia with attacks of colic, with 
 occasional vomiting and with diarrhoea, alternating 
 with constipation. Eight days before the man's 
 death, which occurred shortly after an enterotomy 
 had been performed, he was seized with somewhat 
 acute symptoms associated with much vomiting, with 
 occasional action of the bowels, but with no abdominal 
 tenderness, and with little jDain. The movements of 
 the intestinal coils were visible through the parietes. 
 The fatal issue had probably been provoked by the 
 administration of purgative medicines which had 
 hurried much intestinal matter into the amjjulla and 
 so produced the obstruction. 
 
 Apropos of these cases, one might notice an 
 
 B 
 
 Fig. 23. 
 
 * M. Bricheteau (Bull, de la Soc. Anat. Je Paris, 1862, page 
 257) rwjiorts a case of occlusion by a closed loop, the exact cause of 
 ■which is obsciH-e, where the patient died with acute symptoms in 
 twelve days. 
 
cW- VI.] Matting of the Bowels. tip 
 
 instance of obstruction of the lesser bowel by a large 
 gall-stone where the gut at the obstructed point was 
 bent upon itself and the bend retained in a fixed 
 position by adhesions, apparently of recent formation.* 
 In the second set of cases, alluded to at the com- 
 mencement of this paragraph, certain coils of the 
 intestine are found matted together in a confused 
 mass. The condition is similar to that met with in 
 chronic tubercular peritonitis, from which, however, 
 it must be distinguished. The tubercular affection 
 involves the whole mass of the intestine and is a 
 diffused process. In the present set of cases the 
 causative peritonitis is quite local and only a portion 
 of the lesser bowel is involved. The adherent coils 
 usually form a roundish mass, which may be almost 
 as distinct as a tumour, and which compares con- 
 spicuously w^ith the uninvolved and normal bowel. 
 The matted intestine may also be adherent to the 
 parietes, or it may be quite free. Sometimes the 
 matting is brought about by a multitude of isolated 
 adhesions. In other cases the coils are enveloped in 
 fine membranous adhesions so that they may appear 
 as if enclosed in a bag of tough tissue paper. An 
 example of this latter condition is afforded by Fig. 24. 
 Some of the coils in the mass may be of normal 
 lumen, others may be dilated, and many may be 
 compressed. They are commonly strangely distorted. 
 When obstruction has been caused, the bowel entering 
 the mass will be found dilated, w^hile that leaving it 
 will be more or less shrunken. The amount of gut 
 involved varies. It may be but a few inches, as in 
 a case reported by M. Julliard, where six inches only 
 were involved,! or it may be several feet as in an 
 
 *Dr. Van der Byl; Path. Soc. Trans., vol. viii., page 231. 
 An almost precisely similar case, minus the adhesions, is reported 
 by Dr. Draper, Neio York Medical Journal, 1882, j)agel7. 
 
 + Bull. et Mem, de la Soc. de Chir., Paris, tome v., 1872, page 
 627. 
 
120 
 
 Intestinal Obstruction. [chap. vi. 
 
 instance recorded by Dr. Bristowe, where nearly one 
 half of the ileum was found matted into a confused 
 mass.^ In several instances a part of the colon has 
 been involved in the adhesions, as was the case in a 
 specimen described by Mr. Sydney Jones, where the 
 coils of the lower ileum were not only matted together 
 but were adherent also to the ceecum.f 
 
 Fig, 24.— Diffused Peritoneal Adhesions. 
 
 Various forms of local peritonitis have led to this 
 condition of the bowels. It has followed after opera- 
 tions upon strangulated hernia, aftei* ovariotomy, 
 after pelvic peritonitis, and peritonitis due to other 
 lesions than operation wounds. In one case at least 
 the intestines were found matted together by a peri- 
 toneal inflammation induced by cancer of the bowel 
 itself. I 
 
 *Path. Soc. Trans., vol. viii., page 200. 
 
 •\L<n\cd, vol. i., 1883, page 818. 
 
 X Bull, de la Soc. Auat., 1877, page 473 ; M. Regeard. 
 
Chap. VI.] Matting of the Bowels. 12 1 
 
 The symptoms that arise are in tlie main identical 
 with those associated with stricture of the small in- 
 testine. The onset is gradual, the progress of the 
 malady is irregular, severe periodic attacks are com- 
 mon, and an acute termination to the case is not 
 unusual. Constijmtion is partial, and often alter- 
 nates with a copious diarrhoea. The vomiting is 
 usually slight, irregular in occurrence, and uncertain 
 in duration. During an exacerbation of the symp- 
 toms, and especially during a final acute attack, it 
 may become stercoraceous. In one case there was 
 constant feculent vomiting for fourteen days before 
 death. The pain, such as it is, is paroxysmal, the 
 intervals between the paroxysms decreasing as the 
 case advances. Early in the case there may be an 
 attack of colicky j^ain not more frequently than once 
 or twice a week. Towards its termination the 
 paroxysms may come on at intervals of a few minutes. 
 The patient usually emaciates, and the movements of 
 the distended and hypertrophied coils of intestine 
 above the obstruction are, as a rule, evident through 
 the parietes. There is little or no distension of the 
 abdomen unless an acute form of obstruction super- 
 vene, and even in such a case the meteorism is 
 usually by no means excessive. In two or three in- 
 stances the mass of adherent bowel has been detected 
 through the abdominal parietes as an ill-defined 
 tumour. That the tumour, however, may be some- 
 times very distinct is shown by a remarkable case 
 reported by Dr. Fleetwood Churchi]! in his work on 
 the " Diseases of Women." The patient in this in- 
 stance was a woman, aged twenty -three, who had a 
 tumour in the lower part of the abdomen on the left 
 side, that was dull on percussion. It was diagnosed 
 to be an ovarian growth. She had never had any 
 intestinal symptoms. The abdomen was opened by 
 an operation intended to be an ovariotomy, but the 
 
t22 Intestinal Obstruction. [ciiap. vi. 
 
 tumour was found to be composed of many coils of 
 intestine matted together by old adhesions. Tlie 
 wound was closed and the patient recovered. 
 
 This form of obstruction seems to be as common 
 in men as in women. 
 
 The duration of the cases when once symptoms 
 have appeared varies, and may be reckoned in months 
 rather than in weeks. In one case due to peritonitis 
 intestinal symptoms were present for four years 
 before a final and acute attack came on which ended 
 in death. During the four years the patient had 
 been liable to colicky pains, and to an obstinate constipa- 
 tion, which at the end of two years changed to an 
 equally obstinate diarrhoea. In other instances symp- 
 toms resembling those due to stricture of the lesser 
 bowel had existed for two, three, four, and six months 
 respectively. As a rule they made their appearance 
 very soon after the causative peritonitis. In one 
 case, reported by Dr. Fagge, the patient died with 
 symptoms of obstruction that had continued for 
 twelve days after the relief of a strangulated hernia 
 by operation. Here coils of gut were found matted 
 together, but the cause of death was due most pro- 
 bably rather to the direct damage to the bowel in- 
 flicted by the strangulation, and to the peritonitis, 
 than to the adhesions. These latter had formed since 
 the operation. 
 
 As Dr. Churchill's case shows, even an extensive 
 matting together of intestinal coils need not be 
 attended by any evidences of intestinal disturbance. 
 
 2. Tlie larg^e iiitestiue.— The colon being a 
 more or less fixed part of the bowel, it follows that it 
 is not susceptible to quite the same morbid conditions 
 as have just been described as frequent in the lesser 
 bowel. As a result, however, of distension, parts of 
 the colon may become greatly elongated, and the 
 abdominal coils thus formed may become matted 
 
Chap. VI.] Matting of the Bowels. 123 
 
 together by adliesions. The eftects of colic distension 
 are often well seen in the bowel above the seat of 
 a chronic obstruction. 
 
 I can find no case where the descending colon, 
 the most fixed part of this bowel, is stated to have 
 altered its position to any conspicuous extent as a 
 result of distension."^ In one instance a dilated 
 ascending colon appears to have become so curved that 
 its convexity was found to be adherent to the ovary, f 
 The sigmoid flexure when distended is apt to stretch 
 towards the right iliac region, and then to mount 
 up into the right hypochondriac region. The two 
 limbs of the dilated loop may be found matted to- 
 gether, or the summit of the loop may be found 
 adherent to the csecura, to the peritoneum in the 
 right iliac or hypochondriac regions, or even to the 
 under surface of the liver. The transverse colon 
 undergoes a peculiar and common change when much 
 distended. Its central point tends to pass down- 
 wards towards the pelvis, so as to produce a V or'U- 
 shaped bend (Fig 25, b). The apex of the V or the 
 bend of the U may become adherent to the mesentery, 
 or to the peritoneum about the pelvis, or to a pelvic 
 viscus, such as the fundus of the uterus. | One limb 
 of the V may become adherent to the whole length of 
 the ascending colon, § and so produce a '' double- 
 barrelled ascending colon," or the other limb may 
 attach itself to the descending colon in a like fashion, 
 and produce a similar appearance on the left side. || 
 
 * Mr. Ctu'ling reports a case of stricture of tlie rectum where 
 the " descending colon " is said to have been coiled upon itself, 
 and to have reached the right iliac fossa ; but the gut in question 
 appears to have been rather an immense sigmoid flexure (Path. 
 Soc. Trans., vol. x., page 157). , 
 
 t Duchaussoy ; Mem. sur I'Anat, path, des Etrang. internes, 
 1860. 
 
 X ]\Ir. Shaw; Path. Soc. Trans., vol. iv., page 147. 
 
 § Dr. Hilton Fagge, loc. cit. 
 
 II Bte case of George Luff (page 125). 
 
124 
 
 InTES TINA L ObS TR UC TION. 
 
 [Chap. VI. 
 
 (Fig. 25, c and d). In most cases this deformity 
 of the colon has been the result of chronic obstruction 
 in the lower part of the bowel, such as a stricture 
 of the sigmoid flexure or rectum. 
 
 In a few instances it would appear that the V- 
 shaped bend may be rapidly produced. Thus, in a 
 
 case of volvulus of the sig- 
 moid flexure in a woman, 
 aged twenty-seven, that 
 ended fatally in four days, 
 the transverse colon was 
 found to have descended 
 in an angular loop as far 
 as the pubes."^ It is quite 
 common at autopsies to 
 find this ansfular bend in 
 the arch of the colon with- 
 out intestinal obstruction 
 p Q of any kind or at any part. 
 
 Pig. 25. Such examples may be the 
 
 result of chronic constipa- 
 tion, and so far as my experience extends are mostly 
 met with in the aged, in those over sixty more often 
 than in those whose ages fall between fifty and sixty, f 
 There are cases where one limb of the bent colic 
 arch is found adherent to the ascending or descending 
 colon for its entire length, but where no obstruction 
 of any kind is found in the gut below the distorted 
 segment. I am disposed to ])elieve that such cases 
 d(^pend upon ulceration of the colon. The ulceration 
 leads to peritonitis, distension and distortion of the 
 transvcr.sc colon may follow, and then a part of the 
 altered arch may become adherent to the inflamed 
 
 * Dr. Fagge, loc. cit. Assuming that the bend was not con- 
 genital. 
 
 t In several cases, appearing in young patients especially, there 
 id no doubt but that the distortion of the colon is congenital. 
 
Chap. VI.] Matting of the Dowels. 125 
 
 serous coat of the ulcerated bowel. Thus, in the case 
 reported by Mr. Shaw, the position depicted in Fig. 
 25 c was found, and along the whole length of the 
 colon were discovered the cicatrices of ulcers. It 
 is a conspicuous fact that in these cases no adhesions 
 ai'e usually found except between the two united 
 segments of the colon. The deformity of the 
 ascending colon and of the sigmoid flexure above 
 alluded to is due probably in all cases to distension 
 following obstruction lower down in the bowel. 
 
 No abdominal symptoms may be excited by these 
 conditions of the colon, although there is more usually 
 some evidence of simple chronic constipation. The 
 matting of the sigmoid flex\u"e in the way described 
 is very apt to lead to volvulus of that part ; and in 
 the case of the deformed and adherent colic arch more 
 or less acute obstruction may supervene from occlusion 
 by kinking. 
 
 In Mr. Shaw's case subacute symptoms set in. 
 The patient, a man aged sixty-three, had had severe 
 constipation for some three weeks before his death. 
 He obtained some relief by aperients, but for the last 
 seven or eight days of his life the constipation had 
 been absolute. He vomited ; his abdomen was dis- 
 tended and tender and the seat of colicky pain. He 
 died the day after a right lumbar colotomy had been 
 performed. The case was complicated by tlie presence 
 of a fistula bimucosa between the ascendintf colon 
 and the jejunum. This accounted for the stercoraceous 
 vomiting that set in some three or four days before 
 death. 
 
 The following case may be quoted as presenting 
 several points of interest : 
 
 George Luff, aged seventy-three, was admitted into the 
 London Hospital on September 11th, 1882, with a fracture 
 of the femur and a contusion over the region of the liver, the 
 results of a fall. He is said to have never had any abdominal 
 
126 Intestinal Obstruction. [Chap. vi. 
 
 troubles and to have enjoyed good health. His bowels were regu- 
 lar. On the 14th he vomited a little. On the 19th he developed 
 some evidences of local peritonitis about the seat of the blow. 
 He again vomited : his bowels became absolutely confined, and 
 his belly was distended and tympanitic. He became rapidly 
 worse, the vomiting became incessant, although never stercora- 
 ceous, the abdominal pain increased, and the patient died on the 
 following day, the 20th. The autopsy revealed an enormous 
 distension of the large intestine with a condition of the trans- 
 verse colon similar to that shown in Fig. 25 d. The descending 
 part of the colon and one limb of the distorted transverse colon 
 were firmly blended by old adhesions. The hepatic flexiu'e 
 was connected by dense fibrous bands to the liver and gall 
 bladder, and over this spot, which corresponded to the seat 
 of the injury, was a trifling amount of recent peritonitis. The 
 rest of the peritoneum was qi;ite normal. The mucous mem- 
 brane of the colon was unfortunately not examined ; nor was 
 the cause of the mischief about the hepatic flexure explained. 
 All parts of the large intestine were eq\ially distended, and the 
 rectum was normal. Here it would appear that the old man 
 Buffered no inconvenience from his distorted colon while his 
 health was good ; but the shock of the accident, his advanced 
 age, and the peritoneal mischief seem to have thrown the colon 
 hors de combat, to have induced a pai-alysis of its walls, and a 
 sudden cessation in its functions. Had such a man organic 
 disease of his heart, or advanced disease of his kidneys, a 
 similar combination of circumstances may have produced a 
 like disturbance in the functions of those organs, and have led 
 to a still more rapid death. 
 
 6. Obstruction <liie to changes effected in 
 the intestinal walls as a result of traction. — 
 
 The form of stenosis of the bowel to which I would 
 here call attention has, so far as I am aware, not 
 attracted the notice of those who have written upon 
 the subject of intestinal obstruction, or perhaps it 
 would be more proper to say that for a certain series 
 of cases I have ventured to propound a new theory 
 of causation. 
 
 It would be well to commence the consideration of 
 this matter by an illustrative case that is fairly typical 
 of the series. 
 
Chap VI.) The Effects of Tract/on. 127 
 
 Dr. Southey* reports tlie case of a boy, aged six- 
 teen, who died with symptoms of intestinal obstruction 
 that had lasted for ten days. The attack came on 
 suddenly (during perfect health) with colicky pains, 
 retching, and purging. The diarrhoea was soon re- 
 placed by absolute constipation that persisted until 
 death. Vomiting came on, and on the sixth day was 
 feculent. It was always copious, and occurred at 
 long intervals. The pain also was intermittent in 
 character. The autopsy revealed slight general 
 peritonitis. A diverticulum, four inches long, passed 
 from the ileum to be atta,ched to the anterior abdominal 
 wall just below the umbilicus. Immediately above 
 the diverticle the gut was so contracted that it could 
 only admit the tip of the little finger. It was also 
 deeply ulcerated here. The two feet of bowel that 
 extended between the abnormal process and the 
 caecum were intensely congested. The lumen of the 
 diverticle was equivalent to that of a goose-quill. 
 {See Fig. 26.) f 
 
 It is suggested in this case that the constriction 
 in the gut was congenital, and that the ileum below 
 the diverticle had been strangulated between that 
 process and the abdominal parietes. With regaixl 
 to the first suggestion, it must be allowed that con- 
 genital strictures of the small intestine are very rare, 
 and do not seem to have been noticed in connection 
 with the diverticulum upon which so many authors 
 have written. If congenital, it is strange that it 
 never produced any inconvenience until sixteen years 
 had elapsed. With regard to the second suggestion, 
 it can only be said that evidence is lacking that can 
 demonstrate the spontaneous reduction of an acutely 
 strangulated loop, except under the circumstances 
 detailed in a previous paragraph (page 93). If the 
 
 * Clinical Soc. Trans., vol. xv., 1882, page 159. 
 t St. Bart.'s Hosp. Musevjn, No. 2,175. 
 
128 
 
 Intestinal Obstruction. 
 
 [Chap. VI. 
 
 gut had reduced itself in the present instance, it must 
 have done so early in the case, and yet the symptoms 
 
 Fig, 26. — Stenosis of the Ileum above the origin of a ti-iie Diverticulum. 
 
 deliberately increased in severity until death appeared. 
 It is, moreovei-, difficult to understand how the 
 
Chap. VI.] The Effects of Traction. 129 
 
 strangulation could have been effected between the di- 
 verticle and the somewhat distant abdominal parietes. 
 
 I would rather venture to suggest that the case 
 was one of sudden closure of the gut by kinking, 
 brought about by traction on the diverticle and 
 rendered possible, or more easy, by the stenosis of the 
 bowel above that process. The more important 
 inquiry relates, however, to the nature of this 
 stricture in the intestine. 
 
 When a band or cord is adherent to some point on 
 the bowel, that band, whether short or long, will tend 
 to interfere with the action of the intestine if the 
 least traction be brought to bear upon the band. It 
 will tend to fix it more or less ; it Avill interfere with 
 the normal passage of a peristaltic wave through it, 
 and it will prevent the bowel from straightening itself 
 out as that wave goes by. Moreover, the traction 
 must bend the gut a little, and so afford some obstruc- 
 tion to the passage of its contents, slight though that 
 impediment might be in many cases. Intestinal 
 matters will tend to linger about the adherent part, 
 or even to accumulate there ; increased action will be 
 required in the gut above to prevent stagnation ; more 
 blood will be brought to the part, and it is con- 
 ceivable that under these various influences the 
 mucous membrane immediately aboTe the point of 
 attachment of the band may in time become ulcerated, 
 and that following upon that ulceration, cicatrisation 
 and stenosis may ensue. It is significant that in the 
 present case the gut was ulcerated, and that the 
 stenosis xi^as immediately above the point of attach- 
 ment of the diverticle. 
 
 Like cases belongmg to this class show similar 
 changes. 
 
 This theory as to the causation of these stenoses 
 is illustrated and supported by the condition found in 
 other forms of adherent bowel. It is extremely 
 J— 12 
 
130 Intestinal Obstruction. [Chap. vi. 
 
 common to find that an adherent loop is actually 
 strictured at the point of its attachment, and equally 
 common to discover that that stricture was the result 
 of ulceration. Stenosis of adherent bowel may be 
 due to three causes : 1. The gut may be occluded by 
 actual bending, by the condition I have to ventured 
 to describe as the " closed loop." 2. A primary ulcer 
 may have formed in the bowel, which may have led to 
 peritonitis of a limited character, and from that 
 peritonitis the adhesion may have followed. 3. The 
 ulceration may be secondary, as above described, 
 and subsequent to the adhesion. In considering this 
 matter I have carefully excluded the first two 
 varieties ; and have found many cases where a coil of 
 normal bowel has become attached to some point 
 within the area of a definite peritonitis, and has then 
 become more or less extensively stenosed. 
 
 One singular case may be mentioned here that 
 may throw, even if a little obliquely, some light 
 upon this matter. A patient died after laparotomy 
 performed on the thirteenth day for acute obstruction 
 depending upon strangulation of the small intestine 
 by an omental band. The band was composed of the 
 free end of the great epiploon, and by the traction to 
 which it had been subjected it is evident that the 
 transverse colon must have been dragged upon. 
 During the progress of the case a remarkable 
 symptom apj)eared ; a distended transverse colon 
 became prominent and distinctly visible as to its 
 outhnes through the abdominal parietes. The autopsy 
 showed that the only obstruction present was situated 
 in the ileum.* Why, then, was the colon not in the 
 usual state of partial collapse 1 Is it not possible 
 that the sudden and severe traction upon the gut 
 might have led to disturbance of its function, to a 
 
 * Bull, et Mem. de la Soc. de Chir. de Paris, tome vi., 1880, 
 page 601. 
 
Chap. VI.] The Effects of Traction. 131 
 
 species of paralysis of its walls, and so permitted the 
 strange condition of distension that it exhibited % 
 
 To return to the original subject, some examples 
 may now be given of this variety of obstruction. 
 Dr. Southey reports another case (in the same paper) 
 of a girl, aged 13 J years, who died with general 
 peritonitis depending upon an acute obstruction of 
 six days' duration, Four years previously she had 
 been under treatment for severe constipation. At the 
 autopsy a diverticulum extended between the lower 
 ileum and the umbilicus. The gut immediately above 
 it was so constricted as to have a diameter of only 
 half an inch. No other cause of obstruction was 
 found. Here also there is little doubt but that the 
 final acute attack was due to kinking, rendered more 
 possible by the stenosis, which had been in existence 
 probably for some time. The symptoms, especially the 
 intermittent pain experienced, and the fact that the con- 
 stipation was not absolute from the first, well accord with 
 the ordinary manifestations of occlusion by kinking. 
 
 In a case by Dr. Hare a diverticulum one and 
 three quarter inches in length was adherent to the 
 inguinal canal into which it had been herniated. The 
 ileum immediately above the diverticle was so nar- 
 rowed as to be only two-eighths of an inch in diameter. 
 The mucous membrane was here ulcerated, and a fatal 
 perforation had occurred."^ The patient had had 
 symptoms of some chronic obstruction in the small 
 intestine. In a case placed on record by M. Carriere, 
 a maUj aged twenty- eight, had peritonitis eighteen 
 months before his death. Since this attack he had 
 had intermittent griping pains with constipation. He 
 ultimately succumbed to an acute attack of obstruc- 
 tion lasting about ten days. A true diverticulum 
 arose from the ileum and was attached to the gut 
 
 *Path. Soc. Trans., vol. viii., page 181. 
 
132 Intestinal Obstruction. [Chap.vi. 
 
 lower down. Through the loop thus formed a coil of 
 small intestine had been strangulated (the cause of 
 the final acute attack). The ileum was so narrowed 
 at the point of origin of the diverticle that it would 
 barely admit the little finger.* 
 
 In the Museum of the Koyal College of Surgeons 
 is an interesting specimen (No. 1,361) which may, I 
 think, be regarded as an example of the present con- 
 dition. It shows a diverticulum, two inches in length 
 and one inch in width at its base, that ends in a cord 
 two and a half inches long attached to the mesentery 
 one and a half inches from the margin of the gut. 
 One inch above the origin of the diverticulum the gut 
 suddenly becomes narrowed to a diameter of about 
 half an inch, and remains this size down to the point 
 at which the abnormal process comes ofi". Both above 
 and below the narrowed segment the bowel is normal. 
 Beneath the arcade formed by the adherent pi'ocess 
 two loops of intestine were strangulated. 
 
 Several cases very similar to these may be cited 
 where the small intestine was gi'eatly contracted 
 about the point of attachment of an isolated adhesion. 
 The relation, however, of the adhesion to the stenosis 
 in these instances is open to doubt, f 
 
 The symptoms in these cases pertain to those 
 associated with stricture of the lesser bowel. In 
 some there is a continuous chronic course, with inter- 
 mittent pain, partial constij)ation associated with 
 occasional diarrhoea, slight sickness, some emaciation, 
 and in time visible peristalsis. Other cases are mostly 
 characterised by a final and acute attack due to 
 kinking of the adherent bowel or to blocking up of 
 the stenosed segment. 
 
 * Bull, de la Soc. Anat. de Paris, 1864, page 496. 
 
 t Mr. Gay ; Path. Soc. Trans., vol. iii., inige 101. Mr. Avery; 
 ibid., vol. iv., page 156. M. Guiter ; Le Progres Medical, 1882, 
 page 112. 
 
Chap, vi.i Shrinking of the Mesentery. 133 
 
 7. Narrowing: of tlie bowel from shrinking 
 of tlie mesentery after inflammation. — When 
 the mesentery has been extensively inflamed it may 
 subsequently undergo such marked and extreme con- 
 traction as to greatly narrow the bowel to which it is 
 attached. In such cases the involved coils are often 
 found bound down to the spine by the shortened 
 mesentery and much shrunken in appearance. This 
 is very often the result of mesenteric gland disease. 
 I might refer to four well marked examples, all in 
 young patients, of this form of contraction."^ 
 
 "We also meet," says Leichtenstern, "with an 
 insidious process of chronic peritonitis in a diffuse 
 form spread over the greater portion of the peri- 
 toneum, especially of that covering the mesentery, 
 and then it often presents a certain independent 
 character, and causes thickening and shortening of 
 the mesentery, thus binding the convolutions of the 
 small intestine down to the vertebral column. This 
 cirrhosis of the peritoneum (peritonitis deformans, 
 Klebs) results from chronic venous congestion in 
 diseases of the heart, and sometimes exquisite 
 examples are found with cirrhosis of the liver and 
 atrophied nutmeg liver, and also occasionally with 
 granular atrophy of the kidneys."! 
 
 The symptoms that arise in these cases are practi- 
 cally identical with those of stricture of the small 
 intestine, or with those of matting together of many 
 coils of the bowel. It would appear from Dr. Fagge's 
 cases that the evidences of obstruction may extend 
 over years, e.g. for four years in one case, for two in 
 another. 
 
 *Dr. Hilton Fagge (loc. cit.) three cases ; and a fourth case 
 by the same physician, in Path. Soc. Trans., vol. xxvii., page 157. 
 fLoc. cit., page 632. 
 
134 
 
 CHAPTER yil. 
 
 VOLVULUS. 
 
 Under the general term " volvulus " may be in- 
 cluded two distinct methods of producing obstruction. 
 In one the bowel is so twisted about its mesenteric 
 axis, or even in rare cases upon its own axis, that it 
 becomes occluded. In the other form two suitable 
 coils of intestine are so intertwined or knotted 
 together as to cause also an obstruction in their 
 lumina. 
 
 The subject may be most conveniently considered 
 under the following heads : 
 
 1. Volvulus of the sigmoid flexure. 
 
 2. Volvulus of the ascending colon and caecum. 
 
 3. Volvxdus of the small intestine. 
 
 1. VoIviilHs of the sigmoid flexure.— This 
 
 part of the bowel may be occluded by either of the 
 two methods just named. 
 
 (1) It may be twisted upon its mesenteric axis. 
 (2) It may be intertwined with a suitable coil of 
 small intestine. 
 
 (1) The bowel is twisted about its mesen- 
 teric axis: Pathology.— This is the most usual 
 form of volvulus, and may, indeed, be said to be the 
 only form that is at all common. If all the cases of 
 volvulus of the intestine be considered collectively, it 
 will be found that about two-thirds of the number are 
 instances of twist of the sigmoid flexure about its 
 mesenteric axis. 
 
 The normal flexure forms a loop that is more like 
 a capital C than a Greek 2. It first passes obliquely 
 
Chap. vii. j Vol vul us. 135 
 
 upwards and inwards, then bends almost vertically 
 do^\^.lwards, and finally ascends in an upward and 
 outward direction, to tenninate in the rectum. Its 
 curves and its outline vary greatly. Its meso-colon 
 may be very long. In normal instances it has been 
 Ions: enouo-h to allow the bowel to reach to the um- 
 bilicus, and even to stretch as far as the csecum. This 
 condition is not infrequently seen in newly-born chil- 
 di'en, in whom, as is well known, the sigmoid flexure 
 is relatively very large. In the sigmoid flexure that 
 is usually met A\dth, a flexure of moderate size with 
 moderate curves and with a short but wide meso- 
 colon, volvulus cannot occur. 
 
 The aiTangement of the gut that is necessary for 
 the production of a volvulus is the following : The 
 loop must be of considerable length, the meso-colon 
 must be long and very narrow at its parietal attach- 
 ment, so that the two ends of the loop may be brought 
 as close together as possible. This condition is shown 
 in Fig. 27 A, where it will be seen that the loose and 
 free coil has practically a fixed pedicle around which 
 it could with great ease be twisted. 
 
 This arrangement of the parts may be congenital, 
 although such a circumstance must be uncommon 
 since volvulus of the sigmoid flexure is extremely 
 rare in the young. It may be brought about by peri- 
 toneal adhesions, especially by such as have been 
 formed after great distension of the bowel. It may 
 be readily produced by inflammatory conditions in the 
 meso-colon leading to cicatricial contraction. 
 
 The commonest cause, however, is, without doubt, 
 chronic constipation. In this condition the flexure is 
 more or less constantly distended, its walls become 
 partly paralysed by that distension, and becoming 
 filled with fsecal matters and flatus, it hangs down 
 into the pelvis an inert heavy mass. So placed it 
 must drag upon its meso-colon, and while the position, 
 
136 
 
 Intestinal Obstruction. [Chap. vii. 
 
 on the one hand, tends to elongate that membrane, 
 it appears, on the other, to approximate the two ends 
 of tlie loop. Possibly the slight chronic obstruction 
 always present in the part may lead to a little local 
 peritonitis which may tend to render permanent the 
 deformity produced. 
 
 When the loop is in this condition it is easy to 
 understand that a twisting of it upon its mesenteric 
 
 Pig. 27.— Volvulus of the Sigmoid Flexure. 
 
 axis may be brought about. 
 
 Some irregular move- 
 
 ment in the bowel may effect this, or faeces may accu- 
 mulate in one side of the loop only, in such away that 
 the weighted end could fall over the less distended 
 coil. When a heavy loop blocked with faeces is con- 
 cerned, the position of the body may become a factor 
 in the causation of the twist, a circumstance that 
 certain cases would appear to illustrate. Lastly, 
 
Chap. VII.] Volvulus. 137 
 
 distension of the bowel alone has great influence in 
 both producing and maintaining a volvuluSj a fact to 
 which further allusion will be made. 
 
 According to Potain there are two kinds of twist. 
 In one the superior part of the loop is carried from 
 above downwards, and from behind forwards, in 
 front of the lower half of the loop, so that the 
 end of the descending colon is brought into contact 
 with, and in front of, the commencement of the rectum 
 ('^ type rectum en arriere "), Fig. 27 b. In the second 
 form the superior part of the coil is carried from 
 above downwards, and from before backwards, be- 
 hind the lower segment of the loop, so that the end 
 of the descending colon is brought into contact with, 
 and behind, the commencement of the rectum ('' type 
 rectum en avant "), Fig. 27 C. 
 
 Of these two A'arieties the former is by far the 
 more common. The twist may extend through an 
 arc of 180° to 360°, or the bowel may be twisted 
 twice or even three times about its mesenteric axis. 
 Since at the root of flexure the two ends of the loop 
 are nearly parallel to the mesenterial axis, it follows 
 that when the latter is twisted the former also must 
 be twisted upon their own axes. 
 
 When the volvulus has once formed it is soon 
 made permanent. The heavy and distended coil has 
 no power of straightening itself. Its ends being- 
 closed it begins to increase rapidly in size from dis- 
 tension with gas, and becomes moreover engorged by 
 blood from pressure upon the vessels that enter at the 
 pedicle of the loop. The more the bowel becomes 
 distended the more fixed is the volvulus. In the 
 autopsy the twist may be almost entirely un- 
 rolled by main force, but the moment the hand is 
 removed the loop springs back into its former dis- 
 torted position. On evacuating the gas, however, that 
 distends the coil the volvulus can be readily reduced, 
 
138 Intestinal Obstruction, [Chap.vii. 
 
 or may even become reduced spontaneously. In other 
 experiments where the volvulus has been reduced, it 
 has been made to immediately reappear upon distend- 
 ing the bowel from above. 
 
 The unyielding abdominal parietes (anterior) take 
 some share in the production of a volvulus. Melchiori 
 has demonstrated this by experiments made upon a 
 body that presented a volvulus. As he inflated the 
 now untwisted flexure with air from the colon it be- 
 gan to form a volvulus, but as the coil increased in 
 size and mounted up in the abdomen it gradually 
 unwound itself again. When, however, pressure was 
 applied that would correspond to that exercised by 
 the anterior abdominal walls the volvulus was ren- 
 dered permanent."^ In some cases the volvulus may 
 be held down by adhesions, upon the division of which 
 it becomes readily reducible.! In other instances a 
 coil of small intestines with a long mesentery may be 
 thrown across the pedicle of the volvulus and so help 
 to maintain its permanency.! 
 
 In volvulus the occlusion of the bowel is brought 
 about by the mutual pressure that the two ends of 
 the coil exercise upon one another. The loop is 
 therefore closed at both ends. Cases have been re- 
 corded where extensive degrees of volvulus have been 
 associated with a narrowing of the lumen of the gut 
 of so slight a character as to cause no symptoms. 
 Leichtenstern reports a case where such a condition 
 was met with and where distension actually relieved 
 the volvulus. The specimen was from the body of a 
 boy, aged eleven, who had had no intestinal troubles. He 
 presented a chronic twisting of the flexure, with close 
 approximation of the ends of the loop. " If air is 
 
 * Quoted by M. Liebaut, Du Volvulus de I'lliaque du Colon. 
 TMse de Paris, 1882. 
 
 t Case by Dr. Atherton ; Boston Med. and Surg. Journ.^ 
 1883, page 531. 
 
 X Case by M. Leger ; Bull, de la Soc. Anat. de Paris, 1875. 
 
Chap. VII.] Volvulus. 139 
 
 forced in from the side of the colon, the S loop un- 
 twists, and again resumes its twisted position when 
 the air is allowed to escape, a proceeding that must 
 have been repeated during life with every passage of 
 fseces." 
 
 At the autopsy in fatal cases the sigmoid flexure is 
 found to be enormously distended. It seems to occupy 
 the whole abdominal cavity. The rest of the colon 
 and the small intestines lie behind it and are more or 
 less hidden by it. In cases of slight distension the loop 
 about reaches to the umbilicus. As it becomes more 
 distended it tends to move towards the right hypo- 
 chondriac region. It then lies in front of the stomach 
 and ultimately reaches the liver. In severe cases the 
 diaphragm is much pressed upon and may be pushed 
 up to within 16 cm. (6| inches) of the clavicle, or 
 even up to the level of the third or fourth rib."^ In 
 one instance, fatal at the end of seven days, the 
 diaphragm had been raised to the level of the third 
 rib, the lung had been much compressed, while its 
 lower parts were hepatised and empty of air. f 
 
 The twisted coil is more or less intensely con- 
 gested. In colour it may present any depth between 
 a dark red and a black. Its walls are often much 
 thickened by infiltration, and are softened and friable. 
 The serous coat is very commonly found to exhibit 
 a rent, or even several rents. These may be exten- 
 sive and often involve the muscular coat also, whilst 
 the mucous membrane escapes. I am not aware 
 that these rents have ever led to actual rupture of 
 the twisted loop during life, nor can I find any case 
 where perforation of the loop has occurred from ulce- 
 ration of its mucous lining. If the patient lives long 
 enough and the case is severe, the walls of the flexure 
 
 * Li^baut, loc. cit. 
 
 fDr. Esau ; Deutches Archiv fiir clinischeMed., b. xvi., 1875, 
 page 474. 
 
140 Intestinal Obstruction. [Chap. vii. 
 
 become gangrenous. This gangrene is met with in 
 the form of one or more patches that involve all the 
 coats of the bowel. 
 
 The twisted loop will be found to contain much 
 flatus, and to be otherwise occupied by fluid faecal 
 matter mixed with harder masses. Sometimes the 
 contents are entirely solid, and in other instances en- 
 tirely liquid. Blood, often in considerable quantity, 
 may be found mixed with these contents.* The 
 twisted meso-colon will be of a violet or purple colour 
 and engorged with blood. 
 
 The rest of the intestines, and especially the colon, 
 are distended. The distension seems to be only 
 limited by the size of the sigmoid flexure. In cases 
 where the involved loop is of enormous size the 
 distension of the rest of the intestine is usually 
 comparatively slight, the gut actually lacking room 
 within which to expand. The descending colon is 
 often much enlarged and congested. I find that only 
 twice, in twenty recorded cases that I have collected, 
 has perforation occurred. In one instance the per- 
 foration was in the caecum, in the other in the bowel 
 just above the volvulus. In one or two instances 
 the mucous membrane in the lower part of the 
 descending colon is described as being rent. 
 
 Peritonitis is singularly constant in this affection. 
 It develops early, commences upon the involved 
 bowel and then spreads over the rest of the serous 
 membrane. In seventeen of the twenty cases just 
 alluded to the state of the peritoneum is described. 
 In only two cases out of this number was there no 
 peritonitis. In one of these examples the patient had 
 died in forty-eight hours, in the other he died suddenly 
 at the onset of the attack. In the remaining fifteen 
 cases there was peritonitis. In one of these instances 
 
 * In a case by Dr. Crisp, the coil contained a pint of thick 
 blood; Path. Soc. Trans., vol. xxiii., page 112. 
 
Chap. VII.] Volvulus. 141 
 
 it was still limited to the sigmoid flexure (the patient 
 had died on the fourth day). In two instances there 
 was perforation. The remaining cases were simple 
 examples of acute difi'used peritonitis. 
 
 In many instances there was much bloody fluid 
 in the peritoneum. 
 
 Symptoms. Frequency. — Volvulus of the 
 sigmoid flexure forms about :^th part of all cases 
 of intestinal obstruction."* 
 
 Sex and age. — It occurs much more frequently 
 in men than in women. Of my twenty cases, sixteen 
 were males and four females. The great bulk of the 
 cases fall between the ages of forty and sixty. The 
 average age in the twenty cases was forty-nine, the 
 youngest patient being twenty-seven, the oldest 
 seventy-two. It is rare before thirty, and extremely 
 rare before twenty. Leichtenstern mentions one case 
 in a child aged ten. This circumstance of age has 
 been explained by the greater frequency of constipa- 
 tion in those past middle life, and by the possibility 
 that the condition of the gut that favours volvulus 
 may require some years for preparation. 
 
 Previous history and mode of onset.— In 
 no less than fourteen out of the twenty cases collected 
 there is a history of a previous chronic constipation. 
 Many of the patients had suffered from obstinate 
 constipation for years, others for months only. In 
 several instances there had been attacks of colic, 
 associated mth some swelling of the abdomen and 
 with nausea, if not with actual sickness. In a few 
 examples diarrhoea had now and then alternated 
 with constipation, the purging being probably of 
 a spurious character, and akin to that associated with 
 the constipation in stricture of the rectum. In no 
 instance had these previous symptoms been of a very 
 
 * Excluding hernia, diaphragmatic hernia, and affections of 
 the rectum. 
 
142 Intestinal Obstruction. [chap.vii. 
 
 severe character, nor reached the gravity often 
 observed in attacks of obstruction that have preceded 
 fatal strangulation by bands and diverticula. 
 
 The mode of onset is usually abrupt, often sudden. 
 This was observed in twelve out of eighteen cases 
 where the precise manner in which the disease com- 
 menced was noted. 
 
 The symptoms begin with sudden pain in the 
 abdomen, with some slight degree of collapse in many 
 instances, and are soon associated with swelling of 
 the abdomen and nausea or even vomiting. In some 
 cases the attack had been preceded by an unusually 
 long period of constipation. In two instances out of the 
 twenty cases it had followed upon an attack of diar- 
 rhoea. In several examples it came on after a meal, 
 or some time after eating indigestible food. Thus 
 a case is reported of fatal volvulus after eating many 
 cherries together with their stones. In this instance 
 many stones were removed by enema and ejected by 
 vomiting, the total quantity thus evacuated being 
 "about a quart. ""^ In several of the cases of sudden 
 onset no cause, probable or improbable, could be 
 assigned for the attack. In one case the patient had 
 had many previous attacks of colic with distension, 
 which were always relieved by lying in a particular 
 position upon his back with the legs bent. In the last 
 attack the position failed to give relief. In the cases 
 where the onset is not sudden there is usually a 
 history of obstinate constipation for days, associated 
 with distension of the abdomen, with a feeling of 
 malaise, and loss of appetite. Then nausea appears, 
 or the patient is troubled with eructations, colicky 
 pains gradually develop and the symptoms rapidly 
 progress as in the more acute attacks. 
 
 In several instances an acute aspect has been 
 
 given to the case by the administration of an aperient. 
 
 * Dr. Atherton ; Boston Med. and Surg. Jowrn.y 1883, jjage 531. 
 
Chap. VII.] Vol vvl us, 143 
 
 Fain is usually the earliest symptom, and is a 
 marked feature of the affection. As a rule, however, 
 it is neither so conspicuous nor so severe as it is 
 in cases of strangulation by bands. One does not 
 read of the patient being "bent double" by it, nor 
 of his "rolling on the floor" in pain, nor of his 
 "writhing in agony," expressions that are not un- 
 commonly met with in the description of the latter 
 form of obstruction. The pain is often paroxysmal 
 at first ; a feature that probably indicates that the 
 obstruction is not at the onset quite complete. In 
 some marked cases of paroxysmal pain the patient 
 has passed a motion after the commencement of the 
 attack. The pain soon becomes constant but presents 
 exacerbations. The constant pain may be due to the 
 volvulus itself, the exacerbations to an increase in 
 the twist from peristaltic action. The more acute the 
 case the more severe the pain. It is at first com- 
 plained of about the umbilicus, or, less frequently, 
 I think, about the seat of the sigmoid flexure itself. 
 As the case advances, and as peritonitis sets in, the 
 pain becomes more diffused, being often, however, most 
 felt about the region of the distended coil. It 
 appears to diminish rather than to increase as the 
 malady advances. There are cases where most pain 
 has been experienced about strange parts, such as 
 the pubes and the upper and left-hand side of the 
 abdomen. 
 
 Tenderness on pressure is absent at first, 
 although when the early pain is felt about the region 
 of the volvulus, pressure there may add to its in- 
 tensity. As peritonitis commencing in the distorted 
 loop is very constant, it happens that tenderness soon 
 develops over the region the gut occupies^ and as the 
 peritonitis becomes general so also does the tenderness 
 become diffused. There is no form of intestinal 
 obstruction where marked pain on pressure is eKcited 
 
144 Intestinal Obstruction. [Chap.vii. 
 
 earlier than in the present cases, if exception be made 
 of certain examples of acute intussusception. 
 
 Vomiting: is by no means so conspicuous a symp- 
 tom as it is in strangulation by bands. It appears 
 less early and may on the whole be spoken of as 
 not being very severe. In six cases out of twenty 
 vomiting may almost be said to have been absent. 
 Three of the patients did not vomit at all ; of the 
 others, two only vomited after food, and one patient 
 was sick but once, and that was after a dose of castor 
 oil. These patients lived respectively forty-eight hours, 
 sixty-four hours, four daysj(two), seven days, and eleven 
 days after the commencement of the attack. In the 
 first of these cases there was no peritonitis, in the 
 rest it had not reached a severe grade, while the last 
 patient died of perforation. The vomited matters are 
 at first alimentary, and then bilious. Very rarely are 
 they feculent. In the twenty cases there are only 
 three instances of stercoraceous vomiting. In one 
 case it appeared on the fourth day, the patient dying 
 on the seventh ; in aiiother instance it appeared on 
 the sixth day, the patient dying on the eighth ; in 
 the third example the symptoms were very acute, the 
 vomiting was incessant and soon became feculent, 
 although the duration of the attack was only two 
 days. In some cases the vomiting abated considerably, 
 or was even absent for a while. As already stated, 
 it may be absent at first, and I find instances where 
 the vomiting did not commence until the third, fourth, 
 fifth, or sixth day of the attack. Li6baut alludes 
 to a case where vomiting appeared for the first time 
 on the eighth day. 
 
 Frequent eructations are singularly common in 
 this form of obstruction. 
 
 Constipation exists, as a rule, from the first, 
 and is absolute. In many cases scybala have been 
 removed by enemata, but they have evidently been 
 
Chap. VII.] Volvulus. 145 
 
 derived from the rectum below the volvulus. In a 
 few instances a motion has been passed during the 
 progress of the case, as, for example, on the second or 
 third day. In one case scanty motions were evacuated 
 during the first three days of the attack. A purge 
 has produced a slight stool after the symptoms of 
 vomiting have set in, but, as a rule, aperients add to 
 the severity of the manifestations of the malady, and 
 to the completeness of the constipation. In these 
 exceptional cases it may be assumed that the occlusion 
 of the two ends of the loop is not complete, or is, 
 at least, not complete at all times. The scanty stools 
 that may be passed are probably derived from the 
 contents of the flexure itself, and depend upon im- 
 perfect closure of the lower end of the loop, the 
 upper end being still entirely occluded. 
 
 Oeneral conditioii.— When the symptoms are 
 severe there is some degree of collapse established, 
 although it is seldom so marked as it is in cases of 
 strangulation by bands. It depends to a great extent 
 upon the suddenness of the onset, the severity of the 
 pain, and the rapidity of the progress of the disease. 
 In two instances, where the patients died in forty- 
 eight hours, death appears to have been due to a 
 gradually deepening collapse. In any case there is 
 usually great prostration, great and sudden loss of 
 muscular strength, a pinched face, sunken eyes, a cold 
 or clammy skin, and a sensation of anxiety and 
 alarm. 
 
 The pulse is small and rapid and is apt to soon 
 assume the character of the pulse in peritonitis. 
 
 The temperature is usually below normal at first, 
 and may remain so until death. In any case it will 
 probably be found to be subnormal until peritonitis 
 sets in. Even when peritonitis occurs no appreciable 
 rise in temperature may be noted, and acute perito- 
 nitis has been found in the autopsies of patients who, 
 K— 12 
 
146 Intestinal Obstruction. [Chap. vii. 
 
 throughout the whole progress of the attack, never 
 recorded a temperature above 98-6. As a rule, how- 
 ever, peritonitis will be associated with an increase in 
 the bodily heat, an increase that may bring it up to 
 the normal level or a little above it. The thermometer 
 as a means of indicating the accession of peritonitis 
 in these cases is of little value. 
 
 The respiraiions are usually much increased in 
 frequency, a symptom that depends mainly upon the 
 great and often abrupt distension of the abdomen. 
 Dyspnoea has in many cases been a marked feature, 
 and a great sense of suffocation and of discomfort 
 about the thorax have been complained of. 
 
 As will be pointed out below, death from inter- 
 ference with the functions of the thoracic organs is 
 not infrequent in volvulus of the sigmoid flexure. 
 
 The tongue is coated, and often much coated ; 
 being at first moist, and then usually becoming dry 
 and brown. Great thirst is not usually complained of 
 unless there has been severe and copious vomiting or 
 much collapse. 
 
 In the acuter cases the quantity of urine is as a 
 rule diminished, although this feature is not so marked 
 nor of so frequent occurrence as it is in cases of 
 strangulation by bands. As occurs in that form of 
 obstruction, so in this ; the more marked the pain and 
 collapse and evidences of general constitutional dis- 
 turbance, the more likely is the quantity of urine to 
 be diminished, while under the influence of opium the 
 diminished excretion may again attain to its normal 
 proportions. 
 
 In only one case in the series of twenty does 
 stranguary appear to have been a symptom. In this 
 isolated instance the patient was seized on the second 
 day of the attack with such a very frequent desire to 
 urinate, that he was thought to have cystitis. He 
 died sixty-four hours after the appearance of the first 
 
Chap. VII] Volvulus. 147 
 
 symptom. The distended sigmoid flexure was found 
 to have reached the diaphrai^m. Ho never vomited 
 except to reject some oil he took. If vomiting is in 
 these cases, to a great extent, the result of reflex 
 nerve disturbance, it would appear as if in this 
 instance the nerve aj)paratus of the bladder had been 
 irritated instead of that of the stomach. The man 
 might almost be said to have vomited with his bladder 
 instead of with his stomach. 
 
 Tenesmus, as may be expected, is often noticed in 
 volvulus of the sigmoid flexure. In three of the 
 twenty cases alluded to this symptom was very- 
 marked, incessant, and severe. 
 
 Tlic coiiclition of tlic abdoiiBCii.— One of 
 the most conspicuous features in volvulus of the 
 sigmoid flexure is the enormous distension of the 
 abdomen. This distension appears very early and 
 attains very considerable proportions. It depends 
 mainly upon the dilatation of the sigmoid flexure itself, 
 although there is much distension of the rest of the 
 intestine. The i-apidity with which the meteorism 
 develops is considerable. In patients who have died 
 in sixty-four or sixty-eight lioui's the twisted liowel 
 has been found to reach the diaijhragm, and has 
 appeared at first sight to occupy the whole of the 
 abdomen. The swelling is usually localised at first, 
 appearing as a rounded elevation in the left segment 
 of the umbilical region, and then occupying the whole 
 of that region together with the epigastric. In the 
 matter of locality, however, it shows much variety."^ 
 Very soon the swelling becomes uniform and the 
 abdomen appears as evenly blown out as a distended 
 bladder. 
 
 The swelling that forms early in the case may be 
 
 *In one case at least the swelling was most conspicuous in 
 the right iliac region. The twisted gut usually passes towards 
 that fossa before it mounts up in the abdomen. 
 
148 Intestinal Obstruction. [Chap.vii. 
 
 dull over some part of its extent and of well limited 
 outline. Such was the case in a patient whose history is 
 recorded by Mr. Spencer Watson. Here a dull rounded 
 swelling was detected, which the autopsy showed 
 depended upon a volvulus of globular outline and 
 about the size of a child's head.* Much thickening 
 of the wall of the volvulus from infiltration would 
 obviously tend to diminish its resonance on percussion. 
 Since the volvulus always extends in front of the 
 other intestines, all its parts must be more or less 
 exposed to examination through the parietes. 
 
 The abdominal walls are at first more or less 
 flaccid, and in a normal condition when manipulated. 
 As the distension increases they become of course 
 tenser, and as the peritonitis advances, more and 
 more rigid. 
 
 In a few cases the movements of coils of intestine 
 have been visible through the parietes before the 
 distension had reached a great magnitude. This 
 visible peristalsis cannot be regarded as associated 
 with the volvulus, but rather as due to a long con- 
 tinued obstruction in the bowels upon which the twist 
 itself had probably depended. In the tAventy cases 
 alluded to I have met with only two instances of this. 
 In both the attack came on gradually, and in both 
 there was a history of long continued previous con- 
 stipation. One of the patients lived seven days, the 
 other eight. 
 
 I know of no instance where the hand has been 
 introduced into the rectum in these cases for the 
 purpose of diagnosis. If such manoeuvre were adopted 
 there is no doubt but that the obstruction could be 
 felt. 
 
 The use of enemata as a means of diagnosis is of 
 much value. It shows that tlie bowel will hold no 
 more fluid than a rectum could accommodate, and 
 * Med. Times and Gazette, vol. ii., 1879, page 31. 
 
Chap. VII.] Volvulus. 149 
 
 auscultation would demonstrate that the injected 
 matter did not pass the region of the sigmoid flexure. 
 It is said that about one and a half litres of fluid can 
 without diflS.culty be introduced into the rectum 
 alone. 
 
 Course, duration, progriiosis.— Volvulus of 
 the sigmoid flexure is, so far as is known, invariably- 
 fatal unless relieved by surgical interference. The 
 case progresses from bad to worse, as a rule un- 
 interruptedly, but sometimes with remissions in the 
 severity of the symptoms. 
 
 The average duration of the attack in my twenty 
 cases was six days. The longest period during which 
 the patient lived was twenty days, * the shortest 
 sixty- four hours, f Th e only circum stance that appears 
 to influence the rapidity of the case is the severity of 
 the twist. It is unafi'ected by the age of the patient 
 and by the preceding symptoms. The cases that set 
 in abruptly usually display the most rapid course. 
 In the patient, however, who lived twenty days the 
 onset was sudden. In another case, on tlie other 
 hand, where the onset was gradual the patient died in 
 three days. The causes of death in the more rapid 
 cases are collapse and interference with the thoracic 
 organs, in the more chronic cases peritonitis and 
 exhaustion. The two patients who lived for the 
 shortest periods (sixty-four and sixty-eight hours 
 respectively) are both said to have died asphyxiated. 
 In cases that have survived for a longer time the 
 fatal issue is often somewhat sudden ; and here it 
 may be surmised that the greatly distended flexure 
 has interfered with the action of the heart or lungs 
 by actual pressure through the diaphragm. Before 
 death the patient has, in more than one instance, 
 
 * Contrib. a 1' Etude de I'Occlusion intestinale, by Dr. Le 
 Moyne. Paris, 1878. 
 
 t A case by Melchiori quoted by Dr. Liebautin his monograph. 
 
150 Intestinal Obstruction. [Chap. vii. 
 
 complained of great pain in the chest and of trouble 
 in the cardiac region.* An instance of sudden death 
 reported by M. Potain may here be noticed. A man, 
 aged thirty-three, who had been long troubled with 
 constipation, was admitted into hospital wdth simple 
 obstruction. His bowels had not been relieved for 
 eight days. An enema merely brought away a few 
 scybala. His abdomen was swollen, but it was neither 
 tender nor painful. He had not vomited. He had no 
 dyspnoea. The morning after his admission he was 
 found dead in his bed. His decease had not been 
 observed by the patients lying on either side of him 
 in the ward. The autopsy revealed a double twist of 
 the sigmoid flexure but with no peritonitis. The gut 
 was fully distended. All the other viscera were 
 healthy. Two patients out of the twenty cases died of 
 perforation of the bowel above the volvulus. 
 
 There is no evidence to show that a volvulus of 
 this part can ever spontaneously relieve itself when 
 once the twist is well established. The case alluded 
 to above of a patient who had had previous attacks of 
 pain with obstruction, and who on each occasion but 
 the last obtained immediate relief by assuming a 
 peculiar posture, suggests a possible means of spon- 
 taneous relief in slight and recent cases. When the 
 gut has become twisted it is conceivable that a change 
 in the patient's position, or some shifting in the 
 position of the irregularly placed contents of the coil, 
 or some unusual movement of the bowel itself may 
 unwind the volvulus. When, however, the occlusion 
 has lasted long enough to allow the bowel to become 
 distended the volvulus is almost certain to be 
 rendered permanent. 
 
 1 have already alluded to the fact that when the 
 lower part of the sigmoid flexure or the upper part of 
 
 * /S^ee for example a case by JVIi'. Gay; Path. Soc. Trans., 
 vol. X,, page 153. 
 
Chap. VII.] Volvulus. 151 
 
 the rectum become suddenly occluded by the process 
 known as kinking, symptoms may be induced that 
 precisely resemble those of the present form of ob- 
 struction. I have mentioned an example of this 
 where all the symptoms closely resembled those of 
 volvulus. The patient was middle-aged; she had 
 been troubled with constipation for some time; the 
 onset of the attack was sudden ; swelling of the 
 abdomen was rapid and marked; the pain was con- 
 stant, with exacerbations ; the vomiting was not 
 severe and not feculent ; peritonitis was developing. 
 The rectum had been closed by kinking and the 
 sigmoid flexure filled a great part of the abdomen 
 (page 108). 
 
 (2) The toowel is intertWinecl with a suit- 
 able coil of small intestine. — In these cases the 
 sigmoid flexure must have the anatomical arrangement 
 described in the preceding paragraph, i.e. it must form a 
 long, free loop with a narrow pedicle. The loop of 
 small intestine should possess also an unnatural 
 mobility, and should have an unduly long and narrow 
 mesenteric pedicle. In cases where two such coils 
 have become intertv/ined it is found that the loop of 
 the lesser bowel varies in length from four to twenty- 
 one inches, while that of the sigmoid flexure measures 
 from twelve to forty inches (Leichtenstern). The 
 usual mode of intertwining is as follows : The loop of 
 small intestine falls in front of, or across, the 
 pedicle of the sigmoid flexure. The flexure then 
 winds itself around the axis formed by the lesser coil. 
 It passes upwards in front of the loop of small intestine 
 and then moves backwards and downwards so that its 
 free end passes behind the pedicles of the two coils. 
 In this way the abnormal sigmoid flexure forms a 
 complete turn around the coil of lesser intestine. 
 Both segments of the bowel become strangulated, but 
 the occlusion will be most severe in the axial loop. 
 
152 Intestinal Obstruction. [Chap. vii. 
 
 According to Leichtenstern, this variety of intertwin- 
 ing occurs in more than one half of all the cases 
 belonging to this species of volvulus. Three other 
 methods, however, of intertwining occur. In one the 
 loop of ileum lies in front of the pedicle of the sigmoid 
 loop, which in this instance forms the axis. In the 
 remaining two cases the small intestine passes behind 
 the pedicle of the sigmoid flexure, when the loop of 
 ileum may form the axis around which the flexure is 
 entwined. 
 
 In all these examples strangulation is very severe, 
 and is marked by great vascular engorgement of the 
 involved loops. Such engorgement is met with in all 
 cases where an extensive mesenteric pedicle is pressed 
 upon. Not only are the walls of the engorged bowel 
 infiltrated with blood, but much haemorrhage may take 
 place into its cavity, and there is usually an abun- 
 dant sero-sanguineous exudation into the peritoneal 
 cavity. 
 
 Leichtenstern has collected no less than twenty- 
 one examples of this form of obstruction. With one 
 exception only the patients were all males. They 
 were, moreover, all adults, the ages ranging between 
 twenty-four and seventy-three. 
 
 The syjiiptoms that attend these cases are those of 
 strangulation of a very acute character. The onset 
 is more or less sudden, a marked degree of collapse is 
 soon developed, vomiting is incessant and profuse, 
 there is great pain and absolute constipation. The 
 symptoms, indeed, are those incident to acute strangu- 
 lation of the small intestine. Diarrhoea is apt to pre- 
 cede this kind of incarceration of the bowel, and a 
 loose stool may be passed after the onset of the 
 symptoms. It is evident that the great engorgement 
 of the involved coils in these cases would lead to a 
 copious discharge of fluid into the cavity of the 
 intestine. In the matter of diagnosis it would be 
 
Chap. VII.] Vol vvl us. 153 
 
 practically impossible to distinguish these cases from 
 cases of strangulation of a large loop of intestine by a 
 " band," or through an aperture. 
 
 Death is very rapid. In only one case out of the 
 twenty-one just alluded to did the patient live until 
 the sixth day. All the rest died within the first two 
 days, and many within the first twenty-four hours. 
 
 It will be seen from this that the present form of 
 obstruction constitutes one of the most acute forms of 
 strangulation of the bowel that is known. 
 
 2. Volvulus of the ascending colon and 
 csecum. — Volvulus occurring in this part of the in- 
 testine may assume a variety of aspects, and is, in any 
 case, apt to adopt a very complicated arrangement. 
 
 It may be considered under three categories. (1) A 
 twist of the ascendino- colon around its own axis. 
 (2) Tmsts brought about by an abnormal loop formed 
 by the ascending colon and caecum with a long and dis- 
 tinct meso-colon. (3) Twists of the csecum "upon 
 itself " or about its own axis. 
 
 (1) Occlusion of the bowel may be brought about 
 by a twist of the ascending colon around its own 
 vertical axis. It would appear that this condition 
 may be found in a colon that presents no anatomical 
 abnormalities. It is extremely rare. I have been 
 able to find but one distinct instance of it. This was 
 in a case reported by Mr. Curling. The patient was 
 a man, aged twenty-seven, who was attacked with 
 symptoms of intestinal obstruction that ended fatally 
 in eight days."^ More than one writer on intestinal 
 occlusions refers to this variety of volvulus, but gives 
 no case. 
 
 The two other varieties of twist met with in this 
 
 region depend, so far as I can ascertain, upon certain 
 
 congenital abnormalities in the bowel, without which 
 
 neither form of volvulus could have been possible. I 
 
 "*■ Path. Soc. Trans., vol. ix., page 317. 
 
154 Intestinal Obstruction. [Chap. vii. 
 
 liave collected seven cases of these species of twist, 
 and in every instance there was some congenital mal- 
 formation of the parts involved. Before considering 
 the matter in any detail it would be well to take a 
 brief glance at the commoner congenital malforma- 
 tions of the colon. 
 
 In the foetus the small bowel occupies at one time 
 the right side of the abdomen, while the large gut is 
 represented by a straight tube that passes on the left 
 side vertically from the region of the umbilicus to the 
 pelvis. The ca3cum is at first situated within the 
 umbilicus, and tlien ascends in the abdomen towards 
 the left hypochondrium. It next passes transversely 
 to the right hypochondrium, and then descends into 
 the corresponding iliac fossa. It may be permanently 
 arrested at any part of its course. Thus the caecum 
 may be found about the umbilicus, or in the left 
 hypochondriac region (the ascending and transverse 
 parts of the colon being absent), or it may be found 
 in the right hypochondrium, the ascending colon only 
 being unrepresented. The whole of the large intes- 
 tine has at one time an extensive mesentery, and in 
 some rare cases this condition may persist throughout 
 life. It will be seen that in the forms of volvulus 
 now to be noticed certain of these abnormal conditions 
 are present. 
 
 (2) The ascending colon and caecum may be pro- 
 vided with a very long meso-colon, as long, or even 
 longer than the mesentery. The abnormal coil thus 
 produced is very apt to get into difficulties. It may 
 become twisted about its own mesenterial axis, just as 
 is the case with the sigmoid flexure. An instance of 
 this is recorded by Mr. Avery. Here the distended 
 ascending colon formed an enormous loop. The 
 patient, a man aged fifty-five, died after nine days of 
 almost complete obstruction.* Left lumbar colotomy 
 *Patli. Soc. Trans., vol. ^ii., i^age 222. 
 
Chap. VII.] Volvulus. 155 
 
 had been performed, and the portion of gut opened 
 was found to be the extremity of the loop formed by 
 the ascending colon. 
 
 When this part of the large intestine is practically 
 free, and has a large and long mesentery, it may form 
 an axis around which a suitable coil of small intestine 
 may be entwined, or, on the other hand, it may itself 
 wind around any loop of the lesser bowel that is in a 
 position to be so engaged. The arrangement of parts 
 is, indeed, precisely the same as has been described in 
 connection with the sigmoid flexure. The latter form 
 of volvulus, where the large gut winds round the 
 small, is the more common. A good instance of it 
 has been recently placed on record. In this case 
 " the caecum was found lying under the diaphragm, 
 close to the spleen, the large intestine attached to it 
 having been twice twisted round the lengthened 
 mesentery of the small intestine, causing a double 
 obstruction."* 
 
 The symiotoms in these cases are not so acute as 
 in corresponding examples of volvulus implicating 
 the sigmoid flexure. In Mr. Firth's case, for example, 
 the attack began with sudden pain, followed by 
 vomiting, which, however, did not become severe until 
 the next day. The abdomen became distended and 
 tender, and the bowels absolutely confined. On the 
 fifth day laparotomy was performed, but the obstruc- 
 tion was not found. Feculent vomiting commenced. 
 On the evening of the sixth day the vomiting abated 
 and ceased to be stercoraceous. On the seventh day 
 the bowels were opened eight times. The patient 
 became gradually worse, and died collapsed on the 
 
 * Case by Mr. Charles Firth; Brit. Med. Journ., vol. ii., 1882, 
 IDage 166. See case by Dr. Sands, where the Ccecum was m the 
 right hypochondrium, and where the mesentery and small in- 
 testine were encircled and constricted by the meso-colon. jy-sw 
 York Med. Record, vol. xxxi., 1882, page 427. 
 
156 Intestinal Obstruction. [Chap. vii. 
 
 eighth day. Perforation of the csecum had occurred. 
 There was commencing general peritonitis. 
 
 (3) In this variety of volvulus the caecum has been 
 described either as " bent upon " itself or as twisted 
 upon itself. The difference between these two very 
 similar terms is really greater than perhaps the terms 
 themselves would permit. In the former instance, 
 the csecum is bent about a line at right angles to its 
 long axis. The result is that the lower part of the 
 caput coli is found in front of the ascending colon, 
 its posterior surface becomes anterior, while the aj)- 
 pendix and the lowest point of the caecum become 
 uppermost. At the angle of the bend there is of 
 course a deep crease across the bowel, and by the 
 bendins: in of the mucous membrane at this crease the 
 lumen of the gut is occluded. Two good examples of 
 this volvulus have been described, one by Dr. Fagge,* 
 the other by Dr. Handfield Jones, f 
 
 In the other variety the caecum is twisted around 
 its own long or vertical axis so that its relations to 
 the ascending colon are practically undisturbed. 
 Three examples of this form have been recorded by 
 Dr. Fagge.J 
 
 In all of these five instances of volvulus the 
 caecum presented some abnormality that may be safely 
 regarded as congenital. In one instance it was found 
 in the right hyi)ochondrium, in another in the left, 
 in a third example it occupied the pelvis, and in a 
 fourth it was found to the left of the umbilicus. In 
 each of these cases the ascending colon, or the gut 
 that should represent it, presented a corresponding 
 anomaly, while the mal-placed bowel was provided 
 with an extensive meso-colon. 
 
 These forms of twist must be classed among the 
 
 * Guy's Hosp. Reports, vol. xiv, 
 
 \Mtd. Times and Gazette, vol. i., 1872, jjage 3. 
 
 J Guy's Hosp. Keports, vol. xiv. 
 
Chap. VII.] Volvulus. 157 
 
 least common varieties of intestinal obstruction. Of 
 the mechanism involved in their formation nothing- 
 appears to be known, although many speculations 
 have been vouchsafed upon the subject. 
 
 The. symptoms of volvulus of the caecum vary greatly, 
 and even among the five instances just alluded to 
 there are examples of an acute, of a subacute, and of a 
 chronic case. Four of the patients were males, one a 
 female. Their ages ran between twenty-eight and 
 fifty-five. The fatal attack had in one case been 
 preceded by severe diarrhoea, and in the other in- 
 stances by obstinate constipation. In two examples 
 the onset may be said to have been sudden, while in 
 the remaining cases it was gradual. Dr. Jones' 
 patient was seized suddenly, soon after a meal, with 
 pain, followed by vomiting and constipation. On the 
 third day of the obstruction, as the patient was 
 getting out of bed he became suddenly collapsed and 
 died in a few minutes of syncope. In one of Dr. 
 Fagge's cases the attack ended fatally in three and 
 a half days. In another case the attack was sub- 
 acute. There was pain which subsided once and then 
 returned ; constipation which yielded once and then 
 persisted; vomiting which became feculent on the 
 twelfth day and fsecal shortly before the patient's 
 death about the eleventh day. In another instance 
 the patient died four months after admission into 
 hospital, the chief symptom during that time being 
 obstinate vomiting. In one other patient there had 
 been severe constipation for two weeks, but vomiting 
 did not set in until the day before death. 
 
 The symptoms, therefore, show every variation 
 between acute obstruction of the colon on the one 
 hand and chronic or partial obstruction on the other. 
 
 Distension of the abdomen, often of an irregular 
 character, was constant. In all cases peritonitis was 
 found at the autopsy. The caecum was, in every 
 
158 Intestinal Obstruction. [Chap. vii. 
 
 example, of enormous proportions. In one case it 
 is said to have filled nearly one half of the abdomen, 
 and in another instance to have apparently occupied 
 the greater part of that cavity. Once it is spoken 
 of as gangrenous, and in two instances it was either 
 ruptured or perforated. 
 
 3. Volvulus of the small intestine. — Twists 
 of this part of the bowel may be considered under 
 two categories. In one a loop of the small intestine 
 is twisted about its own mesenteric axis, in the other 
 a suitable xjoil or loop of the bowel is engaged in a 
 volvulus with another suitable coil. 
 
 (1) A volvulus of tJie small intestine about its 
 mesenteric axis. — Here a loop of the bowel is twisted 
 around an axis represented by a line passing along the 
 mesentery from its root at the spine to the intestine. 
 It has already been pointed out that this form of 
 twist is quite common in cases of strangulation by 
 bands and through apertures. Many instances of such 
 strangulation are recorded where the occlusion of the 
 involved bowel has been brought about rather by its 
 having become twisted upon itself than by its being 
 actually pressed upon by the band or by the margin 
 of the aperture. On relieving the volvulus by per- 
 forating the bowel the gut has been found to be so 
 lightly held that the slightest degi'ee of traction has 
 served to reduce it. These cases are often associated 
 with evidences of incomplete obstruction, with pain 
 that is paroxysmal, with vomiting that is irregular in 
 amount and intensity, and with constipation that need 
 not be absolute. 
 
 Many instances also may be alluded to where 
 adherent loops and coils of the lesser bowel have 
 become so twisted upon themselves as to produce 
 occlusion, and such a circumstance has often given an 
 acute ending to a chronic case. 
 
 In the present set of cases the gut is entirely free 
 
Chap. VI I .] Vol vul us. 159 
 
 from adhesions and the volvuhis entirely independent 
 of any constricting band. The condition of \\\q intestine 
 that favours twisting is identical with that that pre- 
 disposes to volvulus of the sigmoid flexure. A certain 
 part of the bowel has an unduly long mesentery 
 whereby it becomes to some extent separated from the 
 remainder of the intestine. The two ends of the coil 
 so individualised are brought more or less together, so 
 that a possible pedicle is formed, about which the gut 
 may be twisted. This condition of parts may be 
 found in a loop of ileum that has long been herniated 
 and then reduced. The approximation of the two 
 ends of a coil may be brought about by mesenteric 
 peritonitis due to glandular disease or to other causes. 
 In cases where the elongation of the mesentery is a 
 conspicuous feature a congenital origin may probably 
 be ascribed to the condition. In a case of volvulus 
 reported by Dr. Fowler, the mesentery of the involved 
 coil measured from seven to eight and a half inches 
 from its root to its attachment to the bowel.* The 
 mechanism of the volvulus and the exact means 
 whereby it is brought about are still matters of 
 speculation. The twist is usually froin left to right, 
 and as a rule represents one complete turn. Fatal 
 obstruction may^ however, follow in instances where 
 the bowel has described but half a turn.f Distension 
 of the involved coil has evidently much to do with 
 the volvulus. In two or three instances it was noticed 
 at the autopsy that the tAvist became spontaneously 
 reduced when the bowel was punctured, but reappeared 
 when it was again inflated. | 
 
 The general appearance of a simple volvulus of 
 
 * Lancet, vol. i., 1883, page 1119. 
 
 t See case by Dr. Sutton; Brit. Med. Journ., vol. i., 1881, 
 page 848. 
 
 X As an instance, see case by Dr. Verneuil ; Bull, de la Soc. 
 Anat,, 1870, page 411. 
 
i6o Intestinal Obstruction. [Chap. vii. 
 
 the small intestine is well shown in Fig. 28 from 
 a specimen in St. Thomas's Hospital. 
 
 Fig. 28.— Volvulus of lower Ileum, 
 a' and a2 join one another after many convolutions. 
 
 The involved coil, being closed at both ends, 
 becomes greatly distended. This distension may 
 cause it to attain huge dimensions, as in a case of 
 
Chap. VII.] Vol vul us. i 6 i 
 
 volvulus of the duodenum recorded by Dr. Rombold, 
 where the twisted loop looked like the stomach, and 
 is said to have been larger than an adult's head. * 
 
 The walls of the distorted loop are deeply con- 
 gested, may be black in colour, or in a condition of 
 approaching gangrene. I have met with no instance 
 where the intestinal wall had given way during life. 
 
 I have only been able to collect ten examples of 
 the present form of obstruction. The amount of 
 bowel involved varies greatly. In the majority of 
 the cases a large loop, probably about one foot to two 
 feet in length, is implicated. In one instance five 
 feet of bowel were discovered to have been twisted, f 
 
 As regards the segment of the bowel involved, in 
 no less than seven cases out of the ten the volvulus 
 was in the lower ileum. In the three remaining cases 
 the twist was respectively in the duodenum, in the 
 upper jejunum, and in the lower jejunum. Seven of 
 the patients were males, while only two were females. 
 In one case the patient is merely described as " an 
 infant." The average age of nine patients (omitting 
 the case of the infant) was twenty-three years, the 
 youngest individual being ten years old and the oldest 
 forty. 
 
 The symptoms met with in this form of volvulus 
 vary considerably. The course of the malady may be 
 acute or chronic. One patient out of the ten above 
 alluded to exhibited symptoms of partial obstruction 
 for thirty-six days, while another was troubled with 
 abrupt attacks of obstruction at uncertain intervals, 
 for more than a year before death occurred. In the 
 remaining eight cases the average duration of the 
 attack was five days, the extremes being thirty-two 
 hours and nine days. 
 
 * Oestreichische Zeitschrift fiir prack. Heilkunde, 1865. N. 6. 
 t Dr. James Wilson ; Amer. Jour, of Med. Sciences, July, 1879, 
 page 78. 
 
 I.— 12 
 
1 6 2 JnTES TINA L ObS TR UC TION. iChap. VI I. 
 
 In five of these eiglit cases the attack came on 
 suddenly. In several instances no cause could be 
 assigned for the intestinal trouble. In other cases 
 diarrhoea, or less frequently constipation, had preceded 
 the symptoms of obstruction. Pain appears to be 
 always the first symptom complained of. It is severe 
 and of a colicky character, and at first usually 
 localised about the umbilicus. As the case progresses, 
 and probably as some local peritonitis sets in, the pain 
 may become more definitely localised. In several 
 examples it is described as continuous but with 
 exacerbations. There is usually no tenderness at first, 
 although that symptom may appear before the termi- 
 nation of the case. It depends probably upon the 
 development of some peritonitis. 
 
 Vomiting appears early. It is a marked symptom, 
 .but would seem to occur rather at long intervals and 
 in large quantities than to be incessant and less 
 copious. Out of the eight cases, the vomited matters 
 became stercoraceous in two instances, in five instances 
 it is described as non-stercoraceous, and in the re- 
 maining case all description is lacking. In one of the 
 cases where the vomiting was non- feculent the duo- 
 denum was involved, and in another the jejunum. 
 
 Constipation is usually complete from the first. 
 The lower bowel may, however, be emptied by enemata 
 of any contained faeces, and occasionally a motion has 
 been passed that may have been due to some tempo- 
 rary relaxation of the volvulus. The abdomen soon 
 becomes swollen, and an indistinct mass or tumour 
 may be felt within if the twisted bowel be of good 
 length and in a position to present itself beneath the 
 parietes. Auscultation during the administration of 
 an enema will, as a rule, demonstrate readily that the 
 colon is uninvolved. In one case where the lower ileum 
 was implicated the patient complained of severe tenes- 
 mus and of a sensation as of a cord encircling the body. 
 
Chap. VII.] Volvulus. 163 
 
 Mr. Harrison Cripps has recorded a case of con- 
 genital volvulus of the ileum that is probably unique. 
 The child had had no action of the bowels, suffered 
 from obstinate constipation and frequent vomiting. 
 Littre's operation was performed on the third day of 
 life under the impression that the rectum was mal- 
 formed. The infant died of peritonitis. The colon 
 was found to be normal, and the volvulus to be slight 
 and very readily reduced. 
 
 In one of the chronic cases (in a girl aged ten) 
 the attack came on suddenly with intense pain, 
 vomiting and tenesmus. The acute symptoms soon 
 subsided and the case became chronic. The somewhat 
 obstinate constipation was interrupted by an occasional 
 stool, the vomiting became stercoraceous, the abdomen 
 was much distended, and showed through its parietes 
 the peristaltic movements of the bowels. The child 
 was much emaciated, and died at the end of thirty- 
 six days, after twenty-four hours of intense abdominal 
 pain. There was a volvulus of the lower ileum but 
 no peritonitis.* In the other chronic case the patient 
 had no less than seven severe attacks of obstruction in a 
 little more than twelve months. These attacks were 
 somewhat sudden in their onset and associated with 
 constipation, vomiting, and severe pain. They were 
 relieved, as a rule, at the end of a few days by means 
 of enemata, the patient recovering often very slowly. 
 Here the volvulus was in the upper end of the jejunum. 
 This case suggests the possibility of spontaneous cure 
 in cases of volvulus, and it may be that several of 
 the examples of acute intestinal obstruction that have 
 either ceased spontaneously or yielded to some 
 nostrum, have been instances of volvulus of the 
 lesser bowel. 
 
 Out of the ten cases, acute general peritonitis was 
 
 *Dr. Handfield Jones; Med. Times and Gazette, vol. i., 1872, 
 page 3. 
 
164 Intestinal Obstruction. [Chap. vii. 
 
 met with in four instauces, in an equal number of 
 autopsies the serous membrane was found to be 
 healthy, in the remaining two cases its condition is 
 not described. 
 
 Leichtenstern describes a volvulus that implicated 
 the whole of the jejuno-ileum. As I have been able to 
 lind no other cases than the few to which he alludes, 
 I might give the account of this form of twist in 
 his own words : " If the root of the mesentery be 
 unusually short, while its height and the length of the 
 intestine are normal, if the radix mesenterii runs 
 more vertically than usual, if the mesentery attains 
 its full height at the jejunum suddenly, and loses it 
 just as abruptly in the neighbourhood of the caecum, 
 then the small intestine is in a condition to undergo 
 twisting as a whole about its mesentery. The twist 
 is usually 180 degrees, and the direction such that 
 the upper end of the intestine is carried to the left 
 and downwards, the lower end to the right and 
 upwards. The right side of the mesentery faces to 
 the left, and the left to the right. This twist does 
 not always cause absolute occlusion, often only a con- 
 striction at each end of the twisted convolution, the 
 beginning of the jejunum and the end of the ileum, 
 the latter of which, when occlusion takes place, is 
 often twisted at the same time about its own longi- 
 tudinal axis. Twisting of this kind has been seen in 
 very young children, and it seems as if that variation 
 in the development of the mesentery in which the 
 ileum, csecum, and ascending colon possess a common 
 mesentery, especially disposed to it." * Dr. Whipham 
 reports a case where " the small gut with the caecum 
 and ascending colon were attached by their mesenteric 
 envelopes to the same point near the last dorsal 
 vertebra ; so that the usual attachment of the colon 
 to the right iliac fossa was deficient. The pedicle of 
 * Loc. cit. , page 565. 
 
Chap. VI I] 
 
 Volvulus. 
 
 165 
 
 conjoined mesentery was twisted from left to right 
 across and around tlie union of the duodenum with 
 the jejunum, so as to compress that part iirmly." The 
 jejunum was in the early stage of gangrene. The 
 patient, a female, aged nineteen, had presented 
 symptoms of intestinal obstruction for twelve days 
 before her death. She suffered from severe vomiting 
 that was never stercoraceous, and from constipation 
 that was relieved once during the twelve days. There 
 was no swelling of the abdomen save a little in the 
 epigastric and hypogastric regions. She had had 
 previous attacks of constipation attended with colic 
 and sickness.* 
 
 (2) Two suitable coils of small intestine are twisted 
 together, the one acting as an axis about which the 
 other is wound. The suitability consists in the in- 
 volved loop being possessed of a long and narrow 
 mesentery, or of the loop that forms the axis being 
 fixed by its extremity to some 
 point on the parietes. Such 
 a case is shown in the ac- 
 companying diagram from 
 Leichtenstern, where the axial 
 loop was adherent to the 
 parietes at the point a (Fig. 
 29) ; h points to the coil that 
 was twisted about the axial 
 loop. 
 
 This form of volvulus is 
 very rare. It would appear 
 that the symptoms to which 
 it gives rise are of an acute 
 character, as is often seen in 
 like forms of volvulus where two coils of bowel are 
 involved, one coil being composed of small intestine. 
 
 Dr. Rundle describes an autopsy where two 
 * Med. Times and Gazette, vol. ii., 1876, page 33. 
 
 Fiar. 29. — Volvulus of smnll 
 lutestiues. (Leiclitensteni). 
 
1 6 6 JnTES TINA L ObS TR UC TION. [Chap. VIII. 
 
 adjacent coils of small intestine were found to Le 
 adherent, while around them a third segment of the 
 lesser bowel had become twisted. The patient was a 
 man, aged forty, who was seized with sudden and 
 severe abdominal pain associated with vomiting. 
 Collapse soon appeared, and he died in less than 
 twenty- four hours.* 
 
 Attention has already been drawn to cases where 
 a volvulus has been formed by an intertwining between 
 a loop of small intestine on the one hand and the 
 sigmoid flexure, or an abnormal caecum or ascending 
 colon, on the other. 
 
 CHAPTER VIII. 
 
 INTUSSUSCEPTION : PATHOLOGY. 
 
 By the term intussusception is understood the pro- 
 lapse of one part of the intestine into the lumen of an 
 immediately adjoining part. In cases where the 
 extremity of the ileum is protruded through the ileo- 
 cjBcal valve into the colon, the term prolapse is singu- 
 larly appropriate. In other cases, as, for example, in 
 intussusceptions limited to the small or to tlie large 
 intestine, the condition may be better expressed by 
 saying that one part of the circumference of the 
 bowel has been turned into the part adjacent to it. 
 
 Intussusception is a very common form of intes- 
 tinal obstruction. Classing all varieties of obstruc- 
 tion together, it forms more than one-third of the 
 whole. Its actual share is probably represented by 
 three-eighths. Among 1,152 f cases of intestinal 
 
 * Med. Times and Gazette, vol. i., 186G, page 306. 
 fFrom this collection are excluded congenital obstructions, 
 stenoses of the rectum and the various forms of hernia. 
 
Chap. VIII.] InTUSS USCEP TION : Pa THOL OGY. 
 
 167 
 
 obstruction of all kinds collected by Leichtenstern are 
 no less than 442 cases of intussusception. In a special 
 monograph upon the subject this author deals with 
 the substantial total of 593 recorded cases.* 
 
 Patliolog'ical anatomy. — If an intussusception 
 be viewed in vertical section it will be seen to be 
 composed of six layers of intestine, three on either 
 side of the central canal, all more or less parallel to 
 one another. It will be noticed also that the arrange- 
 ment of the layers is such that mucous membrane lies 
 in contact with mucous membrane, and peritoneum 
 
 c 
 
 Ob" \ 
 
 a- 
 
 Fig. 30. — Vertical and Transverse Sections of an Intussusception. 
 
 o, tbe sheath or intussuscipiens ; 5, the entering or inner layer ; c, the returning 
 or middle layer. 
 
 with peritoneum. On horizontal section the invagi- 
 nated mass will show three concentric rings of bowel, 
 with of course the same mutual relations with regard 
 to the mucous and serous surfaces (Fig. 30). All 
 parts of the intussusception are named, and the 
 nomenclature has suffered somewhat from an exu- 
 berance of terms. The external of the three layers is 
 known as the intussuscipiens, the sheath, or the re- 
 ceiving layer (Za gaine of the French, Fig. 30, a). 
 The innermost cylinder is known as the entering layer 
 
 * Vierteljahrschrift f. d. prakt. Heilk. Prague, 1873-4. 
 
1 68 Intestinal Obstruction. [Chap. vin. 
 
 (Fig. 30, 6), and the middle one as the returning layer 
 (Fig. 30, c). Taken together, these two layers form 
 the intussusceptura {le boudin of the French). The 
 " neck " of the intussusception is at its upper part, 
 where the returning layer joins the sheath (Fig. 30, a). 
 The ridge formed by the junction of these two layers 
 is known as le bourrelet. The " apex " of the intus- 
 susception is at the lower part of the intussiisceptum, 
 where the entering and returning layers join. The 
 arrangement of the various parts of an intussusception, 
 are well shown in Fig. 31. All intussusceptions are 
 complete in the sense that the intussusceptum is com- 
 posed of all the coats of the bowel, and that it enters 
 the sheath evenly and equally. Some authors have 
 described partial or lateral intussusceptions. In these 
 cases a polyp exists, and by a dragging upon the 
 tumour the part of the intestinal wall to which it is 
 attached is drawn into the lumen of the gut, so as to 
 form a funnel-like depression on the surface. Such 
 invaginations do not enter into the present category, 
 and I have been unable to find any examples of them 
 in the museums of London. 
 
 Anatomical varieties. — Invaginations may 
 occur at any part of the intestine from the duodenum 
 to the rectum. They may be conveniently divided 
 into the three classes : (1) the enteric; (2) the colic 
 or rectal ; and (3) the intussusceptions that involve 
 the ileo-c?ecal segment of the bowel. 
 
 (1) Enteric invaginations may occur in any part 
 of the lesser bowel. In the upper part of the small 
 intestine they are rare, although an isolated case or 
 so has been recorded of intussusception of the duo- 
 denum. They are most common in the lower jejunum 
 and then in the ileum. 
 
 It would appear that jejunal intussusceptions bear 
 to ileic intussusceptions the proportion of about four 
 to one. Invaginations involving the small intestine 
 
Chap. VIII.] Intussusception : Pathology. 
 
 i6g 
 
 seldom attain great length. They are often very 
 short,, and in the fliajority of cases do not involve 
 
 Fig. 31. — Intussixsceptioii of Jejiinnm. 
 a, internal cylinder ; 6, middle cylinder; c, external cylinder. 
 
 more than a few inches of the bowel, about three to 
 ten inches, on an average. Some may be, however, 
 
170 Intestinal Obstruction. [Chap. viii. 
 
 of considerable length, as in a case reported by Mr. 
 Henry Morris, where two feet of the lower ileum were 
 involved ; * or another, recorded by M. Bucquoy, 
 where over two yards of jejunum were implicated 
 in the invagination.! 
 
 Under this class must be included the great ma- 
 jority of "the intussusceptions of the dying." 
 
 (2) Colic intussusceptions present many varieties. 
 Tlie ascending colon may be invaginated into the 
 transverse, the transverse into the descending, and 
 the descending colon into the sigmoid flexure. They 
 are most frequently met with in the two last-named 
 parts of the colon. Owing to the comparative fixity of 
 the large intestine, it happens that these intussuscep- 
 tions are usually short, and, indeed, taken as a whole, 
 they form invaginations that in point of size are the 
 smallest of the whole series. When the rectum is 
 involved the upper segment of this intestine is invagi- 
 nated into the lower part. Such intussusceptions 
 must of necessity be short, since in the most extreme 
 cases they must be limited by the length of the 
 rectum itself. 
 
 (3) The intussusceptions that occur in the ileo- 
 csecal region may be divided into two main classes, 
 the ileo-csecal and the ileo-colic. 
 
 The ileo-c9ecal form is the commonest variety of 
 invagination, while the ileo-colic is the most rare. In 
 the former the ileum and csecum pass into the colon 
 preceded by the ileo-csecal valve. The internal cylin- 
 der is formed of the termination of the ileum ; the 
 external cylinder or sheath is formed by the colon 
 
 'Path. Soc. Trans., vol. xxviii., jiage 131. See also case by 
 Mr. Eager (Lancet, vol. i., 1882, page 604), where one and a half 
 feet of the upper jejunum were involved. 
 
 t Recueil des Travaux de la Soc. Med. d'Observ.,tome i., page 
 192. Paris, 1857. See also case by Dr. Johnstone of Baltimore 
 {Lancet, vol. i., 1883, page 176), where forty inches of small gut 
 were passed by the anus, with recovery. 
 
Chap. VIII.] Intussusception: Pathology. 171 
 
 alone, while the apex of the intussusception is repre- 
 sented by the ileo-csecal valve. This form may attain 
 great size, and it is not infrequent for the valve to 
 traverse the whole length of the lai'ge intestine and 
 ultimately present itself at the anus or even protrude 
 through that sphincter. 
 
 In the ileo-colic variety the termination of the 
 ileum is prolapsed through the ileo-csecal valve. The 
 valve and the caecum remain, for a time at least, in 
 their normal situations. The apex of the intussus- 
 ceptum must always be formed by some portion of 
 the terminal part of the ileum. This intussusception 
 is commonly associated with some secondary invagina- 
 tion of the csecum and colon itself, concerning which 
 more will be said when speaking of the mode of in- 
 crease observed in these abnormal conditions of the 
 bowel. A third variety met with in this region has 
 been termed by Leichtenstern the iliaca-ileo-colica. 
 In this form a primary intussusception is formed in 
 the terminal part of the ileum. This invagination, 
 when it reaches the valve, may either pass through it 
 (just as does the uninvaginated gut in the pure ileo-colic 
 form) ; or it may be arrested at the valve and then 
 be associated with an invagination of the csecum into 
 the ascending colon. In the former of these two sub- 
 varieties the apex of the intussusception will be 
 formed of ileum, in the latter it will be represented 
 by the ileo-csecal valve. 
 
 Relative frequency of tlie various forms, 
 — According to Leichtenstern, whose statistics are by 
 far the most numerous at present published, the dif- 
 ferent anatomical varieties are thus distributed in 
 one hundred cases: Ileo-csecal, 44 per cent. ; enteric, 
 30 per cent. ; colic (including rectal), 18 per cent. ; 
 and ileo-colic, 8 per cent. With these results the 
 statistics published by Brinton and others very closely 
 affree. 
 
172 Intestinal Obstruction. [Chap. viii. 
 
 Tlie uiode of gi'owtli of tlie iiitiissuscep- 
 tion. — In all the forms, with the exception of the 
 ileo-coHc, the method of increase is as follows : "When 
 an intussusception increases in length after a piece 
 of bowel has been primarily invaginated, the in- 
 crease is at the expense not of the entering layer, but 
 of the external or receiving layer. For example, let 
 it be supposed that a portion of the termination of 
 the jejunum is invaginated into the ileum. If the 
 mass increases in length it will do so solely at the ex- 
 pense of the ileum. No more of the jejunum will 
 actively enter into the intussusception, so that no 
 matter what segment of gut formed the original 
 apex of the intussusception, that apex will remain 
 the same even if the invagination doubled or trebled 
 its original length. In the ileo-c^ecal variety the 
 cjecum is turned into the ascending colon, and the 
 valve forms the apex of the intussusception. As the 
 invao:ination increases the ascending colon becomes 
 inverted, then the transverse and descending colon, 
 until at length, when the sigmoid flexure is reached, no 
 trace of the ascending, nor probably of the transverse, 
 colon will be left, but the valve w^ill still form the tip 
 of the intussusception. It is ob%dous that in the 
 growth of this variety much depends upon the mobility 
 of the colon, and since the colon is usually much less 
 fixed in the child than it is in the adult, it follows 
 that extensive in^'aginations of this species are most 
 commonly met with in the young. 
 
 The amount of traction brought to bear upon the 
 parts in growing intussusceptions that involve the 
 colon must often be considerable. This is well illus- 
 trated in a specimen in St. Bartholomew's Hospital.* 
 It shows an ileo-caecal intussusception. The caecum, 
 the ascending and transverse colon have disappeared 
 from view, the ileum appears to enter directly into 
 * St. Bart.'s Hosp. Museum, No. 2,188. 
 
Chap. VIII.] Intussusception : Pathology. 173 
 
 the descending colon. The vermiform appendix and 
 the ileo-c?ecal valve project beyond the anus. By 
 means of the dragging upon the transverse colon the 
 stomach has been rendered vertical and has been 
 brought into close contact with the intussusception. 
 
 In the ileo-colic variety the method whereby the 
 intussusception increases is, in the first instance at 
 least^ somewhat different. A portion of the terminal 
 ileum is protruded through the ileo-caecal valve, and 
 the invagination may increase for some time solely by 
 the prolapse of more and more ileum, the sheath re- 
 maining perfectly unchanged. This is exactly the 
 opposite to what happens in other intussusceptions. 
 When once the prolapse has commenced no obstacles 
 are offered to its increase other than those presented 
 by the resistance of the valve and the dragging upon 
 the ileic mesentery. When once the invaginated 
 small intestine is in the spacious colon it meets with 
 practically no resistance. Sooner or later, however, 
 no more ileum can become prolapsed. The part pro- 
 truded may become fixed by adhesions ; or from con- 
 gestion or distension of the ileum the valve offers a 
 rigid resistance to any further invasion of the colon. 
 In such a case, if the intussusception still continues to 
 increase it must do so by the method observed in other 
 forms of invagination, viz, at the expense of its sheath. 
 No more ileum can enter, but the caecum can be 
 turned in, and then the ascending colon, and so on 
 until at last the rectum may be reached. A good 
 specimen of ileo-colic intussusception associated with 
 little or no secondary invagination of the caecum is 
 shown in Fig. 32 from the Museum of the College of 
 Surgeons.* 
 
 The iiitiissusception of the dying^. — All 
 invaginations can be divided into two great forms 
 according to the circumstances of their origin. 
 * No. 1,368 C. 
 
[Chap. VIII. 
 
 Fig. 32, — Ileo-colic Intussusception. 
 «> SBcending colon ; b, ileum ; c, vermiform appendix. 
 
Chap. VIII.] Intussusception : Pathology. 175 
 
 (1) The common or obstructive intussusception 
 and (2) the intussusception of the dying. With the 
 former only is surgery concerned. The latter is a 
 form of invagination that occurs probably a little 
 while before death, and depends upon certain irregular 
 peristaltic movements that may be conceived to occur 
 during the act of dying. It is well known that as a 
 patient lies in articulo mortis muscular actions become 
 often irregular and disordered before they cease for 
 ever. It is consistent with experience to imagine that 
 a like feebly tumultuous action may pervade the 
 muscle of the intestine during the death struggle, and 
 that it may be such as to produce some invagination 
 of the bowel. Intussusceptions of this kind cause no 
 symptoms during life. They are first discovered at 
 the autopsy. They are always very small, are always 
 free from any trace of congestion or inflammation, 
 and interfere little with the lumen of the bowel. 
 With the most trifling amount of traction they can 
 be reduced. They are most usually met with in 
 children, and especially in such as have died of brain 
 disease. They occur in association with perfectly 
 normal abdominal \dscera. They are uncommon in 
 adults. 
 
 In two other points may they differ from common 
 intussusceptions, viz. in number and in direction. 
 These points may be considered in more detail. The 
 obstructive invagination is usually single : the 
 intussusceptions of the dying are often multiple. 
 There are a few recorded cases where several intus- 
 susceptions have been found which collectively caused 
 obstruction and which were apparently not of the 
 precise nature of those that form just before death. 
 The multiple invaginations are always small and 
 nearly always limited to the small intestine, while 
 at the same time they are associated with but 
 slight changes in the gut. The common obstructive 
 
176 InTES TINA L ObS TR UCTION. [Chap. VIII. 
 
 intussusception that is associated with adhesion of its 
 parts, with gross changes in both its sheath and its 
 intussusceptum, and often with gangrene of the latter 
 is, so far as I can ascertain from the records of cases, 
 invariably single. It is true that such invaginations 
 may be associated with others that are secondary to it 
 and that are clinically of no significance ; but I am 
 aware of no instance where two obstructive intussus- 
 ceptions distinctly independent of one another, and 
 both attended by such morbid changes as are common 
 in such invaginations, have existed at the same time 
 in the same body. 
 
 The intussusceptions of the moribund, on the 
 other hand, are more often multiple than single. It 
 
 Fig. 33.— Intussusception of the Dying. 
 
 is common to find four or five within a little distance 
 of one another, and even as many as ten have been 
 met with in a single case.* 
 
 In direction the obstructive intussusception is 
 almost invariably descending, i.e. the in-turning of 
 the bowel wall is in the direction of the anus. It is 
 true that a primary invagination of this kind may be 
 associated with a secondary ascending intussusception. 
 
 * Dr. Gee ; Brit. Med. Jnurn. , Nov. 14 , 1861. See also Mr. 
 Gay's paper on Intussusception. London, 1862. 
 
Chap. viii.] Intussusception : Pathology. ijj 
 
 But such secondary formations are unimportant, 
 have little or no influence upon the primary trouble, 
 and are devoid of any clinical significance. The in- 
 tussusceptions of the dying are often ascending or 
 retrograde, and the two varieties are not infrequently 
 found to be present in the same body. A specimen 
 of such a case is to be found in Guy's Hospital,* 
 while Fig. 33 f shows the common appearance of the 
 invaginations of the moribund. 
 
 These non-clinical intussusceptions have formed 
 the bases of many erroneous conclusions and have 
 been accredited with producing an obstruction that 
 may have existed for days and weeks before they 
 themselves had any existence. A case reported by 
 M. Leger | may probably be an example of this. A 
 woman of sixty-five died after presenting symptoms 
 of chronic obstruction that had extended over twelve 
 months. She died of inanition. The autopsy revealed 
 an intussusception of the upper part of the jejunum 
 18 cm. in length. This invagination presented no 
 adhesions, and showed an absence of congestion and 
 indeed of any other morbid changes in its walls. 
 It is extremely improbable that this intussusception 
 could have induced abdominal symptoms for over 
 twelve months, and yet after death be found to be 
 as free from structural changes as a piece of 
 intestine but recentlv invao-inated. The diagnosis of 
 chronic intussusception presupposes that the invagina- 
 tion had existed unreduced for the period covered by 
 the symptoms. Elsewhere in the abdomen were 
 ancient adliesions the products of a past peritonitis. 
 It would probably be more reasonable to assume that 
 the chronic obstraction was due to the adhesions, and 
 that the intussusception was of the character of those 
 that form when the patient lies in articulo mortis. 
 
 * No. 1,851 (42). t St. Thomas's Hosp. Museum, No. E 2. 
 I Bull, de la Soc. Anat., 1876, page 719. 
 M— 12 
 
I 7 8 IntES TINA L ObS TR UC TION. [Chap. VIII. 
 
 Another case of a dijQTerent nature, reported by M. Le 
 idoyne,''^ may possibly fall under the present category. 
 The patient, a man aged thirty-five, died with symp- 
 toms of subacute obstruction. The autopsy revealed 
 six intussusceptions of the small intestine. They 
 were all small, readily reduced, and free from any 
 structural or vascular changes. The sigmoid flexure 
 was blocked with a mass of fcecal matter and un- 
 digested food, whicli formed so large a collection as to 
 produce a tumour that was seen through the parietes 
 several days before death. In this instance I would 
 venture to suggest that the mass in the colon more 
 probably caused the fatal obstruction than did the 
 intussusceptions which all possessed a lumen large 
 enough to admit the point of the little finger. 
 
 Retrog^rade, double, and triple intussiis- 
 ceptioiiiS. — These unusual forms may conveniently 
 be considered here. It has been already said that the 
 common or obstructive invagination is almost invari- 
 ably descending as regards its direction. To this ob- 
 servation there are very few exceptions. Out of a 
 collection of 593 cases Leichtenstern could find only 
 eight examples of a primary ascending or retrograde 
 intussusception of the obstructive (or, as he calls it, of 
 the inflammatory) variety. He considers that these 
 eight instances all depended upon a rare association 
 of anomalous circumstances, and regards them all as 
 allied to the invaginations of the death-struggle, 
 among which retrograde forms are by no means un- 
 common. A case or two, however, of retrograde in- 
 tussusception of the obstructive variety may be named 
 that would appear to be of less complicated origin 
 than Leichtenstern is disposed to admit. Such a case 
 is reported by M. Besnier.f It concerns a female, 
 
 * Contrib. a I'Etude des Invaginations de I'Intest. grele. 
 Paris, 1879. 
 
 \ Th^se de Paris, 1857, page 52 
 
Chap . V 1 1 1 . ] I NT USS USCEP TION : Pa THOL OG V. 
 
 179 
 
 aged 22, who, after presenting symptoms of chronic 
 obstruction, died after nine days of somewhat acute 
 manifestations. The autopsy revealed a small and 
 simple retrograde intussusception of the sigmoid flexure 
 into the descending colon. The invaginated layers 
 were secured in position by solid adhesions, and 
 formed in the lumen of a gut a species of obstructive 
 valve. The bowel above the impediment was 
 ulcerated. 
 
 A primary descending intussusception may be 
 associated with a secondary ascending one, the two 
 occupying the same segment of the bowel. In such 
 cases the retrograde invagination is external to the 
 layers that take a descending direction. It is 
 extremely probable that such secondary invaginations 
 depend upon a flaccid and plaited sheath, a fold of 
 which may slip up between itself and the intussus- 
 ceptum and so produce the appearance described"^ 
 (Fig. 34). It is significant that these complicated 
 forms are usually met witli in 
 the colon. An arrangement of 
 sheath that would favour the 
 complication is shown in Fig. 32. 
 A good example of the cases 
 now under notice is reported in 
 a recent " annotation " in the 
 Lancet. The patient was a child, 
 aged six months, who died with 
 symptoms of intussusception oc- 
 curring after an attack of diar- 
 rhoea. There was at the autopsy 
 a double intussusception of the 
 colon. The primary invagination was downwards and 
 was about five inches in length. The layers composing 
 it were adherent and deeply congested. The retrograde 
 intussusception evidently involved the sheath after 
 * See Leichtenstern loc. cit. , page 612. 
 
 3 layers- "f^ 
 
 5 tajers 
 3layers^—\ 
 
 Fig. 34. 
 
 n 
 
iSo Intestinal Obstruction. [Chap. viii. 
 
 the manner just described. It was about half the 
 length of the original tumour and free from all 
 adhesions. Thus the involved segment showed from 
 above downwards first three layers of bowel, then 
 five layers, and again three layers (Fig. 34). I can 
 find no recorded case that would support the state- 
 ment of some to the efiect that a descending and a 
 retrograde intussusception may start from two points 
 of the intestine, remote from one another, and then 
 by growing ultimately meet and inter-penetrate one 
 another. 
 
 Instances of double intussusceptions are fairly 
 common. In these cases one invagination is primary 
 the other is secondary. The primary tumour acts as 
 a foreign body in the intestine and leads to fresh 
 infolding of the walls of the bowel. The secondary 
 invagination concerns only the sheath or receiving 
 layer of the primary tumour. This variety is met 
 with both in the colon and in the small intestine, and 
 in the intussusceptions of the dying as well as in the 
 obstructive forms. It is most usually 
 found in the former species of intus- 
 susception. When met with in the 
 obstructive invagination the secondary 
 layers may or may not present adhesions. 
 Usually they are free. A good example 
 of a double intussusception is in the 
 London Hospital Museum.* It will be 
 obvious that such invaginations will 
 present five layers of intestine instead 
 of three (Fig. 35). 
 Cases of trijole intussusception are not so common. 
 Here also there is a primary invagination and then 
 two secondary invaginations, the first of which 
 involves the sheath of the primary intussusception. 
 In these cases it will be evident that the tumour will 
 * Lond. Hosp. Museum, No. 25. 
 
 Fig. 35. 
 
Chap. VIII.] Intussusception: Pathology. 
 
 I5I 
 
 present no less than seven layers of intestine, as can 
 be seen in the annexed diagram (Fig. 36). An 
 excellent example of this variety is described with 
 great clearness by Bucquoy.'^ It was met with in 
 a male patient, aged twenty-two, who died after 
 having presented the symptoms of 
 chronic intussusception for about six 
 weeks. For many months preced- 
 inof the onset of the final attack he 
 had had somewhat similar seizures, 
 but of slighter character and of 
 short duration. Both the terminal 
 attack and one of the previous 
 seizures were associated with the 
 appearance of a very distinct ab- 
 dominal tumour. The post-mOrtem I (J I 
 inspection revealed a triple intus- 
 susception that involved nearly the 
 whole of the jejunum. The tumour 
 formed was eleven and a half inches 
 loncf and six inclies in circumfer- 
 ence, and presented seven layers of 
 intestine. 
 
 Fig. 36. 
 
 THE GENERAL PATHOLOGICAL CHANGES IN AN 
 INTUSSUSCEPTION. 
 
 1. The part played by the mesentery.— As 
 
 an invagination increases it is obvious that the 
 mesentery must be drawn in with the bowel. In a 
 tumour of any magnitude it is found between the 
 two layers of the intussusceptum, drawn out into 
 the form of a cone, with its apex at the extremity 
 of the intussusception and its base at the neck. 
 As the invagination increases the traction upon the 
 
 *Recueil des Travaiix de la Soc. Med. d'Observ., page 192. 
 Paris, 1857. 
 
1 8 2 InTES TINA L ObS TR UC TION. [Chap. V 1 1 1 . 
 
 mesentery must be great. In cases of extensive 
 intussusception it may be well imagined that that 
 traction is often considerable. For instance, the 
 ileum with its mesentery may be inverted into the 
 caecum, and may travel along the whole length of the 
 colon, until it presents or even protrudes at the anus. 
 It is obvious that in such cases the mesentery must 
 be either unduly long or must have been greatly 
 stretched. The increased length, however, required 
 in the mesentery to permit its appeai'ance at the anus 
 is not so considerable as may at first sight appear. 
 As the prolapsed gut travels from the ctecum to the 
 anus it practically describes a circle. The centre of 
 this circle may be taken as the vertebral attachment 
 of the mesentery, and the radii of the circle as 
 represented by the mesentery itself. The distance 
 between the involved bowel and the mesenterial 
 centre is not greatly increased as the prolapsed part 
 passes along the colon. Indeed, the greatest demand 
 upon the length of the mesentery is made by the 
 dragging of the membrane into the narrow tube of 
 the intussusception. 
 
 The fact that an ileo-caecal or ileo-colic intussuscep- 
 tion may be felt in the rectum within comparatively 
 a short time of its formation will show that the 
 elongation of the mesentery need not be considerable, 
 even if allowance be made for congenital super- 
 abundance. 
 
 The traction exercised by the mesentery has a 
 considerable effect upon the tumour. It bends the 
 intussusception so that it becomes curved in outline, 
 the concavity of the curve being towards the 
 mesenterial attachment. Sometimes the bending is 
 considerable and almost angular, while a deep trans- 
 verse fold forms across the concavity of the cylinder 
 of the intussusceptum. This altered outline is 
 communicated in a much diminished form to the 
 
Chap. VIII.] Intussusception: Fatholqgv. 183 
 
 investing layer, and thus the whole tumour has a 
 tendency to assume a curved outline. The concavity 
 of this curve looks towards the root of the mesentery. 
 As another result of the traction, it happens that the 
 axes of the intussusceptum and intussuscipiens do not 
 correspond. The former does not lie in the axis of 
 the latter, but is placed eccentrically nearer to the 
 mesenteric border of the bowel. It follows also that 
 the orifice of the intussusceptum is made to assume the 
 aspect of a slit, and looks not so much towards the 
 lumen of the bowel below as towards the mesenteric 
 side of the receiving layer. 
 
 The extent of these changes varies considerably. 
 They may be entirely absent, especially, as Leichten- 
 stern remarks, in intussusceptions of the middle part 
 of the ileum. They are, perhaps, best seen in the 
 invaginations of the ileo-ceecal region. 
 
 In the colon the meso-colon may play somewhat 
 the same part as the mesentery. In colic intussuscep- 
 tions, however, it is very common to find the various 
 layers of the mass parallel to one another, the 
 aperture in the centre and directed towards the 
 central axis of the gut below. On the other hand, 
 several museum specimens show that the intussus- 
 ceptum may be as curved in a colic invagination as it 
 is in any enteric form of the affection. Such a 
 specimen is shown in Fig. ST,"^ where the descending 
 colon has become invasdnated into the sio-moid flexure. 
 As an example of a straight or non-curved intussus- 
 ception of tlie colon, I might cite a specimen in the 
 London Hospital, f 
 
 Intussusceptions of the rectum are all more or 
 less free from curving. \ 
 
 * St. Thomas's Hosp. Museiim, No. R 12 
 t No. Ae. 47. 
 
 X As examples see Coll. of Surgeons Museum, Nos. 1,380 and 
 1,380a. 
 
1 84 
 
 .Intestinal Obstruction. [Chap. viii. 
 
 Fig. 37.— Intussusception of descending Colon into Sigmoid Flexure. 
 
 a, the sheath. 
 There is great thickening of the intussusceptum, especially on its convex Bide. 
 
Chap. VIII.] Intussusception : Pathology. 185 
 
 2. How obstruction aiitl sti'aiig:iilatioii 
 are produced. — Mere invagination of the bowel 
 need not, by any means, lead of necessity either to 
 strangulation of the involved part or to complete or 
 even serious obstruction to the lumen of the intestine. 
 
 Many cases are recorded where the patients have 
 lived for months, presenting evidences of the 
 abdominal disturbance, and have died without ever 
 displaying the symptoms of strangulation or acute 
 obstruction of the bowel. At the autopsies made 
 upon such patients, the intussusception that caused 
 death has often been found to show none but the 
 most insignificant structural changes and to be 
 perfectly reducible. As one instance I might quote 
 a case of Dr. Brinton's, the case of a man who died 
 of chronic intussusception lasting over four and a 
 half months. The post-mortem revealed an ileo- 
 csecal invagination quite free from any gross local 
 changes."^ There is also Mr. Hutchinson's oft-quoted 
 case of a child, aged two, who had suffered from 
 chronic intussusception for one month. At the end 
 of that time Mr. Hutchinson opened the abdomen, 
 and readily reduced the invagination he found therein. 
 The patient recovered.! Many other examples could 
 be given. Such cases, however, are exceptional. 
 More usually the compression of the involved 
 mesentery and the manner in which it is dragged 
 upon lead to some obstruction of its vessels. The 
 veins would be more especially involved, the return 
 of blood from the inturned gut would be prevented, 
 and as a result the intussusceptum would become 
 engorged and swollen. It is to be noted that this 
 interference with the circulation is of the very kind 
 that tends to produce irregular movements in the 
 intestine. The part indeed may become strangulated, 
 
 * Lancet, vol. i., 1863, page 409. 
 tMed.-Chir. Ticans., vol. xxxvii., 1874. 
 
1 86 Intestinal Obstruction. [Chap. viii. 
 
 and as a result the whole of the intussusceptum may 
 become gangrenous. The intussusceptum is, in fact, in 
 the position of a strangulated hernia involving a 
 knuckle of bowel. 
 
 Speaking generally, therefore, it may be said that 
 patients with intussusception may die of one of 
 two principal causes. They may die of strangulation 
 of the bowel and its results, or they may gradually 
 waste and die, worn out by long-continued pain 
 and sickness and other effects of narrowing of the 
 bowel. Chronic cases very often terminate with 
 acute strangulation. 
 
 The actual obstruction to the passage of matters 
 along the intestine may be brought about in many ways. 
 
 (1) The orifice of the intussusceptum is rendered 
 slit-like by the dragging of the mesentery, and may 
 be opposed to the wall of the receiving layer. 
 
 (2) The intussusceptum may be so bent or curved 
 upon itself as to greatly narrow the lumen of the 
 inner cylinder. This is, to some extent, shown in 
 Fig. 37. 
 
 (3) The considerable thickening that the tunics 
 of the involved bowel undergo, as the results of con- 
 gestion, exudation, and inflammation, tend to greatly 
 narrow the lumen of the passage. So extreme may 
 the narrowing from this cause alone be that it may 
 reduce the calibre of the central canal to that of a 
 No. 10 or No. 12 catheter. 
 
 (4) The already narrowed passage may be finally 
 occluded by some accidental circumstance. Thus Mr. 
 Gay mentions a case of ileo-csecal intussusception 
 where the valve was found to be blocked by some 
 undigested rice.* In other instances the central canal 
 has been plugged by blood clots, f In at least one case 
 
 * On Intestinal Obstruction by Invagination. London, 1862. 
 -^ Lancet^ vol. ii., 1846, page 88 ; and Path. Soc. Trans., vol. 
 xxviii., 1877, page 131. 
 
Chap. VIII.] Intussusception : Pathology. 187 
 
 the polyp that caused the intussusception finally 
 blocked entirely its lower aperture,"^ and it has been 
 said by Dr. Brinton that an obstruction may be pro- 
 duced by a gangrenous intussusceptum after it has 
 separated, f 
 
 3. HoAv tlie iiivag:iiiation becomes ii're- 
 ducible.— This is a matter of extreme importance in 
 the prognosis. If the intussusceptum is irreducible, 
 then cure by spontaneous reduction is impossible, as 
 is also reduction by means of forcible enemata or by 
 laparotomy. On the other hand, if the tunics of the 
 mass be glued together by adhesions about the neck 
 the pai-ts are most favourably placed for spontaneous 
 recovery by elimination of the gangrenous intussus- 
 ceptum. 
 
 The irreducibility very commonly depends upon 
 adhesions. Peritonitis is excited in the invaginated 
 mass, and the serous coats of the inner and middle 
 layer become glued together, while more extensive 
 adhesions involving also the external coat may occur 
 about the neck of the tumour. The situation of the 
 adhesions varies. Sometimes they are limited to the 
 neck of the mass, at other times to its apex, while in 
 a third class of case they involve the whole length of 
 the inner and middle layers. On the whole, the last 
 named are the most common, although adhesions 
 limited to the neck of the intussusception are prob- 
 ably the more usual in acute cases. Adhesions occur- 
 ring only at the actual apex of the intussusceptum are 
 certainly the least frequently met with. 
 
 In any case the false bands may vary from a few 
 insignificant fibres to a dense membrane closely binding 
 together the opposed layers. 
 
 In extensive invaginations it is common to find 
 the first few inches of the intussusception fixed by 
 
 *M. Fernet; Bull, de la Soc. Anat., 1863, page 296. 
 t Intestinal Obstruction. London, 1868. 
 
1 8 8 InTES TINA L ObS TR UCTION. [Chap. VIII. 
 
 adhesions while the remainder is quite free. In these 
 cases it is probable that the adherent parts represent 
 those first invaginated, no adhesions forming between 
 the layers subsequently prolapsed. Thus it happens 
 that the whole intussusception can be readily reduced, 
 with the exception of the last inch or so. 
 
 Of the circumstances that influence the formation 
 of these adhesions little is known. Their appearance 
 is most uncertain. They may be absent in a case that 
 has lasted for months and present in one of but a few- 
 days' duration. Putting aside, however, exceptional 
 cases it would appear that the element of time has 
 the most marked eifect upon this occurrence. In 
 examples of chronic intussusception adhesions are the 
 rule. They are present in about 80 per cent, of 
 the cases. In acute invaginations adhesions are as 
 often absent as present. Indeed they would appear 
 to be mnore often absent than present, for an examina- 
 tion of nearly sixty recorded instances of the acute 
 form that I have collected myself shows the presence 
 of adhesions in about 45 per cent, only of the 
 cases."* The earliest time for the appearance of defi- 
 nite adhesions is the third day. It is needless to 
 observe that recent adhesions are very soft and yield- 
 ing, so that in acute examples, although false liga- 
 ments may exist, yet they need not, in themselves, 
 offer any serious obstacle to attempts at reduction. 
 
 Irreducibility, however, may depend upon other 
 causes than the results of local peritonitis. 
 
 (1) The swelling of the intussusceptum may be so 
 excessive as to entirely prevent reduction. "Very 
 often the swelling is most marked near the apex, so 
 
 * These statistics include cases of recovery without operation 
 where the reduction of the mass was effected by artificial means. 
 The figxires are probably fallacious. Cases free from adhesions are 
 obviously the most likely ones to yield to treatment, and thus to be 
 placed on record. An examination of museum specimens places 
 the nimiber of cases where adhesions exist iu a higher i^ercentage. 
 
Chap. VIII.] 
 
 189 
 
 Fig. 38.— Ileo-caecal Intussusception with, great swelling of the Intu9- 
 
 susceptum. 
 
1 90 Intestinal Obstruction. [Chap. viii. 
 
 that the inner cylinders present at their extremities 
 a huge knob that would withstand all attempts to 
 replace the parts. A good example of this is afforded 
 in Fig. 38.* 
 
 (2) Since the swelling and thickening of the coats 
 are most apt to affect the convexity of the intiissus- 
 ceptum it happens that so curved an outline is often 
 given to that part and so great an alteration effected 
 in its density that reduction is for this reason also 
 quite impossible. {See Fig. 37.) 
 
 (3) The invaginated bowel may become peculiarly 
 twisted and may on this account be rendered irredu- 
 cible. Thus Mr. Royes Bell performed laparotomy on 
 the fifth day in a case of intussusception. There were 
 practically no adhesions, yet the mass was so twisted 
 that all attempts at reduction failed. In this instance 
 the colon was involved.! In Fig. 39, from University 
 College Museum, a specimen of a twisted intussuscep- 
 tion is shown that only implicated the ileum. \ 
 
 (4) In ileo-colic invaginations an especial obstacle 
 to reduction is offered by the ileo-csecal valve, which 
 tightly grips the prolapsed gut and induces in it a 
 rapid engorgement. 
 
 (5) When a polyp exists at the apex of the intus- 
 susceptum, it forms, when associated with swelling of 
 the gut above it, a very definite impediment to reduc- 
 tion. This is well illustrated in the specimen from 
 which Fig. 40 is taken. § 
 
 4. Changes in the gnt above.— The bowel 
 above the intussusception shows in acute cases no 
 gross changes other than those of dilatation and con- 
 gestion. In chronic forms, however, its walls are 
 usually hypertrophied, and in some instances this hy- 
 pertrophy has attained considerable dimensions. 
 
 * St. Thomas's Hosp. Museum, No. R 8. 
 
 \ Lancet, vol. i., 1876, page ]2. J No. 1,176. 
 
 § Coll. of Surgeons Museum, No. 1,378. 
 
Chap. VIII.] 
 
 191 
 
 Fig. 39. — Intussusception of Ileum. 
 a, Intussusceptum. 
 
192 
 
 Intestinal Obstruction. [Chap. viii. 
 
 Great faecal accumulation above the invagination 
 is rare in any case, the lumen of the bowel being 
 usually sufficiently patent to allow of the passage of 
 
 Fig. 40. — Intussusception of Ileum. 
 
 A firm oval tumour exists at the end of the intussusception, 
 the lumen of the gut. 
 
 A bougie indicates 
 
 matters for at least some time. Ulceration of the in- 
 testine above the involved segment is comparatively 
 rare, and is somewhat more common in chronic than 
 in acute cases. Perforation may occur as a result of 
 this ulceration. In at least two instances the bowel 
 above the invagination underwent spontaneous rup- 
 ture. Both cases were more or less chronic, were in 
 
Chap. VIII.] Intussusception : Pathology. 193 
 
 males and adults. In one example"^ the ileum had 
 ruptured above an ileo-ciecal invagination; in the 
 other t the rent was found in the middle of the ascending 
 colon, the intussusception being limited to the rectum. 
 
 5. Changes in the iiitiissuscipieiis.— The 
 sheath or receiving layer seldom shows any gross 
 changes. It may be congested, or a little thickened. 
 It may be much Avi'inkled and thrown into many 
 folds. It may be the seat of some local peritonitis. 
 Such morbid conditions are common. Among the less 
 frequent changes may be noted the following. The 
 sheath may be greatly thickened. 1: In a case re- 
 ported by Hauf, the thickness of the three layers of a 
 chronic intussusception amounted to one inch.§ This 
 layer not infrequently presents ulcerations of its 
 mucous membrane, which are often multiple and may 
 lead to perforation, or a part of the wall of the sheath 
 may become gangrenous. This local gangrene is 
 often due to the pressure of a greatly curved intussus- 
 ceptum, and after it has occurred that part may pro- 
 trude through the hole formed in the sheath. An 
 excellent example of such protrusion is shown in Fig. 
 41. li {See also Fig. 39.) 
 
 In a case of acute intussusception of the ileum 
 reported by Mr. Morris, there was extensive gangrene 
 of the sheath on the sixth day with a threatening 
 perforation in three or four places. ^ An instance of 
 chronic intussusception had been placed on record 
 where the sheath was entirely ruptured and divided 
 into two distinct parts, one of which contained the 
 intussusceptum while the otlier was empty. ^"^ 
 
 * Grissolle ; Bull, de la Soc. Anat., 1835, page 71. 
 t Holmes ; Path. Soc. Tran.s., vol. viii., page 77. 
 T London Hosp. Musenm, No. Ae 45. 
 § Heidelb. Med. Annal, 1842, b. 8, s. 428. 
 II Univ. Coll. Museum, No. 1,175. 
 IfPath. Soc. Trans., vol. xxviii., page 131. 
 ** Journ. de Med. de SediUot. , toiiae 50, 1814, page 446, 
 N— 12 
 
194 
 
 Intestinal Obstruction. [Chap. a^iii. 
 
 Perforations which may occur either in the 
 sheath or in the gut above the intussusception, are a 
 
 Fig. 41.— lutussusceptiou of the Ileum. Protrusion of the Ictussus- 
 
 ceptum tlirough an ulcerated Opening in the Sheath. 
 a, upi>or end of inv(jlvi'd trut ; b, lower end of involved gut ; c, tlie i>rotriulinp in- 
 
 tussusceptinu. 
 
 little more frequent in chronic than in acute cases. 
 Out of fifty-five examples of chronic intussusception 
 
Chap. VIII.] Intussusception: Pathology. 195 
 
 collected by M. Rafinesque,"^ there were twelve in- 
 stances of perforation. Among 175 cases, both acute 
 and chronic, Leichtenstern found twenty-eight exam- 
 ples of perforation. This complication is most common 
 in the ileo-csecal forms and least common in the ileo- 
 colic. 
 
 6. Changes in tlie intiissiisceptuiii. — The 
 cylinders involved become engorged with blood, and 
 haemorrhages may occur in their substance or from 
 their surfaces. It is from the latter source that is 
 derived the bleeding that is so often a conspicuous 
 feature in intussusceptions, especially those of an 
 acute character. The walls may become rapidly 
 oedematous and greatly swollen, and the condition run 
 on readily to gangrene. In more chronic cases great 
 thickening of the layers of the intussusceptum may 
 be met with as a result of long-continued congestion 
 and insidious inflammation of a low type. In both 
 acute and chronic cases the thickening of the layers 
 may be equally distributed throughout the involved 
 cylinders, but far more usually it is most conspicuously 
 marked in two places, viz. at the apex of the intus- 
 susceptum (.<?ee Fig. 38), and along its convexity. (/S'ee 
 Fig. 37.) Swelling can most conveniently occur in 
 these places, since these parts of the intussusceptum 
 are the most free from pressure. Along the concavity 
 of a much curved tumour much cedema would be 
 impossible, the layers there being thrown into 
 tightly compressed folds and greatly pressed upon. It 
 must also be noted that the convexity of the involved 
 bowel is the part most remote from the entrance of 
 the intestinal vessels, and is thus the more likely to 
 first show e\ddences of vascular disturbance. For 
 identical reasons, early engorgement may be expected 
 at the apex of the mass when constriction at the neck 
 is prominently marked. The swelling and thickenin,.; 
 * Th^se, Paris, 1878. 
 
196 Intestinal Obstruction. [Chap. viii. 
 
 about the apex lead to the knob-like tumour that 
 offers so great an oljstacle to reduction. It is also the 
 soft swelling at the extreme end of the intussusceptum 
 that gives to that part the appearance and the 
 response to the touch of the os uteri with which it 
 has been so many times compared. In both acute 
 and in chronic cases the middle cylinder suffers more 
 and shows more advanced changes than does the 
 inner cylinder. Thus, when there is much thickeniiig 
 of the intussusceptum, it, as a rule, mostly concerns 
 the middle layer. The thickness of this layer may be 
 considerable. In one case, recorded by Mr. Sidney 
 Jones, the width of the wall of the middle cylinder 
 varied from one-third to one half of an inch,"^ The 
 intussusceptum had existed for nine weeks. The inner 
 cylinder or entering layer is often gi-eatly contracted, 
 a circumstance that may be met with in both acute 
 and chronic cases. Thus in one acute case this 
 cylinder was found to be no larger than the iliac 
 artery. Tlie invagination involved the ileum and 
 occurred in a patient thirteen years of age. f 
 
 One of the most important and most constant 
 changes in the intussusceptum is gangrene. This 
 condition is met with in both acute and chronic cases, 
 although it is always more common, and usually more 
 extensive in the former. It may involve the whole 
 mass of the intussusceptum, which may separate at 
 the neck and be discharged from the bowel. This 
 occurs, as a rule, in acute invaginations, although it 
 is sometimes met with in clironic cases that end 
 acutely. The gangrenous part that is eliminated may 
 vary in length from a few inches to several feet. 
 Cruveilhier has recorded an instance where three 
 metres of bowel were discharged by this process. 
 The gangrene usually appears first and remains most 
 
 *Path. Soc. Trans., vol. viii., page 179, 
 f Ibid., vol. xxviii., page 131. 
 
Chap. VIII.] Intussusception : Pathology. 197 
 
 advanced in the middle layer. Thus it happens that 
 when the separation of the intussusceptum occurs 
 the middle cylinder may be disintegrated and in 
 some parts missing, while the entering layer, although 
 dead, may still be sufficiently well preserved to show 
 the structure of the bowel. Sometimes the anatomi- 
 cal details of the part are singularly well preserved 
 in the separated intestine. An example of this is 
 afforded by a specimen in Guy's Hospital * showing 
 the caecum and the whole of the ascending colon, 
 which were passed on the eleventh day, the patient re- 
 covering. Sometimes, however, the inner cylinder is 
 more extensively involved in the gangrenous process 
 than is the middle layer. This condition is usually 
 met with in ileo-csecal invaginations, where the part 
 of the intussusceptum formed by the small intestine 
 may perish before that segment formed by the large. 
 The matter of an interval of time between the separa- 
 tion of the inner and middle layers may affect the 
 condition of the gut as it appears when discharged 
 from the anus. This can, however, only concern in- 
 tussuscepta that are free from adhesions. Suppose 
 that in the invagination (Fig. 42, a) separation takes 
 place along the transverse line 6, and that the two 
 cylinders are adherent, it is obviously a matter of 
 indifference, as regards the appearance of the dis- 
 charged mass, which layer separates first. The 
 cylinder that first comes away will have to wait, as it 
 were, for its fellow, and they will then be discharged 
 together, retaining the mutual relations that existed 
 between them before gangrene set in. Suppose, how- 
 ever, that no adhesions exist, and that the middle 
 cylinder separates first, as is most usual (Fig, 42, 5), 
 the separated layer may immediately unfold itself, 
 and when the inner cylinder is set free the dead gut 
 will be discharged as one continuous tube, with its 
 
 * No. 1,875. 
 
198 
 
 IntES TINA L ObS TR UC TION. 
 
 [Chap. VIII. 
 
 a 
 
 u 
 
 ^ 
 
 u 
 
 serous covering external and its lumen lined by 
 
 mucous membrane. 
 
 If, however, the inner layer is set free before its 
 
 fellow (Fig. 42, c), it may become unfolded, and when 
 
 the separation is 
 complete the gan- 
 grenous bowel will 
 be passed as a con- 
 tinuous tube, but 
 with its mucous 
 layer external and 
 with its lumen lined 
 with the serous coat. 
 In such cases (and 
 many examples h a ve 
 been reported) the 
 gut is said to have 
 been passed ' ' turned 
 insideout." Autliors 
 who describe these 
 cases are apparently 
 under the impres- 
 sion that the process 
 of " turning inside 
 out" is effected in 
 
 y 
 
 I. 
 
 A 
 
 m 
 
 u 
 
 A 
 
 U? y 
 
 the dead gut as it 
 
 _ passes along the in- 
 
 g Fig. 42. ^ testine. This, how- 
 
 ever, is not only 
 difficult to understand, bub is suj^ported, so far as I can 
 ascertain, by no evidence of any kind. I have already 
 said that cases marked by more advanced gangrene of 
 the entering layer belong to the ileo-csecal type of in- 
 vagination, and it is only among examples of this type 
 that I have been able to find instances of gangrenous 
 intestine passed with its walls turned inside out."^ 
 
 * A good example of this apparently inverted bowel is given 
 
Chap. VIII.] Intussusception : Pathology. 199 
 
 In some instances one of the cylinders alone may 
 be separated as a definite tube, the other coming away 
 in the form of gangrenous shreds. 
 
 In another set of cases, which as a rule belong to 
 the chronic form of the malady, the gangrene com- 
 mences at the apex of the intussusceptum. It may 
 remain limited to this part, producing but limited de- 
 struction. This is illustrated by a case recorded by 
 Rafinesque where the ileo-csecal valve that formed the 
 point of the intussusceptum was the only part de- 
 stroyed. More usually, however, it spreads, and the 
 invaginated mass perishes slowly, and is eliminated in 
 shreds and putrid fragments which may pass unrecog- 
 nisefd. In one case of chronic invagination where 
 the parts were becoming gangrenous, the inner and 
 middle layers presented a rent which permitted the 
 intestinal contents to pass between the intussusceptum 
 and the intussuscipiens."^ 
 
 In the least marked form of the destructive pro- 
 cess the mucous membrane is alone involved. This 
 membrane may be gangrenous in part or be ulcerated, 
 the morbid changes in any case being as a rule limited 
 to, or most marked at, the apex. Such mi]d forms are 
 much more common in chronic than in acute cases. 
 
 Speaking generally, then, it may be said that in 
 acute invaginations gangrene is more common and ex- 
 tensive, that it involves principally the neck of the 
 mass, and is associated with an elimination of the 
 cylinders more or less in their entirety. In the 
 chronic forms the gangrene is less rapid, is most 
 marked at the apex, and leads usually to a slowly 
 progressing destruction wdiereby the intussusceptum 
 is eliminated in fragments. 
 
 by Dr. Fagge in his monograph in the CtHy's Hospital Eeports. 
 Dr. Fagge thinks that the i>rocess of ' ' turning inside out " goes on 
 duiing the expulsion of the gangrenoiis and inert mass. 
 
 * Lhonneur and Vulpian. Bull, de la Soc. Anat., 1855, 
 page 100. 
 
200 Intestinal Obstruction. [Chap.viii. 
 
 Among less common and less important changes 
 in the intussnsceptiim the following may be mentioned. 
 Tiie inner and middle layers may alter their mutual 
 positions after the invagination has formed. This, I 
 think, is demonstrated by those cases where a polyp 
 is associated with the intussuscejition, but where it is 
 found some way up upon the returning layer instead 
 of at the apex of the tumour. 
 
 The mucous membrane may be densely pigmented in 
 some chronic cases as a result of long abiding congestion."^ 
 
 Eafinesque has collected one or two cases of 
 chronic intussusception where soft and scanty ad- 
 hesions existed between the mucous surfaces of the 
 sheath and of the returning layer. 
 
 Lastly may be noticed the remarkable association 
 of ejntJielioiyia with chronic intussusception. In 
 several recorded cases, and in some museum specimens, 
 I find that an epithelioinatous growth has been found 
 upon the apex of the intussusceptum. Whether this 
 growth preceded or followed the invagination is of 
 little moment. It is very certain, however, that the 
 neoplasm may grow after the intussusception has 
 formed. The remarkable and, I think, unique speci- 
 men from which Fig 43 f has been taken shows the 
 internal layer of an ileo-csecal invagination enormously 
 thickened by a peculiar dejDosit. This deposit on ex- 
 amination proved to be composed of the tissue of a 
 cylindrical epithelioma. The specimen was obtained 
 from the body of a man, aged 56, avIio had presented 
 symptoms of chronic intussusception for about twelve 
 months before his death. He was under the care of 
 Mr. Christopher Heath, who relieved the patient for a 
 little while by establishing an artificial anus. | The 
 
 * As an example, see Lctncct, vol. v., 1803, page 409. 
 t Univei-sity College Museum, No. ."),592. 
 
 J An account of the case will be foiuiil in the Registrar's 
 Reports of University Coll. Hosp. for 1881, page 27, case No. 84. 
 
Chap. VIII.] Intussusception : Fa thologv. 
 
 2CT 
 
 growth 
 
 lumen of invagi- 
 natecl ileum is 
 greatly reduced in 
 size. The neoplasm 
 has invaded mainly 
 the convex surface 
 of the intussus- 
 ceptum, involving, 
 however, both sur- 
 faces at the apex of 
 the protrusion. 
 
 The 
 
 along the convexity 
 of the intussuscep- 
 tum has been evi- 
 dently influenced by 
 the lesser degree of 
 pressure exercised 
 upon that part of 
 the mass. It is not 
 improbaljle that in 
 this case the cylin- 
 droma commenced 
 at the ileo-csecal 
 valve, and, acting 
 as a foreign sub- 
 stance, produced the 
 invagination, and 
 then continued to 
 develop in the di- 
 rection offering the 
 least resistance. 
 
 Fig. 43. -Clu'onic Intus- 
 susception with Epi- 
 tlPiliomaof tlie middle 
 Layer. 
 
 A 1iouf,'i"e occupios the lumen 
 of the iiite.stine. 
 
202 Intestinal Obstruction. ichap ix. 
 
 There lias recently been added to the Museum of 
 the lioyal College of Surgeons a specimen which very 
 closely resembles the one just descriljed.* It shows 
 an intussusception, the middle layer of which has 
 undergone an extreme degree of thickening. This 
 thickening involves the a]3ex of the intussuscej)tum 
 and, to a much greater extent, the convexity of it. 
 On section the mass has an appearance almost 
 identical with that presented by Mr. Heath's 
 specimen, and indeed the resemblance between these 
 two specimens is singularly striking. Comparing it 
 with Mr. Heath's case one would not have hesitated 
 to declare it also an example of epithelioma, but Dr. 
 Goodhart, by whom the specimen was j)i'esented to 
 the College, assures me that a microscopic examina- 
 tion of the thickened gut wall revealed merely the 
 results of chronic inflammation. 
 
 Another specimen in the College of Surgeons 
 Museum f shows an cpitheliomous growtli attacking 
 the apex of an intussusception of the rectum. The 
 patient from whom the specimen was obtained had 
 presented symptoms for nine months. 
 
 CHAPTER IX. 
 
 THE ETIOLOGY OF INTUSSUSCEPTION. 
 
 1. X'lie iiiitiBcdiatc cause. — Many theories 
 have been advanced to explain the invagination of 
 one portion of the intestine into another. Some of 
 these have not withstood the test of time^ while 
 others are too vague and too indefinitely expressed 
 to be susceptible of criticism. With such theories 
 
 *No. 2,G99a. t No. 1,380. 
 
Chap. IX,] Intussusception: Causes. 203 
 
 and with the verbose discussions to which they have 
 given rise I propose to have no concern ; but will 
 consider merely the one explanation that, I venture 
 to think, has in it the greatest element of truth. 
 
 There is practically unanswerable evidence to 
 show that intussusception is brought about by 
 irregular action in the muscular wall of the intestine. 
 
 The precise nature of that irregularity may be 
 a matter open to some question. So far as the facts 
 at present at our disposal would show, it would 
 appear that an intussusception occurs either at a 
 point where the gut is the seat of a limited and 
 severe muscular contraction, or at a point where a 
 paralysed segment joins a part still capable of 
 vioforous contraction. Thus had arisen the division 
 of intussusceptions into two forms, the invaginatio 
 spasmodica and the invaginatio paralytica. 
 
 The chief data in connection with this subject have 
 been furnished by the elaborate vivisection experiments 
 of Nothnagel,"^ of which some account may now Ije 
 given. The intestines of a rabbit having been 
 exposed with suitaVjle precautions, a segment of the 
 bowel is stimulated by means of a faradaic current 
 applied through electrodes placed so close together 
 that a perfectly circumscribed ring-like contraction 
 is produced. On increasing the current a contraction 
 follows which extends for a consideraVjle distance 
 upwards, i.e. towards the stomach, but only for a 
 very slight extent downwards. The gut at the point 
 of stimulation is by this time converted into a 
 perfectly pale hard cord from contraction of the 
 circular muscle. Proceeding upwards, the contracted 
 segment is found to pass either gradually into the 
 normal intestine or to end quite abruptly. In the 
 latter instance a minute intussusception forms. The 
 
 *B6itrage zur Physiologie and Pathologie des Dai-mes, pa^e 12. 
 Berlin, 1884. 
 
204 
 
 InTES TINA L ObS TR UC TION. 
 
 [Chap. IX. 
 
 wide tube of the normal gut above slides a little 
 over the contracted part below. Thus is formed a 
 retrograde intussusception. Such invaginations, how- 
 ever, are always very small, show no tendency to 
 increase and are indeed of only momentary duration. 
 Proceeding downwards from the point of stimulation 
 a very different condition is met with. A proper 
 descending invagination is found to be forming. On 
 closely examining its mode of development, these 
 points are to be noticed. The spot at which the 
 ^ electrodes are applied forms practically 
 
 a fixed point. The normal gut immedi- 
 f^ ately below the contracted part turns 
 
 itself upwards to a slight extent over 
 this strongly contracted and greatly 
 
 \. narrowed portion. A minute invagina- 
 
 tion is thus i)roduced, which increases 
 solely at the expense of the intussus- 
 cipiens. This mode of development is 
 clearly demonstrated by the following 
 experiment. In Fig. 44 the condition 
 of the gut at the time of the experiment 
 is shown, c is the upper end {i.e. to- 
 wards the stomach), d is the lower end, 
 and e is the contracted segment. At 
 one spot a on the bowel a fine blue 
 thread was drawn through the serous 
 coat and then cut short. At another 
 point h lower down a red thread was 
 in like manner introduced. The elec- 
 trodes were applied at the point a, rej^re- 
 sented by the blue thread. An ascend- 
 ing contraction e of the bowel followed, 
 while below the point of stimulation an 
 invagination formed. During the development of 
 this intussusception the electrodes remained unmoved 
 at a, and the blue thread kept always at the 
 
Chap. IX.] Intussusception: Causes. 205 
 
 upper retiring angle or neck of the invagination. 
 Tiie red thread, however, moved gi-adually upwards 
 until it reached the upper retiring angle, when it 
 disappeared. After a while, Avhen the intussuscep- 
 tion was cut open, the red thread was found about 
 the middle of the middle layer. 
 
 The invaginations so produced existed for a certain 
 length of time, and then disappeared as the gut 
 became restored to its normal condition. 
 
 Nothnagel found that stimulation of the bowel 
 above the intussusception had no effect in promoting 
 its unfolding, while stimulation of the intussus- 
 cipiens merely caused the invagination to become 
 all the more rigid. Stimulation, however, of the gut 
 below the involution caused an ascendino- contraction, 
 by means of which the intussusception was at once 
 relieved. 
 
 Thus, in one case where an invagination of the 
 colon had been artificially produced, it was made to 
 disappear by an antiperistalsis induced by an enema 
 of a solution of common salt. 
 
 The experiments described so far refer to invagi- 
 natio spasmodica. Nothnagel's investigation of the 
 invaginatio j^av^^lytica give the following results. 
 
 A segment of bowel from three to six inches 
 in length was entirely paralvsed by crushing. When 
 stimulation was applied above the paralysed part 
 nothing followed save the usual ascending contraction. 
 When, however, the electrodes were applied to the 
 gut immediately below the inert segment a typical 
 descending intussusception developed. This invagina- 
 tion gTew solely at the expense of the normal bowel. 
 The paralysed part was not concerned in it, the 
 electrodes remaining quite unmoved at the original 
 place of application, just as occurred in the previous 
 experiment at the mark of the blue thread. 
 
 These researches serve to demonstrate, so far as 
 
2o6 Intestinal Obstruction. [Chap. ix. 
 
 they go, the existence of both a spasmodic and a 
 paralytic form of intussuscei)tion. Nothnagel con- 
 siders that the former variety is infinitely more 
 common than the latter, and the evidence afforded 
 by clinical observation would support his opinion. 
 
 The distinction between these two forms is not 
 of material imj^ortance. The simple fact remains 
 that intussusception depends upon irregular action in 
 the muscular wall of the intestine. 
 
 The experiments detailed should serve to correct 
 the common impressions that exist as to the produc- 
 tion of invagination, and that are expounded in the 
 chief text-books. There is no driving of a contracted 
 segment of gut into the non-contracted part below 
 by the " propulsive action of the intestine." Peris- 
 talsis in the bowel above the contracted portion 
 appears to have no influence in the formation of the 
 intussusception ; and it is a question rather of one 
 piece of gut being drawn over another than of one 
 part being thrust into the subjacent segment. It 
 is important also to note that the whole length of the 
 contracted segment is not used in the invagination 
 as is, I believe, very usually supposed. 
 
 I do not think that sufiicient importance has 
 been attached to the action of the longitudinal layer 
 of muscle in producing intussusception, although 
 Nothnagel makes some mention of the probable part 
 it plays. 
 
 If the arrangement of parts be considered in that 
 area of the bowel where a vigorously contracted seg- 
 ment joins a non-contracted portion, the condition of 
 the muscle of the intestine will be as follows : The 
 action of the circular layer must cease abruptly at the 
 line where the contracted and non-contracted parts 
 meet, since the fibres of this layer are placed at right 
 angles to the long axis of the gut. The action of the 
 longitudinal fibres must extend, however, beyond the 
 
Chap. IX. j Intussusception: Causes. 207 
 
 line of meeting. If they be considered to act from 
 the contracted segment as from a fixed point, it is 
 evident that they will tend to draw the wide non- 
 contracted segment over the narrow and contracted 
 piece. In this way, by the drawing of one part of 
 the intestinal tube over another part, the intussuscep- 
 tion is formed, and this mode of formation ai)plies as 
 well to the retrograde as to the descending invagina- 
 tions. 
 
 When once the invagination has taken place it is 
 probable that the intussusceptum acts the part of a 
 foreign body in the intestine, stimulates the intus- 
 suscipiens to contract and so force along the inturned 
 cylinder. 
 
 Many clinical facts support the association of 
 intussusception with disordered intestinal movements. 
 Conspicuous are the attacks of colic, which are so 
 early and so marked a sign of the condition ; the 
 frequent association of the intussusception with states 
 attended, or apt to be attended, by disturbed peri- 
 staltic movements, such as diarrhoea, intestinal polypi, 
 the presence of masses of undigested food in the bowel, 
 and the like."^ 
 
 Intussusceptions have been met with in cases 
 where a cause of grave intestinal disturbance already 
 existed. Thus Mr. Joseph Bell reports a case of 
 strangulation by band, for the relief of which he 
 performed laparotomy. On opening the abdomen he 
 discovered an invagination of the bowel, four inches 
 in length, which was readily reduced.! The occur- 
 rence of intussusception after injury to the abdomen 
 may depend upon some local disturbance in the 
 activity of the intestine resulting from the lesion. In 
 some few instances intussusceptions have occurred 
 
 *Griesenger has sliowu that in dysentery a paralysis of i\ 
 section of the intestine is not uncommon. 
 ■\ Edinh. Med. Journ., 1882, page 53, 
 
2o8 Intestinal Obstruction. ichap. ix. 
 
 after typhoid fever, after cholera, after severe rauco- 
 enteritis, and after the reduction of strangulated 
 hernia, all being conditions under which disordered 
 intestinal action may be expected. 
 
 It may be noted also that invaginations are most 
 common in the young, in Avhom nerve processes are 
 active, and in whom the tissues are susceptible of 
 ready change and capable of being readily disturbed. 
 
 The " invaginations of the dying," moreover, are 
 most apt to occur in those who have died of some 
 grave nerve lesion, such as meningitis, and in whom 
 it may not be unreasonable to expect a disturbance of 
 so important a part of the nervous system as that 
 supplying the intestines. 
 
 And here, by-the-by, I might venture to suggest 
 that slio'ht invaijinations havinsc a more or less mo- 
 mentary existence are probably much more common 
 in the human subject than is supposed. It seems to 
 me that there is good reason for believing that some 
 attacks of colic, especially such as follow upon the 
 ingestion of unassimilable food, may have for their 
 anatomical basis a series of temporary invaginations 
 of the bowel. 
 
 The resemblance between these colicky attacks and 
 an attack of intussuscci^tion appears to be often pecu- 
 liarly complete, and the divergence between the two 
 sets of cases to depend simply upon the element of du- 
 ration or persistence. In Ijoth there is the same kind 
 of pain, the same disposition to vomit, the same form 
 of constitutional depression, and often the common 
 symptom of marked tenesmus. When the invagina- 
 tion becomes strangulated the resemblance of course 
 ceases. It is dilhcult to avoid the belief that many, 
 perhaps most, of the cases of protracted " spasms " 
 met with in delicate women, and in persons liable to 
 digestive disturbances, are due to definite intussuscep- 
 tions, which in time reduce themselves instead of 
 
Chip. IX.] Intussusception: Causes. 209 
 
 passing on to strangulation. The sudden onset of 
 these attacks, their equally sudden cessation, and the 
 manner in which they yield to opiates, appear to 
 strongly support this belief. 
 
 The peculiarly frequent occurrence of invagina- 
 tions in the ileo-cascal region requires some slight 
 explanation. This frequency may dej)end to some 
 extent upon the difference in size between the ileum 
 and the colon, and the ease with which the former 
 could be prolapsed into the capacious crecum. Facili- 
 ties for inTagiuation, moreover, are offered by the fixed 
 position of the c?ecum as compared with the mobility 
 of the lower ileum, and by the circumstance that at 
 the valve of Bauhin an active segment of the bowel 
 meets a comjiaratively inert portion. 
 
 Leichtenstern and others, however, have pointed 
 out the great influence that the sphincter-like valve 
 may have in producing invaginations when their 
 formation is associated with tenesmus. They have com- 
 pared the ileo-ciecal orifice to the anus, and the intus- 
 susceptions of this region to prolapse of the rectum. 
 The matter cannot be better expressed than in 
 Leichtenstern's own words. '■' If we consider that the 
 ileo-C£ecal opening is distinguished by a sphincter, the 
 contraction of which can increase to powerful tenes- 
 mus, we recognise that there is a complete analogy 
 between the conditions of invagination in the reoion 
 of the caecum and the difterent kinds of prolapse of the 
 rectum, which, like ileo-c£ecal invaginations, is found 
 most frequently in early childhood. Just as anal 
 tenesmus, excited by any cause whatever (rectal 
 blennorrhoea, profuse diarrhoea), usually excites and 
 accompanies prolapse of the rectum, so is ileo-csecal 
 tenesmus, excited by catarrh or abnormal irritability 
 of the terminal portion of the ileum, of gTeat im- 
 portance in the production of many ileo-csecal and 
 ileo-colic invaginations. In many cases in which we 
 0—12 
 
2IO Intestinal Obstruction, [Chap. ix. 
 
 see invaginations in the region of the c?ecum follow 
 prolonged diarrhoea or colic, the taking of unsuital)le 
 food, or, especially in early infancy, the withdrawal of 
 the mother's milk and the substitution of improper 
 food, csecal tenesmus plays an important part. If the 
 caecum and the colon are rendered easily movable by 
 their mesentery, as is regularly the case during early 
 life, the repeated and more forcible peristaltic pres- 
 sure towards the persistently contracted ileo-csecal 
 sphincter causes ileo-caecal invagination. If the csecum 
 be firmly fastened down, so that it cannot be turned 
 in and invaginated into the colon, prolapse of the 
 ileum into the colon takes place, with formation of an 
 ileo-colic invagination, just as prolapse of the rectum 
 may follow violent anal tenesmus. If neither of these 
 happens, invagination of the lowest part of the ileum 
 may occur, as is the case also in the rectum when it 
 becomes invaginated in itself above an obstinately 
 contracted (tenesmus) sphincter, and is finally pro- 
 lapsed. If ileo-C8ecal invaginations are very common 
 in children, and ileum invaginations, on the contrary, 
 very rare, the reason lies in the greater mobility of 
 the caecum and ascending colon allowed by their 
 mesentery, and the consequent removal of an obstacle 
 to invagination. In adults this element is not re- 
 moved, and we find ileiuii invaginations as frequent 
 as ileo-csecal." "^ 
 
 2. The remote or exciting: cause. — A great 
 deal has been written upon the question of the ex- 
 citing causes of intussusception, and stress laid upon 
 the circumstance that with a more perfect knowledge 
 of these causes a more definite form of prophylactic 
 treatment may be attempted. Precise knowledge 
 upon this point is still, however, wanting. From an 
 examination of a number of reported cases, and from 
 certain statistics bearing upon the matter of etiology, it 
 * Loc. cit . Ziemsseu's Cyclopaedia, vol. vii., page 617. 
 
Chap IX.] Intussusception: Causes. 211 
 
 is probable tliat in 100 examples of intussusception 
 the exciting causes would be distributed as follows : 
 
 1. No evident exciting cause .... 62 per cent. 
 
 2. Diarrhoea, dysentery, enteritis, marked ) g 
 
 irregvilarity of the bowels . . ) " 
 
 3. Polypi 5 ,, 
 
 4. Ingesta 5 „ 
 
 5. Injuries and exposure to cold . . . 5 „ 
 
 6. Certain acute and chronic ailments which 
 
 may or may not have had a concern 
 in the etiology, such as typhoid fever, 
 whooping cough, measles, scarlet fever, 
 small-pox, cholera, and hernia ; with 
 these may be included pregnancy and 
 labour 15 ,, 
 
 Total 100 
 
 Some more detailed notice may be taken of the 
 circumstances to be considered under these six head- 
 ings. 
 
 1. It would appear that in more than half of the 
 cases that have been recorded no cause could be found 
 for the invagination. It is probable that this per- 
 centage is too high, since in many of the cases coming 
 under this heading the evidence is negative, the 
 patient's previous condition not having been detailed. 
 Leichtenstern, however, out of a total of 593 cases 
 found no less than 111 in which it was distinctly 
 stated that the trouble appeared abruptly in patients 
 enjoying at the time perfect health. 
 
 In reading through a collection of well recorded 
 cases one cannot but be struck with the great fre- 
 quency with which invaginations have appeared in 
 persons of delicate health. Many are simply de- 
 scribed as delicate, others as wasted, several have 
 been anaemic, and not a few have been tlie subject 
 of heart disease or of chronic pulmonary mischief."^ 
 
 *For marked examples see Path. Soc. Trans., vol. xxiv., page 
 108 (anaemia). Ibid., vol. xxxii., page 82 (heart disease), ami 
 Bull, de la Soc, Anat., 1867, page 136 (chronic phthisis). 
 
212 Intestinal Obstruction. [Chap. ix. 
 
 Although the matter cannot be expressed numerically, 
 it would certainly appear that intussusception is more 
 common in the delicate than in those possessing vigo- 
 rous health. 
 
 2. Probably the cases coming under this heading 
 are represented, on the other hand, by too low a figure. 
 The association of intussusception with diarrhoea is 
 marked, although in some instances I think the purg- 
 ing has been rather a symptom of the disease than a 
 cause of it. Possibly in many cases of chronic 
 diarrhoea in children, where the purging suddenly 
 ceases some little while before death, and where the 
 mothers are apt to say that " the child was purged 
 until there was nothing more to pass," there may be 
 an intussusception present to account for the altered 
 circumstances of the case. 
 
 Intussusceptions presumably due to diarrhoea are 
 most commonly met with in children, and are most 
 often of the colic or ileo-c?ecal varieties.* In one or two 
 cases an intussusception has appeared after the ad- 
 ministration of powerful aperients. 
 
 3. An example of the association of an intus- 
 susception with polyp is shown in Fig. 40. f The 
 polyp is usually found attached to the apex of the 
 intussusceptum, although in rare cases it may be 
 found about its middle, owiug probably to a shifting 
 of the entering and returning layers. In some ex- 
 amples the association is no doubt accidental, as was 
 probably the case in a specimen descril3ed by Sir 
 Prescott Hewett, where a pedunculated polyp, the size 
 of a pear, was attached to the intussuscipiens just 
 below the invagination. \ The polypi in these cases 
 
 *For marked examples, see Lancet, vol. i., 1876, page 12. 
 Path. Soc. Trans., vol. viii., page 177. St. Bart.'s Hosp. Reports, 
 1876, page 95. 
 
 t See also specimens in Lond. Hosp. Museum, No. Ae 45, and 
 Coll. of Surgeons Museum, No. 1,380 a. 
 
 ^ Path. Soc. Trans., vol. i., page 95. 
 
Chap. IX.] Intussusception: Causes. 2 it, 
 
 vary in size from a hazel nut to an Qgg or a pear. 
 As a rule, however, they are quite small. They are 
 oval, usually pedunculated and nearly always attached 
 to the convex wall of the intestine. In two-thirds of 
 the cases they are found attached to the lower ileum, 
 and thus they most frequently lead to enteric, or to 
 ileo-ceecal, or ileo-colic invaginations. They have pro- 
 duced intussusceptions inthe jeyunum, the duodenum,"* 
 the colon and the rectum. They more usually pro- 
 duce acute than chronic forms of the malady. As a 
 rule, only one polyp is found associated with the in- 
 vagination. Dr. Fuller, however, records, a case where 
 thirty of such tumours were found, with the largest of 
 which an intussusception was involved.! In one re- 
 markable instance three polypi at some distance apart 
 caused three separate intussusceptions in the same 
 patient. The three tumours formed were visible 
 during life. J 
 
 4. The severe colic often produced during the 
 passage of undigested food through the intestine 
 would suggest that masses of such matters may not 
 infrequently cause invagination. A good example of 
 this association is shown in a specimen in University 
 College Museum. § The specimen is from the small 
 intestine of an animal, and it will be seen that the in- 
 vagination has formed itself about a large piece of un- 
 digested tendon. In a case recorded by M. Le Moyne, it 
 is supposed that a mass of partly digested beans found 
 at the autopsy in the sigmoid flexure had, during its 
 passage through the intestine, produced no less than 
 six invaginations, which were found after death. || In 
 a patient of M. Dubois',^ the symptoms appeared soon 
 
 * Bull, (le la Soc. Anat., 1864, page 37. 
 t Path. Soc. Trans., vol. xxi., page 188. 
 i Bull, de la Soc. Anat. , 1870, page 200. 
 
 I No. 1,170. , 
 
 II Contrib. a I'Etude des Invaginations. Paris, 1879. These, 
 ni Gaz. des Hop., 18G3, page 298. 
 
214 Intestinal Obstruction. [Chap. ix. 
 
 after swallowing a number of clierry stones. In a 
 case by Mr. Gay,"^ a mass of rice was found in the 
 intussusceptum, and other instances of this association 
 of undigested food masses with invagination have 
 been given with equal clearness. 
 
 5. The relation between injuries and invaginations 
 is, it must be confessed, not very clear. The intes- 
 tinal trouble has appeared after blows upon the 
 abdomen, after a patient has been ridden over, and 
 after severe compression of the belly. Three or four 
 examples have been given where the symptoms of in- 
 vagination developed suddenly while the child was 
 being "jumj)ed" in some one's arms.f Leichtenstern 
 has collected six cases where the symptoms apjDeared 
 after exposure to cold. In a solitary instance the 
 evidences of invagination came on shortly after drink- 
 ing much cold water while sweating. In the Lancet for 
 1867 is recorded the case of a child, aged five, who died 
 in four days from the effects of a burn. For the last 
 forty-eight hours of its life there had been feculent 
 vomiting. The autopsy revealed three invaginations ; 
 two v/ere recent, but the third had evidently existed 
 for some little time. % 
 
 6. Under this heading it is impossible to assign 
 any definite position in the etiology of intussusception 
 to the various maladies that are mentioned. Not in- 
 frequently the association has probably been purely 
 casual. 
 
 In other instances the debility produced by the 
 previous ailment has probably been an influential 
 factor in the causation of the disorder in the bowels. 
 In those examples, however, where invaginations have 
 followed upon cholera and hernia, it may be allowed 
 
 * Monograph, loc. cit. 
 
 f llilliet et Barthez ; Trait(^ clinique et prat, des Mai. des En 
 fants, 1861, tome i., page 806 (two cases). Latwet, vol. i., 1877, 
 page 273. 
 
 X Dr. Heckford; Lancet, voL i., 18G7, page 362. 
 
Chap. X.] Intussusception: Symptoms. 215 
 
 that a morbid state of the bowel has been induced 
 that could readily lead to intussusception. 
 
 Among the rarer causes, real or apparent, of in- 
 vaginations, may be mentioned stricture of the ileo- 
 cascal A*alve, growths or vegetations attached to the 
 valve,"^ and cancerous affections of the intestine. f One 
 of the most remarkable cases of invagination is illus- 
 trated by a specimen in Guy's Hospital Museum that 
 is probably unique. It shows a small and short 
 Meckel's diverticulum springing from the lower ileum. 
 This diverticle had become inverted so as to project 
 into the lumen of the intestine, and when in that 
 position had led to the formation of an intussus- 
 ception.! 
 
 CHAPTER X. 
 
 THE SYMPTOMS OF INTUSSUSCEPTION. 
 
 Following the excellent classification of Eafinesque, 
 intussuscej)tion, when regarded from a clinical stand- 
 point, may be divided into four forms. 1. The ultra- 
 acute, when the patient dies within the first twenty- 
 four hours. 2. The acute, when the duration of the 
 disease extends between two to seven days. 3. The 
 subacute, when it extends between seven and thii-ty 
 days. 4. The chronic, when the malady lasts lieyond 
 the period of one month. No definite line, of course, 
 can be dra^Ti to separate these various forms from 
 one another. The division is arbitrary, but from a 
 purely clinical point of view the arrangement is con- 
 venient. 
 
 * Dance; Ai'cli. C4eu. de Med., 1832, xxviii., page 177. 
 t Sec specimen Xo. 1,380 in Coll. of Siu-geons 5luseiim, show- 
 ing an invagination of the rectum depending upon an epithelioma. 
 % Guy's Hosp. Museum, No. 1,819-'''. 
 
2 1 6 InTES TINA L ObS TR UC TION. [Chap. X. 
 
 It will be well to consider in the first place some 
 circumstances, such as those of sex, age, etc., that are 
 common to all forms of invagination ; and then to 
 review the symptoms as thej concern, first acute and 
 subacute cases, and secondly as they concern the 
 chronic forms. 
 
 The chief clinical features of intussusception Avill 
 be considered when dealing with cases belonging to 
 the former category. 
 
 FreqtBeBiey.— In his statistics of 1,152 cases of in- 
 testinal obstruction of all kinds (excluding hernise and 
 affections of the rectum), Leichtenstern places 412 
 cases of intussusception. Thus invaginations form 
 about 30 per cent, or a little less than one-third of all 
 species of obstruction of the bowels. 
 
 From an examination of sundry tables of mortality, 
 and from my own collection of recorded cases, I think 
 that among 100 examples of intussusception the chief 
 clinical varieties may be divided as follows : acute, 
 50 per cent., subacute 32 per cent., and chronic 18 
 per cent. 
 
 Sex. — Intussusception is more common in males 
 than in females. Of Leichtenstern's 442 cases, 285 
 occurred in males and 157 in females. Mr. Gay, 
 however, dealing with 1,289 cases obtained from the 
 Registrar General's Reports for five years, finds the 
 proportion to be 678 males to 611 females, or about 
 I'll to 1. The age of the patient, however, has cer- 
 tainly a conspicuous infiuence upon this proportion. 
 The younger the individual the more marked is the 
 preponderance of the male sex. Thus, in twenty-five 
 cases in children, collected by Rilliet, twenty-two were 
 in male subjects and three only in females. Mr. 
 Gay's statistics, however, are probably more reliable. 
 He shows that in children under one year old the 
 pro|)ortion of males to females is as 163 to 93. As 
 age advances the disproportion becomes gradually less 
 
Chap. X.] Intl'ssusception: Svmptoms. 217 
 
 marked, until between tlie ages of twenty-five and 
 thirty-five the number of cases met with in the two 
 sexes is about equal. After thirty-five there appears 
 to be a preponderance on the side of the females, the 
 proportion between the ages of thirty-five and forty- 
 five being, according to Mr. Gay, as 74 females to 55 
 males. 
 
 This matter appears to be somewhat influenced 
 also by the chronicity of the case. Thus, out of 
 fifty-one cases of chronic invagination collected by 
 Eatinesque, thii'ty-eight were males and thirteen 
 females. 
 
 Ag"e. — Intussusception occurs so frequently in 
 children that it forms the most common variety of 
 obstruction to which they are liable. More than 50 
 per cent, of the cases are met with during the first 
 ten years of life, and about 25 per cent, 
 during the first year of existence. Taking the mean 
 of the somewhat voluminous tables that have been 
 published upon this subject, I think that the following 
 percentage will fairly represent the frequency of the 
 disease during the various decades of life : 
 
 Before tlie age of 1 1 years 
 Between 11 and 20 years 
 ,, 21 and 40 years 
 „ 41 and 60 years 
 Beyond 60 years 
 
 53 per cent. 
 1'? 
 
 20 „ 
 
 11 „ 
 
 4 ,, or probably less.* 
 
 Taking the jDercentages of a large number of 
 chronic cases only the following results are obtained : 
 
 Before the age of 11 years . 25 per cent. 
 
 Between 11 and 20 years . 10 ,, 
 
 „ 21 and 40 years . 50 „ 
 
 „ 41 and 60 years .11 „ 
 
 Beyond 60 years . .4 ,, 
 
 * Mr. Gay's tables show a much larger percentage of cases in 
 I^atients over sixty years of age, but his results differ so widely 
 from those iDublished by others that I fancy some error must have 
 crept in. 
 
2i8 Intestinal Obstruction. [Chap. x. 
 
 A comparison made between these two tables 
 shows in a striking manner the influence of age upon 
 the chronicity of the case. It seems to show the 
 great frequency of the acuter forms during the first 
 ten years of life, and of the chronic forms during the 
 period of active adult age. 
 
 Previous history. — In the previous history of 
 cases of intussusception there is little to note that is 
 of clinical or diagnostic interest. Indeed, the only 
 circumstances to be considered in such a history are 
 those that have been already described as concerned 
 in the etiology of the disease. Several cases have 
 been reported in which there is little doubt but that 
 the patients had had previous attacks of intussuscep- 
 tion from which they recovered more or less readily, 
 Such a case was that of a child, aged fifteen months, 
 who was suffering from an intussusception that 
 protruded at the anus. Since its birth the child 
 had been liable to attacks of " colic," during which a 
 mass would appear in the epigastric region and 
 subside as the pain passed off.* In a very similar 
 case, in the person of a girl aged nineteen, who died 
 of acute intussusception, there was a history of 
 attacks of colicky pain which probably depended upon 
 invaginations that after a while reduced themselves. 
 
 The mode of onset is usually sudden. In 
 acute and subacute cases a sudden mode of onset is 
 to be noticed in about 75 per cent, of the examples. 
 
 In chronic cases the sudden ajjpearance of 
 symptoms is noted in about 30 to 40 per cent, 
 of the recorded instances. The mode of onset is 
 somewhat influenced by the nature of the invagina- 
 tion. In ileo-colic intussusceptions the commence- 
 ment is nearly always sudden, while in the colic 
 and rectal varieties it is more frequently gradual. 
 The symptoms may appear (as already noted when 
 *-Nao York Med. Journ., July, 1877. 
 
Chap. X. ] I NT USS USCEP TION : SVMP TOMS. 2 I Q 
 
 speaking of tlie etiology of the disease) during perfect 
 health. They may come on abruptly during exe?.'cise 
 or while at rest, and even during sleep. "^ Several 
 cases in infants displayed their first evidences while the 
 child was being suckled. As a rule, in both the acute 
 and the chronic cases, the fii'st symjDtom is pain, a 
 symptom the characters of which are described below. 
 Yomiting is not usually among the initial symptoms. 
 
 Among the rarer commencing symptoms the 
 following may be noted. The first evidence of the 
 invagination may be simply tenesmus without 
 abdominal pain ;t or tenesmus with much straining at 
 stool. In one case of gradual origin the malady was 
 ushered in with slight colicky pains, with much 
 tenesmus and with dysuria. :j: In at least one instance 
 the first definite signs of intussusception were 
 afforded by an escape of blood from the anus, and 
 shortly after by the projection of the invaginated gut 
 through the sphincter. § 
 
 It by no means follows that cases marked by 
 violent and abrupt symptoms at the commencement 
 necessarily take an acute course. They frequently do ; 
 although, on the other hand, many chronic cases have 
 begun with very urgent manifestations. As one 
 instance of the latter association I might quote a case 
 by Hauf || where the first symptoms were those of 
 pain so violent as to cause the patient to roll upon 
 the gTonnd. The subsequent course, however, of the 
 disease was linoferins:. 
 
 Before commencing a notice of the separate 
 symptoms a superficial comparison may be made 
 
 *Patli. Soc. Trans., vol. xi., page 109; IMr. Niuineley. 
 tMr. Pitts ; St. Thomas's Hosp. Eeports, 1882, page 75. 
 JOlile. Mag. fiir die gesam. Heilk. Rust., 1817, bd. ii., 
 s. 253. 
 
 § Mr. H. Marsh; St. Bart.'s Hosp. Eeports, 1876, page 95. 
 II Heidelh. Med. Anal., 1842, bd. 8, s. 428. 
 
2 20 Intestinal Obstruction. [Chap. x. 
 
 between the acute and the chronic cases. In the 
 acute form of the disease, the symptoms depend 
 mainly upon strangulation of the invaginated bowel 
 and actual obstruction of its lumen. They are 
 marked by paroxysmal pain, by tenesmus, by the 
 passage of bloody mucus, if not by diarrhoea, and by 
 the presence of a tumour. In chronic intussuscep- 
 tion a patient may die from one of two conditions. 
 He may succumb, emaciated and worn out by the 
 frequent pain or vomiting and the gross interference 
 with the functions of the intestine ; or after exhibiting 
 for some time the evidences of chronic invagination, 
 he may die of an acute attack supervening upon the 
 chronic. In the lingering form the symptoms are 
 usually very ambiguous, and an aspect may be 
 assumed by the case that may be lacking in all the 
 most distinctive si^ns of invagination. 
 
 THE ACUTE AND SUBACUTE FORMS. 
 
 Pain.— Pain, as already stated, is usually the first 
 symptom of intussusception. It is also one of the 
 most constant and conspicuous. Sometimes the 
 initial attack of pain reaches at once the maximum 
 of that felt, and after its subsidence the suffering 
 becomes moderate. Usually, however, the pain in- 
 increases gradually in severity up to a certain point, 
 and then beijins to subside. Durinor the time that the 
 in\'agination is increasing and while the process of 
 strangulation is active the pain may be acute, but 
 when the parts have become well fixed by adhesions, 
 or more especially when gangrene has set in, it com- 
 monly becomes greatly modified in its character. 
 This tendency of the pain to become less at a certain 
 stage in the case is a conspicuous feature in 
 intussusception. Tlie pain in any given case may 
 commence gradually in the form of trifling attacks of 
 colic appearing at long intervals or coming on only 
 
Chap. X.] Intussusception : Symptoms. 221 
 
 after clefEecation, or a violent initial attack may be 
 preceded for a while by a definite but trifling sense of 
 discomfort in the abdomen. The form of in vagina- 
 tion that is most usually associated with intense pain 
 at the onset is the ileo-colic. 
 
 The pain is colicky, and its great feature is its 
 occurrence in paroxysms. Intermittent pain, as has 
 been already stated, nearly always indicates an 
 incomplete obstruction in the intestine and in 
 intussusception, therefore, it may be expected to be 
 well marked. The pain may at first occur at long in- 
 tervals, during which the patient is free from suffering. 
 As the case advances the intervals become shorter and 
 shorter. In the acuter forms the intervals are not 
 marked. The patient very often is never free from 
 pain ; but here, although the pain is continuous, it is 
 broken in upon by definite exacerbations. The 
 intervals between the attacks are sometimes very 
 precise, the paroxysms appearing every twenty or 
 thirty minutes, and having a more or less exact 
 duration. In any case, as the intussusceptum becomes 
 congested, its neck more and more strangulated, and 
 its lumen narrowed, the pain becomes more con- 
 tinuous although it is still associated with exacerba- 
 tions. When the j)aroxysms are marked they usually 
 appear suddenly and subside suddenly, although to 
 this circumstance there are many exceptions. 
 
 The pain in intussusception depends upon violent 
 and irregular peristaltic movement. It is more 
 severe, as a rule, in cases involving the small than in 
 those involving the large intestine. Some of the 
 most severe instances of pain have been in the ileo- 
 colic varieties and in invaginations high up in the 
 small intestine where the muscular coat is well 
 developed. It has been said that the intervals 
 between the paroxysms are shorter when the small 
 gut is involved, as compared with the colon. This is 
 
2 2 2 IntES TINA L ObS TR UCTION. [Chap. X. 
 
 often true, but the fact depends ratlier upon tlie 
 <Treater deiiTce of occlusion met with in the lesser 
 bowel than upon the anatomical position of the lesion. 
 Everything depends upon the state of the intussuscep- 
 tion itself. A small invagination in the colon may- 
 cause early and intense pain, while on the other hand 
 an ileo-caecal invagination may actually project at the 
 anus before much pain has been produced. 
 
 I cannot endorse the statement that the move 
 empty the bowel the less the pain. Were this the 
 fact the least painful cases would be those that have 
 followed upon diarrhoea. The reverse, rather, is what 
 is usually met with. It is well known that when a 
 patient has a sore throat it is more painful to swallow 
 a teaspoonful of water than a large bolus of soft 
 food like arrowroot. The large mass demands but 
 little contraction of the fauces to pass it along. In 
 one well-marked case of invagination the symptoms 
 came on after diarrhoea. The gut in this instance 
 may be considered to have been empty ; a purge was 
 given and pain of the severest character followed. 
 
 In a few cases the pain has been described as 
 agonising, but as a rule it is much less severe than in 
 other forms of acute intestinal obstruction. In 
 position it is at first very ill defined, but as the in- 
 vagination advances, and especially as a definite 
 tumour develops, the pain becomes more or less dis- 
 tinctly localised about the seat of the lesion. At first 
 the abdominal parietes are not tender on pressure, 
 and are flaccid, or, at least, not in a state of tension. 
 It often happens, indeed, that pressure over the more 
 painful part relieves the patient's suffering, just as 
 cramp" in other parts, such as in the calf, may often 
 be relieved by pressure. Muscles, however, that have 
 been long in a state of cramp become tender, and so 
 in intussusception the al)domen in time usually be- 
 comes somewhat tender on pressure, especially about 
 
Chap. X.] Intussusception: Symptoms. 223 
 
 the site of the invagination. This is partly the result 
 of continued irregular muscular action, but is perhaps 
 in a greater extent clue to the engorgement of the in- 
 vaginated parts and the development of some local 
 peritonitis. A well localised tenderness is, in the 
 absence of a definite tumour, a valuable guide to the 
 position of an intussusception. Sometimes the pain 
 has been relieved when the patient has assumed a 
 peculiar posture. The longer the case lasts the 
 greater is the tendency for both the pain and the ten- 
 derness to become diffused, presuming that they have 
 been previously more localised. 
 
 Vomitiiag' is, in intussusception, by no means so 
 conspicuous a symptom as it is in other forms of acute 
 intestinal obstruction, such as in strangulation by 
 bands. It does not appear so early; it seldom becomes 
 excessive or very distressing ; it is less often stercora- 
 ceous, and is apt to fluctuate considerably. 
 
 Vomiting is more constant and severe in acute 
 cases than it is in clironic. In about three-fourths of 
 the acuter cases it appears with the earliest symp- 
 toms, coming on either with the pain or a little while 
 after it. In the remaining cases it appears later, 
 and on an average about the third day. Its onset 
 may be much delayed, as in a case where laparotomy 
 was performed on the eighteenth day, and where 
 vomiting did not appear until the fifteenth day. In 
 chronic forms the delay may be still greater, and 
 vomiting may not set in until a few days or hours 
 before death. In about 8 per cent, of the acute 
 and subacute cases vomiting does not appear to have 
 occurred at all during the course of the malady. 
 
 There is often great irregularity in the appearance 
 and character of the sickness. Indeed, as a rule 
 in intussusception this symj)tom is marked by con- 
 siderable fluctuations. I might take the following 
 as a fairly marked instance : In a case of ileo-colic 
 
224 Intestinal Obstruction, [Chap. x. 
 
 invagination, fatal on the fourteenth day, vomiting 
 appeared early with the initial pain. It persisted for 
 five days. During the sixth day the patient did not 
 vomit at all ; on the seventh day the sickness re- 
 turned in a more severe form than ever. On the 
 eighth it was again much better ; wdiile on the ninth 
 it became feculent.'^ In many cases the vomiting, 
 after having been severe, has been absent for 
 several days together. In several examples of the 
 acute form of the malady that I have collected the 
 patient was only sick once, while in other instances 
 the vomiting appeared at long and irregular intervals. 
 The attacks of vomiting often coincide with attacks 
 of pain. In one case of acute invagination where the 
 sickness had ceased, the symptom was caused to reap- 
 pear by introducing the finger into the rectum. f 
 
 The exammation of a number of recorded 
 cases shows that the vomiting is least severe and 
 least constant in those cases that are associated 
 throughout with diaiThoea. It is also very often 
 slight in degree in those instances of the malady that 
 are attended by distinctly paroxysmal pain. In other 
 words, the sickness is least troublesome when the 
 lumen of the bowel is still patent. Most of the worst 
 instances have been in cases marked by early and 
 persistent constipation, excluding from that term the 
 passage of blood and mucus unmixed with faeces. In 
 any case the sudden cessation of diarrhoea is usually 
 attended by an increase in the vomiting. 
 
 In many instances the vomiting gives much tem- 
 porary relief. This is especially the case when it 
 ai)pears at long intervals. This feature is more 
 marked in the vomiting of intussusception than in any 
 other form of obstruction. 
 
 The vomited matter is usually alimentary or 
 
 *BulL de la Soc. Anat., 1867, page 136 ; M. Naudier. 
 ^Lancet, vol. i., 1877, page 273 ; Mr. Hansford. 
 
Chap. X.] Intussusception : Symptoms. 225 
 
 bilious. Feculent vomitinir is not met with in more 
 tlian 25 per cent, of all cases of acute or suljacute in- 
 tussusception. In chronic cases it occurs only in 
 about 7 per cent. In the acuter cases stercoraceous 
 vomiting is in nearly every instance associated with 
 constipation, or at least with the passage of no ftecal 
 matter in the discharge from the anus. It is met 
 with most frequently in invaginations about the ileo- 
 C£ecal region, and then in those involving the lower 
 extremity of the small intestine. It appears, on an 
 average, on the fourth or fifth day. It often, how- 
 ever, does not ajjpear for a week or a fortnight, or not 
 until near the termination of the case, when the pro- 
 gress of the malady is distinctly subacute. In two 
 or three instances blood has appeared in the vomited 
 matter. This symptom is usually met with in chil- 
 dren and in enteric intussusceptions. 
 
 On the whole, it may be said that vomiting is 
 most marked in the enteric and ileocolic invagina- 
 tions, less marked in the ileo-ctecal forms, and least 
 conspicuous in the colic and rectal varieties. 
 
 Tlie state of tlie bowels in intussusception 
 presents some very distinct characters. As a result of 
 the violent peristaltic action excited by the invagina- 
 tion, diarrhcea is a very common condition ; and as a 
 consequence of the great engorgement of the intussus- 
 ceptum it happens that the motions passed are usually 
 stained with blood. When the lumen of the bowel be- 
 comes so occluded that no more faecal matter passes, the 
 evacuations may consist simply of bloody mucus. 
 
 Constipation, as indicated by the passage of no 
 faecal matter, is not common in intussusception. In 
 the majority of the acute and subacute cases there is 
 some diarrhoea at first and then absolute constipation 
 towards the termination of the case. The occurrence 
 of more or less constipation as a marked feature dur- 
 ing the jyr ogress of the malady does not pertain to 
 p— 12 
 
2 26 Intestinal Obstruction. [Chap. x. 
 
 more than 30 per cent, of the cases. Sometimes 
 diarrhoea continues throughout the whole course of 
 the case, being, aa a rule, more marked at the 
 commencement than the end. At the same time it 
 may be noticed that a severer diarrhoea, or a 
 diarrhoea after constipation, may precede, attend, or 
 follow the elimination of a gangrenous intussuscep- 
 tum. Sometimes a loose state of the bowels alter- 
 nates with some constipation, but this condition is 
 more usual in the chronic forms of the malady. The 
 diarrhoea may be severe ; and from ten to twenty 
 evacuations may pass in the twenty-four hours. 
 
 The occurrence of blood in the stools is a striking 
 feature. As a rule, the more acute the case and the 
 more violent the strangulation, the more conspicuous 
 is the haemorrhage. In acute cases this symptom is 
 present in about 80 per cent, of the examples. It is 
 met with less frequently in those following a subacute 
 course, and is found in no more than 50 per cent, of 
 tlie chronic cases. It is perhaps more marked in 
 children than in adults. It is most constant in the ileo- 
 colic varieties, then in the ileo-caical, next in the 
 colic, and is probably least constant in enteric invagi- 
 nations. The amount of blood is usually not exces- 
 sive. The liaemorrhage may, however, be so profuse 
 as to be the principal cause of death. ^ As already 
 observed^ the clots of blood may block up the lumen 
 of the intussusceptum and may even plug the bowel 
 below the seat of the invagination. In any case the 
 symptom is usually more marked at the commence- 
 ment of the attack than during its later progress. 
 Bleeding may, however, attend the evacuation of the 
 intussusceptum. 
 
 l*ciiesiiiiis is a striking symptom. It is more 
 commonly met with in acute and subacute than in 
 
 *Le Moyne, loc. cit. , page 23. Med. Times atvd Gazette, vol. ii., 
 1865, page 195. Anier, J own. Med. Sciences, vol. xii., page 372. 
 
Chap. X.] Intussusception: Symptoms. 227 
 
 chronic Ctases. Indeed, other things being equal, the 
 more chronic the case the less fre(i[ucnt is the a])])ear- 
 ance of the symptom. I find that in acute and sub 
 acute forms tenesmus occurs in about 55 per cent, of 
 the exam})les. Kafinesque finds an account of the oc- 
 currence of this symptom in only 13 per cent, of dis- 
 tinctly chronic cases. The mean, therefore, for all 
 forms of invagination would be about 24 per 
 cent. Leichtenstern in his able monograph gives 
 this mean as 17'G per cent., but I cannot help 
 thinking that this percentage is much too low. It 
 must be remembered that in many accounts of in- 
 vagination re[)orted from a pathological point of view 
 the symptoms are often im])erf ectly given ; and many 
 of such cases can hardly but be included among Leich- 
 tenstern's statistics. The frequency and severity of 
 the tenesmus depend mainly upon the nearness of 
 the intussusception to the anus. The symptom there- 
 fore is very usual in rectal and colic invaginations, is 
 common in the more extensive ileo-CiX!cal varieties, and 
 is least often met with in the pure enteric forms. 
 Leichtenstern finds 94 cases mai-ked by tenesmus to 
 be thus divided : eiiteric foim 4, ileo-ciecal forms 
 75, colic forms 15. The proper value of these figures 
 can be ai)preciated by reference to the table showing 
 the relative frequency of the various varieties (page 
 171). 
 
 Tenesmus is usually an early symptom of intus- 
 susception, and is indeed often among its first mani- 
 festations. It may be so constant and so severe as to 
 cause intense distress, as in a case re[)orted by Dr. 
 Ballard.-^" When the invagination occupies the 
 rectum or sigmoid flexure the tenesnuis may be fol- 
 lowed by paralysis of the sphincter ani whereby a 
 patulous condition of the anus is produced. A good 
 example of this complication has been placed upon 
 *rath. Soc. Trans., vol. xviii., 18G7, page 92, 
 
228 Intestinal Obstruction. [Chap. x. 
 
 record bv Mr. Holmes. It occurred in a man a^ied 
 forty, who had a rectal invagination. The sphincter 
 became so relaxed that several fingers could be intro- 
 duced into the anus."^ 
 
 Ociicral symptoms.— Of the general constitu- 
 tional condition of the patients suffering from acute 
 and subacute intussusception little need l)e said. The 
 condition is nearly the same, although differmg a 
 little in degree, as that met with and described in 
 connection with strangulation by bands. 
 
 Collapse is usually much less marked, because on 
 the whole the progress of the case is less acute and the 
 pain less severe than in obstruction by bands. In 
 oome ultra-acute cases collapse may appear early and 
 lead on to death. This is especially the case with 
 acute invaginations in young infants. Leichtenstern 
 has only been able to collect five instances of death 
 during the first twenty -four hours, and of these cases 
 no less than four were in infants not over one year 
 old. 
 
 As regards the temperature it will be below 
 normal in cases associated w4th shock. In the 
 majority of the cases, and especially in such as are 
 subacute, it is normal or a little above normal. It is 
 important to recognise the fact that there may be a 
 rise of temperature in intussusception apart from any 
 evidences of local peritonitis. As a good illustration 
 of this may be cited a case recorded by Dr. Eastes. 
 It concerned a little girl aged eleven. On the seventh 
 and eighth day of the symptoms the temperature 
 reached 101-3. On the evening of the eighth day the 
 invagination was reduced by means of foi"ced enemata. 
 On the ninth day the temperature was 97 '6. The child 
 made a good recovery. 
 
 Thirst is by no means so frequently complained 
 of in invagination cases as it is in examples of 
 * Path. Soc. Trans., vol. viii.,page 177. 
 
ciiap. X.] Intussusception: Symptoms, 229 
 
 strangulation by bands. This circumstance depends 
 mainly upon tlio ksss copious cliaractor of the vomiting. 
 When th(3 vomiting is very profuse in intussuscej)tion 
 nnich thirst may be complained of. The symptom, 
 however, in a marlced form is quite rare. 
 
 The quantity of urine passed may be diminished, 
 for the same reasons that obtain in other forms of 
 acute obstruction of the bowels. The symptom 
 is rarely present, and is seldom, if ever, so marked 
 as in examples of strangulation by band. It is 
 limited to the more distinctly acute instances of the 
 malady when it does occur. 
 
 I can only find two instances of intussusception 
 where stranguary was complained of, and no case 
 associated with the appearance of crauips in the limbs. 
 
 In the subacute cases the ])atients become thin and 
 anaemic and often much wasted. A condition readily 
 induced by the continued digestive disturbance, the 
 frequent attacks of vomiting and pain, the loss of 
 appetite, and the broken rest. 
 
 TITE STATE OP THE ABDOMEN. 
 
 Tension of llie silxloiiiiiRnI wnlls is not met 
 
 with in inlussuscei)tion, or at least not in the earlier 
 stages. It appears when local or genei-al peritonitis 
 develops, and may ])e present during the attacks of 
 pain, especially wlien they have existed for some time 
 and are attended by tenderness on pressure. 
 
 Mcteorisiu is also rare in these cases. In a 
 marked form it is seldom, if ever, met with. It de- 
 pends undoubtedly upon the condition of the bowels. 
 It is found in instances where constipation exists and 
 where the lumen of the intestine is practically oc- 
 cluded. It is thus most commonly met with towards 
 the end of the attack. When diarrhoea exists, not 
 only is no meteorism ])rcsent, but the abdomen is 
 often, on the contrary, distinctly sunken in. On the 
 
23c> Intestinal Obstruction. [Chap. x. 
 
 cessation of the diarrhoea, the symptom may develop. 
 It is usually quite moderate in degree. It is needless 
 to say that it af)pears to a gi-eater or less extent wher 
 peritonitis sets in. 
 
 The " sigiie de Dance " is of little or no value. 
 It is said to be met with in cases where the ciecum has 
 become invaginated, as in the ileo-c^ecal forms of the 
 disease, and consists in a depression about the right 
 flank or right iliac fossa. It is supposed to indicate 
 the displacement of the caput coli. One would expect 
 this symptom to l)e more marked in chronic cases, yet 
 out of tifty-three examples of this form collected by 
 Rafinesque the " signe de Dance " was only noted in 
 two instances. 
 
 A tiiinoiir. — The presence of a tumour formed by 
 the invaginated mass, and to be felt either through 
 the abdominal parietes or rectum is of great diagnostic 
 value in cases of intussusception. It is to be dis- 
 covered in a little less than 50 per cent, of all cases, 
 and would appear to be not more frequently felt in 
 the chronic than in acute forms. Thus Leichtenstern, 
 taking all varieties of intussusception, found that it 
 was met with 222 times in a total of 433 cases. 
 Rafinesque, dealing only with chronic cases, found 
 24 examples of the occurrence of a tumour in 53 re- 
 corded instances. 
 
 The tumour is more commonly met with in some 
 anatomical forms of invagination than in otliers. It 
 is most frequently associated with the ileo-cfecal and 
 colic varieties, least frequently witli the enteric and 
 ileo-colic. The relative frequency in the different 
 varieties may be expressed as follows : In the ileo- 
 csecal form it occurs in 61 per cent, of the cases ; in 
 the colic in 52 per cent. ; in the enteric in 24 per 
 cent., and in the ileo-colic in 23 per cent. 
 
 It is usually more distinct in children than in 
 adults. The tumour varies in size. It may be as 
 
Chap. X.] Intussusception : Symptoms. 231 
 
 small as a hen's ^^^g^ or it may attain the thickness 
 of tlio adult fore-arm. It is cylindrical, and is very 
 commonly doscrilxMl as sausage-shaped. It often 
 shows the distinct curve of the intussusception. As 
 regards length, it is usually short and sff^xy rarely 
 exceeds six inches. This limitation in length does 
 not necessarily correspond to the length of the in- 
 vagination mass. It depends rather upon its position. 
 The tumour is not evident when it occupies the he- 
 patic or splenic flexures of the colon, and thus the 
 portion that can bo detected cannot well exceed the 
 length of the transverse or descending colon, or of 
 part of the right limb of the large bowel. 
 
 It has assumed the appearance of a double tumour, 
 one part having been felt in the transverse and the 
 other in the descending colon, the intermediate 
 portion in the splenic flexui'e not being evident. In 
 the ileo-cajcal variety the tumour will be more distinct 
 the nearer the mass is to the rectum. While in the 
 cjecum and lower ascending colon the tumour must 
 necessarily be small. The rarity of a tumour in the 
 ileo -colic variety is explained by the small size of 
 those invaginations when simple, and by the fact that 
 the intussusceptum is composed of small intestine 
 enclosed in large. 
 
 It thus happens that the tumour is most often met 
 with over the descending colon, and next in frequency 
 over the transverse colon. Enteric invaginations 
 usually form a tumour in the csecal region, the lower 
 ileum being the part most often involved. 
 
 The tumour varies in distinctness, and it is 
 seldom that all parts of it can be equally made out. 
 It usually appears fixed. It may often, however, 
 especially in chronic cases, be observed to change its 
 position, to now advance along the colon in the 
 direction of the anus, and now to return by the 
 inverse direction. ' It can often be made to move 
 
232 INTESTI^^AL Obstruction. [Chap. x. 
 
 under tlie use of enemata, the mass being forced back 
 towards the caecum. This can only occur in invagina- 
 tions that involve the colon. The progress of the 
 in vaccination from the c?ecum to the rectum can often 
 be distinctly watched. A tumour that remains long- 
 stationary in the csecal region probably depends upon 
 an ileo- colic invagination. 
 
 In consistence it feels hard and resisting. Its 
 density may vary greatly. During attacks of pain it 
 may be large, prominent, and haixl. During the 
 intervals it often becomes less distinct and softer. 
 When first noticed it frequently happens that it is 
 only present while painful peristaltic movements are 
 going on, being quite absent when the patient is free 
 from pain. When it has existed for some time it is 
 generally tender ; but in earlier periods any pain that 
 may be felt in it is ofteii relieved by pressure. In 
 any doubtful case an examination of the abdomen 
 should be made under chloroform. 
 
 M. Homolle rej^orts a case where three invagina- 
 tions existed in the small intestine, which gave rise to 
 three separate tumours."^ 
 
 The importance of the abdominal tumour in the 
 diagnosis of the affection, and in attempts to estimate 
 the condition of the involved segment, is considerable. 
 
 In no case should a tumour be pronounced as 
 absent until the abdomen has been examined during 
 a paroxysm of i)ain. When present, the exact site 
 of the swelling should be noted, its size, its outline, 
 and its mobility. 
 
 It is especially to be observed whether the mass 
 increases in size duiing attacks of pain, whether it 
 changes its position during attacks of pain, and 
 whether it is tender on pressure. 
 
 The following table from Leichtenstern's mono- 
 graph will show the relation between the tumour and 
 *Bull. de la Soc. Anat., 1870, page 260. 
 
Chap. X.] Intussusception : Symptoms. 
 
 233 
 
 the diffei'oiit forms of intussusception, together with 
 the coTnj)arative frequency of the mass in different 
 
 situations. 
 
 
 Seat of 
 
 
 Intussusception. 
 
 Seat op Tumour. 
 
 6 s3 
 
 Hi f 
 
 
 
 
 
 ■A 
 
 8 
 6 
 
 1 Unknown. 
 Total. 
 
 Ca3cal region 
 
 9 
 
 
 
 9 
 
 4 
 
 5 27 
 
 Region of ascending colon .... 
 
 1 
 
 2 
 
 1 
 
 
 
 3 7 
 
 Ti-ansverso colon 
 
 12 
 
 2 
 
 4 
 
 
 
 1 19 
 
 Region of descending colon 
 
 12 
 
 4 
 
 2 
 
 1 
 
 1! 20 
 
 Region of sigmoid flexure .... 
 
 25 
 
 10 
 
 3 
 
 2 
 
 12 52 
 
 Tumour in the rectum .... 
 
 10 
 
 10 
 
 
 
 1 
 
 10 31 
 
 Tumour piojecting from anus . 
 
 20 
 
 12 
 
 
 
 1 
 
 8 41 
 
 Tumour in hypogastiium .... 
 
 
 
 
 
 3 
 
 
 
 0; 3 
 
 Moving of tmnour from ascending to trans- 
 
 
 
 
 
 
 verse colon ...... 
 
 1 
 
 
 
 
 
 
 
 ] 
 
 Moving of tumour from transverse colon 
 
 
 
 
 
 
 to sigmoid flexure .... 
 
 8 
 
 
 
 
 
 
 
 8 
 
 Moving of tumour from caecum to sigmoid 
 
 
 
 
 
 
 flexure 
 
 2 
 
 
 
 
 
 
 
 2 
 
 Site of tumour unknown .... 
 
 
 
 1 
 
 4 
 
 
 
 4! 9 
 
 1 
 
 Total 
 
 100 
 
 !1 
 
 26 
 
 9 
 
 44 220 
 
 Tumour in tlie rectima. — It will be seen from 
 the above table that in thirty-one instances the 
 tumour was felt in the rectum, while in forty-one it 
 projected from the anus. This fcondition is, as may 
 be surmised, almost limited to the colic and ileo-csecal 
 invaginations. It appears much more frequently in 
 children than in adults. In children, moreover, the 
 tumour reaches the rectum much more quickly, owing 
 to the greater mobility of a child's colon. In such 
 patients it has reached the rectal region by the second 
 day of the attack, and may be, as already stated, one 
 of the early evidences of the invagination. Asa rule, 
 
234 Intestinal Obstruction. [Chap. x. 
 
 the tumour appears much later, on an average (in 
 acute and subacute cases) on the seventh day. In 
 chronic forms the average date for the appearance of 
 the mass in the rectum is the fifteenth day. It has, 
 liowever, appeared as late as the third and fourth 
 months,. and in one case as late as the seventh month 
 of the duration of the symptoms. The protrusion is 
 usually small (being about three inches in length), and 
 conical in shape. It may attain greater length (I 
 have seen one eight inches long), and cases are 
 reported where ten and twelve inches of bowel have 
 projected from the anus. The protruding mass is 
 usually deeply congested and much altered in structure. 
 It may be gangrenous. The intussusception has, how- 
 ever, been successfully reduced by enemata, insuffla- 
 tion, or laparotomy, even when it has protruded for 
 some time at the anus."* The projecting tumour may 
 present at its apex the ileo-caecal valve, and near its 
 extremity the orifice of the appendix. When ex- 
 amined by the finger introduced into the rectum, the 
 tumour, before it has prolapsed, presents tolerably 
 characteristic features to the touch. Its swollen 
 extremity wdth its narrowed lumen has been many 
 times compared to the os uteri, and the comparison 
 is a very suitable one. 
 
 The tumour wlien in the rectum, or when pro- 
 truding beyond it, has been on several occasions the 
 cause of an error in diagnosis. It has been mistaken 
 for prolapse, for rectal polyp, and for piles. Un- 
 fortunately the error has extended from* the dia- 
 gnosis to the treatment, and the mass has been in- 
 cised or cauterised and even cut off. There are some 
 remarkable cases of recovery after these operations. 
 
 * The best case is the well known one of Mr. Hutchhison's. 
 Here the symptoms had lasted one month and the prolapse had 
 existed for fifteen days. The bowel was reduced after laparotomy, 
 and the child recovered. Med.-Chir. Trans., vol. Ivii., page 31. 
 
Chap. X.] Intussusception : Symptoms. 235 
 
 In one the patient was a man aged sixty^ and the 
 tumour, prolapsed beyond the sphincter, was taken 
 for a polyp or a cancerous growth. It was re- 
 moved en masse by the galvanic wire and found to 
 be a piece of greatly hypertrophied ileum with the 
 ileo-c?ecal valve. The patient recovered, and was 
 relieved of a con^ftipation from which he had long 
 suffered.* In another case, in the person of a child 
 aged fifteen months, four inches of intussuscepted 
 bowel were cut away at the anus without any evil 
 followino'.t In a third instance the tumour was con- 
 sidered to be " hsemorrhoidal," and was incised to the 
 extent of one inch, laparotomy was then performed, 
 the intussusception reduced, and the wound in the 
 colon stitched up. The patient died. J 
 
 On the other hand, in cases of intestinal obstruc- 
 tion tumours have been found in the rectum that 
 have been mistaken for invaginated masses. Thus, in 
 a case reported by Dr. Piatt, a child aged nine had 
 symptoms of obstruction associated with some of the 
 signs of intussusception. High up in the rectum a 
 defined soft and elastic swelling could be felt which 
 had an orifice like the os uteri. In a few days it was 
 found to be a little lower down. The child died. 
 The autopsy revealed a stricture of the small intestine 
 but no invao'ination. The tumour was a remarkable 
 false diverticulum in the rectal wall, into the orifice of 
 which the finger had been passed. § In another case, in a 
 boy aged thirteen, there was an intussusception of the 
 ileum. Laparotomy was performed with a fatal result. 
 During life there was felt in the rectum " a soft 
 velvety but resisting body with a small central depres- 
 sion, suggestive of the os uteri. Around this, and 
 
 * Boston Med. Journ., July 6, 1876. 
 
 j-Weio Vork Med. Journ., July, 1877. 
 
 J Mag. fiir gesam. Heilk. Rust., s. 253. Berlin, 1817. 
 
 % Lancet, vol. i., 1873, page 42. 
 
236 Intestinal Obstruction. [Chap. x. 
 
 between it and the rectum wall, the finger could be 
 swej^t freely, and the injection tube, when guided by 
 the finger, could be passed upwards for a few inches." 
 The autoi)sy revealed an invagination in the ileum 
 nine inches from the caecum, wdiile the rectal tumour 
 was simply a mass of firm blood-clot.* 
 
 I caii only find two cases among the acute or 
 subacute forms of intussusception where coils of 
 intestine were visible through the abdominal parietes. 
 One instance occurred in Mr. Morris' patient, to whose 
 case allusion has just been made. The feature was 
 noticed on the sixth day of the attack, the patient 
 dying on the eighth. The other instance concerned a 
 case of ileo-colic invagination in a girl aged seventeen.! 
 The symptom appears to have been first noticed on 
 the eleventh day, death taking place on the fourteenth. 
 It is worthy of note that this patient was emaciated 
 by chronic phthisis at the time of tlie attack. 
 
 THE CHRONIC FORMS 
 
 By an arbitrary division those cases of intus- 
 susception are considered to be chronic that have 
 lasted for more than one month. 
 
 Details as to frequency of occurrence, sex, age, 
 and mode of onset have ah'eady been given ; and in 
 the account of the acute forms a general notice has 
 been taken of the symptoms of invagination. 
 
 It remains only now to enter into certain special 
 points. 
 
 Tlic aiisttoiBiienl form of intussusception that is 
 most often met with in chronic cases is the ileo-caical. 
 It forms more than one-half of all the examples. The 
 enteric form is the variety that is tlie least often 
 chronic. The relative proportion is thus given l)y 
 
 *Patli. Soc. Trans,, vol. xxviii., page 131 ; Mr. Henry Morris, 
 fliull, de la Soc. Auat., 18G7, page 13G. 
 
Chap. X.] Intussusception : Symptoms. 237 
 
 Rafinesqiie; his conclusions being based upon a col- 
 lection of fifty-five distinctly chronic cases.* 
 
 Ileo-ctecal ...... 60 per cent. 
 
 CoHe 15 „ 
 
 Enteric 15 „ 
 
 Ileo-colic 10 „ 
 
 100 
 
 To appreciate the full value of this talde it should 
 be compared with that on page 171. which deals with 
 intussusceptions of all kinds both acute and chronic. 
 
 The clinical featiu'es of chronic intussusception 
 are often, and indeed usually, very ambiguous. No 
 form of intestinal obstruction presents so many con- 
 fusing elements in the diagnosis ; no form has led to 
 more conspicuous errors in the right appreciation of 
 the nature of the malady. 
 
 Out of the fifty-five cases collected by Eafinesque 
 many were never suspected to be examples of intus- 
 susception, and no less than twenty-seven were the 
 sultjects of an absolutely incorrect diagnosis. Chronic 
 intussusception has been mistaken for fsecal accumula- 
 tion, for rectal polyp, for cancer of the bowel, for 
 ulcer of the stomach, for dyspej)sia, for chronic 
 dysentery, for gastro-enteritis, for chronic peritonitis, 
 and for other ailments equally remote from the nature 
 of the actual disease. 
 
 The course of the malady may extend over many 
 months, and may be protracted even for a year. In 
 one instance there are good reasons for believing that 
 the intussusception had existed for more than a year. 
 Pohl has recently reported a case of intussusception in 
 
 *In the follomng account of clironic invagination in its 
 clinical aspect I have made free use of the remarkable mono- 
 graph of Eafinesque, a monograph so elaborate and exhaustive that 
 it leaves little ground untouched and available for subsequent 
 writers. 
 
238 Intestinal Obstruction. [chap. x. 
 
 a young man, which he affirms had existed for no less 
 a time than eleven years. The invagination involved 
 2-i cm. of the lower ileum, and the lumen of the gut 
 was almost ohliterated. The patient, who had pre- 
 sented intestinal symptoms during the eleven years, 
 died of an acute attack, which ended on the fifth day 
 in perforation. * 
 
 During its progress the malady usually follows a 
 most irregular course. The bowels may be at one time 
 constipated, and at another in a state of diarrhoea. 
 There may be violent pain one day and none the next. 
 Some patients are troubled by severe vomiting, while 
 others are never sick. In some cases there are long 
 intervals of freedom from sickness, while in others 
 there are no such breaks. There is no method in the 
 ii-regularity and but few common features that under- 
 lie all the cases and that may serve as certain signs. 
 
 The onset of the malady is usually a little 
 indefinite, and the earliest symptoms are often ascribed 
 to indigestion, to mild colic, or to simple irregularities 
 in the bowels. In about 30 per cent, the commence- 
 ment has been abrupt, the case suljsequently assuming 
 a chronic aspect. In any case pain is usually the iirst 
 symptom. The ileo-colic form of chronic invagination 
 usually begins suddenly. 
 
 The pain that occurs during the progi-ess of the 
 disease is paroxysmal. Attacks of pain may appear 
 several times a day or only once in the twenty -four 
 hou rs. Sometimes days and c ven weeks have elapsed be- 
 tween the paroxysms. The intervals between the attacks 
 are seldom regular, and when the pain does appear at 
 stated times the occurrence is probably due each time 
 to a repetition of the same cause ; as, for example, 
 when the paroxysm has usually appeared at night after 
 a late supper. 
 
 As the malady advances the intervals between the 
 * Prager Med. Wocheuschr., No. 21, 1883. 
 
Chap. X.] Intussusception : Symptoms. 239 
 
 attacks of pain become shorter and the pain itself 
 more diffused. In the less protracted cases there may 
 be almost continuous suffering, marked, however, by 
 exacerbations. 
 
 The pain, when jiresent, iias the general character 
 described when dealing with the acute form of the 
 disease. 
 
 VoiiiUiii;^' is not a very conspicuous symptom. In 
 forty of Rafinesque's cases where this symj)tom is 
 mentioned it occurred more or less frequently in 
 twenty-four instances. In four instances the patient 
 was sick at rare intervals, in seven vomiting did not 
 appear until within a few days or hours of death, and 
 in three cases there was an (uitire absence of vomiting 
 throughout the progress of the malady. In any case 
 the attacks of sickness were very rarely continuous. 
 Usually they appeared at ii'regular intervals coin- 
 ciding with the attacks of pain or depending upon 
 some alimentary excess. 
 
 The duration of the affection appears to have 
 little effect upon this symptom. Age has some in- 
 fluence, since nearly all the cases where the vomiting 
 was insignificant or absent occurred in adults. Vomit- 
 ing is most constant in the ileo-colic and enteric forms, 
 and usually appears earlier in tliose varieties of the 
 disease than it does in the other forms. Feculent 
 vomiting is met with in less than 7 per cent, of the 
 cases. It de|)ends rather upon the degree of ob- 
 struction in the intestine than upon the seat or dura- 
 tion of the intestinal lesion. 
 
 The api»etit.e usually becomes much impaired, 
 and the synq)toms ai'e often aggi'avated by food. In 
 a large number of instances it showed considerable 
 fluctuations, and in at least one case it was voracious.* 
 
 The state of the bowels is most variable. 
 Natural and regular stools may be passed during the 
 * Path. Soc. Trans., vol. x., page 160; Dr. Quain. 
 
240 Intestinal Obstruction. [Chap. x. 
 
 greater part of the disease, or there may be long- 
 continued diarrhoea, or marked constipation, or alter- 
 nations between the two last named conditions. In- 
 deed, the only certain feature in the state of the 
 bowels in chronic invagination is the feature of un- 
 certainty. On the whole, a tendency to diarrhoea is the 
 most common condition, and a noi'mal state of the bowels 
 the most rare. From an examination of forty- six cases 
 Eafinesque obtained the following results : Motions 
 normal or nearly so, seven cases ; alternations of con- 
 stipation with diarrhoea, eleven cases ; predominance 
 of constipation, twelve cases ; and predominance of 
 diarrhoea, sixteen cases. Constipation is most marked 
 in the enteric forms, diarrhoea in the ileo-ctecal, and 
 alternations between these two conditions in the colic 
 and rectal varieties. 
 
 Blood is passed with the stools in about 50 per cent, 
 of the cases, while tenesmus is present in 1 3 per cent. 
 
 In chronic invagination the bowels usually respond 
 to the action of aperients. Tliese drugs sometimes 
 give much relief, but more often provoke at least a 
 temporary aggi-avation of the symptoms. 
 
 In any case of long-standing intussusception a 
 certain degree of persisting obstruction must exist in 
 the intestine. As a result of this, the bowel above 
 the invagination becomes hypertrophied by excessive 
 development of its muscular wall. The patients, on 
 the other hand, usually emaciate, and the anterior 
 abdominal parietes of course share in the general 
 wastmg. Thus it happens that coils of intestine are very 
 often to he seen in movement beneath the belly wall, a 
 circumstance that will be most distinct when vigorous 
 and irregular peristaltic waves are passing along the 
 disordered intestine. Tliere are few forms of chronic 
 obstruction where this feature is more marked than it 
 is in the present class of cases, and it serves as a 
 valuable factor in the diairnosis. 
 
Chap. X.] JNTUSSUSCEPTION : SYMPTOMS. 24 1 
 
 The general eoiiclitioii of the patients in 
 chronic invagination shows, as may be imagined, 
 consideraljle variation. In the early periods of the 
 disease, and in the intervals between attacks of pain, 
 they may appear to be in fair health. In time, how- 
 ever, they usually become anaemic and emaciated. 
 Tliey are worn out by the frequent pain, and exhausted 
 by the vomiting and diarrhoea. Some die of an acute 
 attack that suddenly appears and puts an end to the 
 case. Others die simply of exhaustion and marasmus. 
 A few succumb to perforative peritonitis, and a small 
 number to effects depending upon the spontaneous 
 elimination of the intussusceptum. 
 
 With regard to the state of the abdomen, little 
 can be added to what has been said when speaking of the 
 acute form of the malady. As a rule the abdominal 
 walls remain flaccid and present no abnormal feature. 
 When a long continued diarrhoea exists with emacia- 
 tion they may be retracted. When marked constipa- 
 tion exists there may be some meteorism, which will, 
 however, always be moderate. Tenderness on pressure 
 is very seldom to be noticed except in cases that are 
 associated with peritonitis. 
 
 As already stated, a tumour is to be found in 
 about one-half of the cases. Its characters have been 
 fully described above. 
 
 Among the fifty-five cases collected by Kafinesque, 
 the tumour Avas felt in the rectum in seven instances, 
 and had protruded beyond the sphincter in nine. Thus 
 it will be seen that in chronic cases the invaginated 
 mass reaches the rectum in about 32 per cent, of the 
 cases. 
 
 In Rafinesque's series the mass was discovered in 
 the rectum on about the fifteenth day in three 
 instances, and at the third, fourth, fifth, and seventh 
 month respectively in the remaining four examples. 
 
 Q— 12 
 
242 
 
 CHAPTER XL 
 
 THE COURSE AND PROGNOSIS OF INTUSSUSCEPTION. 
 
 As has been already remarked, the course of an in- 
 tussusception may be either ultra-acute, acute, sub- 
 acute, or chronic (page 215). 
 
 The relative frequency of these diflferent forms, as 
 ascertained from an examination of the fatal cases, 
 may be expressed as follows : 
 
 Acute 48 per cent. 
 
 Subacute . . . . . 34 ,, 
 Chronic . , . , .18 ,, 
 
 100 
 
 The ultra-acute form is extremely rare. Leich- 
 tenstern met with only five examples of it among 
 nearly 270 fatal cases. 
 
 The site of tlie invagination greatly influences its 
 course. Thus the enteiic and ileo-colic forms are 
 usually acute or subacute, the great majority of the 
 exami)les of both these varieties terminating within 
 the first fourteen days of the attack. Colic and rectal 
 invaginations are more often chronic or subacute 
 than acute. 
 
 Ileo-csecal intussusceptions, being the most common 
 form of the malady, are met with in all tlie grades of 
 the affection. Three-fourths, however, of the cases 
 are either subacute or chronic. Attention has already 
 been drawn to the fact that GO per cent, of the 
 examples of chronic invagination belong to the ileo- 
 csecal variety. 
 
 Tlie age of the patient also greatly influences the 
 progress of the aflection. This is well demonstrated 
 
Chap. XL] Intussusception: Prognosis. 243 
 
 in the subjoined analysis of 269 fatal cases collected 
 by Leiclitenstern. It shows that invagination in the 
 very young lias a great disposition to run an acute 
 course. Four out of five ultra-acute cases occurred in 
 children not over a year old ; and no less than 79 
 out of 129 acute cases occurred also in patients who 
 were not more than twelve months of age. 
 
 The general mortality of intussusception is about 
 70 per cent. Leiclitenstern has pointed out that the 
 malady is somewhat more fatal in females than in 
 males, and gives the following as the results obtained 
 from his statistics : Males, mortality 68 per cent. ; 
 females, 70 per cent. 
 
 The ultra-acute cases are all fatal, the patients 
 dying of shock within a comparatively short time from 
 the commencement of the attack."^ A very high 
 mortality runs through the acute cases, especially 
 through such as occur in young children. Most of the 
 cases of recovery are met with in the subacute 
 variety of the malady. The mortality among dis- 
 tinctly chronic cases is again high. Out of fifty-nine 
 chronic cases collected by Eafinesque there vvere no 
 less than fifty-one that terminated fatally. 
 
 The extremely fatal character assumed by intus- 
 susception in infants under one year old is well 
 illustrated in the subjoined table. In over 80 per 
 cent, of the fatal cases death occurred before the 
 seventh day. 
 
 Ill children that are a little older the fatal termi- 
 nation usually takes place towards the end of the first 
 weekj or the commencement of the second. In adults 
 death usually takes place during the course of the 
 second and third weeks ; many, however, dying after 
 the malady has become chronic. 
 
 According to Leiclitenstern, the deaths between the 
 
 * As a good example, see Lancet, vol. i., 1882, page 604. Child 
 lived thirteen hours. 
 
244 
 
 InTES TINA L ObS TR UC TION. 
 
 [Chap. XI. 
 
 ages of eleven and sixty years are met with in the 
 different anatomical varieties in the following propor- 
 tions : The ileo-caecal forms, 71 per cent. ; enteric, 
 57 "8 per cent. ; colic, 70-9 per cent. 
 
 
 
 
 
 Ages of Patients. 
 
 Time of Death. 
 
 u 
 
 CO* 
 
 o 
 
 to 
 
 t 
 
 CO 
 
 
 of 
 U 
 
 
 
 
 
 o 
 I— 1 
 
 o 
 o 
 
 O 
 
 o 
 o 
 
 o 
 
 CO 
 
 o 
 
 
 
 tH 
 
 -p 
 
 +3 
 
 4J 
 
 -*J 
 
 -tJ 
 
 o 
 
 a 
 
 
 
 
 (N 
 
 ^ 
 
 1-1 
 
 r-l 
 
 1-1 
 
 < 
 
 P 
 
 
 The 1st day 
 
 4 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 5 
 
 The 2nd day . 
 
 
 
 
 18 
 
 4 
 
 2 
 
 1 
 
 1 
 
 
 
 
 
 
 
 26 
 
 The 3rd day . 
 
 
 
 
 26 
 
 2 
 
 1 
 
 2 
 
 
 
 1 
 
 
 
 3 
 
 35 
 
 The 4th to the 7th day 
 
 
 
 
 35 
 
 10 
 
 7 
 
 4 
 
 3 
 
 4 
 
 1 
 
 4 
 
 68 
 
 In the 2nd week . 
 
 
 
 
 10 
 
 6 
 
 4 
 
 10 
 
 13 
 
 5 
 
 1 
 
 2 
 
 51 
 
 In the 3rd week 
 
 
 
 
 2 
 
 2 
 
 1 
 
 3 
 
 8 
 
 
 
 
 
 2 
 
 18 
 
 In the 4th week 
 
 
 
 
 2 
 
 1 
 
 1 
 
 
 
 5 
 
 4 
 
 1 
 
 1 
 
 15 
 
 In the 2nd and 3rd months 
 
 
 
 2 
 
 1 
 
 2 
 
 5 
 
 8 
 
 5 
 
 
 
 4 
 
 27 
 
 In the 4 th and 5th months 
 
 
 
 1 
 
 2 
 
 
 
 
 
 7 
 
 1 
 
 
 
 
 
 11 
 
 In the 6th and 7th months 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 2 
 
 3 
 
 In the 8th month . 
 
 
 
 
 
 1 
 
 1 
 
 
 
 1 
 
 
 
 
 
 
 
 3 
 
 In the 9th month . 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 1 
 
 In the 10 th or 11th month 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 
 
 
 
 1 
 
 3 
 
 After 1 year . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 2 
 
 After 2 years . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 20 
 
 1 
 
 Total . . J10029 19 
 
 25 
 
 51 
 
 21 
 
 4 
 
 269 
 
 Illetliocls of spontaneous cure.— In a great 
 many instances intussusceptions Lave been cured by 
 treatment, some have been successfully reduced after 
 laparotomy had been performed, others have been un- 
 folded by means of enemata and insufflation of air. 
 
 With these cases, liowever, we have at present no 
 concern, and liave to deal only with instances where 
 the invagination has cured itself. 
 
 Cases of spontaneous cure may be divided into 
 two distinct categories : 1. Those that occur in 
 
Chap. XL] IXTUSSUSCEPTIOy : PROGNOSIS. 245 
 
 invaginations that are still reducible. 2. Those that 
 occur in invaginations that are quite irreducible. 
 
 To the first category belong instances of sponta- 
 neous reduction. Of the existence of this mode of cure 
 there can be little doubt, although its occurrence uiust 
 be a matter of extreme rarity. There are se^^eral instances 
 reported of fatal intussusception in which the patient 
 had had one or more previous attacks which in all points, 
 save in duration, resembled the earlier stages of the 
 fatal attack. There is every reason to suppose that 
 such previous attacks were due to the formation of intus- 
 susceptions that underwent spontaneous reduction. 
 
 I think, moreover, that some of the cases of sup- 
 posed cure of invagination by large doses of opium, 
 administered promptly, may have been instances of 
 spontaneous reduction ; the curative movement being 
 rendered more easy by the state of nerve repose in- 
 duced by the sedative. 
 
 There are one or two cases where patients have 
 died after ha^ong presented many of the symptoms of 
 invagination, and where after death nothing was 
 found save a piece of small intestine shrunken 
 and congested. Such cases might well have been in- 
 stances of the spontaneous reduction of an enteric 
 invagination, although they are described as examples 
 of death from "spasm," or from paralysis of a portion 
 of the bowel. "^ A case reported by Mr. Gay affords 
 probably a little more dii^ect evidence concerning this 
 matter. The patient was a woman, aged thirty-eight, 
 who was admitted into hospital with symptoms of 
 obstruction. The symptoms had appeared suddenly ; 
 there was fixed and localised pain, a hard tumour to 
 the left of the umbilicus, constipation and vomiting. 
 
 * See case recorded by Henrot ; Des Pseudo-etranglements, 
 page 53. Paris, 1865. Also case by Travers ; Inquiiy into the 
 Process of Nature in repairing Injuries of the Intestines, page 211, 
 London, 1812. 
 
246 Intestinal Obstruction. [Chap. xi. 
 
 The symptoms in a short while passed off suddenly. 
 The patient was phthisical, and died in two days of 
 pulmonary hsemorrhage. The autopsy revealed a 
 contraction of a limited portion of the ileum, and the 
 gut presented distinct evidences of recent constriction. 
 
 It may be surmised that spontaneous reduction 
 can only occur in quite recent cases, and probably 
 only in the enteric form of invagination. A remark- 
 able case recorded by Rilliet would appear to point to 
 the possibility of spontaneous reduction in cases of 
 some standing, Rilliet's patient was a boy, aged ten, 
 who was taken on July 1st with abdominal pains. On 
 August 4tli he A'omited ; August 5th and 6th were 
 marked by the appearance of severe intermittent 
 attacks of colic, and evidences of a painful tumour in 
 the right flank. Black fetid stools were passed. The 
 attacks of pain were followed by intervals of complete 
 ease. By the 9th the tumour had become softer 
 and less defined. Diarrhoea set in on the 10th, 
 the stools containing a little blood. The tumour 
 gradually diminished and disappeared and the child 
 got well.* Rafinesque reports in his monograph a 
 somewhat similar case. In both these cases it would 
 have to be shown that the obstruction Avas not due to 
 the impaction of faeces or undigested food l)efore they 
 could be accepted as intussusceptions. 
 
 To the second category belong two kinds of case. 
 In one a fiecal fistula is formed in the bowel above 
 the intussusception. In the other, spontaneous cure is 
 brought about by elimination of the invaginated bowel. 
 
 The formation of a fsecal fistula must be ex- 
 tremely rare. I have only been able to find one 
 example of such a mode of relief. The case is re- 
 ported by Bruchet, and concerns a man of sixty-seven, 
 who for three or four months before his death passed 
 fsecal matter with his urine. The autopsy showed a 
 * Gazette des Hdpitaux, 1852. 
 
Chap. XI.] Intussusception : Prognosis. 247 
 
 short intussusception of the colon into the sigmoid 
 flexure with above it a fistulous opening into the 
 bladder.* It will be understood that should a faecal 
 fistula (due to ulceration above the obstruction) form 
 and make its outer orifice in the integuments, an 
 artificial anus may be produced that could gi\'e per- 
 manent relief. 
 
 Elimination of the invaginated boAvel by gangrene 
 is the only common form of spontaneous cure. The 
 account of the pathology of the process has already 
 been given (page 196). For statistics on the matter 
 we have again to turn to Leichtenstern, whose collec- 
 tion of cases is greatly in excess of that made by any 
 othei" author. 
 
 ►Spontaneous elimination occurs in about 42 per 
 cent, of all cases. It is a little influenced apparently 
 by sex, occurring in 54 per cent, of the female cases 
 and in 31 per cent, of the cases in males. 
 
 It is greatly influenced by the position of the in- 
 tussusception. 
 
 Thiis, in the ileo-c.Tcal invaginations 
 
 it occurred in . . . .20 per cent, of the cases. 
 
 In colic 28 ,, „ 
 
 In enteric 61 ,, ,, 
 
 Still more conspicuously is spontaneous elimination 
 influenced by age, being extremely rare in children 
 under two years of age. 
 
 Leichtenstern's statistics upon this point yield the 
 following results : 
 
 In the first year of age spontaneous 
 
 elimination occurred in . ,2 per cent, of tl\e cases. 
 
 Between the 2nd and 5th year . G ,, 
 
 ,, 6th „ 10th ,, . a8 ,, 
 
 11th „ 40th „ . 40 
 
 „ 41st „ 60th „ . 44 
 
 Above the age of 60 years . . 46 ,, 
 
 * Revue Mensuelle de Med. et de Cbir., 1S7?^, tome ii., pao-e 
 255. 
 
248 
 
 JnTES TINA L ObSTRUC TION. 
 
 [Chap. XI. 
 
 The period of time in the course of the malady at 
 which elimination occurs is fully shown in the follow- 
 ing table also from the same monograph. 
 
 3ontan< 
 
 30US elmnnation occ 
 
 urrea : 
 
 
 
 At the 
 
 end of 3 days in 
 
 
 . 1 
 
 case 
 
 
 4 „ 
 
 5 to 7 days in 
 8 to 10 „ 
 
 
 . 2 
 . 8 
 . 14 
 
 
 5) 
 
 11 to 14 „ 
 
 
 . 35 
 
 
 After the 3rd week, in 
 
 
 . 34 
 
 
 
 4th „ _ . 
 2nd month, in 
 
 
 . 12 
 9 
 
 
 „ 4th „ 
 „ 6th 
 After about one year, in 
 
 
 . 3 
 . 3 
 . 3 
 
 (?) 
 
 It must not be supposed, however, that when 
 spontaneous elimination has occurred cure and recovery 
 must necessarily follow. 
 
 Over 40 per cent, of the patients who have been 
 the subjects of elimination of the bowel die from 
 effects directly coiniected with the intestinal lesion or 
 with the elimination process itself. The mortality 
 after separation is a little lower in colic invaginations 
 than it is in the remaining forms, and is con- 
 sj)icuously affected by the age of the patient. If one 
 excepts the very young, it may be said that the older 
 the patient the greater becomes the probability that 
 elimination of the bowel will be followed by death. 
 In patients between eleven and twenty yeai's of age 
 the deatlis after spontaneous separation are only 28 per 
 cent. ; in those between twenty-one and forty years 
 32 per cent., between forty-one and fifty the percen- 
 tage of deaths rises to 3(3, and in patients between 
 fifty-one and sixty years of age to 50 per cent. In 
 ])atients above sixty years of age the mortality is as 
 higli as 85 per cent. 
 
 It only remains now to consider what are the 
 
Chap. XL] Intussusception : Prognosis. 249 
 
 modes of death after spontaneous elimination of the 
 gangrenous intestine. 
 
 In the first pkice it often happens that the separa- 
 tion is in a sense premature and occurs Lefoi'e the 
 parts about the neck of the mass have become securely 
 fused together. After tlie intussusceptum has been 
 removed a perforation or rupture occurs, through 
 which f?ecal matter escapes into the peritoneum, lead- 
 ing to a fatal peritonitis. 
 
 Or the fusion of the parts about tlie neck may be 
 perfect but slight. The gangrenous segment in its 
 passage along the intestine blocks the canal : some ob- 
 struction occurs : the gut above the obstructed point 
 becomes distended, and a rupture occurs along the 
 line of se2:)aration of the gangrenous intestine. 
 
 In another set of cases persistent ulceration re- 
 mains about the elimination line. This may lead to 
 chronic diarrhoea, which may in time prove fatal, or 
 may cause death much more readily Ijy producing a 
 perforation. This and like perforations may either 
 open upon the peritoneal surface or into the subperi- 
 toneal tissue. In the latter instance a large faecal abscess 
 is produced and the fatal issue more or less delayed. 
 
 A part of the intussusceptum may remain and may 
 lead to a new invagination, which in its turn may 
 prove fatal. 
 
 Some patients die of haemorrhage incident to the 
 separation of the gangrenous gat.'^ Others perish 
 from pysemia, and of this form of death Mr. Holmes 
 has recorded an excellent example, f 
 
 Hafinesque has discovered two recorded cases of 
 gangrene of one of the lower limbs following upon 
 eliuiination of invaoinated bowel. In both these in- 
 stances it is probable that the result was brought 
 about by thrombosis of the iliac veins. 
 
 * Amer. Joiirn. Med. Sciences, vol. xii., page 372. 
 f Path. Soc. Trans., vol. xix., page 207. 
 
250 
 
 Intes tin. I L Obs tr uc tion. 
 
 [Chap. XI. 
 
 It is said that stricture of the intestine may 
 follow from cicatrisation at the line of elimination, 
 and that the stricture so produced may cause in its 
 turn fatal obstruction. Such an occurrence must be 
 very rare. It is true that some narrowing of the 
 
 Fig. 45.— Contraction of Colon after the separation of an Intussi\sception. 
 
 a, ileum ; h, colon ; c, CKcmn ; d, seat of contraction. 
 
 parts may occur after the separation, as is well shown 
 in Fig. 45.* Recovery following ui)on elimination is 
 comparatively common, yet I cannot find in any of the 
 museums in London a straightforward case of stricture 
 of a marked kind following upon intussusception, nor 
 have I discovered any recorded cases (save, perhaps, 
 
 * College of Surgeons Museum, No. 1,377. For another ex- 
 ami»lo, .srrlSr. Hare's case ; Path. Soc. Trans., vol. xiii., page 86. 
 
Chap. XI.] Intussusception: Prognosis. 251 
 
 one mentioned belo^v) where such a circumstance has 
 without doubt occurred. It would appear, then, that 
 stricture of the intestine of a grade sufficient to cause 
 fatal obstruction must be excessively rare as a result 
 of the elimination of the gut in invagination. 
 
 In one case of stricture of the lesser bowel that is 
 supposed to have followed invagination, there is no 
 history of a piece of gut having been passed, nor indeed 
 any evidence that the patient, a woman of thirty- 
 eight, had ever had intussusception. This patient, 
 moreover, had a cicatricial strictirre in her gullet, and 
 a cicatrix in her stomach that had o-reatlv deformed 
 that viscus. In the absence of some complete 
 evidence it may be suggested that the cicatrix in the 
 jejunum was due to the same cause that produced the 
 two other cicatrices."^ The solitary case alluded to 
 above is placed on record by Dr. Fuller. It concerns 
 a patient, aged twenty-one, who died of subacute in- 
 tussusception of the ileum. When twelve years old 
 she had had a severe attack of colic attended by 
 vomiting and much pain in the iliac region. The symp- 
 toms subsided in seven days. She had since then been 
 much troubled with constipation. The autopsy re- 
 vealed no less than thirty polypoid growths in the lesser 
 bowel. Four and a half feet above the caecum the ileum 
 presented a cicatricial stricture, as if from an ulcer, 
 the bowel here resembling the ileo-c^cal valve. It may 
 in this case be surmised that the attack at the age of 
 twelve was due to an intussusception, brought about 
 perhaps by a polvp, and that the cicatrix had resulted 
 from the separation of the involved part. 
 
 This conclusion, however, can be nothing more 
 than a surmise. 
 
 Among the signs that mark the separation of 
 gangrenous bowel are the following : The evacua- 
 tions commonly become exceedingly foul, blood often 
 * Dr. Biistowe ; Path. Soc. Trans. , vol. xx. , page ISO. 
 
252 Intestinal Obstruction. [Chap. xii. 
 
 appeal's in the stools, together with small shreds of 
 matter that on examination prove to be gangrenous 
 fragments of intestine. The elimination may be pre- 
 ceded by absolute constipation and by severe symptoms 
 of obstruction. Or it may be preceded by a profuse 
 and sudden diarrhoea. After the separation is com- 
 plete there is usually a cessation of symptoms, with 
 the exception of some diaiThoea, which may persist for 
 a while. 
 
 Finally it must be remembered that in many 
 patients the elimination occurs too late to save life 
 and the sutferer dies of the effects of the intussuscep- 
 tion rather than from any e'sils incident to its 
 separation. 
 
 One point remains. On page 199 a case has been 
 alluded to where, as a result of limited gangi^ene, a 
 rent formed in the inner and middle layers of an 
 invagination tumour whereby the intestinal contents 
 were able to pass between the intussusceptum and the 
 intussuscipiens. This is the only example I can find 
 of what may possibly proA*e to be one other mode of 
 spontaneous cure. 
 
 CHAPTER XII. 
 
 STRICTURE OF THE INTESTINE : PATHOLOGY. 
 
 Under the general term "stricture of the intestine" 
 should be included all those morbid conditions of the 
 boAvel that have led to a definite narrowing of its 
 lumen. This should, perhaps, more particularly hold 
 good in any account of intestinal obstructions wherein 
 the subject was approached from a clinical rather than 
 from a pathological standpoint. 
 
Chap. XII.] Stricture: Pathology. 253 
 
 For purposes of convenience, however, and to 
 avoid bringing together under one heading many 
 perfectly distinct pathological processes, the term 
 " stricture " is here limited to a narrowing of the 
 lumen brought about by changes in the coats of the 
 bowel itself. These changes, it should be further 
 observed, take origin, in probably every instance, in 
 the mucous and submucous layers of the gut, for 
 they depend upon only two conditions, upon cicatrisa- 
 tion after loss of substance and upon carcinomatous 
 deposits. Thus from the present category are excluded 
 those cases of stenosis of the bowel due to tlie con- 
 traction of inflammatory products in its serous coat, 
 and also those instances of narrowing of the lumen 
 of the bowel from kinking, from the rigid bending 
 effected by adhesions, from the matting together of 
 sundry coils, and from the shrinking of the mesentery. 
 
 Two forms, however, of genuine stricture of the 
 intestine, as expressed by the above definition, have 
 been already considered. One concerns the changes 
 that may be induced in the walls of the bowel as the 
 result of long-continued traction, as from a diverti- 
 culum ; the other concerns the constriction that may 
 follow after the sejoaration of an intussusception. 
 
 All strictures of the intestine, as limited by the 
 definition already given, may be divided into two 
 gTeat classes, the cicatricial and the cancerous. 
 
 1. THE CICATRICIAL STEICTUEE. 
 
 This depends upon the contracting of a cicatrix con- 
 sequent upon loss of substance by ulceration or limited 
 gangrene of the inner coats. The aspect and degree of 
 the stricture will obviously depend upon the situation 
 and extent of the original loss of substance. A 
 limited patch of ulceration placed in the long axis of 
 the bowel may lead to very insignificant narrowing 
 of its lumen, while an ulcer no more extensive but 
 
2 54 Intestinal Obstruction. [Chap. xii. 
 
 disposed transversely around the gut may produce an 
 annular constriction that may almost close the tube. 
 Some contracting cicatrices may merely alter the 
 course or direction of the bowel, others that are not 
 annular may pucker up a portion of the intestinal 
 wall and produce great distortion of the tube, but 
 without much narrowing of it. An evenly dis- 
 tributed scar may produce a regular narro\^ing of the 
 bowel, while an unequally contracting cicatrix may 
 produce obstruction as well by actually diminishing 
 the size of the canal as by distorting the intestinal 
 walls. 
 
 It will be readily understood that the cicatrix that 
 produces the greatest amount of harm with the least 
 amount of contraction is that that assumes an annular 
 form ; w^iile the least harmful cicatrix is the one that 
 is longitudinal in direction and that involves only 
 a part of the circumference of the bowel. 
 
 It is convenient to divide the cicatricial strictures 
 into three classes. 1. Those depending upon primary 
 ulceration. 2. Those that are subsequent to lesions 
 following strangulated hernia. 3. Those that may 
 follow injury. The first class concerns both the large 
 and small intestine. The others, so far as the cases 
 I have collected serve to show, concern only the 
 lesser bo^\'el. 
 
 1. Strietui'c after ulceration. — It must be 
 confessed that our knowledge of ulcerative processes 
 in the intestine is still very incomplete, not only in 
 their pathology but also in their clinical bearings. 
 Following the arrangement of Leube,* intestinal 
 ulcers may be divided into six classes. 1, typhoid ; 
 2, dysenteric ; 3, catarrhal ; 4, peptic ; 5, syphilitic ; 
 and 6, tubercular. 
 
 *Ziemssen's Cyclopaedia of Medicine, vol. \'ii., page 399. 
 See aho Die Symptom, der Darmgeschwiire, by Nothnagel in 
 Volkmaun's Sammlung, No. 200, 1881. 
 
Chap. XII.] Stricture: Pathology. 255 
 
 1. Typlioid. — The characters of these ulcers are 
 well known. They lead to distinct and recognisable 
 scars, but it is only in extremely rare cases that they 
 produce any stenosis of the intestine. This is not 
 always easy to understand. It is true that the 
 primary typhoid ulcer is often of no great extent, is 
 arranged parallel to the long axis of the bowel, and 
 involves but a portion of its circumference ; but the 
 serpiginous ulcers that may follow upon the primary 
 lesion are often very extensive, involving large tracts 
 of the intestine, and extending so deeply as to pro- 
 duce, in a few instances, perforation. In criticising a 
 case of reputed stricture after typhoid it is well to 
 remember that the morbid process is usually limited 
 to the ileum. It extends to the colon in about 50 
 per cent, of the cases, but even then very rarely indeed 
 does it go beyond the c?ecum or ascending colon. In 
 the other direction also it is extremely unusual for 
 the disease to extend higher than three metres from 
 the ileo-csecal valve.* Klob gives a case of stenosis 
 after extensive typhoid ulcers. I have not been able 
 to find any recorded instance, except this, that 
 appears to be an midoubted example of stricture after 
 enteric fever. Many of the reputed cases do not 
 bear examination, and the association of a f)revious 
 typhoid with these examples is probably accidental.! 
 
 2. Dysenteric. — The ulcers left by dysentery 
 are frequent causes of stricture. These ulcers may 
 be met with in the rectum alone or in the sigmoid 
 flexure or in the CEecum alone. In general terms it 
 may be said that they become less common as one 
 passes up the colon from the rectum. In some 
 instances the whole of the large intestine has been 
 
 * See Hoffmann's Statistics ; Untersuch. uber die path-anat. 
 Verand. der Organe beim Abdominal Typhus. I^eipzig, 1869. 
 
 ^Seeiov examples case by Dr. Bristowe ; Path. Soc. Trans., 
 vol. iv., page 152. Case by Dr. Larguier des Bancels ; These 
 de Paris, No. 142, 1870, page 86. 
 
256 Intestinal Obstruction. [Chap, xii. 
 
 involved. The ulcers iii this malady are often very 
 destructive. They have a tendency, as they spread 
 and fuse, to isolate little patches of mucous membrane, 
 which remain undestroyed and stand out like islands 
 amonoj the ulcerated districts. As the scar contracts 
 these islands are often rendered very prominent, and 
 project from the surface as hard wartj'^-looking excres- 
 cences. The cicatrix is often extensive, rigid, and 
 dense. The contraction may be very irregular. The 
 gut may be much puckered, or thrown into ii'regular 
 folds or in other ways distorted. The mucous mem- 
 brane often becomes undermined durinsr the ulcerative 
 process, and the bands of membrane thus isolated 
 commonly remain as rigid bars and cords that con- 
 tribute one more element to the irregular aspect of 
 the cicatrix. Unilateral scars may produce a bending 
 of the gut or may cause sickle-like folds of the 
 intestinal wall to project into the lumen of the tube. 
 Such folds may act the part of valves and increase 
 the obstruction, and the same may sometimes be said 
 of the elevations and excrescences that so often mark 
 the dysenteric cicatrix. An example of stenosis after 
 dysentery is shown in Fig. 46.* I think that the 
 nature of the more exuberant of the cicatrices has 
 sometimes been unrecognised. I believe that not a 
 few instances of so-called "scirrhus" of the colon are 
 examples really of dense, hard, dysenteric scars, 
 associated with much contraction and with firm warty 
 excrescences. It is not improbable that one of the 
 specimens of " scirrhus " shown m the St. Thomas's 
 Hospital collection f is really an example of extensive 
 contraction after dysentery, and I have found several 
 museum specimens that are, T think, susceptible of 
 the same inter})retation. Dysenteric strictures are 
 most often met with in the rectum, sigmoid flexure, 
 
 * St. Bart.'s Hosp. Museum, No. 1,'J87. See also No. 1,986. 
 fSt. Thomas's Hosp. Museum, No. Q 141. 
 
Chap. XII ] 
 
 ^57 
 
 Fig. 46.— Stricture of Colon after dysenteric Ulceration. 
 E— 12 
 
258 Intestinal Obstruction. [Chap. xii. 
 
 and descending colon. They are fairly common, also, 
 at both the hepatic and the splenic flexures. 
 
 3. Catarrhal. — These ulcers are met with in acute 
 and chronic catarrh, especially in the latter. They 
 usually begin as erosions, and in the small intestine 
 often follow for a while the edges of the valvular 
 coniventes. They may spread in a serpiginous manner 
 and so isolate patches of healthy mucous membrane. 
 In another form described by Leube the mischief 
 commences in the lymphoid follicles, the tissue of which 
 inflames and, breaking down, forms a follicular ulcer. 
 
 Catarrhal ulcers are most commonly limited to the 
 colon. 
 
 With them must also be included the so-called 
 stercoral ulcers due to the mechanical and chemical 
 irritation of arrested fsecal masses. These ulcers are 
 often met with in the colon in chronic constipation, 
 and in the bowel above an obstruction in the large 
 intestine. They most frequently occur in the caecum 
 and next in fiequency at the flexures of the colon. 
 They may lead to perforation and are no doubt often 
 the starting point of stenosis. They are usually 
 multiple, are oval and parallel to one another, follow 
 the transverse folds of the bowel, and are thus at right 
 angles to its long axis."^ 
 
 4. Peptic.^This ulcer is met with at the com- 
 mencement of the duodenum, and is said to be pro- 
 duced by the digestive action of the gastric juice. It 
 is usually single, is most common between the ages of 
 thirty and forty, and is more frequent in males than 
 in females in the proportion of ten to one. It may 
 yjerf orate, and, according to both Leichtenstern and 
 Leube, may lead to stenosis. 
 
 5. Sypliilitir ulcers of the bowel are said to be 
 most often due to the breaking down of gummata in 
 
 ■•• SV. inijiaiiccfj by Dr. Dicldiisou ; I'ath Soc. Trans., vol. xviii., 
 page 101. 
 
Chap. XII.] Stricture : Pathology, 259 
 
 the submucous tissue. The ulcers thus formed may 
 iTin round the gut in an annular manner, or may 
 form isolated ulcers with a rounded or serpiginous 
 outline having a remarkably uneven surface and 
 ■well cut and slightly undermined edges. 
 
 Excluding the rectum, this form of ulcer is said to 
 be most common in the lower ileum. 
 
 6. Tubercular.— These ulcers begin in the lym- 
 phoid follicles and assume a course and appearance 
 A'ery much like that observed in scrofulous ulceration 
 of the pharynx. They increase by spreading at the 
 edge and generally ado})t a transverse dii^ection fol- 
 lowing the course of the vessels around the gut. They 
 often thus extend around the whole circumference of 
 the bowel. In other instances the ulcer is oval and 
 elongated with its long axis in the long axis of the 
 intestine. Some, again, are rounded and others sinuous. 
 The edges of the sore may be thin, irregular, and 
 undermined, as if the mucous membrane had rotted off 
 in patches. In other and probably more advanced 
 cases the margin becomes defined, thickened, and 
 rounded. 
 
 These ulcers may be met with in almost any part of 
 the intestine, and often involve a great extent of the 
 bowel. They are most common, however, in the 
 lower ileum and about the ileo-caecal valve. When 
 associated with marked tuberculous deposits and with 
 tuberculosis elsewhere they seldom heal. The milder 
 cases, however, cicatrise, and then the annular ulcers 
 may produce some stenosis of the intestine. This 
 stenosis is, T think, usually of a moderate degree. A 
 specimen of stricture from tubercular ulcer is shown 
 in Fig. 47. 
 
 Returning to the intestine and examining the 
 simple strictures of that tube that may be ascribed to 
 cicatrisation after ulcer, one is impressed with the 
 comparative valuelessness of the classification of ulcers 
 
260 
 
 Intestinal Obstruction. [Chap. xii, 
 
 just given. In some 
 instances there is no 
 doubt that the stric- 
 ture has followed a 
 dysenteric or a tuber- 
 cular ulcer, or there 
 are good reasons for 
 supposing that it has 
 been due to a catar- 
 rhal ulcer, but cer- 
 tainly in the majority 
 of the cases the con- 
 clusion as to the 
 origin of the stricture 
 is purely negative. It 
 may be evident that 
 it is not due to ty- 
 phoid or to dysentery, 
 or to tuberculosis, 
 but beyond that the 
 diagnosis, in a vast 
 number of cases, does 
 not and cannot go. 
 
 Regarding these 
 strictures collectively 
 it may be said that 
 they are usually defi- 
 nite and well limited. 
 As viewed from the 
 peritoneal surface 
 they may appear 
 merely as a well- 
 marked constriction of 
 
 Fig.47.— Portion of Jejimum 
 showing two Strictures, 
 the result of tubercular 
 Ulceration. 
 
 The put has Ixen turned inside 
 out so as to show the luucoiis 
 surface. 
 
Chap. XTi.i Stricture : Pathology. 261 
 
 the gilt, as if a cord or tape Iiad been tied about it, or 
 may have induced more distortion of the bo\yel. The 
 former condition is perhaps more often met witli in 
 the large intestine and the latter in the small. In the 
 lesser bowel the strictured part is usually free and 
 exempt from adhesions to adjacent surfaces. In the 
 colon, however, the stenosed segment is often bound 
 down, especially when the part involved is one or 
 other of the flexures. The lumen of the narrowed 
 tube may be regular in outline or much distorted. 
 
 It may at the time of its causing death admit the 
 forefinger, or l^e, on the other hand, so small as to 
 hardly permit the introduction of a probe. 
 
 As regards locality, strictures of the lesser bowel are 
 usually situated in the ileum and preferably in the 
 middle or lower parts of the ileum. In the colon about 50 
 per cent, of these cicatricial strictures are in the sigmoid 
 flexure. Next in frequency come the descending colon 
 and splenic flexure, and beyond those parts the stenoses 
 become rarer and rarer as the ciTecum is approached. 
 
 In comparing the large intestine with the small, 
 one is struck with the fact that the simple stricture of 
 the colon is nearly always single. Indeed, out of 
 thirteen recorded cases that I have collected there is 
 only one example of multiple simple stricture of the 
 large intestine. In this instance the patient, a woman 
 aged twenty-nine, had, in addition to a stricture of the 
 rectum, a stricture at the hepatic and at tbe splenic 
 flexures."^ On the other hand, out of ten recorded 
 cases of cicatricial stricture of the lesser bowel there 
 were six instances of single stricture and four of 
 multiple. In one of the six cases there were cica- 
 trices in the gullet and stomach in addition to that 
 producing stenosis of t\\Q intestine, f The four cases 
 
 * M. Marignac ; Bull, de la Soc. Anat., 1877, page 519. 
 f Dr. Bristowe ; Path. Soc. Trans., vol. xx., page 180. The 
 nature of the cicatrices was unknown. 
 
262 Intestinal Obstruction. LChap. xii. 
 
 (-L iniiltiple stricture present certain very striking 
 characters that are common to the series. The 
 patients were all women except one. They were all 
 young adults, their ages ranging from twenty-two to 
 thirty-three. There were three or four definite 
 strictures in each case, which were placed at varying 
 distances apart. The ileum was involved in each 
 instance. In none of the cases was the nature of the 
 ulceration upon which the cicatrisation depended 
 diagnosed.* 
 
 There is no doubt but that the present variety of 
 cicatricial stricture is very much more common in the 
 large than in the small intestine. The statistics, how- 
 ever, at present available are not sufficiently exten- 
 sive to form the basis for a correct estimation of the 
 comparative frequency. 
 
 My own statistics are, I am aware, misleading, 
 and if one could j udge roughly from a general exami- 
 nation of museum specimens, it may be said that the 
 proportion in which the large and small gut is involved 
 is about as six to one. 
 
 I have met with five recorded instances of stenosis 
 of the ileo-ctecal vah'e subsequent to the cicatrisation 
 of ulcers. In one of the cases the ulcers appeared to 
 have spread from the ileum, and in another example 
 from the colon. In the remaining instances the sten- 
 osis had probably followed a typhlitis brought about 
 by the impaction of freces or masses of undigested 
 
 * As a good example of the series, sec Koeberle's famous case, 
 in which he resected with success tv^'o metres of ileum ; Bull, et 
 M^m. de la Soc. de Chir. de Paris, 1881, page 99. [See also St. 
 Thomas's Hosp. Museum, No. Q 127 and No. Q 129.) Since the above 
 was written a fifth case lias been added to this series in the form of 
 a very interesting specimen exhibited by Dr. Sharkey before the 
 Pathological Society {Lancet, ISIay 24, 1884). Here there were 
 multiple strictures, due obviously to the cicatrisation of ulcers. 
 The patient was a woman, aged twenty-three. The iiart of gut 
 involved was the ileum, and the nature of the ulceration was not 
 esta)>lished, althougli the specimen had been the subject of most 
 careful examination. 
 
Chap. XII.] Stricture : Fa thology. 263 
 
 food in the cKcum. In two of tlio cases the valve 
 just admitted the point of tlie finger, in another it 
 would only give passage to a No. 9 catheter,'^ and 
 in a fourth case it was almost entirely obliterated.! 
 Tn this last instance the ileum and csecum communi- 
 cated by means of a fistulous opening, and the closure 
 of the valve proved a matter of comparatively little 
 importance. 
 
 An excellent example of stricture of the ileo-caecal 
 valve is shown in Fio* 48. In this case the stenosis 
 was due to cicatrisation after ulcer, t 
 
 2. Stricture after strangulated hernia.— 
 The stricture that may form in a piece of the intestine 
 that has been involved in a stranguliited hernia is due 
 to cicatrisation and follows upon ulceration or limited 
 gangrene of the involved bowel. I have found four 
 recorded examples of this stricture, in addition to 
 several specimens to be seen in some of the London 
 museums. It has followed upon both inguinal and 
 femoral rupture, and has produced symptoms of ob- 
 struction at a period, after the relief of the hernia by 
 operation, varying from one month to " some years." 
 In three cases the ileum was involved ; in one the 
 jejunum. In one instance one and a half inches of 
 the bowel were found contracted and thickened. § In 
 other examples the stricture was of very limited ex- 
 tent and amiular as if a narrow tape had encircled the 
 bowel. In one example the stenosed part would only 
 admit a goose-quill, || and in another water would only 
 pass through it in drops. IT In one specimen"^"^ a large 
 
 * Path. Soc. Trans., vol. xxi., iiage 171. 
 
 t Berlin, kliu. "Wochens, Xo. 26, i)age 393, June, 1879. 
 
 X For examples ^€e. Coll. of Sm-geons Museum, Nos. 1,247 and 
 1,248. 
 
 ^ Med. Times and Gazette, vol. i., 1872, page 3G3. 
 
 II Bull, et Mem. de la Soc. de Cliir. de Paris, 1880, page 706. 
 
 11 Path. Soc. Trans., vol. iii., page 05. 
 
 ** MidtUesex Ho.sp. Museum, Xo. 114, \-iii. ; see also Guy's 
 Ho>ipital IMuseum, Xo. 2,o07 [30). 
 
264 
 
 Intestinal Obstruction. [cimp. xii. 
 
 a 
 
 Fig. 48.— Strictnro of the Tleo-ccecal "Valve. 
 n, cnerum not laid opon ; h, ileum Inid oi.cn ; c, ricatricos of ulcers; rf, piirkered 
 iiiucousnionihrane. The vulvf, winch wns rcduct'd to the size of a No. 12 
 catheter, Is occuviei! by a piece of whalebone. 
 
Chap, xii.] Stricture: Pathology. 265 
 
 valvular fold of mucous meml irane passed across the 
 lumen of the gut at the strictuved part. 
 
 3. Stricture after injiiiy.— I find records of two 
 cases of stricture that were evidently due to cicatrisa- 
 tion following injury to the howel. Both patients 
 were males aged about forty-five. In one case symp- 
 toms of obstruction came on three montlis after the 
 patient had been ridden over,"^ in the other case four 
 months after a blow upon the abdomen, f In the for- 
 mer the ileum was involved, in the latter the upper 
 jejunum. Both strictures were very narrow, and 
 adhesions existed in the vicinity of the stenosed seg- 
 ments. 
 
 In the Pathological Society's Transactions % Mr, 
 Ward details a case where the lower three inches oi 
 the ileum were found much contracted and thickened, 
 the ileo-csecal valve " a mere ridge," and the caecum 
 somewhat narrowed. Some large gall-stones, much 
 worn, were found in the caecum, and it may be that 
 the trouble in the ileum was induced by their tem- 
 porary impaction there. 
 
 I have not entered into the subject of congenital 
 strictures of the intestine. 
 
 It may here be convenient to draw attention to a 
 specimen in the Museum of University College Hos 
 pital, which is, so far as I can ascertain, quite unique. 
 
 A drawing of the specimen is shown in Fig. 49. 
 
 It shows a portion of the small intestine, the lumen 
 of which has been at one point remarkably narrowed. 
 The narrowing is due to an even folding-in of all the 
 coats of the bowel towards the lumen of the tube. 
 
 This infolding involves only a portion of the cir- 
 cumference of the intestine. The infolded parts 
 appear quite normal on section, save for a little 
 
 * Path. Soc. Trans., vol. iv., page loG. 
 t Bull, de la Soc. Anat. , 1877, page 86, 
 X Vol. for 1858, page 365. 
 
266 
 
 Intes tjna l Obs tr uction. 
 
 [Chap. XII. 
 
 thickening of the mucous membrane. The fold is 
 rendered permanent by adhesions between tlie two 
 opposed serous surfaces. The infolding is towards the 
 mesenteric attachment of the ])owel. In the mesen- 
 •tery are certain enlarged and inflamed glands in close 
 contact with the gut. The specimen was obtained from 
 the body of a man who died of intestinal obstruction. 
 
 Fig-. 49.— stenosis due to iu-turnmEr of the Intestinal Wall, the result of 
 Mesenteric Gland Disease. 
 
 Of the nature of the obstruction in this case it is 
 difficult to speak. It is certainly not a stricture in 
 the proper sense. It may be a case of abrupt bending 
 of the intestine with fusion of the oj^posed surfaces at 
 tlie angle of the l)end. Cases of this character have 
 been already dealt with, but they do not present the 
 peculiarities afforded by the i)resent specimen. The 
 
Chap. XII.] Stricture: Pathology. 267 
 
 gut, moreover, if viewed laterally does not present 
 evidences of acute bending. It can only be surmised 
 that the condition is associated with the mesenteric 
 gland disease, and that the little local peritonitis ex- 
 cited had spread from the disordered lymph glands. 
 Above the stenosed part is a considerable pouch. 
 
 2. THE CANCEROUS STRICTURE. 
 
 Carcinoma of the intestine may be either primary 
 or secondary. As a secondary growth it may appear 
 either by metastasis or by extension from neighbour- 
 ing parts. So far as surgical practice is concerned, 
 the growth causing obstruction or definite intestinal 
 symptoms is usually primary ; and the metastatic 
 form need not be considered here."^ 
 
 It must be confessed that the pathology of cancer 
 of the intestine is by no means in a satisfactory con- 
 dition, and there is a great lack among available 
 records of full and detailed accounts of the micro- 
 scopical structure of these growths. According to 
 most authors, primary carcinoma of the bowel includes 
 the following varieties, viz. scirrhus, medullary, 
 colloid, and epithelial. With regard to scirrhus, I have 
 not been able to find any clear description of an un- 
 doubted primary scirrhus growth in the intestine, nor 
 have I been able to find in the various museums any 
 specimens of this condition that are beyond question. 
 I am much, disposed to doubt its existence. Mr. 
 Harrison Cripps, as the result of his extensive investi- 
 gations into new growths of the rectum, doubts the ex- 
 istence of scirrhus or medullary cancer in that part, 
 and has been unal:>le to find any examples of such 
 growths in that segment of the bowel. 
 
 * Mr. R. Williams, in a statistical paper dealing with 5,556 
 cases of carcinoma of all parts, has collected forty-nine instances of 
 cancer of the intestine, twenty-three being in male, and twenty-six 
 in female subjects [Lancet, May, 24, 1884). 
 
268 Intestinal Obstruction. [Chap. xii. 
 
 Tlie same remark that applies to scirrlius applies 
 also to medullary carcinoma. I can find no record of 
 any case of primary cancer of the bowel that upon 
 microscopical examination was proved to have been 
 without doubt an encephaloid growth. 
 
 Putting aside for a moment the subject of colloid 
 cancer, one is now driven to the conclusion that the 
 most usual form of carcinoma of the intestine is cylin- 
 drical eiDithelioma. ]Mr. Harrison Cripps has very 
 clearly shown that the usual " malignant disease " of 
 the rectum is of this character, and the rectum is not 
 so entirely unlike the rest of the intestinal tube as to 
 lead ns to anticipate that it possesses a peculiar mono- 
 poly in its morbid growths. In an admirable mono- 
 graph upon cancer of the int/Cstine recently published 
 by M. Haussmann, the conclusion above expressed re- 
 ceives very substantial confirmation."^ M. Hauss- 
 mann has collected no less than 268 recorded cases of 
 so-called cancer of the intestine. 
 
 In seventy-three of these cases a microscopical ex- 
 amination of the growth is given, with the result that 
 in forty-three instances the neoplasm proved to be a 
 cylindrical epithelioma. In four of the remaining 
 thirty cases the mass is described as colloid and might 
 have been an epithelioma that had undergone the col- 
 loid change. With regard to the rest of the cases, it is 
 significant that they mainly belong to the older de- 
 scriptions and to a period antecedent to the time of an 
 elaborate pathological histology. M. Haussmann's 
 observations upon these statistics, and his general con- 
 clusion upon the whole subject, are expressed in tho 
 following words : " Examinons en effet les dates de 
 nos observations et nous pourrons facilement nous 
 
 * Cancer de I'lntestin. These de Paris, 1882, No. 228. I 
 might be allowed to say that I had funned the conclusion above 
 named many months before I had read ^I. Haussmann's mono- 
 grai»h. 
 
Chap. XII.] Stricture: Pathology. 269 
 
 convaincre de Texistence crun fait important : lo car- 
 cinome intestinal devient de plus en plus rare a mesure 
 que Ton s'approche davantage de I'epoque actuelle. 
 Si nous ne tenons compte de cliaque cote que des faits 
 observes depuis 1875, nous voyons le nombre des car- 
 cinomes descendre a 8, tandis que celui des epitheliomes 
 se maintient a 26. Si nous rapprochons encore notre 
 point de depart et si de 1875 nous le reportons a 1879, 
 c'est 3 carcinomes seulement que nous voyons rester 
 debout en face de 24 epitheliomas cylindriques. II 
 nous semble que cette marche si rapidement decrois- 
 sante du carcinome demontre suffisamment sans meme 
 que Ton entre dans I'examen des faits, que le car- 
 cinome de I'intestine est destine a disparaitre. Nou.s 
 croyons done pouvoir legitimement conclure de cetto 
 discussion que tous les varietes de cancer de I'intestin 
 admises jusqu' a present doivent etre ramenees a une 
 seule : I'epithelioma cylindrique. Nous domierons done 
 du cancer de I'intestin la definition suivante : le cancer de 
 I'intestin est I'epitlielioma cylindrique de cet organe." 
 "With regard to colloid cancer one cannot but be 
 struck with the fact that this form of carcinoma is 
 not so commonly met with as it was. An examina- 
 tion of the "Transactions of the Pathological Society" 
 from their first volume to the present time would 
 induce the belief that this form of neoplasm is 
 becoming extinct. In other words, a more precise 
 and advanced pathology would appear to be rapidly 
 narrowing the extensive ground it once covered. 
 Colloid carcinoma is usually defined as a schirrus, 
 medullary, or epithelial cancer, the cells of which have 
 undergone colloid degeneration. Some of the re- 
 ported cases of colloid cancer may have been incor- 
 rectly associated with that name, others might have 
 been examples of the colloid degeneration of secondary 
 growths, while not a few were probably instances of 
 colloid change in a j^rimary epitheliomatous growth. 
 
270 Intestinal Obstruction, [cuap. xii. 
 
 An exaniinatioii of all tlie so-called specimens of 
 "intestinal cancer" to be found in museums, etc., 
 will show that they can be readily divided into two 
 great classes ; into examples of cylindiical epithelioma 
 and into instances of neoplasms that do not belong to 
 the epitheliomata. One class is positive, the other, so 
 far as pathological knowledge at present extends, is 
 negative. 
 
 We may consider first the growths alluded to as 
 forming the second class in this division, a division 
 that simply has for its object the separation of the 
 well-defined epitheliomata from the other and some- 
 what ambiguous growths that are classed together as 
 ^'cancers "of the intestine. There is no reason for 
 supposing that these neoplasms are all of the same 
 character, although when viewed collectively they pre- 
 sent certain general features which may be expressed 
 in the following description. They appear first as 
 rounded nodules under the mucous membrane and are 
 covered by a healthy layer of that tunic. These nodu- 
 les may be single, but they are nearly always multiple. 
 They may be met with here and there at many different 
 points in the intestine more or less remote from one 
 another, or many may be found clustered together in 
 a comparatively small segment of the bowel. (aS'^^ 
 Fig. 50.*) They usually form very distinct and j)romi- 
 nent projections, varying in size from a pea to a large 
 nu rble. 
 
 These isolated new growths, Mhich are at first 
 separated and surrounded by healthy mucous mem- 
 brane, increase in size, and it is possible that those 
 that are in near relation to one another may coalesce. 
 By one means or by another the morbid growth forms 
 a mass of some magnitude, then the mucous mem- 
 brane that covers it breaks down and the surface of 
 
 * St. Bait.'s Hosi). Museum, No. 2,020. /b'ce uUo Coll. of 
 Surgeons IMuscuiu, No. 1,220. 
 
Oiap. XII.] 
 
 Stricture : Pathology. 
 
 27T 
 
 the tumour becomes excavated by an ulcerative pro- 
 cess. It would appear that the neoplasm may disin- 
 tegrate almost as rapidly as it grows, and so indefi- 
 nitely postpone the serious narrowing of the lumen 
 of the bowel that a])pears always imminent. The new 
 growth spreads in depth as well as superficially. It 
 would seem to take its origin from the submucous 
 
 Fig. 50.— Cauoer of jojuuuni. 
 
 tissue, but soon invades all the coats of the intestine. 
 It commonly assumes an annular form, and, folloM'ing 
 the direction of the blood-vessels, is soon found to lla^■e 
 encircled the intestine. In other instances it remains 
 as a large flattened tumour, that has ajjparently spread 
 equally in all directions, that may extend around 
 three -fourths of the lumen of the intestine, and 
 that will present an ulcerated and broken-down 
 
272 Intestinal Obstruction. (chap. xil. 
 
 surface.* New growths such as these are variously de- 
 scribed as "cancer," "colloid cancer," "villous cancer," 
 and " medullary cancer." They are commonly attended 
 by like enlargements in the mesenteric] glands, and in 
 advanced cases by miliary nodules in the serous mem- 
 brane. As regards the nature of these growths I am 
 inclined to think that the great majority of them are 
 examples of secondary deposits, although they may 
 not be so described in museum catalogues. They pre- 
 cisely resemble, both in appearance and in general 
 arrangement, new gi'owths in the intestine that are 
 avowedly secondary to tumours elsewhere. The mul- 
 tiplicity of the deposits, and the frequent extensive 
 implication of the serous membrane, are features that 
 Avould suggest secondary rather than primary growths. 
 
 It is, moreover, to be noted that this is not the 
 form of cai'cinoma usually met with in surgic^d prac- 
 tice, not the form that is apt to assume a somewhat 
 lingering course and to produce a certain and pro- 
 gressive narrowing of the intestine, and not the form 
 that is usually met with in the clinical records of 
 those who have died Avitli distinct symptoms of 
 stricture of the bowel. Some present all the aspects 
 displayed by specimens of lympho-sarcoma of the 
 bowel, the nature of which has been placed beyond 
 doubt. 
 
 From this somewhat vague and probably hetero- 
 geneous collection of new growths we might turn to the 
 well-defined exami)les of carcinoma that form the first 
 of the two classes above alluded to, the cylindrical 
 epitheliomata. 
 
 Cylindromata may l)e met with in the bowel under 
 three different aspects: (1) As small nodules; (2) 
 as flattened plaques involving only a portion of the 
 
 * For specimens .see Middlesex Hosj). Museum, No. viii. 113a ; 
 Coll. of Surgeons Museum, No. 1,221 ; Guy's Hosp. IMuseum, 
 No 1,881 (97) ; and Lond. Hosp. Muaeum, No. Af. 28. 
 
Chop, xn.] Stricture : Pathology. 273 
 
 circumference of the gut ; and (3) as annular deposits 
 wliich surround the bowel like a ring. Into the 
 microscopic characters of this form of epithelioma it 
 is not necessary to enter. The morljid changes com- 
 mence in the epithelium of Lieberkiihn's glands, and 
 produce at first a great thickening of the glandular 
 layer of the mucous membrane for some distance, or 
 the neoplastic action may be more limited to one spot 
 and a projecting nodule be produced. Some of these 
 nodules form conspicuous tumours which are very apt 
 to assume a polypoid outline. In other instances the 
 growth sjjreads laterally rather than towards the 
 lumen of the bowel, and an epitheliomatous plaque is 
 produced. In this form a raised flattened mass of 
 neoplastic structure is formed upon one part of the 
 intestinal wall. Its edges are well defined and often 
 abruptly raised, its centre is uneven and often ulce- 
 rated. An example of the nodular or polypoid form 
 is afforded by Fig. 51.^ 
 
 The commonest form, however, under which epithe- 
 lioma of the intestine presents itself is that of an annular 
 band around the intestine. Compared with this asjoect 
 of the growth the nodules and plaques may be said to be 
 comparatively rare. The ring-like formation affords 
 an example of the neoplasm directed in its course by 
 the blood-vessels of the part, which here follow a 
 course transversely to the long axis of the bowel. It 
 is this form of epithelioma that usually is met with 
 under the title of malignant stricture of the intestine, 
 and it probably represents the only true cancerous 
 stricture of this part. The appearance of these stric- 
 tures is very typical. The gut at the stenosed part 
 appears to be very suddenly constricted, as if a piece 
 of cord had been drawn tightly about it. The stricture 
 is usually quite annular but insignificant in width, 
 
 * Coll. of Surgeons Museum, No. 1,222. See also Path. Soc. 
 Trans., vol. iv., page 1.54; and St. Bart.'sHosp. Musemn, No. 2,023, 
 
 s— 12 
 
274 
 
 tChap. XII. 
 
 Fig. 51.— Epithelioma of Colon. 
 a, tumour; b. Bite of lumen of bowel ; r, appendices epiiiloicae. 
 
Chap. XII.] Stricture: Pathology. 275 
 
 comparatively little of the gut, as measured along its 
 long axis, being involved. The peritoneum about 
 the stenosed part is often thickened and the bowel 
 itself is not infrequently adherent. On examining 
 the gut from the inside the stricture may appear as 
 an annular and contracted deposit, the surface of 
 which is irregularly ulcerated. Sometimes the stric- 
 ture appears as if contracted about one of the nodular 
 growths already described. In other instances the 
 neoplasm has extended laterally more after the manner 
 of a plaque, and the edge of the new growth, or rather 
 of the ulcerated surface that it has left^ shows a dis- 
 tinct rounded, raised, and everted border which is 
 very typical and very pronounced. This is Avell 
 shown in the specimen from which Fig. 52"^ has Vjeen 
 taken. Strictures of this character are often very 
 narrow. Some, for example, in the colon have been 
 decided as "almost closed," or as allowing only a 
 probe to pass, or as having a diameter no greater than 
 that of a goose-quill. They are much more common 
 in the large than in the small intestine, and I have met 
 with several specimens where the margins of the ileo- 
 csecal valve were the seat of an epitheliomatous growth. 
 
 It is important to recognise the fact that epithe- 
 liomata of the intestine appear as single growths. I 
 have not been able to find any undoubted example of 
 multiple primary epithelioma. In this respect, there- 
 fore, it differs markedly from the other forms of 
 so-called cancer. The mesenteric glands were found 
 involved in about 50 per cent, of the recorded cases, 
 but this complication is, without doubt, late to appear. 
 
 Of the causes that produce these growths nothing 
 
 is known. In one interesting case mentioned by M. 
 
 Isenard a well-marked cylindrical epithelioma appears 
 
 to have developed upon the scar left by a dysenteric 
 
 * St. Bart. '3 Hosp. Museum, No. 2,020. See also Coll. of Sur- 
 geons Museum, No. 1,223. 
 
276 
 
 Intestinal Obstruction, rchap. xii. 
 
 ulcer. The patient had had dysentery two years pre- 
 viously, and in the vicinity of the carcinoma were 
 many dysenteric cicatrices."* 
 
 In addition to the forms of carcinoma here dealt 
 with it is necessary to bear in mind that besides the 
 primary and the metastatic varieties of cancer of the 
 bowel there are cases in which a cancerous growth has 
 
 Fig. 52.— Epithelioma of Colon. Bird's-eye view of the Interior of the 
 
 Bowel. 
 At a, a triangular piece of the intestine has.been cut away. 
 
 spread to the intestine from an adjacent part and has 
 produced obstruction of the lumen of the tube so 
 involved. Thus Mr. McCarthy has recorded a case 
 of intestinal obstruction that was relieved by entero- 
 tomy. The patient lived forty-eight days after the 
 operation. The autopsy revealed a cancer of tlie 
 splenic flexure that had spread to tlio liowel from a 
 primary growth in the stomach, t 
 
 *Bull. de la See. Anat., 1873, page G13. 
 fMed.-Chir. Trans., 1872. 
 
Chap. XII.] Stricture: Pathology. 277 
 
 A similar spreading has been noticed in connection 
 with malignant disease of the uterus. 
 
 The g^eiieral patliolog^ical eliaiiges coii- 
 seqiieiit iipou strictMre. — The gut above the 
 stenosis becomes dilated and its walls liypertrophied. 
 In long standing cases this hypertrophy may be con- 
 siderable and far spread. Thus in cases of stricture 
 of the sigmoid flexure not only has the colon been 
 found dilated and liypertrophied, but also the terminal 
 portion of the ileum. Often above the stricture is a 
 distinct pouch due to distension acting probably upon 
 walls already diseased. The walls of the pouch are 
 thin, the mucous lining is frequently ulcerated, and 
 that ulceration often leads to fatal perforation. These 
 pouches are more commonly met with in connection 
 with simple than with malignant strictures^ and are 
 much more common in the small than in the large 
 intestine. (<S'ee Fig. 53.) 
 
 It is remarkable in how many cases cherry and 
 plum stones have been found in these pouches or in 
 the distended intestine above a simple stricture. The 
 most curious case of this kind is reported by Dr. 
 Wickham Legge. The patient, a female aged twenty- 
 six, for several years before her death evacuated, on 
 various occasions, cherry stones with her stools. She 
 also vomited a few. During life a mass of cherry 
 stone* could be felt through the parietes giving to the 
 hand a peculiar sensation as they were rubbed together. 
 At the autopsy a stricture of the ileo-caecal valve was 
 found, and above it in the small intestine, an imperial 
 pint of fruit stones.* In another case of stricture of 
 the ileo-ciecal valve nearly a litre of cherry stones 
 was found above the obstruction, f In a case reported 
 by Dr. Peacock there were found in a pouch above a 
 stricture of the small intestine thirty- three plum 
 
 *Path. Soc. Trans., vol. xxi., page 171. 
 + L'Uiiion M^d., 1856, No. 57. 
 
278 Intestinal Obstruction. • [Chap. xii. 
 
 stones, sixteen cherry stones, and six orange pips.* 
 In another very simihir instance there were only throe 
 plum stones in the pouch, f Lastly, Dr. Moore has 
 recorded a case of accumulation of a large number of 
 cherry stones above a sim})le stricture of the descend- 
 ing colon. I In most of the instances these foreign 
 bodies had led to perforation of the bowel. It is not 
 improbable that the habit of swallowing fruit stones 
 had, in the present instances, induced the simple 
 stricture that was found in each case. Or it may be 
 that the stricture had an independent origin and then 
 induced the morbid appetite. A third alternative 
 is the assumption that the habit of swallowing fruit 
 stones is very widespread. 
 
 In one curious case of stricture of the lesser 
 l)Owel a conical pouch or funnel was found to hang 
 down into the lower part of the intestine. It had 
 an aperture at its apex and through it all the faeces 
 had passed. The funnel-like process was large and 
 conspicuous and is well depicted in Fig. 53. § It 
 was probably produced by the excessive enlarge- 
 ment of a simple pouch formed above the stricture. 
 The fundus of the pouch would be pressed against 
 the wall of the gut below the stricture, until at last 
 perforation into that part of the intestine would occur 
 and the formation of the funnel-like process would 
 be complete. It may l)e noted that in the specimen 
 the mucous lining of the process can be seen to be 
 continuous with that of the intestine above. 
 
 It is common to find about simple strictures of the 
 lesser bowel certain frajna and bars of cicatricial tissue 
 which are a})parently the jjroducts of an irregular 
 ulceration, and possibly of the adhesions of adjacent 
 inflamed surfaces. 
 
 *ratli. Soc. Trans., vol. x., page 154. 
 
 flbid., vol. iv., page 152. % Lancet, vol. ii., 1876, page 505. 
 
 § St. Thomas's Hosp. Museum, No. Q 129. 
 
Fig. 53.— Stricture of the small Intestine. 
 
 a and «' point to frjena lioUling in position a remarkable pouch of mucous nieniT 
 
 lirane. 
 
2 So Intestinal Obstruction. [Chap. xii. 
 
 The distension of the colon above a stricture may 
 1)6 very great. Thus in a case of epithelial cancer of 
 the sigmoid flexure causing stricture, reported by Dr. 
 Fagge,"^ the splenic flexure of the colon was found 
 to be as large as a distended stomach. In a case of 
 stricture of the splenic flexure by the same author the 
 csecum was found to be as large as the calf of the 
 leg. In another instance where the stenosis involved 
 the descending colon, the large intestine above tlie 
 obstruction had a diameter of from eleven to 
 twelve inches.! The enormous distension of which 
 the colon is capable is well illusti'ated by a specimen 
 in St. Bartholomew's Hospital Museum, j showing the 
 large intestine of a child (who died of rectal stric- 
 ture) that has a diameter of more than one foot. 
 
 The mucous membrane of the bowel above the 
 obstruction is very usually ulcerated, and perforation 
 caused by these ulcers is a common cause of death 
 after stricture. In the small intestine the ulceration 
 is as a rule situated just above the stenosed part, and 
 if perforation occurs it will occur here. There are a 
 few exceptional cases. Thus, for example, in a case of 
 stricture of the ileo-ctecal valve a perforation was 
 found to have taken place in the middle of the ileum, 
 and on the other hand several feet of the small 
 intestine above a stricture may be the seat of 
 ulceration. 
 
 As regards the colon, the whole of its mucous 
 inembrane above the stricture may be ulcerated, but 
 as a rule the ulceration is much more limited. When 
 the stricture is at some distance from the valve 
 ulceration may be noted in two distinct places, viz. 
 just above the obstruction and in the caecum, the 
 intervening mucous membrane being qiiite healthy. 
 
 * Guy's Hosp. Reports, vol. xiv., page 272. 
 ■\ Lanctt, vol. ii., 1870, page 505. 
 J No. 1,952. 
 
Chap, xii.j Stricture : Pathology. 281 
 
 This lias been met with several times in stricture 
 of the sigmoid flexure. When perforation occurs in 
 colic strictures the abnormal aperture may be either 
 just above the stricture or in the csecum. The 
 relative proportion of perforation in these two places 
 is as seven to four. 
 
 In several cases where ulcers have been found in 
 the csecum similar lesions have been at the same time 
 met with in the ileum. In one instance of simple 
 stricture of the splenic flexure there was an annular 
 ulcer in the colon just above the obstruction and six 
 large ulcers in the lower end of the ileum. No other 
 part of the bowel, not even the caecum, was involved. 
 A fatal perforation had occurred in the lower ileum. "^ 
 
 The perforating ulcer above the stricture need not 
 open into the peritoneal cavity. In a few rare cases 
 where adhesions have formed the perforation has 
 been so placed as to give temporary relief at least to 
 the obstruction. Thus in one case of stricture of the 
 valve, the ileum ojDened into the commencement of 
 the colon, forming a fistula bimucosa through which 
 the f?eces could pass.f Other cases of relief by the 
 formation of such a fistula have been reported ; also 
 an instance where the colon above a stricture in a 
 distorted sigmoid flexure Avas found to have opened 
 into the bladder and rectum. | 
 
 Sometimes the changes in the bowel above the 
 obstruction pass the limits of ulceration and the part 
 becomes gangrenous. Gangrene developed under these 
 circumstances is usually found in obstructions of the 
 colon only, and it is only in this part of the intestine 
 that gangrene of an extensive character is met with. 
 Dr. Moxon has recorded a good example of this con- 
 dition. The stricture was in the sigmoid flexure, the 
 
 * Bull, de la Soc. Anat., 1870, page 27. 
 fPath. Soc. Trans., vol. xxi., page 171. 
 J Ibid. J vol. i., page 264. 
 
282 Intestinal Obstruction. [Chap. xii. 
 
 patient an adult. The anterior wall of the ascending 
 colon was wanting (having sloughed) over an area 
 measuring five inches by one and a half inches. 
 Escape of the contents had, however, been prevented 
 by the great omentum, which had become adherent 
 over the gap and had closed it."^ Dr. Goodhart has 
 placed upon record a still more pronounced instance. 
 In this case the stricture was also at the sigmoid 
 flexure and the patient an adult. A great part of 
 the transverse colon and nearly the whole of the 
 descending colon were gangrenous, the mucous mem- 
 brane here being especially involved.! Cases of less 
 extensive gangrene leading to rupture of the gut are 
 fairly common. The gangrene in these instances is 
 due partly to obliteration of the vessels in the 
 intestinal wall by pressure and distension, and partly 
 to the irritating action of retained fseces. 
 
 When the colon is involved in a stenosis at the 
 point of junction of the sigmoid flexure with the 
 rectum, the flexure often becomes much distorted 
 from distension. When so distended it may reach 
 remote parts and become adherent to them. Thus it 
 has been found to be adherent to the pelvic peri- 
 toneum, to the Vjladder, and to the serous lining of 
 the right iliac fossa. 
 
 Tlie c'onclitioii of the sli'ii'liii'c in its rcla- 
 tioii to the clinical aspect of the case.— The 
 stricture at the time of death may be wide enough to 
 admit the tip of the fore-finger ; on the other hand it 
 may be so narrow that water will merely trickle 
 through it in drops, or it will admit only a probe or a 
 goose-quill. As a rule the narrowest strictures are 
 met with in the small intestine, although there are 
 cases of stenosis of the colon where the obstructed 
 part has, at the time of death, only allowed a 
 
 *Path. Soc. Trans., vol. xx., page 181. 
 t Ibid., vol. xxxi., i»:ige 113. 
 
Chap. XII.] Stricture : Patiiology. 283 
 
 common probe to pass. Such extreme cases are, 
 however, rare in the larger bowel. A stricture can 
 attain to narrow dimensions without producing a 
 rapidly fatal result wh(!n the contents of the part 
 of the bowel that it involves are fluid. This is one 
 reason why narrower strictures are more possible in 
 the small than in the large intestine. In Fig. 47 is 
 shown a narrow stricture of the jejunum that never 
 caused obstruction symptoms, the patient dying with 
 diarrhoea. Messrs. Coupland and Morris in their 
 monograph allude to a case of annular stenosis of the 
 jejunum that was so narrow as to only admit a No. 7 
 catheter, and yet the patient presented no intestinal 
 symptoms during life. In like manner, if the contents 
 of the colon be fluid, strictures of that gut that are 
 comparatively narrow may cause no symptoms of 
 obstruction. Such patients die with severe and per- 
 sisting diarrhosa. Many cases have been recorded 
 where this part of the bowel at the autopsy has 
 appeared almost quite blocked by a cancerous new 
 growth or by deposits of lympho-sarcoma, and yet the 
 patient has presented no symptoms of obstruction. 
 The contents of the colon have remained in a fluid 
 condition and death has followed upon a long abiding 
 diarrhoea. 
 
 The precise manner in which a stricture of the 
 intestine brings about the death of a patient is by no 
 means the same in every case. 
 
 In some instances the stricture becomes narrower 
 and narrower, the obstruction becomes by slow degrees 
 more and more complete until at last it causes death, 
 after following a chronic and lingering course. In 
 other cases the stricture, having obstructed the bowel 
 to a certain extent, appears to undergo no further 
 contraction, but the patient dies worn out by the long 
 continued abdonnnal troubles, or succumbs to an 
 increasing marasmus. In cases of malignant disease 
 
284 Intestinal Obstruction. [Chap. xii. 
 
 also the effect of the morbid growth upon the patient's 
 general condition must not be overlooked. There are 
 cases that for a while adopt a lingering progress and 
 then end somewhat more abruptly. That is to say, 
 for some considerable time the malady may present 
 the symptoms of a chronic obstruction, and the fatal 
 issue be brought about by an attack of acute obstruc- 
 tion. Instances of this kind depend upon many 
 diflferent pathological conditions. Thus a plug 
 of hard faecal matter may have blocked up a 
 stricture that had of itself caused no very serious 
 amount of obstruction."^ Or this blocking of the 
 stenosed part may have been brought about by some 
 foreign substance. Thus in a case reported by Dr. 
 Peacock a dry raisin was found impacted in the 
 stricture,! while in another specimen the final occlu- 
 sion of the already narrowed bowel has been brought 
 about by a cherry stone. | In other instances folds of 
 mucous membrane from the gut above the stenosed 
 part may so fall across the orifice of the stricture as 
 to close it like a valve. In these cases water may 
 be injected with ease from below, but only wdtli 
 much difiiculty from above. To cases such as these 
 must be added that extensive series where the 
 small intestine at the seat of the stiicture has 
 become so bent as to have its lumen more or less 
 abruptly occluded, or where " kinking " has occurred, 
 or where the narrowed bowel has become still more 
 occluded by adhesions and by matting of its coils 
 together. 
 
 In stricture of the sigmoid fiexure, moreover, an 
 acute termination to the case is by no means un- 
 common. The greatly distended " flexure " becomes 
 bent upon itself and thereby occluded, or its parts 
 
 *Dr. Piatt; Lancet, vol. i., 1873, page 42. 
 
 fDr. Peacock; Path. Soc. Trans., vol. xiii., page 137, 
 
 I St. Bart.'s Hosp. Museum, No. 2,017. 
 
Chap. XIII.] Stricture : Svmptoms. 285 
 
 are so arranged that a volvulus is produced, or the 
 extremity of its loop contracts adhesions that may 
 serve to fui'ther narrow the lumen of the bowel. 
 
 CHAPTER XIII. 
 
 THE SYMPTOMS AND PROGNOSIS OF STRICTURE OF THE 
 
 INTESTINE. 
 
 Position. Age. Sex.— I have collected twenty- 
 six cases of stricture of the small intestine, eight cases 
 of stricture of the ileo-cfecal valve, and forty-four of 
 stenosis of the colon. "^ Total seventy-eight. Of this 
 number thirty-five were males and forty-three females. 
 
 The cases are thus distributed : 
 
 1 10 cases of cicatrix after ulcer { ^ ?^^^^f 
 26 cases of stric- I * ■ , • .^ • • ^t females. 
 
 ture of the ' ^ »» of cicatrix after injury 2 males. 
 
 small intes- f 4 „ following strang. hernia { ^ f^nial 
 
 tine. 
 
 females. 
 
 ! 10 „ of cancer . . . 1 5 f '^^^^ 
 j " ( o females. 
 
 26 15 males 11 females. 
 
 The average age of the ten patients with cicatri- 
 cial strictures after ulcer was thirty-five. The youngest 
 was a child of nine. The rest were between twenty- 
 one and fifty-eight years of age. 
 
 The average age of the ten patients with cancer 
 was forty-two ; the youngest being thirty-seven, the 
 oldest sixty-five. 
 
 The ages of the four patients with stricture fol- 
 lowing hernia were twenty-six, thirty-four, fifty-two, 
 and fifty-seven. (Three of the hernije were inguinal 
 and one was femoral.) 
 
 * The last-named are exclusive of the cases collected by Dr. 
 Fagge and by Messrs. Coupland and Morris. 
 
286 
 
 Intestinal Obstruction. [Chap. xiii. 
 
 8 cases of stric- 
 ture of the 
 ileo-cacalvalie. 
 
 3 cases of simple stricture 
 
 44 cases of stric- ! 
 ture of the )• 
 colon. I 
 
 J 
 
 28 
 13 
 
 simple stricture 
 natui'e unknown 
 
 ( 1 male 
 
 ( 2 females. 
 
 ( 1 male 
 
 ' \ 4 females. 
 
 2 males G females. 
 
 ( 14 males 
 * ( 14 females. 
 ( 2 male 
 ( 11 females, 
 f 2 males 
 ( 1 female. 
 
 44 18 males 26 females. 
 
 The average age of the twenty-eight patients witli 
 cancer was forty-eight. Only six were under forty 
 years of age. The youngest patient was t\\'enty-two ; 
 the oldest sixty-six. 
 
 The average age of the thirteen patients with non- 
 cancerous stricture was forty-four, the youngest being 
 nineteen and the oldest seventy-six. 
 
 The situation of the stricture in the forty-four 
 cases was as follows : 
 
 Sigmoid flexiu'e . . . . .27 
 Descending colon ..... 5 
 Splenic flexure ..... 2 
 Transverse colon ..... 3 
 Hepatic flexure ..... 5 
 Ascending colon .... .1 
 Ctecum .... . . .1 
 
 Adding to my forty-four cases sixteen that were 
 collected by Dr. Fagge, and thirty- eight by INIessrs. 
 Coupland and Morris, the following result is o))- 
 tained in the total of ninety- eight cases : 
 
 Sigmoid flexure ..... 58 
 Descending colon . . . . .11 
 
 Splenic flexure 
 Transverse colon 
 Hepatic flexure 
 Ascending colon 
 Caecum 
 
 Total 
 
 98 
 
Chnp. xin.] Str/cture: SvMrronTS. 287 
 
 The following general conclusions may ha drawn 
 from the al)Ovo statistics : 
 
 Stricture of the intestine is a little more common in 
 females than in males. In one fomi of stenosis, how- 
 ever (viz. ill the non-cancorous stricture of the colon), 
 the num])(!r of females is greatly in excess of the 
 males, the proportion being as eleven to two. As re- 
 gards the ages of tlie patients it will he seen that this 
 malady is pi-actically limit(Ml to adults. Cases of 
 cancer are extremely rare before forty, while cicatri- 
 cial strictures are met with, taking the average, at a 
 slightly (^arli(!r ag(;. 
 
 Pr<^vioiis liBsloi'y.— Facts in connection with 
 the previous history of pati(nits suflV^j-iug from stric- 
 ture of the iiit(!stine are of comparatively little value. 
 Many of the stenoses follow, as we have seen, upon 
 ulceration. Certain forms of intestinal ulceration are 
 associated with very definite symptoms, as is the case 
 in typhoid fever and dysentery. A history of dysen- 
 tery is of much vahie in tlie clinical account of cer- 
 tain of tlujse cases, since many of tlie cicatricial 
 strictures of the large, intestine depend upon this 
 malady. A history of ty))hoid fever, on the other 
 hand, is practically v^aku^hiss, on account of th(^ 
 extreme rarity of stenosis of the bowel as a conse- 
 fjuence of tlui disease. The frequency of syphilis and 
 the rarity and the indefiniteness of syphilitic aftectibns 
 of the bowel above the rectum render the evidences of 
 that disorder in any given patient of little use in 
 atte'mpting a diagnosis of the case. A history of 
 tuberculosis in any case, or the presence of any evident 
 tubercular malady, may suggest a stenosis due to tuber- 
 cular ulceration in instances where symptoms of ob- 
 struction of the bowel appear. The suggestion, how- 
 ever, would be as feeble as it is indefinite. 
 
 In connection with the less precise forms of intes- 
 tinal ulceration it juust be remembered that even 
 
288 Intestinal Obstruction. [Chap. xiii. 
 
 extensive disease in the tube may be attended by no 
 symptoms. It is by no means uncommon to find at 
 an autopsy ulcers in the bowel that gave not the least 
 evidence of their existence during life. Indeed, if one 
 make exception of typhoid and dysentery I tliink it 
 may be said that ulceration of the intestine is asso- 
 ciated -svith symptoms so vague, so uncertain, and 
 frequently so contradictory, that the malady can 
 hardly be said to have a clinical existence. Many 
 examples may be given in illustration of this. One 
 may be selected. Dr. Fuller reports the case of a 
 man aged fifty, who suftered for six months before his 
 death with general and progressive wasting. He had 
 no abdominal symptoms of any kind. His bowels 
 were always regular and his motions natural. He was 
 never sick and had no tenderness over the belly. He 
 died suddenly of perforative peritonitis. The autopsy 
 revealed extensive ulceration of the ileum, nearly the 
 whole of that segment of the gut being involved. 
 Indeed, in a length of five feet of that bowel there 
 were no less than twenty-five large ulcers. One of 
 these had caused perforation. There were some ulcers 
 also in the colon. In nature they were supposed to 
 have been tubercular.* 
 
 In cases where symptoms are excited there may 
 be constipation, but more frequently diarrhoea. Some- 
 times blood is found in the evacuations in cases of 
 disease in the colon, and when the ulceration involves 
 the lower part of this bowel tenesmus is not uncom- 
 mon. There may be some pain in the abdomen, but 
 it is very indefinite and usually most insignificant. 
 As a rule vomiting only occurs in cases of duodenal 
 ulcer, and in instances where the peritoneum is in- 
 flamed. Leube observes that in the case of the so- 
 called follicular ulcer small plugs of mucus like sago 
 grains may be passed with the stools. 
 
 *Path- Soc. Trans., vol. xi., page 103, 
 
Chap. XIII.] Stricture: Symptoms. 289 
 
 Among other elements in the etiology of stricture 
 that may be displayed in the history of the ease, are 
 injury to the abdoirien, strangulated hernia, typhlitis, 
 perityphlitis, and diarrhoia. If, however, we consider 
 the frequency of these affections on the one hand and 
 the comparative rarity of cicatricial stricture of the 
 bowel on the other, it will be seen that a history of 
 any of these affections in a suspected case will be of 
 but little clinical value. 
 
 As to the interval of time that elapses between 
 the causative affection and the symptoms of obstruc- 
 tion of the bowel; the greatest uncertainty exists. 
 Much depends obviously upon the extent of the initial 
 lesion. The only fact that is to any extent constant 
 is the circumstance that the evidences of stenosis Avill 
 appear at an earlier date when the lesser bowel is in- 
 volved than is the case when the stricture implicates 
 the colon. 
 
 In two cases of stricture of the small intestine 
 following injury, three and four months respectively 
 intervened between the lesion and the appearance of 
 obstruction symptoms. In four cases of stenosis of 
 the ileum following upon strangulated hernia, the 
 interval that elapsed between the reduction of the 
 rupture and the onset of symptoms of stricture was 
 one month, six weeks, seven months, and " some 
 years " respectively. 
 
 With regard to the large intestine I find that 
 periods often of several years have elapsed between 
 an attack of dysentery and the appearance of obstruc- 
 tion symptoms due to contraction of the dysenteric 
 cicatrices. Rokitansky mentions a case where symp- 
 toms of constriction of the bowel did not appear 
 until thirty years after an attack of dysentery. I find 
 a case of stricture of the ileo-colic valve that induced 
 symptoms eleven years after a typhlitis, and an in- 
 stance of stricture of the hepatic flexure of the colon 
 T— 12 
 
290 Intestinal Obstruction. [Chap. xiii. 
 
 that produced evidences of constriction twelve months 
 after an attack of severe diarrhoea. 
 
 The symptoms that precede the actual evidences 
 of obstruction in cases of cancerous stricture will be 
 considered when dealing with the general symptoms 
 of those stenoses. 
 
 THE SMALL INTESTINE— SIMPLE STRICTURE. 
 
 Mode of onset and general course. — The 
 
 simple stricture of the small intestine belongs dis- 
 tinctly to the chronic variety of intestinal obstruction. 
 The symptoms are usually extended over a compara- 
 tively long period of time, and become, as th§ case 
 advances, progressively worse. The stenosed canal 
 simply becomes narrower and narrower until at last 
 it produces a degree of obstruction that, either from its 
 long duration or its completeness, leads to results that 
 produce death. Thus it liappens that many cases of 
 this form of constriction develop very slowly and very 
 insidiously, follow a tedious course and bring about 
 gradually a fatal result. While this can be said of 
 many cases it cannot be said of the majority. Owing 
 to the fluid character of the contents of the small in- 
 testine it happens that the stenosis may become pro- 
 nounced before very serious symptoms are produced. 
 But the narrow stricture is constantly liable to be 
 abruptly closed. A valvular fold of mucous mem- 
 brane is laid across it, or it becomes suddenly plugged 
 by a mass of undigested food, or a foreign substance 
 that has been swallowed, or the involved coil of gut 
 may become abruptly closed by kinking or by some 
 of those methods of producing obstruction that 
 depend upon adhesions. 
 
 Thus it happens that in the clinical history of 
 stricture of this bowel we very often find the symp- 
 toms of chronic obstruction ending in an attack of 
 acute obstruction that has a fatal issue. Before 
 
Chap.xiii.i Stricture: Symptoms. 291 
 
 the final attack the patient may have had several 
 previous attacks of similar nature, from which, 
 however, he has recovered, the lumen of the tube 
 becoming restored. Lastly it may be that the bowel 
 has become gradually much narrowed without any 
 symptoms having been excited that have caused 
 attention. The narrowed tube is suddenly occluded 
 by some of the means just alluded to, symptoms of 
 acute obstruction develop which may rapidly lead to 
 death. Thus there are cases of cicatricial stricture 
 of the lesser bowel that have appeared with all the 
 evidences of acute obstruction, the patient having 
 been free from any marked symptoms of abdominal 
 trouble at the time of the onset of the attack. 
 Examples of such cases will be detailed subsequently. 
 
 Symptoms. — The course of the disease is ex- 
 tremely irregular and is marked by great fluctuations 
 in tlie occurrence and nature of the symptoms. 
 
 The most conspicuous and constant feature con- 
 sists in certain attacks of paroxysmal pain that 
 occur at intervals. The pain in these attacks is of the 
 nature of colic and is often severe. It is associated 
 with constipation and is usually attended by vomiting. 
 The colicky pains are often described as radiating 
 from the navel, and are never, so far as I can ascer- 
 tain, distinctly localised in any one part. It is most 
 significant to note that these attacks usually come on 
 after food, and as a rule some three or four hours 
 after the taking of the food. Sometimes they appear 
 at a shorter interval after meals, but very rarely at a 
 longer. These attacks may begin most insidiously, 
 may appear in patients who present absolutely no 
 abdominal symptoms, or, as is more usual, come on 
 after a long continued intestinal disturbance, some- 
 times marked by diarrhoea, but more often by consti- 
 pation. At the commencement the patient often 
 complains merely of indigestion and flatulency after 
 
292 Intestinal Obstruction. ;chnp xiii. 
 
 food. In time the attacks become more definite 
 and more severe, until at last the individual is liable 
 from time to time to sharp paroxysms of colic asso- 
 ciated with vomiting and other symptoms. 
 
 In other instances the individual attacks are some- 
 what severe from the first. They may appear once a 
 month or once in three or four months. They may 
 last several hours or even days. During the inter- 
 vals between their appearance the patient may be 
 well, or have a little indigestion, or be troubled, as is 
 very common, with constipation, or with diarrhoea 
 alternating with constipation. 
 
 In any case, as time advances the attacks occur 
 more and more frequently, while at the same time 
 they lessen in duration. At last the patient may 
 have attacks of pain every few hours or every 
 quarter of an hour, each attack not lasting probably 
 more than two or three minutes. There is every 
 reason to believe that the attacks of pain are due to 
 a temporary blocking of the stricture. This blocking 
 is effected by imperfectly digested food or faecal 
 matter, aided possibly by some kinking of the bowel 
 incident to peristaltic movements passing through a 
 diseased segment of intestine. In some cases it is 
 possible that kinking is a conspicuous feature in 
 these attacks. So long as the stricture is of good 
 size it will be obvious that these obstructive attacks 
 can only occasionally occur, and thus we find that 
 they appear at very irregular intervals ; at first at 
 intervals that may sometimes be reckoned by months, 
 and at others by weeks or even days. As the stric- 
 ture becomes narrower the obstruction becomes more 
 abiding. 
 
 The attacks become much more frequent and more 
 constant and at the same time their duration is 
 lessened. The obstructive paroxysms are now 
 brought about bv ordinary intestinal matters and are 
 
Chap. XIII,] Stricture : Symptoms. 293 
 
 not dependent upon exceptional masses of unassimi- 
 lated food. 
 
 The association of these attacks with the ingestion 
 of food is a matter of great importance and of much 
 diagnostic value. Usually the patient recognises the 
 association and has to exercise great care in his diet. 
 In several instances the attacks were warded off for 
 a long while by adopting a perfectly fluid diet, and 
 reappeared at once on any relaxation of the rule. 
 
 Some of the earlier attacks are not unlike attacks 
 of subacute obstruction, but as the case advances the 
 chronicity of its course becomes evident. The patient 
 is seen to be suffering from some grave intestinal dis- 
 turbance associated, among other features, with attacks 
 of joain that are of a paroxysmal character and appear 
 at frequent intervals. 
 
 In most instances the patient dies of a definite ob- 
 structive attack. The stricture becomes actually or 
 practically closed, and, no passage being re-established, 
 death ensues. 
 
 It is well to note that when complete obstruction 
 sets in the character of the pain changes. It be- 
 comes continuous, being, however, at the same time 
 liable to exacerbations at intervals. Unlike the pre- 
 vious attacks, the patient is not now free from pain in 
 the intervals. 
 
 Vomiting in these cases, although a constant 
 symptom, is by no means a very pronounced or dis- 
 tressing one. During the more severe of the earlier 
 attacks (attacks that occur at long intervals and last 
 some time) vomiting is present. It appears late 
 and is often scanty. If the attack, however, last for 
 some time, a matter of days, the vomiting is apt to 
 become feculent, although examples of this are in- 
 frequent. 
 
 As a rule the vomiting only becomes feculent 
 towards the termination of the final attack of 
 
294 Intestinal Obstruction. tChap. xiii. 
 
 obstruction. In these attacks it may be severe, but 
 it scarcely ever reaches the severity of the vomiting 
 seen in cases of acute obstruction. 
 
 The symptom shows great fluctuation. During 
 the final attack of occlusion the vomited matters may 
 become feculent, the sickness may then abate and 
 only alimentary and bilious matters be rejected. 
 After awhile the vomit may again become stercora- 
 ceous. The symptom depends in a marked manner 
 upon the degree of the obstruction, and faecal vomit- 
 ing never appears until absolute constipation has be- 
 come a pronounced feature. 
 
 As may be gathered from what has been already 
 said, the state of tlie too-ivels is subject to the 
 greatest variation. In about 60 per cent, of the cases 
 constipation is the predominant feature. In some- 
 thing less than 40 per cent, there is constipation alter- 
 nating with diarrhoea ; but in only a very few cases 
 is diarrhoea the more usual condition of the bowels. 
 During the initial attacks, and during the final attack, 
 constipation is almost invariable and may remain 
 absolute for many days or even for two or for three 
 weeks. The constipation at first yields to treatment, 
 but soon becoDies more and more obstinate. It is im- 
 portant to note that the earlier attacks are often at 
 once relieved by an ajierient. The purge would not 
 only render the intestinal contents more fluid, but 
 would remove the cause of the obstruction, if it be a 
 mass of undigested matter. Like relief may follow 
 the use of an enema. 
 
 Sometimes an attack of long-contmued constipa- 
 tion is suddenly relieved by a copious and sjjontaneous 
 stool. In such cases the plug or other obstructing 
 agent has probably abruptly yielded. 
 
 It is not very uncommon for the patient, after days 
 or weeks of absolute obstruction, to pass a copious 
 motion just before death. This indicates, I think, in 
 
Chap. XIII.] Stricture: Svmptoms. 295 
 
 nearly every case a perforation of the bowel. A 
 pressure within the intestine is removed by this per- 
 foration, and one factor in the production of the 
 occlusion being removed, the stricture yields for the 
 last time. 
 
 In only one case was there any teiiesmiis. It 
 was in a case of stricture following strangulated hernia, 
 and was apparently very slightly marked. The 
 stenosis was in the lower part of the ileum.* 
 
 As regards the general condition of the 
 patients, it only remains to be said that they become 
 progressively weaker as the disease advances, being 
 worn out by the frequent attacks of pain and vomiting 
 and enfeebled by the loss of appetite that is often a 
 conspicuous symptom. Emaciation is usually pro- 
 nounced, and the patient's wasted and cachectic aspect 
 may be such as to suggest the presence of malignant 
 disease. 
 
 The state of the abdomen. — The abdominal 
 walls remain flaccid except during some of the more 
 painful paroxysms or after the development of peri- 
 tonitis. 
 
 During the duration of the attacks of obstruction 
 there will be some meteorism which, however, is never 
 excessive. In the intervals between the attacks the 
 abdomen will not be swollen, and its walls indeed are 
 commonly retracted in cases associated with much 
 wasting and with diarrhoea. 
 
 It is very usual for the movements of the intestinal 
 coils to be visible through the parietes, a circum- 
 stance that is to be especially noticed during the 
 paroxysms of pain. 
 
 In no instance among the rejjorted cases was any 
 tumour to be felt^ nor any localised dullness present 
 that could assist in the diamosis of the ailment. 
 
 *Bti11. et IMem. de la Soc. cle Chir., tome vi., 1880, page 607; 
 M. Berger. 
 
296 Intestinal Obstruction. [Chap.xiil. 
 
 Cases %vitli an acute course. — It has already 
 been said that cases of stricture of the lesser bowel 
 are usually attended by certain painful attacks at 
 intervals, which indicate a temporary obstruction of 
 the strictured part. It may be readily understood 
 that the first occurrence of this obstruction may also 
 be the last ; that, in fact, the stenosis, after existing for 
 some time without causing symptoms, may become 
 suddenly occluded, and that that occlusion may bring 
 about a fatal issue. Such a case is reported by 
 liefrege. It concerns a man, aged forty-nine, who 
 had been liable for some months to constipation. 
 For some days before his admission into hosj)ital he 
 had had some pain in the lower part of his abdomen. 
 On admission the limbs were cold and cyanosed, the 
 face livid, the eyes sunken, the patient much troubled 
 by vomiting, and the pulse very small and feeble. 
 There was constipation. An epidemic of cholera 
 existed at the time, and the case was taken for an 
 example of that disease. The patient was treated 
 with hot baths and by such measures as were then in 
 vogue for the treatment of cholera. He died on the 
 eighth day after admission. Before his death ster- 
 coraceous vomiting had occurred and the general 
 character of the case had been recognised. The 
 autopsy revealed a stricture in the lower ileum that 
 would barely admit a crow-quill.* Another very 
 interesting case is rej^orted by Dr. Piatt. In this 
 instance the patient, a child aged nine, appears to have 
 had no evidence of previous abdominal trouble. The 
 symptoms of obstruction appeared suddenly, and 
 rapidly assumed an aspect of gieat gravity. Death 
 took place on the seventh day. The case had been 
 diagnosed as acute intussusception. The autopsy 
 revealed a stricture of the lower extremity of the 
 
 *Le Diagnostic de I'^lStranglement intestinal a Symptoraes 
 clioleri formes, by Felix Ryfz-ege. Paris, 18G7. 
 
ciiap. XIII.] Stricture : Symptoms. 297 
 
 ileum, which had become obstructed by a plug of 
 clayey feces.* 
 
 THE SMALL INTESTINE — CANCEROUS STRICTURE. 
 
 The sjTiiptoiiis of this form of stenosis are practi- 
 cally identical with those just detailed as incident to 
 simple stricture. In perhaps the majority of cases 
 it would not be possible to distinguish one from the 
 other. Taking a general view of the cases collected, 
 it will be seen that in "cancerous" stenosis there 
 are the same paroxysmal attacks of pain and the 
 same general symptoms with regard to the state of 
 the bowel, the nature of the matters vomited and 
 the physical condition of the abdomen. The usual 
 tendency is towards constipation, although there are 
 cases marked by diarrhoea or by constipation alterna- 
 ting with diarrhoea. The tendency to faecal vomiting 
 is about the same. In one case of so-called " colloid 
 cancer " of the loAver ileum there was complete con- 
 stipation for fifty days before death, with feculent 
 vomiting that appeared some thirty days before the 
 termination of the case. The vomiting, even after it 
 had become stercoraceous, ceased for a while (for 
 twelve days), and on recommencing no longer pre- 
 sented the stercoraceous character.! 
 
 The duration of the symptoms is certainly longer 
 in cases of cancerous stricture than it is in those of 
 simple stricture. It would be, perhaps, more correct 
 to say that the symptoms appear earlier in the former 
 than in the latter form of obstruction. In no instance 
 could the malady have been said to pursue a subacute 
 course. In the least chronic case the symptoms had 
 lasted for at least four and a half weeks before death. 
 In several instances distinct relief attended the 
 administration of aperients. 
 
 * Lancet, vol, i., 1873, page 42. 
 
 fDr. Hilton Fagge ; Guy's Hospital Reports, vol. xiv., 1869. 
 
29S Intestinal Obstruction. tChap- xiii. 
 
 In one case of " cancer " involving the lower part 
 of the ileum there were severe and repeated haemor- 
 rhages from the anus."^ The case was associated with 
 persistent diarrhoea. In these forms of stricture there 
 appears to be more pain than in the simple forms, and 
 especially is there more frequently a fixed pain, which 
 may exist in addition to the pain that is paroxysmal. 
 
 Emaciation is much more marked, appears earlier, 
 and ad^'ances more rapidly. There is also, throughout the 
 case, a more distinct impairment of the general health. 
 
 In three out of the ten instances of cancer of the 
 small intestine that I have collected the new growth 
 formed a distinct tumour that was readily felt through 
 the abdominal parietes. 
 
 Diu'atiou and prognosis. — In two of the 
 cases of simple stricture, intestinal symptoms^ as 
 already mentioned, existed for not more than eight 
 days before death. In another case (that of Kceberle's) 
 the symptoms of stricture had existed for two or three 
 years before the patient was relieved by operation. 
 Putting aside these exceptional instances, I find that 
 the average duration of the remaining thirteen cases 
 was three months. By the duration of the disease is 
 merely meant the interval of time between the first 
 appearance of obstruction symptoms and the termina- 
 tion of the case. 
 
 Kceberle's patient i-ecovered after resection of the 
 diseased intestine. The cause of death in the remain- 
 ing cases was as follows : Two died after operation, 
 eight of perforation, and five of exhaustion attending 
 upon persistent obstruction. 
 
 "o^ 
 
 was five months. In one case death followed upon 
 operation, in two cases it was due to perforation, in 
 three to acute peritonitis independent of perforation, 
 and in the remaining four instances to exhaustion. 
 ♦Bull, cle la Soc. Anat. de Paris, 1875, page 299. 
 
Chap, xin.] Stricture : Symptoms. 299 
 
 The prognosis in stricture of the small intestine 
 is absolutely unfavourable unless the case be relieved 
 by operation. In instances of malignant stricture it 
 will be obvious that even an operation, successful 
 at the time, can only lead to temporary relief. 
 
 Spontaneous relief to the obstructed part may be 
 given by ulceration of the bowel above the stricture. 
 By means of such ulceration this part of the intestine 
 may communicate with the bowel below the seat of 
 the stenosis and through this communication the in- 
 testinal contents may be passed along. Although I 
 am aware of no actual case where continued relief 
 was obtained by these means, yet many cases show 
 that it is quite possible, and indeed in one reported 
 instance of stricture of the ileo-csecal valve this 
 method of spontaneous cure had taken place. In 
 this instance the ileum above the stricture had com- 
 municated with the colon below it.'^ 
 
 It would be quite possible also for a fsecal fistula to 
 form above the stenosed part, which, by a communica- 
 tion with the surface, would play the pai-t of an 
 artificial anus. In a case under my care at the 
 London Hospital an obstruction existed in the small 
 intestine due to a matting together of the coils of the 
 bowel. The mucous membrane had become the seat 
 of tubercular ulcers, one of which had led to perfora- 
 tion, and subsequently to a fsecal fistula discharging 
 near the umbilicus. Through this fistula the contents 
 of the bowel were passed, and for many Aveeks before 
 deatli no fiscal matter was passed in any other way 
 than through this abnormal passage. 
 
 STRICTURE OF THE ILEO-C^CAL VALVE. 
 
 No distinctive symptoms attend stricture of this 
 part. They are practically identical with those asso- 
 ciated with stenosis of the small intestine. Of the 
 *Patli. Soc. Trans., vol. xxi., 1870, page 171. 
 
300 Intestinal Obstruction. [Chap. xiii. 
 
 eight examples I have collected, two patients died of 
 causes not directly connected with the obstruction. 
 In the remaining cases there was, among other symp- 
 toms, vomiting which became feculent in two in- 
 stances, remained non-stercoraceous in three, and is in- 
 definitely described in one example. In each instance 
 the general condition of the bowels was that of chronic 
 constipation. In no case was any tumour detected. 
 As regards the duration of the symptoms, in one re- 
 corded case they appear to have existed for less than one 
 month before death. In this example the valve was 
 occluded by a new growth. In Dr. Wickham Legge's 
 case obstruction symptoms had existed at intervals 
 for at least eleven years. It is supposed that the 
 stricture was in this instance congenital. In the re- 
 maining cases the average duration of the symptoms 
 before death was seven months. 
 
 Two patients, as already noted, died of causes not 
 directly connected with the obstruction. Of the rest, 
 one died after operation, two from perforation, while 
 three succumbed to the effects of long-continued ob- 
 struction of the bowel. 
 
 THE LARGE INTESTINE — SIMPLE STRICTURE. 
 
 The symptoiiis of stenosis of this part have a con- 
 siderable resemblance to tliose depending upon stric- 
 ture of the lesser bowel. In many instances it is 
 difficult and even impossible to precisely differentiate 
 simple stricture localised in these two segments of the 
 intestine. 
 
 The most conspicuous symptom consists of attacks 
 of paroxysmal pain that appear at intervals. These 
 attacks much resemble those already described when 
 speaking of the lesser bowel. Thty may be the first 
 indications of the disease, but usually appear after 
 some such intestinal disturbance as chronic constipa- 
 tion, or constij^ation alternating with diarrhtca. They 
 
Chap. XIII.] Stricture: Sv3TPTonTS. 301 
 
 depend, no doubt, upon some temporary obstruction of 
 the stricture. The pain is usually less severe than is the 
 case in the paroxysms attending stricture of the small 
 intestine. There is also less vomiting which will ap- 
 pear later in the attack, will be comparatively scanty, 
 and will never be stercoraceous unless after many 
 days of absolute constipation. 
 
 The interval of time between the earlier attacks 
 is often considerable. Thus in one case nine months 
 elapsed between the first and second attacks. In 
 other instances there have been three or four attacks 
 a year for some years. As the stricture narrows these 
 occurrences become more frequent and more trouble- 
 some. 
 
 Unlike the strictures of the small intestine^ 
 stenosis of the colon is generally unattended by symp- 
 toms of the nature of indigestion. There is usually 
 no connection between the attacks of pain and the in- 
 gestion of food. Indeed, in only one of the recorded 
 cases have I found this connection. The case in 
 question was one of simple stricture at the hepatic 
 flexure. Attacks of pain and vomiting came on some 
 two or three hours after nearly every meal, so that the 
 patient at last became almost afraid to eat."^ 
 
 The attacks in cases of stenosis of the lesser boAvel 
 are commonly relieved by the administration of a 
 purge. In cases, however, involving the colon the 
 opposite obtains. Aperients are apt to aggravate 
 existing symptoms, a circumstance that depends, no 
 doubt, upon the more solid character of the contents 
 of the larger bowel. The final obstruction is usually 
 preceded by many attacks of paroxysmal pain. Be- 
 tween these attacks the patient may feel fairly well, 
 although he is usually troubled by constipation, or by 
 constipation alternating with diarrhoea and with much 
 flatulence. When the obstruction becomes absolute 
 * EuU. de la Soc. Anat., 1870, page 322. 
 
302 Intestinal Obstruction. [Chap. xiii. 
 
 the character of the pain changes, just as is the case 
 in the small intestine ; it ceases to be distinctly in- 
 termittent and becomes more continuous. 
 
 The prevailing condition of the bo^vels is 
 
 one of chronic constipation, that is now and then as- 
 sociated with a little spurious diarrhcea, just as is seen 
 in cases of stricture of the rectum. In thirteen cases 
 of simple stricture constipation was the prevailing 
 condition in eleven instances. In the remaining two ex- 
 amples there was constipation alternating with marked 
 diarrhoea. The final attack is characterised by abso- 
 lute constipation. Nothing may pass the rectum for 
 ten or twenty days before death. In some cases the 
 period of absolute constipation has exceeded these 
 limits, and has attained a duration of thirty"* and 
 even of forty days, f During the earlier attacks there 
 is also constipation. 
 
 The constipation at first yields to aperients or 
 enemata, but in time becomes more and more obsti- 
 nate. Enemata usually act more efficiently than pur- 
 gative medicines. It has been shown that in some 
 cases water can be injected through the stricture from 
 below, but not from above. 
 
 Toniiting^ is even less marked in stenosis of the 
 colon than in that of the small intestine. In the 
 earlier attacks it may be entirely absent, or appear 
 late and be very scanty. In the more serious attacks 
 vomiting is more frequent, and in the final attack it is 
 constant. It is seldom a distressing symptom and 
 often fluctuates in severity, being sometimes absent 
 for days even during the final obstructive attack. It 
 is rarely feculent except during the obstruction that 
 immediately precedes death. Even in such a circum- 
 stance the cases of stercoraceous vomiting are to those 
 of non-feculent vomiting as five to seven. Feculent 
 
 * Dr. Coupland ; Path. Soc. Trans. , vol. xii. , page 94. 
 ■\ Lancet, vol. ii., 1869, page 80. 
 
Chap. XIII.] Stricture : Symptoms. 303 
 
 vomiting depends more upon the duration and com- 
 pleteness of the occlusion than upon its situation in 
 the colon. There are, however, some striking excep- 
 tions to this. Thus, in the two cases above alluded to, 
 where the duration of complete constipation w^as 
 respectively thirty and forty-six days, the vomiting- 
 was not severe and never became feculent. 
 
 In another case the ejected matters did not become 
 stercoraceous until the fourteenth day of absolute 
 constipation, the patient dying about the sixteenth 
 day. 
 
 Sometimes the vomiting appears at fairly regular 
 intervals, as in one^ case of stricture of the sigmoid 
 flexure, where the patient vomited every half hour 
 with some regularity. 
 
 Among the more special symptoms may be noticed 
 the occurrence of tenesiniis. This is especially apt to 
 occur in cases of stricture low down in the colon, and 
 particularly in cases associated with diarrhoea. It is 
 more marked in the early than in the later stages of 
 the disease, and is, I think, not present in more than 
 one-third of the cases. 
 
 In several instances of stricture in the sigmoid 
 flexure the motions passed have been distinctly 
 flattened or otherwise altered in shape. When the 
 stricture is in a higher part of the colon the faecal 
 matter passed through the stenosed part becomes re- 
 modelled in the lower portions of the bowel as it 
 passes towards the rectum. 
 
 In one case the patient was for a while troubled 
 with stranguary. 
 
 The general condition of the sufferer in these 
 cases may be expressed in the same words that have 
 been applied to the cases of those afflicted with stric- 
 ture of the lesser intestine. 
 
 The abdominal walls remain flaccid unless some peri- 
 tonitis has developed. There is but little meteorism 
 
304 Intestinal Obstruction. [Chap. xiii. 
 
 so long as the bowels act, and in cases associated 
 with diarrhoea the parietes may be retracted. As the 
 obstruction becomes more complete the abdomen be- 
 comes more and more distended, and in fatal cases 
 there may be a considerable enlargement of the belly 
 by the time that death occurs. Yery often the out- 
 line of the colon distended with fsecal matter is very 
 evident, and in any case the distension will be most 
 marked in those parts of the abdomen that are occu- 
 pied by the large intestine. The outline of the colon, 
 moreover, may be indicated by some dullness on 
 percussion, while the region of the small intestine re- 
 mains tympanitic. 
 
 Often large ffecal masses can be felt in the bowel 
 above the obstruction, masses so prominent as to 
 sometimes form very distinct tumours, the nature of 
 which has not ahvays been accurately diagnosed. 
 
 Great assistance in the diagnosis of the seat of the 
 stenosis is afforded by the auscultation of the ab- 
 domen during the administration of enemata, and by 
 these means it is possible in some cases to arrive at a 
 very correct knowledge of the site of the trouble. 
 
 A stricture in the sigmoid flexure or even in the 
 lower part of the descending colon may be felt by the 
 finger when the entire hand is introduced into the 
 rectum. Dr. Sands, however, reports a case where a 
 stricture situated within fifteen inches of the anus was 
 not recognised, although the entire hand had been in- 
 troduced so far as the sigmoid flexure.* 
 
 CANCEROUS STRICTURE. 
 
 In the stenoses of the colon described under this 
 heading the syiiiptoiiis that arise so closely resemble 
 those appertaining to simple stricture that little more 
 is required than to point out cei tain matters of difier- 
 ence. 
 
 * Nzw Ywk Med. Journ.^ vol. xix., 1874, page 622. 
 
Chap. X I n . ] StR I C TURK .* SyMP TOMS. 3 05 
 
 The duration of the symptoms is a little longer 
 in cases of so-called cancer than it is in the cica- 
 tricial stenoses. Duration of symptoms, liowever, 
 need not correspond with duration of disease, and of 
 these cancerous obstructions it would be more correct 
 to say that they lead to the production of evidences 
 of occlusion at an earlier period tlian do the other 
 species of stricture. 
 
 In some instances the patient has had symptoms 
 of narrowing of the intestine for twelve and even for 
 twenty-four months previous to deatli, and the autopsy 
 has then revealed a stricture of a "cancerous" 
 character. I think that in these cases the " cancer " 
 may either have been an innocent growth or that an 
 epithelioma may have developed upon the tissue of a 
 cicatrix that had caused some symptoms for months. 
 
 The general course of the malady resembles that 
 of stricture generally. There would ajjpear to be 
 more pain than is common in non-cancerous cases, and 
 it is usually of a more fixed character. 
 
 In one case the malady appears to have com- 
 menced with severe pain in the back that lasted for 
 two or three months. The stricture was, in this in- 
 stance, in the sigmoid flexure."^ The pain is often 
 worse just before an action of the bowels, a circum- 
 stance that is especially to be noticed in stricture low 
 down in the colon. It is also apt to be increased by 
 the use of aperients. 
 
 The general state of the bowels is a little different 
 from that usual in the i)revious class of stricture. 
 The malady would appear to begin often with 
 diarrhosa, followed by diai'rhcea alternating with con- 
 stipation and then ending in a constipation that is 
 more or less obstinate. From an analysis of twenty- 
 eight cases it appears that in fourteen cases consti})a- 
 tion was the prominent state of the bowels, in eleven 
 
 * Lancet., vol. i., 187n, page 3G9. 
 U— 13 
 
3o6 InT'Estinal Obstruction. ichap. xiii. 
 
 instances there was an alternation of constipation with 
 marked diarrhoea, while in three cases diarrhoea was 
 the predominant feature. 
 
 The cases of diarrhoea and of constipation alter- 
 nating with diarrhoea mostly concerned the higher 
 part of the colon, while nearly all the instances of 
 obstruction in the sigmoid flexure were attended by 
 constipation as the most pronounced condition. 
 
 The fatal termination is usually preceded by a 
 period of absolute constipation, although this circum- 
 stance is not quite so common as it is in cases of 
 cicatricial stricture. The duration of this fatal ob- 
 struction varies from a few days to two or three 
 weeks. In one patient, whose case is recorded by Mr. 
 Cooper Forster, no motion was passed for eighty-eight 
 days before death."* Absolute constipation for thirty 
 days is not very uncommon. 
 
 When the obstruction involves the sigmoid 
 flexure the motions, when solid, are often flattened 
 or much narrowed, or in other ways altered in out- 
 line. 
 
 A bloody discharge from the anus is met with in 
 about 15 per cent, of all the cases, and is mostly ob- 
 served in connection with strictures of the sigmoid 
 flexure. 
 
 Tciicsiiius is more common in this form than in 
 the previous one. It is the more frequent the nearer 
 the occlusion is to the anus, and is most usually met 
 with in cases associated with diarrhcea or with con- 
 stipation alternating with diarrhoea. 
 
 Vomiting' nearly always appears at some tiuie 
 during the progress of tlie malady. It usually sets in 
 late, is very irregular in its occurrence, is scanty, and 
 seldom becomes a very distressing symptom. 
 
 In one case reported by Dr. Bristowe vomiting 
 occurred during the early but not during the final 
 * Guy's Hosp. Reports, vol. xiv. , 18G0, page 377. 
 
Chap. XIII.] Stricture : Symptoms. 307 
 
 attack, in spite of there being pronounced con- 
 stipation.* 
 
 In not a few instances the vomiting was quite in- 
 significant in amount and the cause of comparatively- 
 little trouble to the patient. Out of twenty cases, the 
 vomited matters became stercoraceous in eight in- 
 stances and remained throughout non-feculent in 
 twelve. Most of the instances of feculent vomiting 
 occurred in the final attack and were associated with 
 constipation. Among the cases of feculent vomiting 
 were the greater number of the cases of stricture high 
 up in the colon. In the case already alluded to, in 
 which there was absolute constipation for eighty-eight 
 days, the vomited matters never became stercoraceous. 
 
 The general condition of the patient is similar to 
 that described in speaking of cancerous stricture of the 
 lesser bowel, with the exception, perhaps, that emacia- 
 tion proceeds less rapidly. 
 
 Nothing especial remains to be noted as to the 
 jDhysical condition of the abdoDien. The coils of 
 intestine are usually distinctly visible, especially 
 during the occurrence of paroxysms of pain, just as is 
 the case in the simple strictures. 
 
 From an examination of the recorded cases it would 
 appear that an abdominal tumour has not been ob- 
 served in more than 40 per cent, of all the cases, 
 understanding the term " tumour " to refer to a 
 mass formed by the new growth itself. In some of 
 these recorded instances the abdomen was not es- 
 pecially examined for evidences of a tumour. In 
 others, a tumour that might have been detected in a 
 flaccid abdomen was concealed by the meteoristic con- 
 dition of the 1)ellv. Then ao^ain a new growth 
 situated in the hepatic or splenic flexure may attain 
 considerable dimensions before it becomes largo 
 enough to be evident upon the surface. Moreover the 
 * rath. Soc. Trans., vol. xxiii. , page 119. 
 
3o8 Intestinal Obstruction. [Chap. xiii. 
 
 epitheliomatous stricture very commonly leads to no 
 tumour at all in the sense of a mass that projects 
 beyond the normal lines of the intestine. 
 
 Duratiou and progruosis. — The average dura- 
 tion of the symptoms in simple stricture of the colon 
 is five months and in the so-called cancerous stricture 
 six months. In a few instances the earlier symptoms 
 have been so insignificant that little has been noticed 
 in the record save the final attacks, and such cases 
 would appear to show examples of stricture fatal in 
 sixteen days or even less. The fallacy in such cases 
 is obvious. In thirteen cases of cicatricial stenosis 
 the causes of death were as follows : operation 2, 
 perforation 4, peritonitis independent of perforation 2, 
 and exhaustion from the effects of persisting obstruc- 
 tion 5. 
 
 Out of a total of twenty-eight instances of 
 " cancer " of the colon four patients recovered after 
 operation, six died within a short j^eriod of operation, 
 five deaths were due to perforation, and four to peri- 
 tonitis apart from perforation, while nine died from 
 exhaustion incident to persistent obstruction and to 
 the constitutional effects of the neoplasm. 
 
 The prognosis in all forms of stricture of the 
 colon is entirely bad provided that the stenosed pai*t 
 be narrow enough to offer a definite obstruction. 
 
 The only prospect of spontaneous relief is afforded 
 by ulceration of the gut above the stricture and the 
 subsequent formation of a fistula which can act the 
 part of a praeternatural anus. Thus a faecal abscess 
 may form in the subserous connective tissue and be 
 evacuated externally either by nature or art ; * or the 
 intestine above the obstruction may communicate 
 with the gut below it, as is possible in a case of stric- 
 ture in the lower part of the sigmoid flexure, where 
 the flexure is much distended and freely movable ; 
 *Dr. Dickinson, case ; Patli. Soc. Trans., vol. xxiii., page 161. 
 
Chap. XIV.] Tumours of the Bowel. 309 
 
 or, lastly, the fistulous opening may discharge itself 
 through the wall of the bladder or vagina.^ Such 
 attempts at spontaneous relief are efficacious only for 
 a little while and the changes that attend the forma- 
 tion of the fistida usually lead to such further 
 destructive Drocesses as are incompatible with life. 
 
 CHAPTER XIY. 
 
 OBSTRUCTION OF THE INTESTINE BY NEOPLASMS. 
 
 In addition to the malignant growths from the bowel 
 to which attention has been already directed, notice 
 must be taken of certain benign neoplasms that some- 
 times lead to obstruction. In the production of such 
 stenoses it is possible to recognise many different 
 forms of innocent tumour. 
 
 1. Adenomata. — These grow from the mucous 
 membrane and appear to have their origin in the 
 follicles of Lieberkiihn. They present on section a 
 number of tubes, passages, and sj^aces, all lined Avith 
 columnar epithelium and su^^ported by connective 
 tissue that may vary in structure from a lax myxoma- 
 tous meshwork to a substantial fibrous substance. It 
 is upon the character of this supporting tissue that 
 the physical characters of the growth in some part 
 depend, the laxer tissues forming soft, and the 
 denser structure firm, polypoid masses. The mode of 
 origin of these growths has been very elaborately 
 described by Mr. Harrison Cripps, in regard, at least, 
 to their appearance in the rectum. It would appear 
 that the line of demarcation between them and the 
 cylindrical epitheliomata is very faint, and that one 
 
 *Mr. Simon, case; Path. Soc. Trans., vol. i., page 264. 
 
310 lyTESTINAL OBSTRUCTION. [Chap. XIV. 
 
 species of growth may shade off, as it were, into the 
 other. The majority of these growths assume the 
 aspects of a projecting tumour and have been described 
 under the names of papilloma, fibrous, or mucous 
 papilloma, benign villous polyp and the like. Some- 
 times the neoplasm spreads laterally under the im- 
 mediate surface of the mucous membrane, producing 
 the groM'th known as a " flat adenoma." 
 
 These adenomata are most frequently met with in 
 the rectum and colon and form the commonest variety 
 of l)enign growth. They frequently occur in children, 
 and are perhaps more often multiple than single.* 
 
 2. Fibromata. — These are said to arise from 
 the submucous tissue. A large number of growths 
 are described as " fibrous polypi," but reliable micro- 
 scopic evidence is wanting to shov,- that even the ma- 
 jority of these are composed of fibrous tissue. It is 
 probable that they belong rather to the next variety. 
 
 3. Fibro-iiiyomata. — Several examples of this 
 kind of benign growth have been placed on record, 
 the nature of the tumour having been verified by 
 microscopical examination. They arise from the sub- 
 mucous and muscular coat, and have an ai-rangement 
 of j^arts like that seen in simple fibro-myomata of the 
 uterus. Those having origin from the submucous 
 coat spring, no doubt, from the mucosa musculai-is.f 
 
 4. Lipoiitata. — These growths spring from the 
 submucous layer, take a polypoid form, are often 
 multiple but seldom of great size.| 
 
 5. Among the still rarer growths may be men- 
 tioned aiigioiiiata, examples of which have been 
 described by authors. Some of these are probably in 
 reality very vascular fibro-myomata. 
 
 * See a remarkable case reported in the Brit. Med. Journ., 
 March 1, 1884, page 410. 
 
 t See speciin«n in Lond. Hosp. Museum, No. Ad. 41. 
 X For specimen see Lond. Hosp. Museum, No. Ae. 45. 
 
Chap. XIV.J Ti'AWURS OF TJ/F. BOWFL. 31I 
 
 Kokitansky has described cases where miiltilocular 
 cysts filled with serum were found partly embedded 
 in the intestinal wall. It may be that these were 
 cystic adenomata. 
 
 Considered collectively, benign tumours of the 
 intestine are usually met with in the form of polypi. 
 As such they may have very distinct pedicles. In a 
 case of Sir Prescott Ilewett's the pedicle was the size of 
 the finger and one and a half inches in length. In 
 shape they are round, oval, or pear-shaped. In size 
 they vary from the dimensions of a pea to that of a 
 small orange or a pear. They are usually covered by 
 normal mucous membrane, which may, however, be in 
 a condition of ulceration. As regards -their place of 
 origin, the great majority, probably not less than 
 80 per cent., are met with in the rectum. Next in 
 frequency comes the ileum and then the colon. They 
 are rare in the jejunum and still rarer in the duodenum. 
 As regards the small intestine, the favourite site is the 
 lower extremity of the ileum. 
 
 The growth is usually attached to the convex 
 border of the gut, or at least away from the mesen- 
 teric border. It is not uncommon for tlie polyp to 
 drag in that part of the intestinal wall to which it is 
 attached and so produce a depression or umbilicus 
 upon the surface of the gut. In one case, where an 
 intussusception had been produced, this depression 
 was sufficiently deep and definite to admit the tip of 
 the little finger."^ 
 
 Benign polypi are often very numerous. Allusion 
 has already been made to an instance where no less 
 than thirty of such growths were found in the lower 
 ileum. The occurrence of three, four, or five polypi in 
 the same division of the bowel is quite common. 
 
 Benign growths of the intestine may give rise to 
 no symptoms during life and may even attain large 
 *M. Fcinot; Bull, de la Soc. Anat., 1SG3, j^age 29G. 
 
312 InTES TINA L ObS TR UC TION. [Chap. XIV. 
 
 size and become quite numerous without aflfording 
 any evidence of their existence, Tlius, in two cases 
 of very large polypi of the ileum, reported by Sir 
 Prescott Hewett, no symptoms aj)pear to have been 
 induced until an intussusception arose. One of these 
 growths was as large as a pear, the other measured 
 two and three-quarter inches by one and a half 
 inches."^ These polypi most usually cause symptoms 
 when in the rectum, producing tenesmus, bleeding 
 from the bowel, difficult defsecation and a sense of a 
 foreign substance in the gut. The same symptoms in 
 a less marked degi'ee may attend gi'owths arising from 
 the sigmoid flexure. 
 
 In other parts of the intestine the polyp usually 
 causes obstruction, if it occlude the gut at all, by 
 inducing an invagination. This is particularly the 
 case with such as grow from the ileo-csecal valve and 
 from the terminal part of the ileum. Benign tumours 
 have also produced intussusceptions in other parts of 
 the bowel, in the rectum, in the sigmoid flexure, and 
 in all parts of the colon. 
 
 When the mass is of large size, or when the 
 growths are multiple, symptoms of obstruction may 
 be produced that more or less closely resemble the 
 symptoms of stricture, save tliat they are usually more 
 chronic and for a while at least less marked. Some 
 of the most inarked examples of this form of obstruc- 
 tion have been met with in connection with growths 
 springing from the margin of the ileo-C£ecal valve. 
 
 So far as I am aware, it would be impossible to 
 diagnose cases of obstruction due to simple neoplasms 
 from cases of stricture. I can find no instance 
 recorded where the growth was felt through the 
 j)arietes during life, except perhaps when associated 
 with an invagination. 
 
 In one or two instances these polypi have excited 
 *rath. Soc. Trans., vol. i., page 9.5. 
 
Chap. XTV.] Tumours of the Bowel. 313 
 
 some chronic peritonitis in the wall of the bowel from 
 which they have taken origin. 
 
 In a few cases the polyp has separated from its 
 attachment and has been passed per annm. This 
 mostly occurs in connection with such gi^owths as 
 spring from the rectum or sigmoid flexure ; although 
 I am disposed to believe tliat some reported cases 
 where strange fleshy masses have ])een passed with 
 motions might have been examples of the spon- 
 taneous removal of a x>olyp. An excellent example 
 of separation of such a tumour from the sigmoid 
 flexure or rectum is reported by M. Afezou. It 
 concerned an old woman, aged eighty-three, 
 who had been troubled for a number of years 
 with indigestion, attacks of colic and constipa- 
 tion alternating with diarrha3a. At last the constipa- 
 tion became so pronounced that no relief to the bowel 
 could be obtained except by enemata. One day after 
 an examination of the bowel a soft mass was passed. 
 It proved to be a lij)omatous polyp. All the patient's 
 intestinal troubles at once ceased and the bowels 
 became regular again. "^^ 
 
 Sarcomatous tumours have been met with in 
 the intestine both as primary and as secondary 
 growths. Tliey are usually of the spindle-celled 
 variety, and are, according to Leichtenstern, very 
 seldom of the small-celled kind. They very rarely 
 indeed appear as polypi, but rather tend to spread 
 around the bowel, and then probably produce one 
 form of what is vaguely known as a " cancerous " 
 stricture. To this allusion has been already made. 
 
 In a specimen in the London Hospital Museum is 
 shown a tumour that is apparently a primary melanotic 
 growth arising from the ileum. So far as I can 
 ascertain such tumours are extremely rare. The case 
 from which the specimen is taken is peculiar. The 
 
 *P>uU. (le la Soc. Anat.,, 1875, page 195. 
 
314 Intestinal Obstruction. [Chnp. xiv. 
 
 patient, a woman, died of an intussusception at the 
 apex of which the gTo^\i:h was found. She had a small 
 lump in her groin which was supposed to be a stran- 
 gulated hernia. It was cut down upon and found to 
 be a gland affected with melanosis."^ 
 
 Several examples of lympho-sarcoma of the intes- 
 tine have been recorded in connection with Hodgkin's 
 disease. The neoplasm in these cases appears in the 
 adenoid tissue of the gut and in Peyer's patches, 
 and may attain considerable dimensions. At many 
 parts the whole calibre of the gut has been surrounded 
 by an extensive morbid growth, while in other places 
 only poi'tions of the intestinal wall have been in- 
 vaded, f The most remarkable feature in these cases 
 is, that so far as recorded examples at present show, 
 no obstruction is usually produced. Indeed, the sub- 
 jects of the disease appear to have had either no 
 special abdominal symptoms or else a more or less pro- 
 nounced diarrhoea. Dr. Carrington has recently re- 
 ported a case where a lympho-sarcomatous mass 
 weighing no less than half a pound occupied the 
 caecum, and yet no symjDtoms of obstruction were pro- 
 duced, nor indeed does special attention appear to 
 have been directed to the abdomen during life. \ 
 
 * Loud. Hosp. Museum, No. Ad. 48. 
 
 t See case by Dr. Moxou ; Path. Soc. Trans. , vol. xxiv. , 1873, 
 page 101. And another by Dr. Murchison ; ibid., 1870, page 194. 
 
 Ij: Brit. Med. Journ., vol. ii., 1883, page 773. See also observa- 
 tions by Birch-Hirschfeld ; Ziern.ssen's Cyclopedia of Medicine, 
 vol. xvi., jjage 837. 
 
3^5 
 
 CHAPTER XV. 
 
 COMPRESSION OF THE INTESTINE BY TUMOURS, ETC., 
 EXTERNAL TO THE BOWEL. 
 
 Tumours of various kinds and even displaced viscera 
 may press upon some part of the intestine and cause 
 thereby an occlusion of its lumen. 
 
 In the majority of the cases this compression has 
 been effected by a tumour having origin in the pelvis. 
 
 Thus the bowel may be compressed by a retro- 
 verted or retroflexed uterus, especially when enlarged 
 by pregnancy,"^ or by maglignant or other tumours 
 growing from the uterus,! or by ovarian tumours of 
 any kind.^ The last-named variety of growth is a 
 frequent cause of obstruction by compression. Leich- 
 tenstern has found instances of compression by a large 
 vesical calculus. Mr. Pye gives an example of com- 
 pression due to a large abscess situated between the 
 rectum and the uterus. § Dr. Hall Davis has reported 
 a very interesting case in which the c£ecum was oc- 
 cluded by the pressur ) of a tumour due to tubal preg- 
 nancy of the right side, || Among other causes of 
 pressure upon tlie gut may be mentioned subperi- 
 toneal tumours, tumours of the mesentery or omentum, 
 various tumours of the kidney, psoas abscesses and 
 abscesses about the ciecum,^ hydatid cysts, '^"'^ enlarged 
 
 * Journ. de Med. de Chir. , etc. Bruxelles, 1867. 
 t Mr. Gay ; Path. Soc. Trans., vol. iii., imge 108. 
 X Le Dentu ; Bull, et Mem. de la Soc. de Chir. de Paris, 1879, 
 page 601. Mr. Heath ; Path. Soc. Trans., vol. xvi., page 197. M. 
 Verneuil; Bull, de la Soc. Anat., 1870, page 411. 
 § Brit. Med. Journ., vol. ii., 1882, page 11.52. 
 II Path. Soc. Trans,, vol. iv., page 230. 
 If Cases quoted by Leichtenstern, loc. cit., page 573. 
 ** Path. Soc. Trans. , vol. v. , page 302. 
 
3t6 Intestinal Obstruction. [Chap. xv. 
 
 spleens.* The duodenum especially may be com- 
 pressed by tumours growing from the pancreas,! by 
 growths arising from the liver and by masses of enlarged 
 glands about the portal vein. Dr. Baimbrigge reports 
 a case of obstruction of the gut brought about by 
 pressure indirectly exercised by a disj)laced supple- 
 mentary spleen,! ^^^ ^^- Nervier quotes an instance 
 where a hypertrophied spleen had dragged upon the 
 pancreas and had displaced it so that it had compressed 
 some coils of intestine that had found their way be- 
 neath it. § Ptollet !| gives an instance of compression 
 by the pedicle of a movable kidney, and lastly cases 
 have been reported where a piece of intestine has been 
 engaged and compressed between the ribs and the 
 convexity of the liver. ^ 
 
 With reo^ard to the segment of the intestine in- 
 volved in these cases, the rectum, as it may be 
 supposed, is tlie part that most frequently suffers. 
 This is owing to the preponderance in the pehds of 
 tumours capable of exercising this particular com- 
 pression. The rectum, moreover, is fixed and lies 
 against the solid wall of the pelvis. The parts that 
 are involved next in frequency after the rectum are 
 the sigmoid flexure and the lower ileum. It will be 
 seen that the sigmoid flexure could readily be com- 
 pressed by a pelvic tumour, and that the coils of 
 small intestine that most constantly occupy the 
 pelvis belong to the lower ileum. I have collected 
 twenty-two examples of this form of compression of 
 the bowel, which may be thus divided with regard to 
 the matter of site. Rectum 10, colon 6, caecum 
 1, small intestine 5. Leichtenstern gives the 
 
 * Case quoted by Duchaussoy. 
 
 t Mr. Nathan ; Med. Times and Gazette, vol. ii., 1870, page 238. 
 
 X London Med. Gazette, 1846. 
 
 § De rOcclusion Intestinale, page 47. Liege, 1871 
 
 II Path. u. Therp. d. bewegl Niere, 1866. 
 
 If Cases by Lavater and Kellenberg, quoted by Leichtenstern. 
 
Chap. XV.] Compression Of the Bowel. 317 
 
 following table as a result of the examination of a 
 large number of cases collected by himself. 
 
 Compression 
 
 of the rectum, in . . 
 
 60 
 
 per cent. 
 
 )i 
 
 sigmoid flcxui'e and de- 
 
 
 
 
 scending colon, in 
 
 12 
 
 
 }> 
 
 lower ileum, in 
 
 10 
 
 
 )) 
 
 duodenum, in 
 
 7 
 
 
 )> 
 
 ascending colon, in 
 
 G 
 
 
 5) 
 
 middle ileum, in . 
 
 4 
 
 
 >> 
 
 transverse colon, in 
 
 1 
 
 
 It will be seen that the more fixed parts of the 
 bowel suffer the most, and that the more mobile parts, 
 such as the jejunum and transverse colon, are prac- 
 tically exempt from this form of obstruction. 
 
 In all the instances that I have collected the 
 patients were adults. 
 
 The symptoms of obstruction that aiise in these 
 cases show considerable variety. In no less than 
 twelve out of the twenty-two examples above alluded 
 to the compression led to acute obstruction, the 
 patient dying after symptoms the duration of which 
 varied from two to nine days. 
 
 In two instances the symptoms were subacute, the 
 duration being in each case eighteen days. In the 
 remaining eight examples the obstruction produced 
 was of a decidedly chronic character. 
 
 The acute cases depend upon sudden comjiression 
 of the gut due to abrupt change of position in the 
 tumour or in some abnormally ari-anged viscus, such 
 as an unduly movable spleen or kidney. Or they 
 may be due to kinking of the intestine or to abrupt 
 bending of the more mobile part of the bowel above 
 that fixed by the tumour or to the engagement of a 
 loop of intestine beneath the mass or between it and 
 the pelvic or abdominal walls. The acuteness of the 
 case appears to have nothing to do with the segment 
 of the bowel invohed, but to depend solely upon the 
 
3i8 Intestinal Obstruction. tchap. xv. 
 
 abruptness of the occlusion. Many of the more 
 rapidly fatal cases, cases ending in death on the 
 fourth, sixth, or seventh day, have depended upon 
 sudden occlusion of the rectum or of the lower part of 
 the colon. The case alluded to above as fatal in 
 forty-eight hours was Dr. Baimbrigge's case of com- 
 pression by a displaced spleen. The part of intestine 
 involved was the colon. 
 
 The symptoms that appear in these cases are 
 simply those of acute obstruction. There is less pain 
 and less collapse than in instances of strangulation by 
 bands, and the whole progress of the malady is less 
 violent ; but the points of difference are not 
 sufficiently accentuated to render a diagnosis certain. 
 In many instances the tumour has been felt and the 
 nature of the case has been from the first evident ; 
 but in other examples the diagnosis has been actually 
 complicated by the presence of the tumour. A good 
 instance of the latter condition is afforded by Dr. Hall 
 Davis's case of tubal pregnancy. The patient was aged 
 thirty-two, and was seized with symptoms of acute in- 
 testinal obstruction that ended in death on the ninth 
 day. A fixed and tender tumour could be felt in the 
 right iliac fossa, vaginal examination revealed nothing 
 abnormal, and " all certain signs of pregnancy were 
 absent." The tumour depended upon a tubal preg- 
 nancy and had occluded the csecum by pressure. 
 
 In some of the cases there had been no evidence 
 of intestinal trouble previous to the final attack. 
 
 In certain of the chronic cases the symj^toms 
 were precisely like those of stricture of the intestine, 
 the progress of the case being marked by paroxysmal 
 attacks from time to time. In other instances there 
 was simply an increasing constipation that occasioned 
 no great amount of disturbance until it became ab- 
 solute, and, after resisting all attempts at relief, ended 
 in death. 
 
319 
 
 CHAPTER XVI. 
 
 OBSTRUCTION OF THE INTESTINE BY FOREIGN BODIES. 
 
 By a " foreign body " as applied to the intestinal 
 tract is meant any substance that can resist the 
 digestive action of the fluids of the stomach and 
 bowels. 
 
 These substances may be swallowed by accident, 
 or during fright, or they may be taken intentionally. 
 It would appear that in several instances swindlers 
 endeavouring to pass false coin have swallowed the 
 spurious pieces to escape detection. Some of these 
 foreign substances have been swallowed with suicidal 
 intent. A great many of the reported cases have 
 occurred in the persons of lunatics and in the subjects 
 of hysteria. In not a few instances the substance 
 has slipped down the throat during sleep or un- 
 consciousness from antesthesia, and this especially 
 applies to false teeth. 
 
 These foreign bodies may be conveniently divided 
 into three classes : 1. Rounded or regularly-shaped 
 substances that may be considered capable of passing 
 readily through the intestine. Among such are 
 pebbles, stones, fruit stones, coins, bullets and the 
 like. 2. Sharp-pointed bodies and substances of 
 irregular shape that may readily catch in the mucous 
 membrane or are of an outline that would favour their 
 becoming fixed in the alimentary passages. Such are 
 pins, needles, hooks, plates carrying false teeth, pieces 
 of bone, pieces of metal or of porcelain, nails, screws, 
 and other such substances, many of which have been 
 frequently found in the intestine or have passed 
 
;5 2 IntES TINA L ObS TR UC TION. [Chap. X Vl. 
 
 through it. 3. Indigestible materials of small size 
 which are apt to accumulate until they form huge 
 masses. Indeed, the largest foreign substances found 
 in the alimentary canal have been of this character. 
 They are composed of husks of the oat, vegetable 
 fibres, grape skins, or of hairs, or of wool or yarn. 
 The latter materials have either been swallowed as a 
 matter of habit by dressmakers and others, or have 
 been intentionally taken by lunatics and hysterical 
 individuals. 
 
 There is no doubt but that the majority of the 
 foreign substances that are swallowed are in time 
 passed by the anus. Most of those placed in the first 
 of the above classes would be so evacuated in the 
 course of a few days or even after forty-eight hours. 
 Others would be retained for a week or fortnight or 
 longer without causing inconvenience. Many foreign 
 substances that may be placed in the second class 
 have also been passed with comparatively little in- 
 convenience. Some of such bodies have lingered in 
 the alimentary tube for weeks, for months, and even 
 for years. How many of these substances pass the 
 pylorus and the ileo-csecal valve must remain an 
 anatomical mystery. Thus, in the College of Surgeons 
 Museum is a specimen (No. 1,184) showing a dessert- 
 spoon seven inches long and with a bowl one and 
 a half inches wide lying fixed in the ciecum. The 
 spoon is quite unaltered in shape and had been 
 swallowed by a lunatic. Mr. Pollock C[Uotes a case 
 where a plate carrying six false teeth was swallowed 
 and passed at the end of three days. In another like 
 instance where the plate held together four teeth the 
 mass was evacuated per anum at the end of six 
 months.* In Dr. Marcet's celebrated case a sailor 
 swallowed clasp-knives from time to time until 
 
 * Holmes' System of Surgery, vol. i., page DIO, .3rrl cd. 
 Lond.. 1888. 
 
Chap. y^ww. Obstruction by Foreign Bodies. 321 
 
 he had, in a period of ten years, consumed thirty- 
 seven in all. Many of these were passed per anum 
 entire, others in fragments.^ A door-key was passed 
 in another case four days after it was swallowed, f 
 In another instance a piece of a horse-slioe was 
 passed at the end of two months. % In the intestine 
 of one lunatic were found three cotton reels, two 
 bandages partly unrolled, some skeins of thread, and 
 a pair of braces. Among other strange substances 
 that have passed the whole length of the alimentary 
 canal may be mentioned the following : a pencil- 
 case, a dagger-blade, a small flute, a long breast-pin, 
 and a brace buckle. 
 
 When the foreign substance is not passed per 
 vias naturales it is apt to remain lodged in certain 
 special parts of the tube, viz. in the stomach, the 
 duodenum, the lower end of the ileum, the caecum or 
 the rectum. Of all these situations the csectim is 
 the one in which lodgment is most likely to take 
 place. 
 
 As a foreign body passes along the canal it may 
 cause obstruction at any point, and that obstruction 
 may prove fatal. The progress of the larger and 
 more irregular substance is marked by pain, by 
 attacks of temporary obstruction associated with 
 colic, vomiting, and constipation. In other instances 
 an impacted foreign body has given rise to long 
 continued symptoms of partial obstruction, symptoms 
 that may become very chronic yet never severe. 
 
 There is plenty of evidence to show that these 
 bodies may remain for weeks, months, or years in the 
 stomach or in some part of the intestine without 
 causing active mischief, but that, when so lodged, they 
 may almost at any time induce changes leading to 
 
 *Med..-Chir, Trans., vol. xii., page 52. 
 ■]^ Lancet, vol. i,, 1870, page 757. 
 X Ibid., vol. ii., 1874, page 574. 
 
 V— 12 
 
32 2 Intestinal Obstruction. [Chnp. xvi. 
 
 a fatal result. Moreover even when they have been 
 long retained they may be safely discharged by the 
 natural passages. Thus in one of Mr. Pollock's cases 
 a plate carrying false teeth had been swallowed, and 
 after remaming in the stomach for ninety-seven 
 days was finally ejected by vomiting. The impacted 
 foreign substance, however, is very apt to induce some 
 ulceration of the mucous membrane. This may lead 
 to perforation and to fatal peritonitis ; or some local 
 chronic peritonitis may be excited in the part lodging 
 the substance and the gut may become thereby nar- 
 rowed. Such narrowing may increase after the 
 evacuation of the body, and may lead to obstruction. 
 According to Leichtenstern, " foreign bodies give rise, 
 more frequently than gall or intestinal stones, to a 
 constriction by cicatricial bands or chronic peritonitis, 
 at the spot where they have remained for a long time." 
 
 In another class of cases the ulceration of the 
 mucous membrane leads to the formation of a fistula 
 through which the foreign body may be discharged. 
 This fistula may communicate with the exterior. Thus 
 in the College of Surgeons Museum is a specimen (No. 
 1,187) from a boy, aged eleven, where many cherry 
 and plum stones, that had been swallowed, were dis- 
 charged through an exterjial abscess. The fistula 
 may form between the stomach and the transverse 
 colon, or between the ileum and the colon, or even 
 between the coil lodging the foreign body and the 
 rectum or tlie vagina. By such fistulous channels has 
 the substance been, after a long interval, evacuated. 
 
 With regard to small sharp-pointed bodies, like 
 needles, they may readily penetrate the intestine and 
 work their way to the surface, where they may be 
 recognised and removed. Thus I extracted from 
 under the skin of the groin a needle that had been 
 swallowed by a child some months previously. 
 
 The foreign bodies of the third class that cause 
 
Chap. XVII.] Obstruction by Gall Stones, 323 
 
 obstruction by accumulation may form immense 
 masses. When in the intestine they may lead to 
 chronic and fatal obstruction, or may induce chronic or 
 acute peritonitis. Thus Marshall mentions an occlu- 
 sion of the duodenum by a pound of pins that had 
 been swallowed."^ In an instance quoted by Duchaus- 
 soy in his memoir the obstructing mass was composed 
 of seven hundred cherry-stones. In a case recorded 
 by Dr. Quain the mass consisted of four pounds of 
 cocoanut fibre, f 
 
 It is unnecessary to deal here with those numerous 
 cases in which foreign substances of various kinds 
 have been accidentally or intentionally introduced 
 into the rectum and have caused more or less obstruc- 
 tion. The matter belongs rather to another branch 
 of surgery. 
 
 CHAPTER XYII. 
 
 OBSTRUCTION OF THE INTESTINE. BY GALL STONES. 
 
 The lumen of the intestine may be obstructed at cer- 
 tain points by a gall stone that has entered it from the 
 gall bladder and is passing along its way to be dis- 
 charged at the anus. In the fii'st place, however, it 
 must be acknowledged that in the great majority of 
 cases the gall stone passes without any difficulty along 
 the intestine, and without, indeed, exciting symptoms 
 of any kind. The instances where obstruction, whether 
 temporary or permanent, is produced must be re- 
 garded as quite rare and exceptional, although the 
 gross number of such instances is not small. It may 
 be surmised that a stone that will pass along the 
 
 *Med.-Chir. Trans., vol. xxxv., page 65. 
 fPath. Soc. Trans., vol. v., page 145. 
 
324 Intestinal Obstruction. [Chap. xvii. 
 
 narrow and somewhat rigid bile-duct cannot expect 
 to meet with any obstruction in the intestine. Even 
 the lumen of the ileo-csecal valve is many times 
 greater than is that of the common duct. But the 
 gall stones that cause occlusion do not usually enter 
 the intestine by the biliary passage. They enter by 
 means of a temporary fistulous communication between 
 the gall bladder and the duodenum. In very rare ex- 
 amples the communication has been between the gall 
 bladder and the colon at the hepatic flexure. Indeed, 
 it appears to me, after examining a large number of 
 cases, that at present decided evidence is lacking that 
 would show that a biliary calculus that has passed 
 along the bile duct is capable of causing obstruction 
 symptoms when it reaches the intestine. In many of 
 the reported cases the condition of the gall bladder is 
 not stated. In a case placed on record by Dr. John 
 Abercrombie it would appear that the calculus had 
 reached the bladder through the duct. The patient 
 was a man, aged forty-five, who died of acute ob- 
 struction lasting five days. He had had previous 
 obstructive attacks. In the ileum was impacted a 
 gall stone measuring four inches in its largest circum- 
 ference and three and a half in its least. The com- 
 mon duct easily admitted a finger. Then in the 
 account comes the following statement, which serves to 
 throw some doubt upon the mode of entrance of the 
 stone : " The gall bladder was in a state of inflam- 
 mation and was softened and partially disorganised."* 
 As to the size of the calculus that may cause oc- 
 clusion it must be noted that stones of considerable 
 dimensions have been spontaneously evacuated. Thus 
 calculi have passed the anus measuring 2^ inches by 
 \\ inches, and presenting a circumference of 2>\ 
 inches. Cases of the evacuation of stones so large as 
 
 * Path, and Pract. Researches ou Diseases of the Stomach, 
 etc., page 127, 3rcl ed. London, 1837. 
 
Chap. XVII. 1 Obstruction by Gall Stones. 325 
 
 these are by no means uncommon. The calculi that 
 have been found impacted in the bowels have in 
 many instances attained considerable dimensions. As 
 examples I might mention the following : a stone 
 measuring 4| inches by 2-| inches lodged in the upper 
 part of the jejunum;'*^ one with a circumference of 
 3|- inches impacted in the lower jejunum ; f one 2 
 inches in length and with a circumference of 4 inches, 
 also in the jejunum ; % and another 1 inch in length 
 and with a like circumference impacted in the ileum. § 
 An interesting case has been recorded of a woman, 
 aged sixty-three, who after presenting for five days the 
 symptoms of complete intestinal obstruction passed a 
 gall stone of more than 1 inch in diameter. She had 
 an irreducible enterocele through which the calculus 
 must have passed. 
 
 Some of the larger gall stones appear as casts of 
 the gall bladder which they probably entirely occupied 
 before they were discharged. It must be remem- 
 bered that a gall stone when once lodged in the 
 intestine may become enlarged by subsequent deposit 
 upon it of earthy matters. Leichtenstern describes 
 such a stone that had a circumference of about 5 
 inches, and a diameter of about \\ inches. 
 
 The point in the intestinal tube at which the 
 stone lodges is most frequently in the lowest part of 
 the ileum or in the duodenum and commencement of 
 the jejunum. An examination of thirty-two cases by 
 Lei(;htenstern gives the following result : 
 
 In tho (luodcnum and jejunum . . 
 In tho middlo ileum .... 
 In the lower part of ileum . 
 
 32 
 
 * Mr. E. Pye Smith ; Path. Soc. Trans., vol. v., page 163. 
 t Dr. Baly ; ibi<l., vol. x., page 184. 
 
 X Revue Med. dc la Suisse Roviande, No. 2, 1882, page 82. 
 i^ Dr. Muichisou ; Path. Soc. Trans., vol. xx., page 219. 
 
 10 
 
 cases 
 
 5 
 
 )> 
 
 17 
 
 » 
 
326 Intestinal Obstruction. [Chap. xvii. 
 
 In sixteen recorded cases collected by myself a 
 very similar result is to be noticed. 
 
 It is obvious that if the calculus has passed the 
 small intestine and the valve it can hardly become 
 impacted in the colon, although there may be some 
 difficulty in the way of its evacuation from the anus. 
 In all the fatal cases of obstruction by a calculus the 
 impaction has been always in the lesser bowel. 
 
 In cases of occlusion by gall stones sex and age 
 have much influence. The condition is much more 
 frequent in females than in males and usually con- 
 cerns those who have passed middle life. The pro- 
 portion of females to males is nearly that of four to 
 one. The average age of the patients, as estimated 
 from sixteen cases, was fifty-seven years. They w^ere, 
 Avith one exception, all over the age of forty. The 
 youngest patient, the exception just alluded to, was 
 a woman aged twenty-seven.* The oldest patient was 
 a woman aged seventy-eight. 
 
 With regard to the clinical aspects of these cases 
 it will be evident that there need be no history of 
 hepatic colic in a given instance if it be true that the 
 stone usually reaches the duodenum by ulceration 
 from the gall bladder. 
 
 In many of the cases there has been no histoiy of 
 hepatic colic ; in others there have been such attacks, 
 which depended, however, most probably upon the 
 passage of smaller calculi previous to the entrance 
 into the bowel of the large stone that caused ob- 
 struction. There are instances where the patient 
 was practically free from any abdominal symptoms up 
 to the time of the final obstructive attack. Dr. W. 
 H. Draper has recorded an excellent example of this 
 circumstance.! On the other hand are examples 
 showing evidence of local peritonitis in the vicinity of 
 
 * Dr. Peacock ; Path. Soc. Trans., vol. i., page 255. 
 f New York Med. Journ., vol. xxxvi., 1882, page 17. 
 
Chap. XVII.] Obstruction BY Gall Stoxes. 327 
 
 the gall bladder and associated with symptoms that 
 may be very properly ascribed to the passage of the 
 stone direct from the bladder into the duodenum. As 
 to the length of time that may elapse between the 
 passage of the calculus into the gut and the appear- 
 ance of obstructive symptoms there is little to be said 
 definitely, owing to the vagueness of the symptoms 
 that mark such passage. In several cases the estab- 
 lishment of a fistulous communication between the 
 gall bladder and the duodenum appears to have been 
 effected without producing any noticeable symptoms. 
 In many instances symptoms of obstruction have 
 appeared veiy soon after the supposed entrance of the 
 stone into the bowel, and in other cases a long in- 
 terval has elapsed. Thus in one example there was 
 evidence of local peritonitis in the right hypochon- 
 drium three months before the final attack of obstruc- 
 tion, but in the interval the patient had not been 
 wholly free from intestinal symptoms."^ I cannot 
 think with Leichtenstern that so long a period as 
 three years, as he maintains, can elapse between the 
 introduction of the stone into the intestine and the 
 development of obstructive symptoms. Attacks 
 occurring at so long a period before the final attack of 
 obstruction were probably instances of hepatic colic 
 due to the passage of stones along the bile duct, stones 
 that had long since been evacuated from the bowel. 
 In one instance the local disturbance incident to the 
 passage of the stone from the gall bladder into the gut 
 appears to have been associated with very marked 
 symptoms. The patient was a woman, aged fifty-four, 
 w^ho, six weeks before an attack of obstruction that 
 ended in death, had had an abscess opened in the 
 right hypochondrium that was supposed at the time 
 to have been connected with the liver, j 
 
 * Path. Soc. Trans., vol. v., page 163. 
 
 t Revue Med. de la Suisse Romande, No. 2, 18S2 ; Dr. Carrard. 
 
328 InTES TINA L ObS TR UC TION. [Chap. XVI I. 
 
 In some cases, and perhaps in a large number of 
 cases, a gall stone of considerable magnitude may 
 pass along tlie bowel without exciting any marked 
 disturbance, and may indeed only cause trouble when 
 it comes to be evacuated at the anus. In other in- 
 stances the passage of the calculus is marked by 
 attacks of colic from time to time, by irregularity in 
 the motions, by some meteorism, and by vomiting. 
 The symptoms may be very severe while they last, and 
 indicate, no doubt, a complete but temporary obstruc- 
 tion. The symptoms after being violent are not in- 
 f I'equently suddenly relieved, and the patient passes in 
 a few moments from a state of intense suffering to a 
 condition of almost perfect ease. Such a transition 
 is probably coincident with the passage of the con- 
 cretion through the ileo-caecal valve into the colon, 
 where it ceases to give trouble. The length of time 
 that may intervene between an attack of obstruction 
 and the actual passage of the stone may be consider- 
 able. It may amount to one or two weeks. 
 
 In a great number of the cases the clinical history 
 is as follows : The patient dies of an attack of intes- 
 tinal obstruction that, so far as its duration is con- 
 cerned, may be called acute. In these attacks there 
 will be pain of a more or less persisting nature and 
 of a colicky character, vomiting that may become 
 stercoraceous, constipation that soon develops into 
 absolute obstruction and more or less meteorism of 
 the abdomen. These attacks do not, as a rule, 
 develop suddenly. They are not associated with the 
 severe pain that marks some forms of acute obstruc- 
 tion, such as strangulation by a band, and as a con- 
 sequence are not attended by much collapse, if by any 
 at all. The vomiting is often very copious, and in 
 the majority of the cases, where the lower ileum is 
 concei-ned, becomes feculent ])ofore death. There is 
 no marked abdominal tenderness unless peritonitis be 
 
Chap. XVII.] Obstruction BY Gall Stones, 329 
 
 developing, and the amount of meteorism is usually 
 quite slight. I can find no case where any definite 
 tumour was detected, in no such case was there any 
 tenesmus, and in no instance any evacuation of blood. 
 
 In one instance, where death followed in five days, 
 the patient, a woman of sixty-nine, was seized with 
 cramps and died comatose. 
 
 The average duration of these somewhat acute final 
 attacks is seven days. The shortest period being four 
 days, the longest fifteen days. 
 
 These attacks have often been preceded by similar 
 evidences of obstruction, which may or may not have 
 been brought about by the same stone. Thus one 
 patient had two attacks only, the previous one occur- 
 ring three months before death, another had three 
 attacks that appeared eighteen months, twelve months, 
 and six days respectively before death. In another 
 instance the patient is described as having many 
 attacks of a nature akin to that that proved fatal in 
 the end. 
 
 In the intervals between such attacks the bowels 
 have usually been irregular and the patient liable to 
 digestive disturbances and to sickness ; or in the 
 absence of such attacks there may have been some in- 
 testinal irregularities simply or certain symptoms that 
 would have been associated with the passage of the 
 stone into the intestine. 
 
 In another set of cases the obstruction leading to 
 death has been more chronic. There has been, perhaps, 
 absolute constipation for twenty days before the 
 individual's decease, and the progress of the case has 
 been indolent and gradual. Such cases also may or 
 may not have been associated with previous attacks of 
 intestinal disturbance. In these more chronic cases 
 all the symptoms are less marked. The pain may be 
 intermittent, the vomiting is less pronounced and 
 is rarely feculent, there may be some meteorism, and 
 
330 Intestinal Obstruction. [Chap. xvii. 
 
 the coils of intestine may be visible through the 
 parietes. 
 
 In a third series of cases the stone would appear to 
 cause but partial obstruction, and symptoms are pro- 
 duced that are identical with those of stricture of the 
 small intestine. That is to say, there are attacks from 
 time to time of paroxysmal pain, some vomiting that 
 rarely becomes feculent until quite the end of the case, 
 and constipation that may not become absolute, and 
 that may be relieved by aperients and enemata. The 
 coils of intestine also will be visible if the patient be 
 thin. The symptoms will often be aggravated by food 
 and, indeed, the whole aspect of the case closely 
 resembles that of a case of stricture. Such cases are 
 apt to end by an acute attack, the partial obstruction 
 becoming com]jlete. 
 
 Apropos of partial obstruction, it should be noted 
 that an impacted calculus may in time push out a 
 divei-ticulum from the intestinal wall and become 
 encysted without offering a great obstacle to the 
 passage of intestinal matters. This is said to occur 
 most frequently in the duodenum, although it has been 
 also met with in the ileum. 
 
 It will be obvious that the symptoms will depend 
 somewhat upon the position of the calculus in the in- 
 testine. The nearer the obstruction to the stomach 
 the more marked is the vomiting, and the less marked, 
 or the longer delayed, are the evidences of interference 
 with the action of the bowels. In some cases of im- 
 paction in the duodenum the vomiting has been very 
 severe. The symptoms have become almost imme- 
 diately exaggerated by the taking of food, while con- 
 stipation has not become pronounced until the other 
 symptoms have existed for some time. In the case of 
 Dr. Pye Smith's, already alluded to, the gall stone was 
 in the upper part of the jejunum. The vomiting was 
 profuse, no less than one and a quarter gallons of 
 
Chap. XVII.] Obstruction BY Gall Stones. 331 
 
 bilious fluid having been ejected in forty-eiglit hours. 
 The patient died on the sixth day after the commence- 
 ment of the symptoms. 
 
 It may here be convenient to note two or three 
 anomalous cases which possess some interest. 
 
 It Avould appear that under some cii'cum stances 
 the obstruction of the intestine is much assisted by 
 an abrupt l)ending of the bowel at the point of 
 impaction of the stone. Such bending may at least 
 render a partial occlusion a complete one. 
 
 Thus, in the case from which Fig. 54 was taken, 
 the gut was not only blocked by a large gall-stone, but 
 the intestine w^as acutely bent upon itself and fixed 
 in that position by adhesion of its peritoneal 
 surfaces.* In another instance, where such a bend 
 had developed, the calculus w^as at the extreme angle 
 of the bend, and there is little doubt but that the 
 altered contour of the bowel was the cause of the 
 complete obstruction that existed. f In one remark- 
 able case the pressure of the stone had produced 
 gangrene of the gut in two places. The calculus was 
 found in the ileum and was covered by a gangrenous 
 piece of intestine. Higher up in the ileum w^as 
 another patch of gangrene one inch square. At this 
 point fatal perforation had occurred. The calculus had 
 a circumference of three inches, and the patient, a 
 woman of sixty-eight, had had more or less severe 
 attacks of intestinal obstruction for the six weeks 
 that preceded her death. 1 
 
 In a case placed on record by M. Cuflfer the patient 
 died of an obstruction situated in the hepatic flexure 
 of the colon. The caecum was enormously distended 
 and had become perforated. The hepatic flexure was 
 
 * Middlesex Hosp. Museum, No. viii. 57. See also Path. Soc. 
 Trans., vol. viii., page 231. 
 
 •\Ne%o York Med. Joum., 1882, page 17. 
 
 + Patli. Soc. Trans., vol. ix., page 203; Dr. Scott Allison. 
 
332 
 
 tChap. XVII. 
 
 FJfr. 54. —Gall Stone impacted iu tho Ileum. A section Las been ni.ade 
 of the Gall Stone. 
 
Chap. XVI 1. 1 OnSTRUCTION BY GaLL StONES. 333 
 
 adherent to the under surface of the liver by many 
 adhesions, and among these adhesions was a gall stone, 
 the size of a boan. The bile ducts were in a normal 
 condition, but the gall bladder had been destroyed. 
 The obstruction was due to a narrowing of the colon 
 from contraction of the adhesions. In this case it is 
 most probable that the calculus had set up inflamma- 
 tion in the gall bladder, that that structure had in 
 consequence become adherent to the colon, and that 
 the stone, had the case been a little more favourable, 
 would have been discharged into the large intestine 
 and so have escaped. "'^ 
 
 In a case of chronic obstruction, where the 
 diagnosis rested between cancer and impacted gall- 
 stone, a long needle was repeatedly thrust into the 
 abdomen at various points in the hope of striking the 
 stone should one exist. The stone was at last struck 
 at a depth from the surface of four and three quarter 
 inches. No inconvenience followed upon the use 
 of this means of diagnosis.! 
 
 In another instance Dr. George Harley \ struck 
 an impacted calculus in the bile duct by means of a 
 slender trochar which had been introduced through 
 the parietes to a distance of six inches. The patient 
 died twenty-seven days after the sounding. This and 
 like modes of examination are to be condemned except 
 in very special cases. When a distinct tumour can 
 be felt or when the site of the obstruction is well 
 localised, it may be excellent practice to introduce a 
 needle for the })urpose of searching for a gall stone or 
 other foreign substance ; but when these indications 
 are lacking I imagine that a surgeon is hardly justified 
 in thrusting a needle vaguely through the abdominal 
 parietes for the purpose of obtaining aid in diagnosis. 
 
 *Bull. de la Soc. Anat., 1875, page 176. 
 
 \Med. Record of New Yo^-k ; Dr. James Whitaker, 1882, 
 
 X Paper read before Med.-Chir. Soc. ; Lancet, May 17, 1884, 
 
334 Intestinal Obstruction. [Chap. xvii. 
 
 Fifty sucli punctures may be made before a gall stone 
 impacted in some parts of the bowel may be hit. 
 
 Frog:no8is. — There is no doubt that by far 
 the gi'eater majority of all gall stones that find their 
 way into the intestine pass through that canal without 
 causing any definite disturbance. Biliary calculi are 
 common enough, but the instances in which they cause 
 intestinal obstruction may be regarded as compara- 
 tively rare, and indeed as very rare. Leichtenstern in 
 a total of 1,152 cases of intestinal occlusion from 
 various causes includes only forty-one examples of 
 obstruction by gall stones. 
 
 It is still open to some question whether a gall 
 stone that has passed into the bowel along the 
 common duct is capable of producing an obstruction 
 in the intestine, provided that the intestine be normal. 
 The calculus may be arrested above a stricture or 
 above any point the seat of a stenosis ; but if it will 
 pass the bile duct it is more than probable that it will 
 also pass the ileo-csecal valve, especially if we take 
 note of the large and strangely shaped foreign bodies 
 that have succeeded in passing that aperture. 
 
 It is true that calculi may become lodged in the 
 csecum and may cause typhlitis, etc., and some obstruc- 
 tion has been offered by an accumulation of small 
 stones ; * but putting these cases aside, the matter 
 remains as we have just expressed it. 
 
 Then, again, quite large calculi, calculi that may 
 have entered the duodenum direct from the gall 
 bladder, have passed through the intestine without 
 causing symptoms or at least without producing 
 definite obstruction of the bowels. 
 
 Finally there are cases where stones of large size 
 have become impacted, have produced severe evidences 
 of occlusion of the bowel, and have, after a varying 
 interval, been spontaneously evacuated. Indeed, out of 
 
 * Se& case by Mr. V. H. Watson; Edinh. Med. Journ., 1868, 
 
Chap. xviL] Obstruction by Gall Stones. 335 
 
 twenty cases where gall stones produced definite and 
 severe symptoms of obstruction I find that six 
 patients recovered by the spontaneous passage of the 
 stone, while in the other fourteen instances the 
 obstruction remained unrelieved and led to death. 
 
 Spontaneous evacuation of the stone may occur 
 even after symptoms of great severity. Thus, in a 
 case recorded by Dr. C. Martin the patient suflfered 
 from absolute obstruction lasting six days, the vomiting 
 became severe and was at last stercoraceous. But on 
 the morning of the seventh day a motion was passed 
 that was followed by the evacuation of a large stone. 
 The patient rapidly recovered."^ The concretion had 
 a circumference of three and a half inches. 
 
 In another case, quoted by Dr. Sands, a woman, 
 aged forty, sufiered from obstruction due to the 
 impaction of a gall stone. The constipation was com- 
 plete for four iveeks. At the end of that time a 
 motion was passed, and seven days later a biliary 
 calculus with a circumference of three inches. Ster- 
 coraceous vomiting commenced on the third day and 
 lasted for three iveehs. The patient had been treated 
 by aperients and by enemata. She made a good 
 recovery, f 
 
 Helief, however, may be aflTorded by other means 
 than the escape of the stone by the natm^al 
 passages. The impacted stone may excite inflam- 
 mation which, passing on to suppuration, may produce 
 a fistula discharging upon the surface, and through 
 this fistula the calculus may be expelled. Leichten- 
 stern well observes that this mode of cure is extremely 
 rare, but quotes no example. I have found one 
 recorded case that bears very directly upon this 
 matter. It concerned a child, aged ten, who had 
 been liable for some time to attacks of indigestion 
 
 *Bull. de la Soc, Anat., 1875, page 570. Paris. 
 ■\New York Medical Record, vol, xxxi., 1882, page 427. 
 
^S^ Intestinal Obstruction. [Chap. xviii. 
 
 and bilious vomiting. Some time after one of these 
 attacks a fluctuating swelling appeared in the right 
 side of the back. This was incised and some thin 
 foetid brown pus escaped. The discharge was followed 
 in four days by the evacuation of a body the size of a 
 nutmeg. This when cleared of faeces showed a 
 nucleus the size of a large pea composed wholly of 
 cholesterin. The child did well."^ 
 
 In another instance an abscess was set up by the 
 process involved by the passing of a calculus from the 
 gall bladder to the duodenum. This abscess was 
 evacuated externally and through it the stone might 
 readily have passed.! 
 
 Some of those who die from the effects of obstruc- 
 tion die from mere exhaustion, others succumb to 
 acute peritonitis and a comparatively small number to 
 perforation of the bowel above the seat of the 
 impaction. 
 
 Mr. Ward has ])laced upon record a case of 
 cicatricial stricture of the terminal part of the ileum, 
 which was, without much doubt, due to ulceration set 
 up by impacted and long-retained gall-stones. | 
 
 CHAPTER XVITI. 
 
 OBSTRUCTION BY INTESTINAL STONES. 
 
 Intestinal calculi or enteroliths may be divided into 
 three classes. 
 
 1. Concretions formed in great part of phospliate 
 of lime, or of phosphate of magnesia, or of the triple 
 
 *Dr, Thorowgood ; Path, Soc. Trans., 1877, page 131. 
 fDr. Carrard ; Revue Med. de la Suisse Rom., No 2, 1882, 
 page 82. 
 
 X Path. Soc. Trans., 1852, page 357, 
 
Chap, xviii,] Intestinal Calculi. 337 
 
 phosphate, or stones formed of mixtures of these 
 salts. 
 
 Such calculi may contain also some carbonate of 
 lime together with soda, and are nearly always com- 
 biiied with a certain amount of animal matter and 
 occasionally with a little cholesterin. In appearance 
 they are heavy and stone-like, and of a grey or pale 
 brown colour when cleared of faeces. On section 
 they show a concentric arrangement of chalk-like or 
 dirty white layers. With such layers often alternate 
 others of a brownish colour. In outline they are 
 rounded or oval, and often appear to have been 
 polished by peristaltic movements. They would 
 appear to be always formed around a nucleus of some 
 indigestible substance. Among such may be men- 
 tioned vegetable fibres and husks, hairs, fruit-stones, 
 biliary calculi, pieces of bone and little foreign bodies 
 that have been accidentally swallowed. 
 
 The concretion is usually single and of quite 
 small size. It is seldom larger than a chestnut, 
 although a few isolated instances of large stones have 
 been recorded. 
 
 In Leichtenstern's list of such calculi are three 
 whose respective circumferences are 4|-, 1^, and 
 9 inches. Mr. P. H. Watson records one 1| inches 
 in length and \\ inches in width. In cases where 
 several stones exist they will usually be found to 
 be facetted by mutual contact and pressure. In a 
 case of Monro's twelve calculi were evacuated, and 
 in a case of Niemeyer's no less than thirty-two that 
 collectively weighed two and a half pounds. 
 
 2. Enteroliths of low specific gravity and of 
 irregular form that are porous in appearance and 
 have the consistence of compressed sponge. They 
 are composed mainly of densely felted masses of 
 vegetable fragments mixed with particles of faecal 
 matter and with a certain amount of calcareous 
 w— 12 
 
^^S InTES TINA L ObS TR UC TION. [Chap. XV 1 1 1 . 
 
 material similar to that met with in the above species 
 of stone. Tliese concretions comprise the "oat 
 stones " or avenoliths that are composed of the indi- 
 gestible fragments of oatmeal. They are said to be 
 not infrequently observed in Scotland and amongst 
 people where much coarse oatmeal is eaten. These 
 stones are usually small and single. Leichtensteni 
 states that there are seldom more than two together,* 
 and adds that they vary in size from a chestnut to 
 that of an orange. 
 
 Closely allied with such enteroliths are certain 
 concretions of indigestible matters that belong per- 
 haps more properly to the list of "foreign bodies." 
 {See page 320.) Thus Dr. Harley reports a case 
 in a man, aged fifty-six, where a solid mass mea- 
 suring nine inches in length and six and a half in 
 circumference was passed after five weeks of suf- 
 fering. It was composed of undigested animal mat- 
 ters of various kinds densely felted together. The 
 same author mentions the case of a woman, aged 
 twenty-five, who, after having dysentery for two 
 months, passed a hard mass the size of a small hen's 
 %^'g. The mass had the appearance of a phos- 
 phatic calculus, but proved upon examination to be 
 composed solely of starch, f In a case by Dr. 
 Down, fatal obstruction was caused by a stone-like 
 mass the size of a hen's ^^^g that had become impacted 
 in the lower ileum. It was composed of densely 
 packed cocoa-nut fibres, and had probably been formed 
 in the stomach and then passed into the bowel. The 
 patient had been engaged in mat-making. \ 
 
 * Dr. Harley reiiorts a case where twenty oat-stones had been 
 passed at different times. They were small, were the colour of 
 brown sandstone, had a section like felt and floated in water. 
 Path. Soc. Trans., vol. xi., page 87. 
 
 t Ibid. 
 
 + Ibid., vol. xviii., page 98. For other cases sec Brit. Med. 
 Journ., March 29, 1884, page 608. 
 
Chap. XVI 1 1.] 
 
 Intestinal Calculi. 
 
 339 
 
 3. Concretions formed of insoluble mineral matters 
 that have been swallowed as medicines. These are 
 most frequently coni[)Osed of magnesia. In a case 
 recorded by Mr. Hutchinson a huge mass with a cir- 
 cumference of at least fifteen inches was felt in the 
 rectum. It had a surface that was hard and rough 
 
 Fig. 55.— Obstruction of tlie small Intestine by a Concretion of Magnesia. 
 The wall of the bowel has been cut away in two places to show the 
 concretion. 
 
 like an oyster shell. It was broken up and removed 
 at several sittings. It was found to be composed of 
 magnesia and iron with some earthy matters and 
 many thousands of strawberry seeds. The patient 
 had been in the habit of taking large doses of car- 
 bonate of magnesia and of iron.* 
 
 *rath. See. Trans., vol. vi., page 20.1. 
 
340 Intestinal Obstruction. [Chap. xviii. 
 
 Fig. 55 is taken from a specimen in St. Thomas's 
 Hospital Museum,* which shows the small intestine 
 at one point almost entirely blocked by a dense mass 
 of magnesia which fills the gut for several inches. 
 Bamberger noticed a stone containing mainly car- 
 bonate of lime in a patient who had taken much chalk 
 for years. In a patient of Mr. Erichsen's a small 
 stone was passed after much intestinal irritation. It 
 was of a dark brown colour and had the aspect of 
 a uric acid calculus. It was found to be composed of 
 gum benzoin. The patient was a singer and had been 
 in the habit of taking little pills of gum benzoin to 
 improve his voice. 
 
 Enteroliths are most commonly found in the colon 
 and with especial frequency in the csecura. In the 
 colon they often occupy the sacculi of the gut. They 
 are often met with also in the rectal ampulla and 
 more rarely in the ileum and in true and false 
 diverticula. 
 
 Taken collectively they may be said to be met 
 with most often in young adults and in individuals of 
 middle age. 
 
 Enteroliths seldom occasion intestinal obstruction. 
 Leichtenstern could find only twenty examples among 
 1,152 instances of obstruction of the bowels. Five of 
 these patients were females and the remaining fifteen 
 males. 
 
 It is evident that these stones, especially the more 
 calcareous, are of very slow formation. They may 
 moreover be dormant, as it were, for years, or excite 
 during that time but insignificant symptoms. In Mr. 
 Hutchinson's case of magnesian enterolith the patient 
 was an elderly woman. She had been in the habit of 
 taking magnesia and iron thirty years before she 
 came under observation, and she had discontinued the 
 use of those drugs for no less than twelve years. 
 
 * No. E 1. 
 
Chap. xviTi.] Intestinal Calculi. 341 
 
 For the eleven years that preceded the evacuation of 
 tlie concretion she had simply sufiered from constipa- 
 tion. 
 
 As to the syiiiptoiiis produced by enteroliths, it 
 may be at first said that they vary greatly and depend 
 a good deal upon the situation of the mass in the 
 intestine. They very rarely cause sudden occlusion of 
 the bowel. In Dr. Down's case of cocoa-nut fibre 
 " stone " the patient, an idiot boy aged sixteen, died 
 of acute obstruction that lasted for fifteen days. In 
 this instance the mass had probably been formed in 
 the stomach, and passing into the bowel had occluded 
 it. In other cases also of sudden occlusion the calculi 
 have been formed in diverticula of the small intestine 
 and have then made their way into the bowel and 
 suddenly occluded it. 
 
 Apart from rare cases such as these the symptoms 
 of intestinal stone are distinctly chronic. In some 
 instances there is a history of long continued digestive 
 disturbances, with occasional attacks of pain and 
 sickness, and with generally some amount of constipa- 
 tion. The patients indeed present the symptoms of 
 a persisting, incomplete, and inert obstruction in the 
 intestine. They are apt to become emaciated and 
 hypochondriacal. Symptoms such as these may con- 
 tinue for years. In Mr. P. H. Watson's case, to 
 which allusion has been already made, the patient, 
 a man over fifty, had had evidences of abdominal 
 trouble for no less than twenty years ; and in other 
 instances the symptoms have lasted for four, for six, 
 and for seven years before the evacuation of the 
 sto]ie. The mass also is not infrequently to be felt. 
 In Mr. Watson's remarkable case a large mass was 
 felt in the right hypochondrium some years before 
 the enterolith was evacuated. This mass gradually 
 moved towards the left hypochondrium and then 
 disappeared. Its disappearance was immediately 
 
342 Intestinal Obstruction. [Chap. xviii. 
 
 followed by evidences of a foreign substance in the 
 rectum. In Dr. Dowii's case also the mass of fibre 
 could be felt through the parietes. It is needless 
 to say that many concretions have been detected by 
 rectal examination when they occupy the terminal 
 part of the bowel. 
 
 In other cases, the calculus when lodged in the 
 caecum may cause typhlitis or perityphlitis and may 
 finally lead to perforation and death. 
 
 When lodged in the ampulla the patient presents 
 all the symptoms of a foreign substance in the rectum. 
 
 The pi'Og^iiosis is good on the whole, since in 
 the great majority of the cases the concretion is 
 either spontaneously evacuated or is removed by 
 forceps from the rectum. As already stated, cases of 
 fatal obstruction are extremely rare. It is not im- 
 probable that an enterolith that forms a tumour to be 
 felt through the parietes and that is associated wdth 
 emaciation and chronic obstruction may be mistaken 
 for a case of cancer of the bowel. 
 
 It is probable that some of the so-called entero- 
 liths that have been passed have been merely unusually 
 hard scybala. 
 
 It will here be con^'enient to mention the subject 
 of certain skin-like cylinders that are sometimes 
 evacuated from the bowel. Thus, in a case recorded 
 by Mr. Hutchinson,* the patient, a woman aged 
 forty-nine, passed for several months " skins," some 
 of which were many inches in length, while others 
 attained a length of several feet. She was at the 
 same time troubled with diarrhoea, bloody evacuations, 
 some vomiting, and epigastric pain. 
 
 These cylinders are composed of mucus and are 
 
 the products of a certain form of chronic intestinal 
 
 catarrh. Speaking of the presence of mucus in the 
 
 stools in intestinal catarrh, Leube says, " In rare 
 
 * Path. Soc. Trans., vol. ix., page 188. 
 
Chap. XVIII.] Intestinal Concretions. 343 
 
 cases, particularly in hysterical women, coherent cy- 
 linders of mucus are discharged in the form of mem- 
 branous casts of the intestine from an inch to a foot 
 in length. Their discharge is accompanied by attacks 
 of colicky pains (often above the umbilicus), distension 
 of the abdomen and an aggravation of the previously 
 existing obstinate dyspepsia (Da Costa). The masses 
 are composed almost entirely of mucin, but sometimes 
 of albumen and fibrin (Whitehead). In some cases 
 these casts are formed in great abundance, and may 
 appear in every stool for months ; but usually the 
 attack lasts only for a few weeks." '^ 
 
 Dr. Harleyt reports a case in a woman, aged 
 twenty-eight, where symptoms of severe obstruction 
 were caused by some fibrinous concretions, four in 
 number, that were finally discharged from the anus 
 with immediate relief to a long continued train of 
 distressing symptoms. One of these masses measured 
 Z\ inches by 2 inches. They were densely laminated 
 and fibrous looking on section. They appeared to be 
 composed merely of "lymph." It may be that these 
 masses were thin " skin-like cylinders," that had been 
 long retained, had accumulated into masses and under- 
 gone alteration in their physical properties. 
 
 M. Martignon describes the intestine as being 
 sometimes blocked by a mass of worms which forms a 
 definite tumour that is dull on percussion and can be 
 felt through the abdominal parietes. The nature of 
 the mass he asserts can be recognised by " une sorte 
 de mouvement vermiculaire sensible k la main."| 
 Many less recent writers describe this variety of intes- 
 tinal obstruction, and lay stress upon the characteristic 
 movement that can be felt in the occluding mass. 
 
 * Diseases of tlie Stomach and Intestines ; Ziemssen's Cyclo- 
 paedia, vol. vii., page 369. 
 
 f Loc. cit. 
 
 + Du Traitement de I'Occlusion Intestinale par le Morcure 
 metalliqne. Paris, These, No. 340, 1879. 
 
344 Intestinal Obstruction. [Chap. xix. 
 
 I can find no trustworthy illustration of this some- 
 what improbable form of intestinal obstruction. Heller 
 in his able monograph upon "Intestinal Parasites" thus 
 refers to this matter: "The larger species (of intes- 
 tinal worm) have been accused of giving rise to 
 intestinal obstruction, being able, it is said, when en- 
 tangled into a ball, to close mechanically the whole 
 calibre of the intestine. Davaine very properly 
 considers this an erroneous idea ; for cases have been 
 known where the intestine was literally crammed 
 with hundreds of round worms, and still the circu- 
 lation of the chyme through the interspaces was not 
 in the least interfered with."* 
 
 CHAPTER XIX. 
 
 OBSTRUCTIOX OF THE INTESTINE BY F^CAL MASSES 
 CHRONIC CONSTIPATION — ILEUS PARALYTICUS. 
 
 Into the consideration of this form of intestinal 
 obstruction, which concerns rather the physician than 
 the surgeon, it is unnecessary to enter at great detail. 
 It is needful only to consider the matter in so far as 
 it concerns the diagnosis of cases of obstruction of the 
 bowels, and in so far as the pathology of the affection 
 throws light upon the nature of the other varieties of 
 occluded intestine. 
 
 The morbid condition that forms the basis of the 
 present form of obstruction is an insufficiency in the 
 forces that move the intestinal contents forwards. 
 This condition may pass on to absolute paralysis of a 
 segment of the bowel, leading to complete arrest of 
 the intestinal contents and sym^^toms of obstruction. 
 
 * Ziemssen's Cyclopsedia, vol, vii., i^age 679. 
 
Chap. XIX.] Chronic Constipation. 345 
 
 In chronic constipation it can only be said that the 
 peristaltic movements are very feeble, or are at least in- 
 adequate to accomplish the effects expected of them. 
 In ileus paralyticus, i.e. in the absolute obstruction to 
 which such constipation may lead, a considerable 
 portion of the bowel is incapable of any peristaltic 
 movements, F^cal matters collect in this segment 
 and form a species of plug which even vigorous action 
 in the bowel above is not able to dislodge. The 
 retained f feces become, more and more solid by absorp- 
 tion of their fluid parts, and the intestine below the 
 obstructed segment usually becomes contracted, if it 
 be empty, and so offers an additional impediment to 
 the progress of the contents. As the case progresses 
 the paralysed intestine becomes more and more dis- 
 tended, its muscular fibres are stretched and even rup- 
 tured, and the possibility of a restoration of peristal- 
 tic movement is rendered gradually more remote. 
 The condition may be further complicated by the 
 development of chronic peritonitis starting about the 
 paralysed and distended part of the intestine. 
 
 In the mucous membrane above the obstructed sesf- 
 ment certain ulcers may form, known as stercoral 
 ulcers. These are due partly to gangrene of the mu- 
 cous membrane from pressure, and partly to the irri- 
 tating and chemical effects of the long retained and 
 altered faecal masses. They generally appear in the 
 form of sloughs of the mucous membrane, which may 
 extend until ulcers of large size are produced. There 
 may be many of such ulcers. They are most commonly 
 met with in the csecum, and in the lower part of the 
 ileum. They may lead to chronic peritonitis or to 
 acute peritonitis due to perforation, or may in cicatris- 
 ing lead to a stricture of the bowel. In some cases the 
 ulcers appear rather in a linear form following the 
 transverse diameter of the bowel, and attack especially 
 the summits of the mucous folds. Such ulcers may 
 
346 Intestinal Obstruction. [Chap. xix. 
 
 be seen in both the large and in the small intestine. Tlie 
 frequent occurrence of stercoral ulcers in tlie caecum is 
 not difficult to understand. 
 
 Ileus paralyticus may aflfect both the small and 
 the lar£:e intestine, but it is much more common in the 
 latter. The ccecum is a part of the colon where the 
 contents are normally disposed to remain for some 
 time and where they become more solidified. There 
 is no doubt that in the great majority of cases of this 
 form of obstruction the valve remains efficient. Fsecal 
 matter cannot pass back from the colon to the ileum, 
 but a vigorous small intestine above the valve may 
 continue to propel the contents of the bowel in the 
 opposite direction. The cfficum thus has to bear 
 the brunt of internal pressure exercised in two direc- 
 tions, while its shape and general arrangement make 
 it well adapted as a receptacle but not as a part for 
 resisting great strain. In cases, therefore, where the 
 main obstruction has been in the rectum, or in the 
 sigmoid flexure, or in the descending colon, stercoral 
 ulcers will most commonly be found located in the 
 caecum. If not in this part they will be found more 
 or less directly above the seat of the main ob- 
 struction, and more especially in the flexures of the 
 colon. 
 
 The colon above the main seat of obstruction may 
 become ruptured from distension without previous 
 ulceration of the mucous membrane. This lesion is 
 most usually met with at the hepatic or splenic 
 flexures. 
 
 In distinctly chronic cases the distension which 
 the colon may undergo is enormous. The caecum may 
 be found almost as large as an adult's head, the 
 sigmoid flexure or the transverse colon may a]ipear 
 to occupy the greater part of the abdomen, while the 
 diameter of the distended bowel may attain to six, 
 eight, or ten inches. 
 
Chap. XIX.] Chronic Constipation. 347 
 
 The immense qnantity of f?eces that may accumu- 
 late in such cases is remarkable. We read of cases 
 where after death a " bucket-full " of faeces was 
 removed from the colon. Lemazurier mentions a 
 case where a mass of fsecal matter weighing thirteen 
 pounds was removed from the rectum. In an instance 
 reported by Renauldin it is said that at the time of the 
 patient's death sixty pounds of faeces had accumulated 
 in the colon. Leiciitenstern in his conmients upon 
 this case wisely remarks that we may entertain 
 " legitimate doubts " of its authenticity. 
 
 The intestine above the obstructed part is apt to 
 become hypertrophied in its long-continued attempts 
 to overcome the stoppage. The hypertrophy may 
 assume considerable dimensions. Thus in a case 
 reported l)y Dr. Little an idiot, aged thirty-four, died 
 of the effects of long-continued constipation. He 
 had possessed an enormous appetite and had been in 
 the habit of eating great quantities of indigestible 
 food. At the autopsy the transverse colon was found 
 to be six inches in diameter, while the descending 
 colon and sigmoid flexure formed a huge pouch 
 measuring twenty inches by twelve inches. The 
 walls of the sigmoid flexure are said to have been 
 from one-third to one-half of an inch in thickness."^ 
 
 The causes of chronic constipation are numerous 
 and complex. Hereditary influence has some eflect, 
 and in certain cases the tendency to constipation has 
 been congenital, f Exercise appears to assist the 
 action of the bowels, and chronic constipation is par- 
 ticularly common in those who lead sedentary lives. 
 There are forms of constipation that depend upon the 
 condition of the faeces. These matters may become 
 too solid, either by the accumulation of much un- 
 digested food or by a diminution in the amount of 
 
 *Path. Soc. Trans., vol. iii., page 106. 
 
 \See case by Dr. Peacock, ibid., vol. xxiii., page 104. 
 
34^ Intestinal Obstruction. [Chap.xix. 
 
 water left unabsorbed in the intestine. They may 
 moreover, lose some of the direct stimulating effect 
 they are supposed to exercise upon the intestine, as in 
 cases where they contain a diminished quantity of bile. 
 There are, again^ forms of constipation that depend upon 
 nerve influences, as seen in the confined bowels of the 
 cachectic, of those suffering from certain brain and 
 cord affections, and in the subjects of hysteria, hypo- 
 chondriasis, and idiocy. Among other causes that 
 have a more direct local effect are the infiltrations of the 
 muscular coat observed in chronic peritonitis ; the 
 oedema of that tunic that may account for the con- 
 stipation in chronic Bright's disease ; and the injurious 
 effect upon the intestinal wall of prolonged inflam- 
 mation, as seen in the chronic constipation tliat follows 
 or attends chronic catarrh. The tendency to ftecal 
 accumulation, moreover, may be assisted by abuor- 
 malities in the colon, by a misplaced c?ecum, by an 
 abnormally arranged transverse colon, by an unduly 
 tortuous sigmoid flexure. 
 
 Symptoms. — Obstruction of the bowels by fsecal 
 accumulation is more common in females than in 
 males, is most frequently met with in those who have 
 passed middle life, and is very common in the subjects 
 of hysteria and hypochondriasis. The patients are 
 liable to habitual and troublesome constipation. 
 Their bowels are seldom opened without the aid of 
 aperients or enemata. Many days may elapse without 
 a stool, normal in amount, being passed, and from 
 time to time enormous quantities of faecal matter 
 will be evacuated by artificial aid. Sometimes there 
 is a brief interlude of so-called diarrhoea. This 
 diarrhoea is wholly spurious. It depends upon 
 catarrh excited in the bowel above the faecal accumu- 
 lation. The catarrh causes a free exudation to be 
 poured into the intestinal canal, this dissolves a 
 certain amount of faecal matter, which, finding its way 
 
Chap. XIX.] Chronic Constipation. 349 
 
 beyond the main mass, appears at the anus as a slight 
 watery motion. 
 
 In such cases an examination of the rectum may 
 reveal the fact that that gut is hlockecl Ijy fsecal 
 matter. These symptoms may exist for years without 
 causing more than a little malaise or a little digestive 
 disturbance, and at no time may severer abdominal 
 disturbances arise. 
 
 In more marked cases the abdomen becomes dis- 
 tended, evacuations are less frequent and more 
 difficult to obtain. The patient complains of a sense 
 of fulness and weight in the abdomen. His appetite 
 is poor, his tongue foul, his breath offensive. He is 
 much troubled by indigestion, by distension after 
 food, by flatulency, and by eructations, etc. He 
 not infrequently becomes much weakened and loses 
 flesh. He may become lethargic and morose, or fret- 
 ful and uneasy, and present some phase of hypo- 
 chondriasis. 
 
 If the abdomen become greatly distended other 
 symptoms may appear. There may be palpitation, a 
 sense of oppression in the chest and a little dyspnoea 
 from a pressing up of the diaphragm by the distended 
 bowels. Pressure may be exercised upon the lumbar 
 or sacral nerves, and the patient may complain of dis- 
 comfort in the genitals, or in the thigh (genito-crural 
 nerves), or down the leg along some part or parts of 
 the great sciatic nerve. Or injurious pressure may be 
 exercised upon certain veins ; upon the spermatic 
 veins, producing varicocele; upon the pelvic veins, 
 causing piles, catarrh or hypersemia of the uterus ; 
 upon the iliac veins, producing uncomfortably cold 
 feet or even oedema of the extremities."^ 
 
 The constipation may remain absolute for weeks 
 and months. All the symptoms may become worse. 
 The abdomen may become enormously distended, the 
 * See case, Path. Soc. Trans., vol. xxiii., page 104. 
 
350 Intestinal Obstruction. [Chap. xix. 
 
 apex of the heart may be pushed up to the third 
 intercostal space, "^ the distended coils may be visible 
 through the thinned parietes, and there may be much 
 rumbling and gurgling heard in the abdomen. When 
 in this condition the patient has most probably lost 
 his api^etite, lie is troubled with frequent and foul 
 eructations, he is greatly distressed by the distension 
 of the abdomen, he suffers from nausea and ultimately 
 from vomiting. This vomiting may become feculent. 
 But even when the symptoms have advanced to an 
 extreme degree, relief may be afforded either by 
 enemata or by a spontaneous evacuation, and after 
 the bowel has been emjDtied recovery may follow. On 
 the other hand, the case progresses from bad to worse, 
 the patient begins to experience pain in the abdomen, 
 or an increase in the comparatively slight pain that 
 may have existed for some time, he develops all the 
 symptoms of ileus, and dies of the effects of the 
 unyielding obstruction. 
 
 In several cases there has been complete con- 
 stipation for two or three months, and the patient at 
 the end of that time has had a relief of the bowels 
 and has rapidly recovered. Mr. Pollock reports the 
 case of a lady, aged thirty-five, who only had one 
 evacuation of the bowels every three months, that is 
 to say, four evacuations in the year.f Dr. John 
 Blake reports the case of a man, aged forty-six, 
 whose bowels were confined absolutely for eighteen 
 weeks. At the end of that time he passed a motion 
 spontaneously, but died within a few days. Not the 
 least interesting fact in this case is the circumstance 
 that an aspirator-trochar was introduced into the 
 abdomen of this unfortunate person no less than 150 
 times during the continuance of the constipation. 
 Before the conclusion of the case the patient was 
 
 *Path. Soc. Trans., vol. iii., page lOG. 
 
 t Holmes' System of Surgery, vol. ii., page 725, 3rd ed. 
 
Chap. XIX.] Chronic Constipation. 351 
 
 taking twelve grains of morphia a clay,"'^ In another 
 case, reported comparatively recently, a man, aged 
 twenty-six, who had been always liable to constipa- 
 tion, had at one time no evacuation of any kind from 
 the bowels for the almost incredible period of eight 
 montlis and sixteen days, f Dr. Thomas Strong, who 
 reports this case with considerable detail, alludes to 
 instances of patients who suffered from absolute con- 
 stipation for periods respectively of seventy-six 
 days, X fifteen weeks^ § seven months, || eight 
 monthSjIT and nine months. "^"^ 
 
 In another and common class of cases the patient 
 is liable from time to time to what may be termed 
 obstructive attacks or attacks of ileus. In these 
 attacks it is probable that the much narrowed canal 
 becomes more or less suddenly blocked, whereas in 
 the previous class of case the occlusion is brought 
 about by very gradual processes. The more abrupt 
 stoppage may be due to the dislodgment of a hard 
 mass of ftcces ; or it may depend upon bending or 
 kinking of the distended bowel. The latter condition 
 may be met with in the transverse colon and in the 
 sigmoid liexure, and especially at the point of junction 
 of the flexure with the rectum. 
 
 A patient, therefore, who has presented for months 
 the symptoms of chronic constipation may be more or 
 less suddenly attacked with severe colicky pains in the 
 abdomen. Associated with this symptom are absolute 
 constipation, increased distension of the abdomen, and 
 very probably tenesmus. The patient is troubled by 
 
 * Boston Med. and Sury. Jo urn., vol. xiv., Nov., 1876, page 
 601. 
 
 fAmer. Journ. of Med. Sc, vol. Ixviii., 1874, page 440. 
 
 i North Amer. Med. and Surg. Journ., vol. iv., page 262. 
 
 § Dr. Baillie, Trans, of a Soc. for the Promoting of Med. and 
 Chir. Knowledge, vol. ii. , page 174. 
 
 jl Staniland; Lond. Med. Gazette, vol. xi., page 245. 
 
 "if Dr. Crampton; Dublin Hosp.' Reports, vol. iv., page 30.3. 
 
 **Dr. Valentine; Bull, dcs Sc. IMdd., tome x., page 74. 
 
352 Intestinal Obstruction. [Chap. xix. 
 
 nausea and foul eructations, and soon begins to vomit. 
 The vomiting is not so easily established as it is in 
 some of the other of the less chronic varieties of ob- 
 struction, nor is it usually very severe. It may, 
 however, become feculent. All the symptoms are 
 commonly aggravated by taking food. Coils of in- 
 testine may be visible, and more or less constant bor- 
 borygmi will be heard in the abdomen. The symptom 
 may become worse, and worse and the patient may 
 finally die of exhaustion. 
 
 Before death he may or may not have developed 
 evidences of peritonitis. 
 
 The first of these attacks may prove fatal ; but 
 such an occurrence is very rare. As a rule, the 
 patient has many obstructive attacks, which pro- 
 bably increase in severity as time advances. These 
 attacks may last from three and four to ten and 
 fifteen days, may be associated with feculent vomiting, 
 and may be at last relieved either spontaneously, or 
 by the use of aperients and eneraata. An enema, 
 whether it at once produce an evacuation or not^ is 
 often followed by an improvement in the symptoms 
 for a while. 
 
 In all cases of obstruction by faecal masses, no 
 matter what may be their particular clinical aspect, 
 there is very usually present a diagnostic feature of 
 much importance to which allusion has not y^t been 
 made. I refer to a tumour formed by the mass of 
 retained foeces. 
 
 In the somewhat uncommon cases where the 
 obstruction concerns the small intestine only no 
 tumour will probably be detected. The distension of 
 the abdomen will mainly concern the umbilical, hy})0- 
 gastric, and epigastric regions, while the district of the 
 colon will reveal upon examination a more or less 
 empty state of the bowel. It is when the obstruction 
 depends upon the impaction of fiecal masses in tlie 
 
Chap. XIX.] Chronic Constipation. 353 
 
 colon that the f cecal tumour is most distinctly met 
 with. This tumour is, as a rule, most readily to be 
 felt in the ca3cum. The caecum, it is needless to say, 
 occupies the right iliac fossa in such a way that its 
 extremity reaches nearly to the middle of Poupart's 
 ligament. The faecal mass, therefore, will correspond 
 to the outer half of the ligament. Such tumours 
 feel hard and uneven, are of a globular shape, and 
 are as a rule, painless. Sometimes, however, the 
 region of the tumour is the seat of much pain and 
 tenderness, a circumstance that probably depends 
 upon a little local peritonitis. In the ascending colon 
 the tumour will possibly feel softer, will be cylin- 
 drical in outline and very like a chronic intussus- 
 ception, especially as its limits cannot be usually well 
 defined. 
 
 Masses in the transverse colon may, when near 
 the hepatic flexure, give rise to the impression that 
 the liver is enlarged, the extent of dulness over that 
 viscus being increased. These tumours, when in a 
 mobile part of the colon, are of course themselves 
 movable. Masses in the transverse colon may cause 
 the gut to become bent down, and the fsecal tumour 
 therefore has in such cases been felt near to the sym- 
 physis. When in the descending colon or sigmoid 
 flexure the f?ecal mass will usually feel harder and its 
 division into scybala may be detected. Indeed, 
 tumours in this situation have been compared to a 
 large rosary on account of their uneven and nodular 
 surface. 
 
 In thin individuals and in others, when under an 
 ana3sthetic, the softer of these fsecal masses may be 
 affected by pressure and may give to the fingers the 
 reaction of a mass of dough or of putty. When 
 such a character is presented by the tumour the dia- 
 gnosis of its nature is placed beyond doubt. 
 
 Faecal tumours may exist unchanged for weeks or 
 x-12 
 
354 Intestinal Obstruction. [Chap. xix. 
 
 montliS; and may coincide with the passage of normal 
 motions or with the spurious diarrhoea to which 
 attention has ah^eady been directed. 
 
 These tumours have been mistaken for cancer, for 
 chronic intussusception, for tumours of the liver, 
 stomach, spleen, and kidneys, for ovarian and otlier 
 pelvic tumours, and for pregnancy. The great disten- 
 sion of the abdomen and the presence of much flatus 
 within the intestine in these cases are apt to obscure 
 the details of the mass when it exists. 
 
 In a case of obstruction from impacted fjeces 
 brought before the notice of the Sheffield Medico- 
 Chirurgical Society* by Dr. Thomas, it is stated that 
 after aperients had been administered and massage 
 applied, " the sound of the moving faeces was heard 
 with the stethoscope." This experience is, so far as I 
 am aware, unique. 
 
 With regard to the prognosis in this form of ob- 
 struction it may be said to be, upon the whole, good. 
 Patients may present the symptoms of chronic con- 
 stipation through the greater part of a lifetime. In 
 the obstructive attacks also, no matter whether of 
 gradual or of abrupt development, a termination by 
 relief is more frequent than a termination by death. 
 At the same time it must be noted that the longer the 
 morbid condition persists, and the more frequent the 
 attacks of ileus become, the more grave is the pro- 
 gnosis. 
 
 The causes of death in these cases are numerous. 
 The patient may die exhausted by prolonged obstruc- 
 tion with its attendant effects upon the digestion and 
 general nutrition. He may die of rupture or perfora- 
 tion of the distended bowel, or of chronic peritonitis, 
 or of stricture following the healing of a stercoral 
 ulcer, or of obstruction depending upon adhesions due 
 to a previous chronic peritonitis. In the more rapid 
 * Brit. Med. Journ., Jan. 5, 1884, page 12. 
 
Chap. XX.] The Symptoms: Collapse, 355 
 
 cases he may die of acute obstruction depending upon 
 sudden blocking of the bowel, or upon acute bending 
 or kinking of the elongated intestine, or upon a 
 volvulus of the distended and tortuous sigmoid 
 flexure. The dependence of volvulus of the sigmoid 
 flexure upon chronic constipation has been already 
 pointed out. 
 
 CHAPTER XX. 
 
 THE DIAGNOSIS. 
 
 The important and complicated subject of the dia- 
 gnosis of the various forms of obstruction of the 
 intestine may be most conveniently considered under 
 the following headings : 
 
 1. The general significance of the leading symp- 
 toms. 
 
 2. The diagnosis of the different forms of intes- 
 tinal obstruction. 
 
 3. The symptoms as modified by the position of 
 the obstruction. 
 
 4. The various affections that have been most 
 frequently confused with cases of obstruction of the 
 bowels. 
 
 THE GENERAL SIGNIFICANCE OF THE LEADING 
 SYMPTOMS. 
 
 Collapse. — The marked and often severe de- 
 gree of shock observed in cases of acute obstruction 
 does not depend obviously upon the mere abrupt 
 occlusion of the intestine, but upon the sudden 
 damage inflicted upon the peritoneum and intestinal 
 walls by the strangulating agent. Shock in these 
 cases is indeed precisely of the same nature as that 
 
356 Intestinal Obstruction. [Chap. xx. 
 
 that attends wounds and other injuries to the abdo- 
 men and as that that results from the perforation of 
 an ulcer of the stomach or intestine. Into the 
 physiological processes involved in the production of 
 the symptoms of collapse it is not necessary here to 
 enter. The matter has been well and fully investi- 
 gated by means of vivisection experiments, and has 
 been illustrated by the effects of injury and dis- 
 ease occurring in the human subject. It has been 
 shown that the manifestations of collapse depend 
 upon a profound impression upon the nervous sys- 
 tem, an impression that acts mainly through the 
 sympathetic centres and displays itself through cer- 
 tain grave and violent vascular disturbances. The 
 altered circulatory conditions are made evident by the 
 lowering of the temperature of the surface, by the 
 cold sweats, by the frequent lividity of the extremities, 
 by the anaemia of the brain, by the small and rapid 
 pulse. 
 
 The degree of the collapse depends mainly upon 
 three circumstances : upon the disposition of the 
 patient, upon the suddenness of the strangulation, 
 and upon the amount of peritoneum or of intestine 
 involved in the lesion. This symptom is usually most 
 marked in cases of acute obstruction occurring in the 
 very J^oung or in the very old, although at the same 
 time it must be allowed that some of the most pro- 
 found cases have been met with in adults about 
 middle life. 
 
 Those instances of collapse in intestinal obstruc- 
 tion of so grave and abiding a nature as to cause the 
 patient's condition to be mistaken for cholera have 
 mostly occurred in vigorous adults in the prime of 
 life. Such individuals are, from the very activity of 
 their bodily processes, capable of presenting Adolent 
 forms of strangulation, wherein the lesion to the peri- 
 toneum outweighs the matter of age as a factor in the 
 
Chap. XX.] The Symptoms: Pain. 357 
 
 production of collapse. It is certain also that the 
 degree of the collapse depends much upon individual 
 peculiarities, just as different individuals may present 
 different capacities for enduring pain. 
 
 As regards the local conditions, the gravest amount 
 of shock is met Avitli in cases where a considerable 
 segment of the intestine is suddenly strangulated, and 
 an injury is thus abruptly inflicted upon an extensive 
 nerve area. 
 
 It will be readily understood that this symptom 
 is more usually associated with strangulation of the 
 small intestine than with that of the large. This 
 depends not only upon the circumstance that the small 
 intestine is the part more commonly involved in acute 
 obstruction, but also upon the more direct association 
 of the nerves of the upper segment of the bowel with 
 the great sympathetic ganglia of the abdomen. This 
 matter will be again referred to in a subsequent 
 paragrajDh, 
 
 Pain. — This symptom, which is so conspicuous a 
 feature in intestinal obstruction, depends upon several 
 conditions. It is due, in the first instance, to the 
 lesion experienced by the peritoneum and by the 
 intestinal walls as a result of the strangulation. It 
 depends at a somewhat later period, or in the first 
 instance in certain cases, upon the tumultuous and 
 irregular peristaltic movements excited in the intestine. 
 These movements are more or less arrested at the seat 
 of obstruction, and the peristaltic wave, no longer 
 moving regularly, leads to disordered muscular con- 
 tractions that are the basis of the symptoms known as 
 " colic." There is no doubt that by the undue reflex 
 action excited by the peritoneal lesion, and by the 
 actual obstruction, the movements in the bowel above 
 the occlusion become unusually vigorous. The perio- 
 dical exacerbations of pain are due to the passage 
 along the intestine of periodic peristaltic waves that 
 
358 Intestinal Obstruction. [Chap. xx. 
 
 hurl themselves, as it were, against the obstruction. 
 This circumstance can often be well displayed in 
 chronic cases associated with emaciation and with 
 visible movement of the intestinal coils. 
 
 The intensity of the pain depends upon the ex- 
 citability of the individual, upon the state of the 
 sensorium, upon the extent of intestine and peritoneum 
 involved, and upon the severity and abruptness of the 
 occluding lesion. As time advances the nature of the 
 pain is influenced by the distension of the gut and 
 by the appearance or non-appearance of peritonitis. 
 
 In the matter of diagnosis, I would call especial 
 attention to a feature in the character of the pain 
 that has, so far as I am aware, not attracted notice. 
 It is this. In cases where the obstruction is complete 
 the pain is constant, although liable to periodic exacer- 
 bations. In cases where the obstruction is but partial 
 the pain is distinctly intermittent, and the individual 
 experiences intervals between attacks of pain during 
 which he is free from suffering. 
 
 To this rule I have been able to find extremely 
 few exceptions that may be regarded as satisfactory. 
 As illustrations of the relationship I might draw 
 attention to the constant pain in acute strangulation 
 as compared with the markedly intermittent pain in 
 stricture. If in a case of stricture the stenosed seg- 
 ment become suddenly occluded the nature of the pain 
 will change almost as suddenly and will become con- 
 tinuous where before it was purely intermittent. 
 
 Moreover, one observes in cases of stricture that 
 as the malady advances, and as the narrowed part be- 
 comes still more narrow, so does the pain appear at 
 less lengthy intervals, until at last, when the intestine 
 has become entirely occluded, the pain will have 
 become also more or less continuous. In intussus- 
 ception, again, the early pain is usually characterised 
 by its distinctly intermittent character ; and tliis 
 
Chap. XX.] The Symptoms: Pain. 359 
 
 character it maintains wliilc the lumen of the 
 invaginated part remains patent, and while the patient 
 evacuates bloody stools. On the occurrence, however, 
 of complete obstruction, the character of the pain 
 changes, and the suffering experienced by the patient 
 is continuous, although aggravated by periodic exacer- 
 bations. 
 
 I would urge, therefore, that in the diagnosis of 
 cases of intestinal obstruction, very particular atten- 
 tion should be paid to the nature of the pain, and 
 especially to the length of the intervals of ease that 
 occur in instances of intermittent pain. 
 
 In examples of intermittence, many of the recorded 
 cases that I have collected show that the duration of 
 the attacks of pain is apt to increase as the duration 
 of the interval of ease diminishes. 
 
 The pain in the earlier stages of intestinal ob- 
 struction is usually not aggravated by pressure. It is 
 unassociated, in fact, with tenderness, and is, indeed, 
 very often much relieved by compression of the abdo- 
 men. The appearance of tenderness is coincident with 
 great hyperasmia of the peritoneum, or with actual 
 peiitonitis. 
 
 The diminution in the severity of the pain that is 
 not infrequently experienced towards the termination 
 of a fatal case may depend upon the colla})se following 
 perforation, or upon diminished activity of the senso- 
 rium, or upon extensive paralysis of the intestine as a 
 result of peiitonitis, or upon a rupture or perforation 
 of the bowel into some part other than the peritoneal 
 cavity. 
 
 T'he great increase in the pain that is often expe- 
 rienced after food, or after the use of enemata, or even 
 after digital examination of the rectum, depends upon 
 increased reflex action and the fresh peristaltic move- 
 ment tliat it excites. 
 
 In one or two cases a rectal exploration induced 
 
360 Intestinal Obstruction. [Chap. xx. 
 
 very violent attacks of pain in examples of obstruction 
 of the small intestine. 
 
 With regard to the situation of the pain, as dis- 
 tinguished from tenderness, I would decidedly dissent 
 from the statements of the somewhat numerous 
 authors who assert that it corresponds to the seat of 
 the obstruction. In the case of the small intestines, 
 I am convinced, not only that the situation of the pain 
 is of no value in diagnosing the site of the occlusion, 
 but that it is, if used for such diagnostic i3urposes, 
 absolutely misleading. In the development of the 
 human intellect, the factors upon which an apprecia- 
 tion of position and distance are founded are tolerably 
 well known and allowed. These factors are constant. 
 The child gradually acquires, by slow experience, a 
 knowledge of the localisation of sensation ui3on various 
 parts of its integument. There is probably a period 
 in its existence when painful sensations are appre- 
 ciated solely by their degree or quality without any 
 reference to locality. It is a matter of gradual expe- 
 rience to distinguish a pain on the back of the hand 
 from one on the back of the shoulder. The factors 
 upon which that experience is founded are constant. 
 The distances between the two painful spots are con- 
 stant, and can be appreciated by sight as well as by 
 feeling. It is by an unconscious j)rocess of repeated 
 comparison that a child acquires a knowledge of its 
 own skin, or of its own skin so far as it is concerned 
 as a vehicle for sensation. With resrard tolthe locali- 
 sation of sensation in the intestine (and we will 
 consider particularly the small intestine), it must be 
 remembered tliat the length of the bowel is very con- 
 siderable ; that the coils are perpetually changing their 
 position and altering the mutual relation they bear to 
 one another ; and that the part is not very directly 
 supplied with spinal nerves. Without discussing the 
 subject at greater length, I think it will be evident 
 
Chap. XX.] The Symptoms : Pain. 361 
 
 that the small intestine at least does not possess that 
 arrangement of parts which we are apt to regard as 
 essential for the proper localisation of sensations pain- 
 ful or otherwise. The j.iassage of a large foreign body- 
 along the lesser bowel is often associated with great 
 and long-continued pain. But neither the nature nor 
 the position of the pain appears to be in any way 
 modified by the localisation of the intruding substance. 
 If the passage along the intestine of a foreign body, 
 capable of exciting pain throughout its whole progress, 
 were a matter of daily occurrence, then in time it 
 may be possible for an individual to localise painful 
 sensations in certain vague segments of the gut ; but 
 even such an experience could never enable any one 
 to localise a pain in one very limited portion of a tube 
 that is many feet in length. In speaking of the 
 symptom of pain in connection with the subject of 
 strangulation by bands (page 73), I have pointed 
 out that no matter in what part of the small intes- 
 tine the obstruction is situated, the pain arising there- 
 from is very usually referred to the region of the 
 umbilicus. 
 
 A little way above the umbilicus is situated the 
 solar plexus, and it is to this centre that the pain is, I 
 think, referred. In the paragraph above alluded to, I 
 have given many examples to show the want of definite 
 connection between the seat of pain and the seat of 
 the lesion that caused it. 
 
 In the case of the stomach and of the colon it is 
 possible to conceive that painful sensations occurring in 
 those parts may be more or less definitely localised, 
 since they are more constant in position and in the 
 relation that their parts bear to one another. The 
 position of the pain in gastric ulcer, and in some cases 
 of cancer of the large intestine, would appear to sup- 
 port this notion, although in the great majority of 
 the cases of stricture of the colon the situation of the 
 
362 
 
 Intestinal Obstruction. iChap. xx. 
 
 pain has been of no value in diagnosing the position 
 of the stenosis. 
 
 Toinitiiig'. — Vomiting in cases of intestinal ob- 
 struction is mainly due to peristaltic action. The 
 bowel becomes occluded at a certain point. Above 
 that point the contents of the tube collect, and 
 some dilatation of the bowel from distension takes 
 place. A wave of peristaltic movement passing 
 along the intestine above the occluded part will tend 
 to induce two distinct currents in the contents of the 
 tube, in the place of the single current in the direction 
 of the rectum that is the result of peristalsis under 
 normal circumstances. One of these movements is in 
 the downward direction and concerns 
 such of the contents as are nearer to the 
 wall of the intestine. The other is an 
 upward movement that concerns the con- 
 tents occupying the axial part of the 
 bowel. This axial current, in the upward 
 direction, is the direct result of the ob- 
 struction offered to the passage of matters 
 along the intestine. Dr. Brinton, who 
 first drew attention to this subject in his 
 well-known monograph, illustrates the 
 double current by the action of a piston, 
 perforated in the centre, as it passes 
 along a tube closed at one extremity 
 (Fig. 56). He further pointed out that a 
 series of such pistons passing down the 
 tube one after the other would tend to 
 indefinitely lengthen the upward axial 
 current and render it perfectly con- 
 tinuous. 
 
 Dr. Brinton also showed that the dis- 
 tended segment of intestine immediately above the 
 obstruction would be ])ractically unaffected by the 
 peristaltic movements, and would have the effect of 
 
 ' 
 
 5U. 
 
Chap. XX.] The Symptoms : Vomiting. 363 
 
 placing the starting point of the upward axial move- 
 ment hio-her and hisiher in the intestine as the accumu- 
 lation increased. 
 
 This latter circnmstance, however, is by no means 
 necessary for the complete demonstration of Dr. 
 Brinton's theory of the emptying of the intestinal 
 contents into the stomach by no other motor power 
 than the peristaltic movements of the bowel itself. 
 As a matter of fact, however, there is more than one 
 factor concerned in the evacuation upwards of the 
 intestinal contents. When the bowel above the 
 occlusion has become filled by gradual accumulation 
 of its contents, its degree of distension may be such 
 that all pressure brought to bear upon the bowel so 
 occupied can do no other than force the contents in 
 the only direction in which they can go, viz. towards 
 the stomach. This pressure may be exercised during 
 every act of vomiting, every contraction of the 
 diaphragm or of the abdominal muscles, and even by 
 the mutual pressure that the distended coils would 
 exercise the one upon the other. 
 
 It will be obvious that the more fluid the contents 
 of the intestine the more easily will they be 
 evacuated, and that ready and early vomiting is more 
 likely to occur when the obstruction is near the upper 
 than when it is near the lower segment of the 
 bowel. 
 
 It is impossible to discuss this subject without 
 some reference to the question of antiperistalsis, 
 which was at one time accredited with beino- the 
 main cause of stercoraceous vomiting. That anti- 
 peristaltic movements occur in the intestine has been 
 placed beyond doubt by numerous observers. These 
 movements have been seen also in cases of artificial 
 obstruction of the bowels induced in animals. There 
 is, however, not the least evidence to show that anti- 
 peristalsis is absolutely essential for the propelling of 
 
364 Intestinal Obstruction. [Chap. xx. 
 
 the intestinal contents towards the stomach, much 
 less that it is the main cause of stercoraceous vomiting. 
 These movements, when observed, have been feeble, 
 imperfect, and irregular, and of comparatively little 
 significance by the side of the tumultuous peristaltic 
 movements passing in the usual direction. 
 
 As Dr. Brinton has well observed, if antijDeristalsis 
 were the cause of the stercoraceous vomiting, then 
 would one expect to find at an autopsy the gut above 
 the obstruction empty and contracted, while the 
 intestine nearer to the stomach would be in a state of 
 distension. It is needless to say that the reverse is 
 what is found. In many cases, moreover, metallic 
 mercury, and other substances introduced into the 
 stomach before death, have been found in the 
 autopsy to have traversed the whole length of the 
 intestine as far as the obstruction, in spite of severe 
 feculent vomiting during life. Leichtenstern, who is 
 entirely opposed to the theory of antiperistalsis as 
 a factor in stercoraceous vomiting, mentions the 
 following as the only facts that appear to favour such 
 a theory : "1st. Those veiy rare cases in which sterco- 
 raceous vomiting is observed in the course of a diffuse 
 peritonitis without demonstrable alteration of the 
 permeability of the intestine. 2nd. The fact that in 
 cases of acute internal incarceration the stercoraceous 
 vomiting occurs only a few hours after the beginning 
 of the attack, at a time when it cannot well be thought 
 that there is any great accumulation of intestinal 
 matter. 3rd. The movements of the intestine in 
 cases of inflammation and other irritations of the 
 peritoneum, differ, so far as their quality and effects 
 are concerned, from what is normal." With regard 
 to the first " fact," it must be noted that in peri- 
 tonitis a large segment of the intestine may remain 
 for a long time non-paralysed. The accumulation of 
 intestinal contents in the paralysed segment would 
 
Chap. XX.] The Symptoms: Vomiting. 365 
 
 constitute a definite obstruction, and if the non- 
 paralysed part consisted of a continuous portion of 
 the bowel extending from the stomach to the involved 
 segment the very condition for the evacuation of the 
 intestinal contents would be established. With regard 
 to the second fact, stercoraceous vomiting within 
 a few hours after the occurrence of strangulation 
 is extremely rare, and it has yet to be shown that 
 a certain accumulation of matters in the bowel is 
 needful for the production of stercoraceous vomiting. 
 The third fact to be of any value must prove that the 
 abnormal movements are in the inverted direction 
 and are of sufficient extent and of sufficient duration 
 to move the contents of the tube (without other 
 assistance) in the direction of the stomach. 
 
 In stercoraceous vomiting the matter is derived 
 from the lower ileum or from the colon. It has been 
 most conclusively shown that for the production of 
 feculent vomiting it is by no means necessary to 
 assume that matter regurgitates from the colon into 
 the ileum through the ileo-caecal valve. The contents 
 of the lower ileum have often the distinct characters 
 of soft faecal matter in normal circumstances, and 
 when retained in a disordered and obstructed intes- 
 tine it is not difficult to understand that they may 
 soon acquire those characters from decomposition, 
 even if they did not originally possess them. At the 
 same time it is now fully allowed that the ileo-csecal 
 valve may become insufficient during life and may 
 permit faecal matter to regiu-gitate from the colon 
 into the lesser bowel. 
 
 This insufficiency may be met with in great 
 distension of the caecum and ileum associated with 
 paralysis of the parts concerned in the valve. Tlie 
 occurrence, however^ of this insufficiency is certainly 
 very uncommon, as is proved by repeated examinations 
 of the parts after death from stricture of the colon. 
 
366 Intestinal Obstruction. tchap. xx. 
 
 When the obstruction occupies the lower duodenum 
 or jejunum the vomited matters are usually very 
 copious and always deeply stained by bile. They can 
 never become really stercoraceous, although if long 
 retained they may become discoloured and acquire so 
 offensive a smell as to be possibly mistaken for fecu- 
 lent matters. In the same way the vomiting in 
 examples of obstruction in the middle of the ileum 
 can never be stercoraceous in the strict sense of the 
 term. If, however, the contents of the bowel have 
 been long retained, as in cases where the vomiting 
 has been subdued by opium, then they may become 
 so altered from decomposition as to have a feculent 
 odour. 
 
 In some cases the stercoraceous vomiting has been 
 due to a fistula bimucosa between the colon and the 
 upper part of the small intestine, as occurred in a case 
 reported by Mr. Shaw."^ 
 
 As already remarked, the main part of the 
 vomiting in cases of intestinal obstruction no doubt 
 depends upon peristaltic action taking place under 
 peculiar conditions. This is, however, not the only 
 cause, nor is it obviously the cause of the initial vomit- 
 ing in acute strangulation. 
 
 This initial vomiting is due to the damage inflicted 
 upon the peritoneal and intestinal nerves by the stran- 
 gulation. It is a purely reflex act, and of precisely the 
 same nature as the vomiting that may follow a wound 
 of the abdomen or a crush of tlie testicle. The more 
 excitable the reflex centres the more readily is the 
 vomiting induced. It thus occurs peculiarly early in 
 children and in delicate and unduly sensitive women. 
 Since the nerve supply of the lesser intestine is more 
 liberal and more directly connected with the great 
 abdominal plexuses than is tliat of the colon, it may be 
 surmised that lesions involving the former segment of 
 *Patli. Soc. Trans., vol. iv., page 147. 
 
Chap. XX.] The Symptoms : Vomiting. 367 
 
 the bowel will be more rapidly followed by sickness 
 than will those implicating the large intestine. 
 
 The dependence of much of the vomiting upon reflex 
 nerve disturbance is illustrated by cases of ]:»seudo- 
 strangulation, by cases where vomiting in instances 
 of intestinal obstruction has been excited by explora- 
 tion of the rectum, and by the close association of the 
 symptom with the symptom of pain. 
 
 One of the best illustrations, however, of the 
 possible independence of vomiting in intestinal cases 
 of peristalsis is afforded by casual vomiting in indi- 
 viduals with an artificial anus. Thus Mr. Bryant 
 reports a case of intestinal obstruction for which he 
 performed enterotomy, leaving a permanent artificial 
 anus connected with the small intestine. The patient 
 was at a subsequent period much troubled by the 
 fseces that had been retained in the colon below the 
 abnormal opening, and that were unable to escape. 
 The irritation of these masses induced much abdo- 
 minal pain and vomiting. The interruption of the 
 intestine between the obstructing masses and the 
 stomach afforded by the artificial anus must have 
 prevented peristaltic movement from taking any 
 dii'ect share in the production of the vomiting.* 
 
 In those cases where feculent vomitino- has 
 alternated with the vomiting of mucous and bilious 
 matters only it must be assumed that the act con- 
 cerned the stomach only in the latter case, but 
 extended to the intestine also in the former. 
 
 There is without doubt a very direct association 
 between the completeness of the constipation and the 
 severity of the vomiting. 
 
 In a few exceptional cases of a chronic nature 
 
 I find that vomiting persisted even while the bowels 
 
 acted freely, and I have met also with two or three 
 
 instances where a good appetite existed in patients 
 
 * Lancet, vol. i. , 1878, page 743. 
 
368 Intestinal Obstruction. [Chap. xx. 
 
 who had been the subjects of long-continued obstruc- 
 tion and had vomited at intervals for weeks. 
 
 Constipation. — The constipation in cases of 
 obstruction of the bowels depends, of course, in the 
 main upon the narrowing or occlusion of the lumen of 
 the intestine. 
 
 It may depend also uj)on paralysis of a segment of 
 the intestine without mechanical obstruction in the 
 intestine itself, as has been explained in speaking of 
 chronic constipation. It is also to a great extent due 
 to reflex nerve-action. Thus^ in cases of acute stran- 
 gulation, the constipation is often absolute from the 
 very commencement, although the obstruction may be 
 in the small intestine and much fsecal matter be 
 lodged between the point of occlusion and the anus. 
 Then, again, constipation is very usual in those cases 
 of partial obstruction of the intestine where a 
 segment of the bowel is suddenly and severely 
 nipped. This is well observed, as a rule, in Littre's 
 hernia, where only a part of the circumference of the 
 bowel is involved in the strangulation. Moreover, 
 constipation of a pronounced type is observed in in- 
 stances of pseudo-strangulation. 
 
 In cases of acute strangulation it is not infrequent 
 for the part of the bowel below the obstruction to be 
 emptied, and in examples where some catarrhal 
 action has been set up in this segment of the bowel 
 the patient may present the evidences of a copious 
 diarrhoea. 
 
 It is not infrequent in acute cases of obstruction 
 for a stool to be spontaneously passed just before 
 death. This may be derived from the bowel below 
 the occlusion, and may be due to certain altered 
 nerve conditions associated with impending death, or 
 the stool may be derived from the intestine above 
 the point of stoppage and may indicate the yielding 
 of the obstruction from perforation or by other 
 
Chap. XX.] The Symptoms : Anuria. 369 
 
 spontaneous means. Or the occlusion may have been 
 incomplete, and the nerve conditions that maintained 
 the constipation may have become modified as death 
 approached. 
 
 The amount of urine passed. — The state- 
 ment of Dr. Barlow, that the higher the obstruction is 
 situated in the intestine the less is the amount of 
 urine passed by the patient, has been fully combated 
 and shown to be incorrect. The anuria or oliguria so 
 often observed in instances of intestinal obstruction 
 does not depend upon the position of the incarceration 
 or occlusion, but upon its nature. 
 
 Anuria, or marked oliguria, is met with in 
 examples of acute obstruction, and, provided that the 
 general severity of the cases is the same, the symptom 
 is as marked when the strangulation involves the 
 sigmoid flexure as it is when it involves the jeju- 
 num. 
 
 It is true that in the great majority of cases of 
 acute obstruction the part involved is the small intes- 
 tine, while the greater number of the chronic cases 
 have a locality in the large intestine, yet this fact, 
 although it lias no doubt been the great cause of 
 error, can obviously not influence the statement just 
 made. 
 
 A like diminution in the amount of urine ex- 
 creted is met with in cases of severe injury to the 
 abdomen, in wounds involving the peritoneum, and 
 in violent attacks of hepatic colic. The symptom, 
 indeed, in these cases, as well as in the earlier stages 
 of acute obstruction, is one of the phenomena of shock, 
 and a direct result of the diminished pressure of the 
 blood in the aorta. It is well known, moreover, that 
 the amount of the renal excretion may be afiected by 
 nerve conditions other than those associated with col- 
 lapse. 
 
 Another cause of anuria in acute obstruction 
 Y— 12 
 
370 Intestinal Obstruction. [Chap. xx 
 
 depends upon the rapid withdrawal of water from the 
 body l>y the violent vomiting and l^y the not infre- 
 quently profuse sweating. The symptom, therefore, 
 is very often associated with another symptom, in- 
 tense thirst. 
 
 The influence of opium in increasing the amount 
 of the urinary excretion, when once it has been 
 seriously diminished, is often very marked. The 
 drug acts in this matter by modifying the effects of 
 shock, by stilling certain violent nerve movements, by 
 moderating peristalsis in the intestine, and by render- 
 ing the vomiting less copious and severe. " The 
 symptom of oliguria has a significance in the dif- 
 ferential diagnosis of the seat of the obstruction only 
 in cases of chronic and incomplete occlusions or con- 
 strictions of the intestine. If these are situated high 
 up, the amount of urine, for the same well-known 
 reason as in stenosis of the pylorus, is constantly 
 diminished, and this is not the case when the occlu- 
 sion is in the lower part of the ileum or in the colon " 
 (Leichtenstern). 
 
 The subject of meteorism will be discussed when 
 speaking of the symptoms, as modified by the position 
 of the obstruction. 
 
 Visible intestinal coils in movement form 
 a symptom often noted in intestinal occlusions, and 
 one that is of considerable diagnostic value. 
 
 The outlines of the convolutions and their peri- 
 staltic movements are not to be seen through the ab- 
 dominal walls in cases of acute obstruction, except in 
 very rare and exceptional instances. In examples of 
 chronic obstruction, however, this phenomenon is 
 quite common. It becomes, therefore, of much value 
 in differential diagnosis, and especially in heli)ing the 
 surgeon to distinguish between an acute attack that 
 has supervened upon a condition of chronic obstruc- 
 tion and an attack that has been acute from the first. 
 
Chap, xxi.i The Diagnosis. 371 
 
 The distinctness with which the intestinal coils are 
 seen when in movement depends mainly upon three 
 circumstances : upon the degree of emaciation of the 
 patient and the consequent thinness of the abdominal 
 parietes, upon the hypertrophy of the intestine above 
 the obstruction, and upon the extent of distension of 
 the hypertrophied coils. It will be evident that the 
 first two of these conditions are especially prone to be 
 associated with a chronic form of obstruction. 
 
 CHAPTEE XXI. 
 
 THE DIAGNOSIS OP THE DIFFERENT FORMS OP 
 INTESTINAL OBSTRUCTION. 
 
 The difficulties in the way of a complete diagnosis of 
 the various forms of intestinal obstruction are both 
 numerous and great. 
 
 In spite of the comparative frequency of the con- 
 dition, the simple recognition of its existence, quite 
 apart from any attempt at differentiating its various 
 aspects, is often a matter of considerable difficulty. 
 It is doubtful if any ailment of an equally common 
 nature has been the subject of so many errors in 
 diagnosis. Our knowledge of the pathology of the 
 affection is by no means imperfect, and yet an increase 
 in that knowledge has not been attended by a cor- 
 responding increase in our familiarity with the 
 clinical history of the condition. There are not many 
 maladies that present so slight a relationship between 
 pathological data and clinical data as does the general 
 subject of intestinal obstruction, while there are few 
 in which it is more important that that relationship 
 should be most intimate. 
 
372 Intestinal Obstruction. [Chap. xxi. 
 
 Many circumstances conspire to make differential 
 diagnosis in cases of obstruction a matter of peculiar 
 difficulty. In the first place, the different forms of 
 intestinal occlusion depend upon a number of very 
 diverse conditions. The bare list of the possible 
 forms of obstruction that are concerned in a complete 
 differential diagnosis is almost appalling. Then, again, 
 certain common symptoms are capable of being induced 
 by very many different causes, although those dif- 
 ferent causes may act probably in a common direction. 
 How many and diverse are the morbid conditions that 
 may excite simultaneously the gi^eat symptoms of ob- 
 struction, viz. pain, vomiting, and constipation ! 
 
 It must be remembered also how many anomalous 
 cases are met %\'ith that interfere sadly ^A\\\ any general 
 diagnostic conclusions. Thus, without making any 
 sj)ecial enquiries, I have found among the recorded 
 cases of intestinal obstruction that I have collected 
 no less than twenty-two examples of a double obstruc- 
 tion existing at the same time in a particular case. 
 In some of these instances the small intestine had 
 been occluded in two places while in other examples 
 an obstruction had involved both the large and the 
 small intestine at the same time. One can understand 
 also how any definite conclusions as to stercoraceous 
 vomiting as a means of diagnosis can be scattered to 
 the winds by a case of obstruction associated with 
 a fistulous communication between the colon and the 
 upper extremity of the small intestines. 
 
 Many of the errors in diagnosis are due to an 
 incomplete investigation. Every case should be sub- 
 jected to a systematic method of examination. The 
 previous history should be carefully studied, as well as 
 the precise mode of onset of tlie disease and the time 
 and mode of appearance of the principal symptoms. 
 In many of the recorded cases no information is fur- 
 nished as to the nature of the pain, as to its situation. 
 
Chap. XXI . J The Dia gnosis. 373 
 
 the duration of its attacks, their manner of commence- 
 ment - and of cessation, nor of tlie length of the in- 
 terval between given attacks of pain, nor of the 
 condition of the patient during those intervals. All 
 evacuations should be personally inspected, and re- 
 peated examinations of the abdomen made. A tumour 
 not evident at one time may be distinct a few hours 
 afterwards, and it is absurd to suppose that in any 
 given case all information derived from an examina- 
 tion of the belly is likely to be obtained during one 
 isolated inspection. 
 
 In no instance should the surgeon fail to examine 
 all the hernial orifices, and to make a complete 
 exj)loration of the rectum. 
 
 In discussing the different forms of intestinal 
 obstruction in a previous chapter, I have entered 
 with some detail into the nature of the symjitoms 
 that are associated with those various forms, and have 
 also pointed out many of the features essential to a 
 differential diagnosis. 
 
 In the present chapter I propose, with as little 
 repetition as j)ossiblc, to take a general view of the 
 whole subject with reference solely to the matter of 
 diagnosis, and to indicate the general scheme upon 
 which I venture to think that all attempts at diagnosis 
 may be most conveniently conducted. 
 
 For purposes of diagnosis all cases of intestinal 
 obstruction may be divided into three great classes or 
 divisions. 
 
 1. Cases oi^ acute ousthuction. 
 
 2. Cases oe chhonic obstruction. 
 
 3. Cases where symptoms of acute oustkuction 
 
 supervene uron those indicative of a chllonic 
 
 OliSTRUCTION. 
 
 This division is of course quite arbitrary, and it 
 may not always be easy to place a given case defi- 
 nitely in one of these three divisions. Many cases of 
 
374 Intestinal Obstruction. LChap. xxi. 
 
 intestinal obstruction adopt such a course as to enable 
 a division to be established for subacute forms. Such 
 examples, however, will be found to be made up of 
 forms of intestinal obstruction that usually adopt 
 either an acute or a chronic course. 
 
 1. ACUTE OBSTRUCTION. 
 
 Let it be supposed that a patient presents the 
 symptoms of acute obstruction. 
 
 The sym^Dtoms that he will display will be in 
 general terms as follows : He has been seized more or 
 less suddenly with severe abdominal pain. This pain 
 has been of the nature of colic. It may be constant 
 and liable to exacerbations, or be more or less dis- 
 tinctly intermittent. In any instance, the longer the 
 pain lasts the more does it tend to become constant 
 and continuous. The patient has vomited. The vom- 
 iting has appeared early, is copious and severe, and 
 may soon become stercoraceous. There is more or less 
 absolute constipation with some distension of the 
 abdomen. There is great constitutional depression 
 with evidence of the effects of shock. Symptoms such 
 as these may depend upon the following different forms 
 of acute obstruction : 
 
 A. Strangulation by bands or through apertures. 
 
 B. Volvulus of the colon. 
 
 C. Acute intussusception. 
 
 D. Some forms of obstruction by foreign substances. 
 
 A. Straiigiilatioii by bauds or tlu'oiigli 
 apertiu'es. — Under this heading are included the 
 following : 
 
 Strangulation bj" isolated peritoneal adhesions. 
 „ by omental cords. 
 
 „ by Meckel's diverticulum. 
 
 „ by normal structures abnormally attached, as 
 
 by an adherent appendix or Fallopian tube. 
 „ through sUts and apertures of various kinds. 
 
Chap. XXL] Acute Obstruction. 375 
 
 The instances of obstruction tliat come under this 
 heading form collectively more than one-fourth of all 
 the varieties of intestinal obstruction. 
 
 Sex. Age. — They are a little more common in 
 males than in females. Are most usually met with in 
 young adults, and are very rare after forty. 
 
 Previous history. — A distinct history of previous 
 peritonitis in 68 per cent. A history of previous 
 attacks of obstruction like to the present in 12 per cent. 
 
 Mode of onset. — Sudden in over 70 per cent. 
 
 Fain is the earliest or one of the earliest signs. 
 Is extremely severe, colicky, continuous, and per- 
 sistent. It may abate a little as the case advances. 
 It is very often situated about the umbilicus. 
 
 Local tenderness is usually quite absent at first, but 
 may come on in a few days. 
 
 Vomiting appears early ; is a marked symptom, 
 being constant, copious, and severe. In 60 per cent, 
 of the cases it becomes stercoraccous, on an average on 
 the fifth day. It affords the patient no relief. 
 
 Consti2Jation is continuous and absolute from the 
 first. Encmata may evacuate the contents of the 
 colon. No discharge of blood. 
 
 Prostration is marked. There is often profound 
 collapse, intense thirst, diminished urine, etc. 
 
 Tenesmus is absent. 
 
 Abdominal parietes flaccid, unless peritonitis has 
 set in. 
 
 Meteorism slight. Appears usually about the third 
 day. Involves first the epigastric and umbilical re- 
 gions in most cases. 
 
 Tumours or localised districts of dullness caused 
 by the distended and strangled loops are extremely 
 rare, and are in any case very indefinite. 
 
 Coils of intestine arc not visible. 
 
 The average duration of this variety is about five 
 days. 
 
376 Intestinal Obstruction. [chap. xxi. 
 
 Under this form of intestinal obstruction may also 
 be included the following (all very rare) : 
 
 Strangulation over bands. 
 
 Acute kinking of the small intestine. 
 
 Volvulus of the small intestine (certain cases). 
 
 Certain cases of tumour outside the bowel producing an 
 
 obstruction of the small intestine by sudden 
 
 pressure. 
 
 In the great majority of instances it will not be 
 possible to diagnose these difierent varieties from one 
 another, but all the facts that can be adduced in the 
 support of a differential diagnosis will be found noted 
 in the account of the symptoms that attend each 
 of these varieties. 
 
 B. Volvulus of the- colon. — This, with very 
 few exceptions, which will not be here considered, 
 involves the sigmoid flexure only. 
 
 Sex. Age. — Volvulus of the sigmoid flexure is 
 more common in males than in females in the propor- 
 tion of four to one. It is very rare before forty. The 
 patients' ages being usually between forty and sixty. 
 
 Previous history. — In nearly every case there is a 
 history of previous constipation. 
 
 Mode of onset. — Usually sudden. 
 
 Pain appears early. Is a marked symptom. Is 
 severe, but not usually so severe as in the previous 
 form. Is commonly intermittent at first, becoming 
 subsequently continuous but with exacerbations. Is 
 very often complained of about the umbilicus, and 
 later on about the region of the sigmoid flexure. 
 
 Local tenderness appears early over the region of 
 the distended coil of colon, and is constant. 
 
 Vomiting appears less early and is less marked 
 and severe than in the previous form of obstruction. 
 It may be absent. It is often scanty. Is feculent in 
 only 15 per cent, of all the cases. It may abate. It 
 often affords much relief to the patient. 
 
Chap. XXL] Acute Obstruction: 377 
 
 Constijmtion. — Early and absolute. No discharge 
 of blood. 
 
 Prostration not so marked as in the above form of 
 strangulation. There may, however, be marked col- 
 lapse, diminished urine, etc. The patient often suffers 
 from dysi^noea and a sense of suffocation, symptoms 
 not met with in the previous class of case. 
 
 Tenesmus is a marked feature in 15 per cent, of 
 the examples. 
 
 Abdominal parietes soon become rigid owing to the 
 early and almost constant appearance of at least local 
 peritonitis. 
 
 Meteorisin appears very early, increases rapidly 
 and becomes very extreme. The thoracic viscera are 
 often displaced by the distended intestines. 
 
 Tumours of a definite character are not met with ; 
 nor are coils of intestine visible. 
 
 The average duration is six days. 
 
 Under this form may also be included the follow- 
 ing (all rare) : 
 
 Volvulus of other parts of tiio colon (certain cases). 
 Cases of acute bending and kinking of an adherent colon. 
 
 The symptoms that may serve to distinguish these 
 different forms from one another will be found noted 
 in the accounts given of the clinical features of each 
 separate variety. 
 
 C. Acute iiitusstiisceptioii. — Sex. Age. Some- 
 what more common in males. Occurs mostly in the 
 young, and more than 50 per cent, of all cases are 
 under the age of ten years. 
 
 Previous history. — In a few rare instances there 
 is an account of previous attacks of obstruction due 
 probably to intussusception. 
 
 Mode of onset. — Sudden in 75 per cent, of the cases. 
 
 Pain. — One of the first symptoms. Is apt to be 
 severe at first, to increase up to a certain point, and 
 
378 Intestinal Obstruction. LCiiap. xxi. 
 
 then to subside. Is, on the whole, not so severe as in 
 cases of strangulation by bands, etc. Is at first 
 usually distinctly paroxysmal or continues with dis- 
 tinct exacerbations. It may be localised about a 
 tumour to be felt in the abdomen. 
 
 Local tetiderness about a tumour is common. 
 
 Vomiting does not appear so early as in the two 
 previous varieties of obstruction, and is usually by no 
 means so severe. In three-fourths of the cases it is 
 among the earlier symptoms, while in the remaining 
 one-fourth it does not appear until, on an average, the 
 third day. In 8 per cent, of acute and subacute 
 cases there is no vomiting. This symptom is more- 
 over liable to great fluctuations, and may be absent 
 for a while and then reappear. In 25 per cent, of the 
 cases the vomited matters become feculent, on an 
 average upon the fourth or fifth day. 
 
 Constipation. — Absolute constipation is extremely 
 rare. Constipation, as a conspicuous feature in the 
 state of the bowels, is noted only in 30 per cent, of 
 the cases. Diarrhoea is more usual, and in 80 per 
 cent, of the cases there is an evacuation of blood 
 from the anus. 
 
 Prostration. — In the more acute cases there is 
 much collapse, especially in the young, but on the 
 whole the amount of shock is less than in cases of 
 strangulation by bands. 
 
 Tenesmus is met with in no less than 55 per cent, 
 of the cases, and is often an early symi)tom. 
 
 The abdominal ^;arie^es are flaccid unless some 
 peritonitis has set in. 
 
 Meteorism is quite rare except in cases associated 
 with pronounced constipation. 
 
 Tumour. — A definite tumour having the dis- 
 tinctive character described in chapter x. is met 
 with in 50 per cent, of the cases. A tumour is fre- 
 quently to be felt in the rectum. 
 
Chap. XXI.] Acute Obstruction. 379 
 
 Coils of intestine arc not visible. 
 
 Tho av(;rago duration of ultra-acute cases is 
 twenty-four hours, of acute cases two to seven clays, 
 of subacute cases from seven to thirty days. 
 
 D. Ob!!»lru<;lion toy fofcigii bodies. — The 
 principal form of acute obstruction met with under 
 this h(!ading depends upon 
 
 Cjvall stones — It must be distinctly under- 
 stood, however, that the great majority of gall stones 
 are passed along the intestine without producing any 
 symptoms, and that many in their passage cause but 
 insignificant symptoms. In other instances the stone 
 remains in the intestine quiescent for a long time, 
 and in another set of cases evidences of chronic ob- 
 struction are produced. 
 
 In a few examples the biliary calculus may cause 
 acute obstruction. In such cases it will be found 
 lodged in the duodenum, jejunum, or more usually in 
 the lower ileum. 
 
 Sex. Afje. — Gall stones are much more common in 
 females than in males. The average age is fifty- 
 seven years. 
 
 Previous histo7"ij. — Gall stones may have been 
 passed previously. In many cases, however, there is 
 no liistory of an antecedent hepatic colic. There may 
 have })een evidences of local peritonitis about the gall 
 bladder. There will probably have been previous 
 attacks of acute obstruction, which will have passed 
 off after varying short periods. 
 
 Nature of attack. — The onset is usually abrupt. 
 There is severe pain of a continuous character, with 
 exacerbations. 
 
 The pam is seldom so severe as in strangulation 
 by bands. 
 
 Vomiting appears early, is often copious, and may 
 in time become stercoraceous. 
 
 There is absolute constipation. 
 
380 Intestinal Obstruction. [Chap. xxi. 
 
 The average duration of an acute fatal attack is 
 seven days. 
 
 In the intervals between the various attacks of 
 acute or subacute obstruction the patient will prob- 
 ably have suffered from indigestion, irregular action 
 of the bowels, and the like. 
 
 Under this heading may also be included : 
 
 Some cases of obstruction by foreign bodies that have 
 
 been swallowed. 
 Some cases of obstruction by enteroHths. 
 
 In the case of the foreign body there will usually 
 be the history of a substance swallowed. 
 
 When in the alimentary canal such substances 
 may produce the same effects as have been just de- 
 scribed as occurring in cases of gall stones. 
 
 Enteroliths lodge mostly in the caecum or colon. 
 In quite exceptional cases they may cause acute 
 obstruction. An account of such cases is given with 
 the account of intestinal calculi. The symptoms are 
 simply those of acute obstruction of the nature in- 
 cident to acute occlusion by gall stones. In some 
 cases fragments of the concretion have been passed. 
 In other instances the mass has formed a tumour that 
 could be appreciated through the parietes. 
 
 2. CHRONIC OBSTRUCTION. 
 
 The causes of chronic obstruction of the bowels are 
 very numerous and pathologically very varied. For 
 diagnostic purposes the cases may be divided into the 
 four following classes : 
 
 A. Stricture of the small intestine. 
 
 B. Stricture of the large intestine. 
 
 C. Faecal accummulation. 
 
 D. Chronic intussusception. 
 
 A. Stricture of tlie small iiitcstiiio. — Sex. 
 
 Age. In the matter of sex there is nothing to notice. 
 Non-cancerous strictures usually occur about early 
 
Chap, xxi.j Chronic Obstruction. 381 
 
 middle life ; while cancerous strictures are very rare 
 before forty. 
 
 Previous history. — In non-cancerous cases there 
 will often be a history of ulcer of the intestine or of 
 conditions that may lead to destructive changes in the 
 gut, e.g. tuberculosis, dysentery, injury, strangulated 
 hernia, typhlitis (involving the ileum). 
 
 Course. — The onset is usually gradual. The course 
 of the malady is peculiarly irregular. Acute attacks 
 of obstruction are apt to appear from time to time, 
 and the case is often fatal through an acute obstruc- 
 tive attack. 
 
 Pain. — The pain is distinctly intermittent, long 
 intervals of absolute freedom from suffering often in- 
 tervening between the attacks. As the intervals 
 between the paroxysms shorten the attacks become of 
 longer duration. These intervals may, in the earlier 
 periods of the case, amount to many days or even 
 weeks. The earlier attacks of pain are slight, and 
 usually ascribed to indigestion, flatulence, etc. They 
 are very usually provoked by food, and especially by 
 indigestible food. As time advances, the attacks be- 
 come more and more frequent, and more and more 
 severe. Wlien complete obstruction sets in, as in 
 a definite attack of acute obstruction, the pain becomes 
 continuous, but with exacerbations. 
 
 There is, in uncomplicated cases, no definite local 
 tenderness. 
 
 Vomiting. — During the earlier attacks of pain 
 there may be nausea. In the more severe attacks the 
 patients vomit. The vomiting is often provoked by 
 food. It is late to appear, is often scanty, and is 
 rarely feculent, except towards the end of an acute 
 obstructive attack. In the interval between attacks 
 of pain the patient either feels well, or complains of 
 indigestion or some nausea, and trouble with the 
 bowels. 
 
382 Intestinal Obstruction. [chap. xxi. 
 
 Constipation is a leading symptom in 60 per cent, 
 of the cases. In 40 per cent, there is constipation, alter- 
 nating with diarrhoea. During the more abiding acute 
 attacks the constipation becomes absolute. In cases 
 of cancerous stricture blood may, as a rare circum- 
 stance, be passed by the anus. 
 
 General condition. — The patient becomes emaci- 
 ated, especially in the carcinomatous cases, and is 
 worn out by the continued pain and digestive dis- 
 turbances, Durmg the more severe acute attacks 
 there may be prostration, amounting in some cases to 
 collapse. 
 
 Teiwsmus is absent. 
 
 The abdominal i^cirietes remain flaccid, unless peri- 
 tonitis be present. 
 
 Meteorism is absent except during the attack and 
 during absolute constipation. 
 
 Tumours. — In non-malignant cases no tumour is 
 to be felt. In the cancerous cases a tumour is to be 
 felt in 30 per cent, of the examples. 
 
 Coils of intestine. — The movements of coils of 
 hypertrophied intestine are visible through the 
 parietes, especially during attacks of colicky pain. 
 This symptom is the inore distinct the more marked 
 the emaciation. 
 
 The average duration of the cases taken together 
 is from three to five months. 
 
 With this form of intestinal obstruction the 
 following diflerent varieties may be associated for 
 diagnostic purposes : 
 
 1. Some cases of bonding of adherent small intestine. 
 
 2. Some cases of adhesions binding- a portion of the bowel 
 
 into a fixed loop. 
 
 3. Cases of compression of the giit by adhesions. 
 
 4. Cases of matting together of several coils of intestine. 
 6. Cases of narrowing of the gut from shrinking of an 
 
 inflamed mesentery. 
 6. Cases of stenosis as an effect of traction. 
 
Chap. XXI.] Chronic Obstruction. 383 
 
 7. Some instances of volvulus. 
 
 8. Obstruction by neoplasms. 
 
 9. Some cases of obstruction by gall stones and foreig-n 
 
 bodies. 
 10. Some cases of compression by a tumour outside the gut. 
 
 All these forms of intestinal obstruction may pre- 
 sent symptoms that more or less closely resemble one 
 another, and that may be considered to find their 
 typical representation in a case of stricture of the 
 lesser bowel. In each instance it will be noted that 
 there is some permanent but partial occlusion of the 
 intestine. 
 
 The resemblance between these various forms of 
 intestinal obstruction is very commonly so close that 
 a certain difierential diagnosis is impossible. 
 
 Any distinctive features (such as they are) that 
 may be associated with any of the above forms of 
 obstruction will be found detailed in the account 
 given of each of these varieties in the previous parts 
 of this work. 
 
 In the first four forms there will probably be some 
 history of a local peritonitis that gave rise to the adhe- 
 sions producing the obstruction. In the fifth form 
 there may be the same feature in the previous history, 
 or some evidence of mesenteric gland disease. In the 
 ninth form there will be the history associated with 
 gall stones and foreign bodies, to which attention has 
 just been directed. In the tenth variety, the tumour, 
 which will probably have origin in the pelvis, may, in 
 many instances, be obvious upon examination. 
 
 B. Stricture of the large intestine. — In these 
 cases the symptoms are very similar to those asso- 
 ciated with stenosis of the small intestine. In the 
 matter of sex and age and previous history there are 
 the same circumstances to be noted that have been 
 alluded to in the previous paragraph. 
 
 The course of the malady is attended by a similar 
 
384 Intestinal Obstruction. [Chap. xxi. 
 
 irregularity, and by the same kind of paroxysmal 
 attack. The character of the pain is the same, although 
 upon the whole it is less severe. Vomiting appears 
 with less frequency, is often absent, and in any 
 instance supervenes at a later period. It is usually 
 less profuse than is the case in stenosis of the lesser 
 bowel. It never becomes stercoraceous except after 
 many days of absolute constipation. Unlike what is 
 the case in stricture of the small intestine, the symp- 
 toms, when the colon is involved, are usually but little 
 affected by food. 
 
 The hoimls are usually in a condition of constiiDa- 
 tion, and the size and outline of the motions is 
 frequently altered. 
 
 Tenesmus is very commonly present. Aperients 
 often give relief in cases of stricture of the small 
 intestine, but are apt to aggravate the symptoms 
 when a like narrowing involves the colon. In cases 
 of cancerous stricture, diarrhcea with constipation is 
 common, and in 15 per cent, of the examples there 
 was a hloocly discharge from the anus. Tenesmus is 
 especially marked in such cases as are associated 
 with diarrhoea. 
 
 Meteorism is often very pronounced, and the coils 
 of intesti7ie are visible through the wasted parietes. 
 In cases of simple stricture no tumour is to be felt, 
 but in the cases of malignant disease a tumour is to 
 be detected through the abdominal walls in no less 
 than 40 per cent, of the examples. 
 
 With this form the following different varieties 
 may be associated for diagnostic pur})oses : 
 
 1. Some cases of bending of adherent colon. 
 
 2. Compression of the gut by adhesions. 
 
 3. Some cases of volvuhis of the caecum. 
 
 4. Obstruction by neoplasms. 
 
 5. Compression by a tumour outside tlie gut. 
 
 6. Some cases of enterolith. 
 
Chap. XXL] Chronic Obstruction. 385 
 
 Tlie symptoms associated with these clifTerent 
 varieties will be found detailed in the accounts given 
 of them in previous chapters. These symptoms gene- 
 rally accord with those of stricture of the colon, and 
 the features in the differential diagnosis are not 
 well marked. Some diagnostic value attaches to the 
 previous history of the patient, as has been already 
 pointed out in connection with the different forms 
 of obstruction that resemble stricture of the lesser 
 bowel. 
 
 C. Faecal accuinulatioiis.— This form of ob- 
 struction is mostly met with in adults, and more 
 frequently in females than in males. It is especially 
 common among lunatics, and the subjects of hysteria 
 and hypochondriasis. 
 
 The symptoms consist mainly in a gradually in- 
 creasing constipation, which more and more resists 
 the action of aperient medicines. The patient's 
 appetit(3 declines, his tongue becomes foul, he is liable 
 to eructations and nausea, and often feels languid and 
 depressed. 
 
 As the case advances, the abdomen becomes more 
 and more distended. Some of the coils of intestine 
 are visible through the parietes. The ^accumulated 
 fajcal masses may press upon the lumbar or sacral 
 nerves, or upon the iliac or pelvic veins, and so pro- 
 duce certain symptoms as a direct result of that 
 pressure. 
 
 As the obstruction becomes more complete, the 
 abdomen may become painful. This pain will assume, 
 at first at least, a paroxysmal character, becoming, 
 later on, continuous, but with exacerbations. Vomit- 
 ing may occur. It appears late, comes on very 
 gradually, is scanty, and rarely becomes feculent 
 unless the obstruction have remained absolute for a 
 considerable period. 
 
 The patient may be liable from time to time to 
 z— 12 
 
386 Intestinal Obstruction. [Chap. xxi. 
 
 obstructive attacks associated with pain and vomiting, 
 which are usually soon relieved by enemata. 
 
 The diagnosis is assisted by the history of the 
 case, by the account given by the patient of long-con- 
 tinued and increasing constipation, and possibly also 
 of certain previous obstructive attacks that have been 
 relieved by eneinata. 
 
 The most important feature, however, in the 
 diagnosis is the faecal tumour. This mass is usually 
 most distinctly marked when it occupies the caecum. 
 Its characters are ])ronounced, and have been fully 
 described in the account of obstruction by fsecal masses 
 given in chapter xix. 
 
 At almost any time the patient may develop the 
 symptoms of acute obstruction. This depends upon 
 an absolute blocking of the intestine as a result of 
 paralysis of a portion of it. An account of this form 
 of obstruction is given under the title of ileus 
 paralyticus. 
 
 D. Chronic iiitussiisceptioii.— No form of in- 
 testinal obstruction offers so many difficulties in the 
 way of its recognition as does chronic intussusception, 
 and no form has been the subject of more errors in 
 diagnosis. 
 
 The term is applied to cases having a duration of 
 not less than one month. The cases may last for 
 many months. The course of the malady is extremely 
 irregular. There may be at one time constipation and 
 at another diarrhoea, at one time pain and at another 
 none. There is, moreover, no method in this irre- 
 gularity. 
 
 Sex. Age. — These cases are met with more fre- 
 quently in males than in females, and are most 
 common during the period of active adult life. 
 
 The mode of onset is sudden or abrupt in about 35 
 per cent, of the cases, the symptoms subsequently 
 becoming more chronic. This feature when present is 
 
ciiap. XXI.] Chronic Obstruction. 387 
 
 of much value when diagnosing this from other forms 
 of cljronic obstruction. 
 
 Fain is distinctly intermittent, and for long in- 
 tervals may he entirely absent. These intervals 
 become shorter as the disease advances, while the 
 duration of the attacks of pain is increased. The pain 
 is seldom severe, and is often, indeed, insignificant. 
 
 Vomiting is a marked feature in only a little over 
 50 per cent, of the cases. In 6 per cent, it is entirely 
 absent throughout the progress of the disease. It is 
 very irregular in its appearance, and commonly coin- 
 cides with the attacks of paroxysmal pain. It is 
 seldom copious or distressing, and is feculent only 
 in about 7 per cent, of the cases. It may be induced 
 in the earlier stages, and made worse in the later 
 stages, by food. 
 
 Constipation. — The state of the bowels varies 
 greatly. They may be normal. As a rule they are 
 irregular, sometimes with a tendency to constipation, 
 but more frequently with a tendency to diarrhcea. In 
 no less than 50 per cent, of the cases a bloody dis- 
 charge from the anus is to be expected. 
 
 In about 13 per cent, of the examples of this 
 afiection there is marked tenesmus. 
 
 General condition. — The patient wastes, becomes 
 cachectic and anaemic, and not infrequently dies of 
 exhaustion and marasmus. 
 
 The abdominal walls are quite flaccid. 
 
 Meteorism is absent except during attacks of tem- 
 porary obstruction or during pronounced constipation. 
 In any case it will be quite slight. 
 
 Coils of intestine are often very clearly seen in 
 movement through the wasted parietes. 
 
 Tumours. — An abdominal tumour of a more or less 
 distinctive character is to be felt in about one half of 
 the cases. In 32 per cent, of the examples the invagi- 
 nated mass reached the rectum. 
 
388 Intestinal Obstruction. [Chap. xxi. 
 
 3. CASES WHERE AN ATTACK OF ACUTE OBSTRUCTION 
 SUPERVENES UPON SYMPTOMS INDICATING A CHRONIC 
 OBSTRUCTION. 
 
 There is no one of the many forms of chronic ob- 
 struction alluded to in the preceding paragi-aphs in 
 which there may not abruptly develop all the evidences 
 of acute occlusion. So important is it to recognise 
 these cases that I have ventured to make of them a 
 special class. 
 
 If the acute obstructive attack develop wliile the 
 case is under the observation of the surgeon there can 
 of course be no difficulty in the diagnosis. If, however, 
 the patient is seen for the first time during the height 
 of one of such attacks, then the symptoms may be very 
 readily considered to depend upon one or other of the 
 pathological conditions that lead to acute strangula- 
 tion. Thus the abdomen has been opened under the 
 impression that a coil of intestme was strangulated by 
 a band, and the primary cause of the occlusion found 
 to be a stricture of the bowel. It might be said at 
 once that there is no one special form of intestinal 
 obstruction that can be placed in this class and in no 
 otlier. There is no form of chronic obstruction of the 
 bowels that invariably leads to an acute attack. 
 
 The most common varieties of chronic obstruction 
 are those that depend upon fiecal accumulation and 
 upon stricture of the colon. In the former, the con- 
 dition known as ileus paralyticus may at any moment 
 develop, and the surgeon be confronted with a form of 
 intestinal obstruction that often presents very pro- 
 nounced and violent features. In connection with 
 strictures, also, the case may proceed quietly for 
 months, the stenosed part becoming narrower and 
 narrower, and the symptoms more and more clearly 
 defined. Suddenly the patient develops an acute 
 attack of ileus; and if death results the gut will 
 
Chap. XXL] Chronic Obstruction. 389 
 
 be found to have become suddenly occluded at the 
 narrowest part. This occlusion may be due to kinking 
 or to acute bending of the bowel, or to blocking of 
 the stricture by some foreign substance, or by a fsecal 
 mass or a mass of undigested food. If the stricture 
 involve the upper parts of the rectum then the dis- 
 tended sigmoid flexure above the stenosis may be found 
 to have become twisted upon itself, and to have 
 brought about the condition of volvulus. 
 
 In the less common forms also of chronic obstruction 
 the same conditions may be met with. Thus, chronic 
 intussusception very often ends in an acute attack 
 which may prove rapidly fatal. Coils of intestine 
 matted together by adhesions may become suddenly 
 occluded by bending or kinking, at one or more points, 
 and so lead to acute manifestations. A case of 
 chronic volvulus, or of volvulus associated with slight 
 symptoms, may, as a result of distension or of para- 
 lysis, become at any moment an example of acute 
 volvulus with the appropriate symptoms. Any portion 
 of the bowel partially occluded by compressing ad- 
 hesions or by a tumour outside its walls, or by a 
 neoplasm or a foreign substance within its lumen, may 
 become at a moment completely obstructed by any of 
 the causes just referred to when speaking of the sudden 
 occlusion of strictures. 
 
 The patient may have many of such attacks, and 
 these very often exhibit an increasing degree of 
 severity. 
 
 With regard to the diagnosis between these quasi- 
 acute attacks and cases of acute strangulation of the 
 bowel, such as may be due, for example, to bands, the 
 most important factor is the patient's past history. 
 There will be usually a history of such symptoms as 
 have been described as incident to chronic obstructions, 
 and there will probably have been previous attacks of 
 like character but of less pronounced severity. 
 
39° Intestinal Obstruction. [Chap. xxi. 
 
 These attacks also are distinctly less abrupt and 
 less violent than are the examples of acute strangula- 
 tion. The pain is usually by no means so severe, nor 
 is the condition of prostration so marked. To one 
 sign, however, in the differential diagnosis too much 
 importance can scarcely be attached. It is this. In 
 the acute attack supervening in a chronic case, the 
 coils of intestine may be visible through the thinned 
 parietes, a symptom that will be absent in cases of 
 primary acute obstruction. In the former variety of 
 case the symptom may be lost sight of if the meteor- 
 ism become extreme, or if peritonitis develop, and it 
 may be rendered much less distinct if the peristaltic 
 movements have been moderated by the use of opium. 
 
 There are unfortunately a few rare cases in which 
 the presence of a partial obstruction of the intestine is 
 revealed for the first time by an acute attack. That 
 is to say, a stricture exists in the intestine (most pro- 
 bably in the small intestine), but it has not yet so 
 narrowed the lumen of the tube as to cause symptoms. 
 On a sudden, however, the stenosed part becomes 
 blocked by a mass of undigested food, or the bowel 
 becomes occluded by kinking at the seat of stricture, 
 and symptoms are thereby produced that assume at 
 once an acute character. An acute attack occurring 
 under these circumstances may be fatal, and there are 
 cases recorded where a stricture of the small intestine 
 has revealed itself by one attack of rapidly developing 
 obstruction which has ended in death. The diagnosis 
 of such a case would in the present state of oui* 
 knowledge be an impossibility. 
 
391 
 
 CHAPTER XXII. 
 
 THE SYMPTOMS AS MODIFIED BY THE POSITION OF THE 
 OBSTRUCTION. 
 
 The questions to be considered nnder tins heading 
 practically resolve themselves into an examination of 
 the clinical differences between obstruction situated in 
 the small and in the large intestines. 
 
 The differences between cases of stoppage situated 
 in these two segments of the bowel have frequently 
 been described in great detail, but I think that the 
 supposed distinctions laid down are often entirely 
 fallacious. 
 
 It is true that the larger number of the cases 
 of obstruction of the colon tend to assume a chronic 
 course, while the larger number of cases situated in 
 the small intestine tend to take on an acute character. 
 Thus, a very slight observation of a series of in- 
 stances of intestinal occlusion may appear to demon- 
 strate conspicuous differences between an obstruction 
 in the large intestine and one in the small. 
 
 When, however, cases of like degree are com- 
 pared, when cases of chronic obstruction in the colon 
 are compared with chronic cases involving the lesser 
 bowel, and when acute obstructions in the one seg- 
 ment are compared with like obstructions in the other, 
 it will be fomid that the great bulk of the fancied dis- 
 tinctions entirely disappears. Thus it would seem to 
 be commonly supposed that obstructions of the colon, 
 when compared with those of the small intestine, are 
 apt to assume a tardy course, to be associated with 
 comparatively little pain, and with a slighter degree 
 of constitutional disturbance, and to be attended by 
 
392 Intestinal Obstruction. [Chap. xxii. 
 
 vomiting that appears late and is much less profuse 
 and distressing. 
 
 This will be true as regards the more common 
 forms of obstruction of the colon, but it does not apply 
 to the acute forms. A case of volvulus of the sigmoid 
 flexure may present symptoms as violent and as 
 rapidly developed as any met with in cases of acute 
 strangulation of the small intestine. Indeed, the 
 more extensive the comparison between obstructions 
 in the large and obstructions in the small intestine, 
 the more distinctly does it become evident that the 
 clinical distinctions are not emphatic, and that they 
 depend more upon the nature of the occlusion than 
 upon its situation. 
 
 Still, however, after all these reservations have 
 been made, it will be found that there are a few 
 features that may be made a basis for comparison in 
 cases of a fairly equal degree of severity, although it 
 is desirable that their individual ^'alue should not be 
 over-estimated in diagnosis. 
 
 In comparing obstructions of the colon with those 
 of the lesser bowel, it is desirable, in the first place, to 
 note the physiological differences between these two 
 segments of the alimentary canal. The small intes- 
 tine is active and very vigorously concerned in the 
 business of the organism, it takes a large and im- 
 portant share in the process of digestion, its walls are 
 muscular, its blood-vessels are numerous, and its 
 nerves, ha^^ng origin from the superior mesenteric 
 plexus, are brought into very direct connection with 
 the creat nerve-centres of the abdomen. On the other 
 hand, the function of the large intestine is to a great 
 extent passive. It serves as a receptacle for the 
 contents of the bowel, so that long intervals may 
 elapse between the evacuation of those contents. In 
 one sense the ileo-c?ecal valve may be regarded as a 
 kind of internal anus. An accumulation of matter in 
 
Chap. XXII.] The Diagnosis of the Seat. 393 
 
 the small intestine soon causes distress, but such accu- 
 mulations in the colon are, within certain limits, 
 normal. The large intestine is not so muscular as the 
 small, nor so freely supplied with blood. Its nerves 
 also are in great part derived from the inferior mesen- 
 teric plexus, and have thus a comparatively indirect 
 connection with the principal abdominal nerve 
 centres. Such parts of the colon as are supplied by 
 the superior mesenteric plexus are supplied by the 
 filaments of that plexus that are most remote from the 
 main source of origin of the nerves. It is said also 
 that the intraparietal nerve plexuses of the intestine 
 are more elaborately developed in the small than in 
 the large intestine. Lastly, the colon has a less ex- 
 tensive connection with the peritoneum, and has 
 therefore a correspondingly less elaborate nerve re- 
 lation. 
 
 From all this it would appear that life is more 
 active in the small gut than in the large ; processes in 
 the former are more vigorous, and morbid changes are 
 likely to show an equivalent degree of activity in the 
 lesser bowel ; moreover, one may expect to find all 
 reflex nerve movements carried on with a much 
 greater alacrity than in the colon. 
 
 This last matter, however, is somewhat modified 
 by the peritoneum. There is no evidence to show 
 that there is any anatomical or physiological differ- 
 ence between the serous membrane as it covers the 
 small intestine and as it covers the colon. When, in 
 two cases of obstruction (one in the small gut and 
 one in the large), an equal amount of peritoneum is 
 damaged to an equal extent, it may be anticipated 
 that the nerve disturbances arising from that lesion 
 will not be very dissimilar. And in connection with 
 this matter it is noticeable that the form of obstruc- 
 tion of the colon that most closely resembles acute 
 strangulation of the small intestine is volvulus of the 
 
394 Intestinal Obstruction, tchip. xxii. 
 
 sigmoid flexure, where, as is well known, a very ex- 
 tensive surface of peritoneum is involved 
 
 In these cases it would appear that the greater 
 surface of serous membrane involved in the volvidus, 
 as compared with the amount usually implicated in 
 small gut strangulations, has been able to overbalance 
 the anatomical differences between the large and small 
 intestine as regards their ability to form the basis of 
 symptoms. 
 
 After these preliminary remarks, a comparison 
 may now be made between the clinical features of ob- 
 structions in the large and small intestines. 
 
 Pain. — In the small intestine the pain usually 
 appears earlier, is more pronounced, more abiding, 
 and more severe. 
 
 Vomiting. — In the small intestine, as compared 
 with the large, this symptom appears earlier, is more 
 distressing, and is more persistent. In the obstruc- 
 tions of the lesser bowel the vomited matters are often 
 copious, are apt to be influenced by food, and more 
 readily become feculent than is the case when the 
 stoppage is in the colon. Vomiting due to trouble in 
 the large intestine may become irregular, may cease 
 for awhile, and may be comparatively slight. 
 
 Constitutional disturbance is, other things being 
 equal, certamly more marked in small gut obstructions 
 than in those of the colon. There is a gi'eater ten- 
 dency to severe collapse, and consequently a more 
 frequent appearance of the various remote phenomena 
 connected with shock. 
 
 Meteorism. — When the lower part of the small 
 intestine is obstructed, the meteorism first shows itself, 
 and remains for awhile most marked, in the hypo- 
 gastric, epigastric, and umbilical regions. In typical 
 cases the abdomen presents the appearance of a six 
 months' pregnancy, and the flanks and iliac fossfe are 
 depressed. This symptom, however, is of no great 
 
Chap. XXII.] The Diagnosis OF THE Seat. 395 
 
 value, for the appearance may be almost exactly 
 imitated by a distension of the sigmoid flexure, when 
 that part of the gut forms a large coil, which projects 
 towards the middle line of the abdomen. 
 
 When the lower part of the colon is involved the 
 meteorism will attain a much greater degree than it 
 does in small gut obstructions. Indeed, upon the 
 whole, it may be said that meteorism is less in the 
 latter cases than in the former. 
 
 Distension of the colon, especially when with solid 
 matters, may map out very precisely the anatomical 
 outline of the bowel and leave the central parts of the 
 abdomen comparatively undistended. In any case, 
 however, the meteorism tends to become general, and 
 any appearances that may be regarded as typical are 
 soon lost. In diagnosing acute volvulus of the sigmoid 
 flexure from some acute strangulation of the small in- 
 testine, great importance attaches to the rapid deve- 
 lopment of a high grade of meteorism in the former 
 affection. 
 
 Apart from this point in diagnosis, I do not think 
 that anything like the importance attaches to meteor- 
 ism as a means of diagnosis that has been ascribed to 
 it. In certainly the great majority of cases the rules 
 given in connection with this matter in many text- 
 books and monographs are not reliable. 
 
 In obstruction situated in the up2:)eT ixirt of the je- 
 junum and in the duodenum we find that the symp- 
 toms are more distinctly influenced by the seat of the 
 stoppage. In acute cases collapse appears early and 
 assumes a grave degree, and the progi-ess of the case 
 is usually rapid and deliberate. In any case vomiting- 
 is among the earliest symptoms. The matters vomited 
 are usually very copious, are always stained with bile, 
 and never become feculent. The vomiting then gives 
 temporary relief, and is, with the other symptoms, 
 often distinctly aggravated by taking food. There 
 
396 Intestinal Obstruction. [Chap. xxii. 
 
 may be no meteorism and the abdomen may indeed be 
 even retracted. When meteorism is present it will 
 be slight in degi'ee, limited to the epigastrium, and 
 apt to be greatly diminished by a copious vomiting. 
 In cases of chronic obstruction there will be evidences 
 of ectasia of the stomach. 
 
 It now remains to consider certain means of inves- 
 tigation that have been adopted with the especial 
 object of diagnosing obstructions of the large and of 
 the small intestine from one another. These means 
 are : 1 , enemata ; 2, the passage of the long tube ; 
 3, auscultation of the colon. 
 
 1. Eiicmata. — A great deal has been written by 
 various authors npon the value of enemata as a means 
 of diagnosing the seat Of the obstruction. The feature 
 in this method consists in a comparative estimation of 
 the amount of water that can be held by certain 
 segments of the bowel. Thus elaborate statements 
 have been made to the effect that if a certain amount 
 of water can be readily injected then the obstruction 
 must be in the sigmoid flexure, if a certain additional 
 quantity can be introduced then the stoppage must be 
 in the descending colon, and finally if a certain number 
 of ounces or pints can be received then the whole of 
 the large intestine must be occupied and the occlusion 
 must be situated in the small bowel. Dr. Brinton, for 
 example, has given very detailed instructions upon 
 this head. The statements are usually based upon ex- 
 periments made upon the cadaver with reference to 
 the actual amount of fluid that various segments of 
 the colon can accommodate. 
 
 For diagnostic purposes this method is, I venture to 
 think, absolutely useless. In the first place, observa- 
 tions made upon the cadaver, where the parts are 
 relaxed and where muscular action has ceased, are not 
 likely to be identical with those made upon the living 
 subject. The method, moreover, does not take into 
 
Chap. xxiT.] The Diagnosis of the Seat. 397 
 
 consideration the condition of the bowel below the 
 obstruction. This part of the tube may be dilated or 
 contracted, may respond vigorously to certain forms of 
 irritation or remain absolutely inert. Then, again, as 
 Dr. Hilton Fagge has pointed out, there are certain 
 strictures, especially those associated with some bend- 
 ing of the gut or with a valvular arrangement of the 
 mucous membrane above the stenosed part, through 
 which water may be injected from below while fluids 
 above the stricture are unable to find a way to escape. 
 I have myself in many cases had an opportunity of 
 verifying the fallacies in this reputed method of 
 diagnosis, and many published cases serve also to 
 illustrate these errors. As an example I may cite one 
 instance of stricture of the sigmoid flexure where over 
 three pints of water were introduced by an enema 
 and were retained for twenty-five minutes. This 
 large quantity of fluid must have been accommodated 
 in the rectum, since the autopsy revealed that none 
 had passed beyond the stricture."^ 
 
 2. The passag:c of tlie loiig^ tube. — In this 
 method a flexible tube or sound is passed into the 
 rectum, and an attempt is made to diagnose the seat 
 of the obstruction by noting to what distance the tube 
 can be introduced. This procedure applies mainly to 
 stenosis of the lower part of the colon. As a means 
 of diagnosis it is, I believe, entirely valueless. In 
 some cases the sound has lodged early in its career 
 against a fold of mucous membrane, and the diagnosis 
 of an obstruction low down in the bowel has been in 
 consequence made. In other instances in stricture of 
 the termination of the sigmoid flexure the tube has 
 reached the upper extremity of the rectum, and has 
 then turned upon itself, or become coiled up in the 
 rectal ampulla, until so much has been introduced that 
 the whole of the colon downwards from the splenic 
 * Path. Soc. Trans., vol. vii., page 207. 
 
398 Intestinal Obstruction. [Chap. xxii. 
 
 flexure has been diagnosed to be free from obstruc- 
 tion. I have good reasons for doubting if these rectal 
 sounds ever go beyond the sigmoid flexure. This im- 
 pression is fully confirmed by experiments made upon 
 the dead body. If the segment of the colon that forms 
 the sigmoid flexure and the free part of the rectum be 
 uncoiled it will appear in the form of a large loop of 
 intestme extending from the psoas muscle to the spot 
 where the rectum becomes fixed opposite about the 
 middle of the sacrum. This loop has the outline of a 
 capital omega, and is usually provided with an exten- 
 sive mesentery. Such is occasionally the length of this 
 mesentery that the summit of the omega loop can be 
 made to touch the caecum or to reach the level of the 
 umbilicus. In some examples I have found this loop 
 to be from eighteen to twenty inches in length. If 
 the lonof tube be introduced into such a coil its 
 extremity may reach the level of the umbilicus and 
 yet not have passed beyond the sigmoid flexure. In 
 one case that I saw in an emaciated subject with 
 chronic obstruction, the surgeon passed a long tube, 
 and demonstrated with triumph that its end could be 
 felt near the umbilicus. He maintained that the in- 
 strument had reached the centre of the transverse 
 colon, and that the bowel below that point was free. 
 The autopsy that came to pass in due time revealed 
 an impervious stricture of the commencement of the 
 sigmoid flexure where it joined the descending colon. 
 Apart from this, this present method of diagnosis takes 
 no account of abnormalities in the colon. Even if it 
 be presumed that the sound has found its way into 
 the sigmoid flexure, it may then have reached one of 
 tliose very extensive and tortuous coils that are at times 
 found to represent this segment of the lai'ge intestine. 
 3. Auscultation of the colon. — This method 
 of investigating the intestine is of much value, and is 
 hardly estimated at its proper importance. 
 
Chap. XXII.] The Diagnosis of the Seat. 399 
 
 It consists in auscultating the region of the colon 
 and ca?cum while fluid is being introduced into the 
 rectum by means of an enema syringe. If the colon 
 be entirely clear, and the stethoscope be placed over 
 the caecum, the water can be heard to reach that part, 
 and if such be the case pretty conclusive evidence is 
 afibrded that the obstruction, wherever it may be 
 placed, is at least not in the large intestine. 
 
 I have had several opportunities, both in the 
 healthy subject and in individuals suffering from 
 intestinal olDstruction, of testing the value of this 
 method of investigation. In making use of this means 
 it is very desirable that the surgeon should first 
 familiarise himself with the various sounds that may 
 be heai'd in the abdomen, especially in the subjects of 
 obstruction. Certain borborygmi closely imitate the 
 noise made by the enema as the water passes along the 
 bowel. Moreover, when the injection is forcibly ad- 
 ministered there is some little difficulty at first in 
 localising the sound it makes, since the noise of the 
 rush of water may be heard over nearly every part of 
 the abdomen. The enemata should be quietly intro- 
 duced, and the water injected be without any admix- 
 ture with air. If the injection be made in an inter- 
 mittent manner the particular sound caused by the 
 enema may be more readily differentiated. The sound 
 of water passing into theciecum must be distinguished 
 from that made by the first rush of the fluid from the 
 enema tube into the rectum. 
 
400 
 
 CHAPTER XXIII. 
 
 THE VARIOUS AFFECTIONS THAT HAVE BEEN MOST 
 FREQUENTLY CONFUSED WITH CASES OF OBSTRUC- 
 TION OF THE BOWELS. 
 
 A VERY large number of diseases fall under this head, 
 and, indeed, it may be said that there are not very 
 many examples of abdominal disease that have not 
 been confused at one time or another with cases of 
 intestinal obstruction. 
 
 A large proportion of the examples of this con- 
 fusion is derived from records that may now be 
 regarded as ancient, and deals with instances of error 
 that could hardly be possible at the present day. 
 
 To discuss every possible form of mistaken dia- 
 gnosis seriatim would involve more space than this 
 work could permit, and at the same time produce 
 material that would be of very little value. 
 
 I propose, therefore, to consider in detail the two 
 morbid conditions that I think most frequently and 
 most seriously complicate the diagnosis of intestinal 
 obstruction, viz. pseudo-strangulation and peritonitis, 
 and then to deal with the remaining causes of error 
 en masse, and in as brief a manner as possible. 
 
 1. Pscii€lo-sti'aii$nil:^t><>»* — There have been 
 recorded from time to time certain cases, that collec- 
 tively assume no inconsiderable proportions, where a 
 patient has presented all the most conspicuous symp- 
 toms of internal strangulation, has died, and has 
 exhibited at the autopsy an intestine entirely free 
 from any mechanical obstruction. 
 
 There is little doubt that these cases are mainly 
 due to paralysis of some segment of the intestine, 
 
Chap, xxiii.] Errors in Diagnosis. 401 
 
 whereby at a certain spot the peristaltic movements 
 cease and the passage of the contents is thereby 
 aiTcsted. While this condition may fully explain the 
 constipation observed in these cases, and while that 
 constipation may in its turn induce such symj)toms as 
 vomiting and colic, it must at the same time be 
 allowed that these latter symptoms are often due to 
 reflex nerve disturbance, and are thus, to a great 
 extent, independent of the interruption in the peri- 
 staltic wave. This statement may perhaps be more 
 conveniently considered in connection with the 
 examples to be given of this form of " obstruction." 
 
 The subject of pseudo-strangulation of the bowel 
 was very elaborately dealt with by Henrot in an oft- 
 quoted monograph that, although produced nearly 
 twenty years ago, is still to be regarded as a master- 
 piece.* 
 
 Henrot's arrangement of the subject is (with some 
 trifling modifications) still the best that can be 
 adopted. 
 
 He divided all cases of paralysis of the intestine 
 leading to obstruction symptoms into three classes: 
 (1) Direct paralysis of a segment of the gut due to 
 changes in its walls. (2) Indirect paralysis depending 
 upon reflex nerve action. (3) Paralysis of the bowel 
 as a feature in a general affection of the nervous 
 symptom. 
 
 (1) Of this form many examples may be given. 
 A loop of intestine has been strangulated in a hernia; 
 it is reduced ; yet the symptoms of strangulation per- 
 sist ; the patient dies, and the autopsy reveals the 
 bowel free from any mechanical obstruction and the 
 peritoneum normal. Here it must be surmised that 
 the involved coil has been paralysed as a result of the 
 injuries sustained by its walls from the strangulation 
 
 * Des Pseudo-etranglements, bv Dr. Henri Henrot. Paris, 
 1865. 
 
 A A 12 
 
402 Intestinal Obstruction. [Chap. xxiii. 
 
 and possibly also from tlie taxis. In sucli a case as 
 this the persistence of symptoms is probably very 
 largely due to reflex action taking origin in the 
 damaged peritoneum and intestinal walls. The nature 
 of this reflex disturbance will be discussed in dealing 
 with the second variety of pseudo-strangulation. 
 There are also cases where the symptoms of obstruc- 
 tion have followed upon a severe injury to the abdo- 
 men, such as a kick from a horse, and where they may 
 be in the main ascribed to a paralysis of the injured 
 portion of intestine. 
 
 In this category must also be placed cases of 
 pseudo-strangulation due to peritonitis, cases where 
 the changes that spread to the walls of the intestine 
 from the inflamed serous membrane are such that the 
 involved segment of the gut is rendered incapable of 
 displaying peristaltic movements. " Furthermore," 
 says Leichtenstern, in speaking of this matter, " those 
 rare cases in which, during diarrhoea, or tuberculosis 
 of the intestine, or typhoid fever, or in the course of 
 a severe chronic intestinal catarrh, death follows with 
 stercoral vomiting and other symptoms of imper- 
 meability of the intestme, while no mechanical ob- 
 struction can be found at the autopsy, cannot be 
 explained otherwise than by serous inflltration, 
 degeneration, and relaxing of the muscular coat, 
 especially in the neighbourhood of large typhoid, 
 tuberculous, or dysenteric ulcers, leading to a paralytic 
 condition of the muscular coat, and thereby to arrest 
 of the advance of the contents of the intestine." 
 
 (2) In the second class of case we have to do with 
 a number of instances of reflex paralysis, and of 
 symptoms due to reflex disturbances other than those 
 causing loss of muscular power. 
 
 But a very limited inquiry into the subject of in- 
 testinal obstruction will show that for the production 
 of its main symptoms it is by no means necessary that 
 
Chap. XXIII.] Errors in Diagnosis. 403 
 
 the lumen of the bowel should be considerably nar- 
 rowed. In Littre's hernia, for example, only a small 
 part of the circumference of the gut need be involved 
 in the strangulation, and yet although the lumen of 
 the bowel presents a free passage the patient may die 
 with all the symptoms of acute straiigulation. 
 
 It is to be readily understood that the bowel in the 
 immediate vicinity of the strangulation may become 
 paralysed from more than one cause. This paralysis 
 may produce constipation and subsequently vomiting, 
 but it can hardly be the sole cause of the violent pain, 
 the severe vomiting, and the appearance of collapse, 
 all of which symptoms may be among the earliest 
 manifestations of the condition. These symptoms 
 must be largely due to reflex nerve disturbance start- 
 ing from the damaged nerves in the strangulated part. 
 The great nerve centres of the abdomen are excited 
 by the lesion j vomiting is produced, and violent and 
 disordered peristaltic movements are set up. The 
 paralysis of the gut, which may be due to purely local 
 causes, tends to give to these symptoms somewhat of 
 the characters they present in true intestinal obstruc- 
 tion. 
 
 A crush of the testicle is often followed by 
 great collapse and with severe and long-continued 
 vomiting. These symptoms, which are also so con- 
 spicuous a feature in acute strangulation, are no 
 doubt due to a damage to the spermatic plexus which 
 arises so high up in the abdomen as to be in very near 
 relation with the great solar plexus. Indeed, a morbid 
 nerve impulse could reach the abdominal nervous 
 centres as readily from the testicle as it could from 
 such parts of the colon as are supplied by the inferior 
 mesenteric plexus. 
 
 The collapse and vomiting that may attend lesions 
 of the peritoneum are of the same character, and ara 
 also of reflex origin. 
 
404 Intestinal Obstruction. [Chap, xxiii. 
 
 Pfliigger found that the moYements of the small 
 intestine could be arrested by mechanical irritation of 
 the skin of the abdomen. Now the integument over 
 the abdomen is supplied by certain dorsal nerves, and 
 from the trunks of these very same nerves are derived 
 the main spinal nerve contril^utions to the splanchnic 
 trunks, and these trunks, it is unnecessary to say, take 
 a very important share in the formation of the great 
 sympathetic plexus in the abdomen. The connection, 
 therefore, between an irritation applied to the skin of 
 the belly and an arrest of movements in the parts 
 supplied by the superior mesenteric plexus is very 
 direct. 
 
 Many cases of pseudo-strangulation are not diffi- 
 cult to interpret when viewed in the light of the above 
 observations. Thus Henrot * mentions a case where 
 the symptoms of strangulation of the intestine were 
 produced by a phlegmon of the abdominal parietes. 
 In this case the constipation, the colic, the vomiting, 
 may all be ascribed to a morbid stimulation of certain 
 reflex centres, the afferent impulse travelling from the 
 surface nerves of the abdomen to certain dorsal nerves, 
 and from them to the splanchnic trunks and the 
 central plexus commanding the abdominal viscera. 
 
 As another example of this form of pseudo-stran- 
 gulation I might mention the case of a male infant, to 
 whom my attention was called by a house surgeon 
 who had diagnosed in the child a strangulated hernia. 
 The infant was in a condition of great prostration, it 
 was troubled with incessant vomiting ; there had been 
 no action of the bowels since the symptoms set in, 
 and there was a fair degree of meteorism. In the 
 groin was a hard and very tender irreducible tumour. 
 This, as I soon discovered, was not a strangulated 
 hernia, but an inflamed retained testicle. Soon after 
 the application of ice to the part the child began to 
 * Loc. cit. page 81. 
 
Chap. XXIII.] Errors in Diagnosis. 405 
 
 improve, and the symptoms of intestinal obstruction 
 spontaneously disappeared. 
 
 Henrot's monograph contains many similar cases 
 in which an inflamed condition of the testicle led to 
 some of the chief manifestations of intestinal obstruc- 
 tion. 
 
 In several instances it would appear that an 
 inflamed hydrocele has been mistaken for a strangu- 
 lated hernia. In one instance no less a surgeon than 
 Dupuytren was deceived by the resemblance, and 
 proceeded to perform the operation of kelotomy.* In 
 one case reported in Henrot's monograph, such grave 
 symptoms analogous to those of intestinal obstruction 
 followed the application of a ligature to piles that the 
 patient's life was threatened. 
 
 In other examples of this form of pseudo-strangu- 
 lation the exciting cause was an abscess or inflamed 
 gland in the region of the groin, or a hernial sac, the 
 walls of which were the seat of active inflammatory 
 change. A complete collection of these cases is to be 
 found in Henrot's paper. 
 
 (3) Under this head are included cases of supposed 
 paralysis of some segment of the bowel, where the 
 local nerve lesion is but an outcome of a more general 
 disturbance of the nervous centre. Under this class 
 are grouped cases of pseudo-strangulation occurring in 
 connection with hysteria, meningitis, etc. 
 
 What may be termed a chronic form of the affec- 
 tion has been touched upon in the chapter on faecal 
 accumulations. 
 
 In some of the cases depending upon hysteria the 
 symptoms have been quite acute, and have borne a 
 very close resemblance to genuine examples of obstruc- 
 tion. Dr. Lusseau alludes to an instance of this kind, 
 where the resemblance was so exact that an operation 
 for the relief of intestinal obstruction was proposed. 
 * Clin. Chir., vol. iii., page 584. 
 
4o6 Intestinal Obstruction. [Chap, xxiii. 
 
 The patient, however, soon recovered when treated 
 by antispasmodics. 
 
 No especial rules can be given for guidance in the 
 diagnosis of these cases of pseudo-strangulation. In 
 most instances there will be no real difficulty, since a 
 condition may exist that may be a known cause of 
 obstruction symptoms, and at the same time there is 
 generally some anomaly in the symptoms themselves, 
 some flaw in the clinical completeness of the case that 
 may at once suggest the spurious character of the 
 disorder. Henrot and others have written a great 
 deal upon the means of recognising these cases, but 
 their observations have little practical utility, and it 
 must be owned that as a knowledge of intestinal 
 obstruction extends so must the number of errors in 
 diagnosis diminish. It is significant that the great 
 majority of the examples of an actual mistake in the 
 diagnosis depending upon pseudo-strangulation are not 
 derived from recent records, but belong to a period 
 when the clinical account of intestinal obstruction was 
 less comyjlete than it is at the present day. 
 
 2. Peritonitis. — The association of acute peri- 
 tonitis with intestinal obstruction is very common, 
 and, indeed, the inflammation of the serous membrane 
 is quite frequently the immediate cause of death in 
 obstruction cases. Apart, however, from this asso- 
 ciation, it is to be noted that the symptoms of peri- 
 tonitis present many points of resemblance to the 
 symptoms of pure obstruction of the bowel, and so 
 close may this resemblance be that the one aflection 
 may be mistaken for the other. It will be well, there- 
 fore, to consider (1) with what clinical manifestations 
 the a^^pearance of diffuse peritonitis is associated in 
 obstruction cases, and (2) how cases of peritonitis may 
 be diagnosed from cases of simple stoppage of the 
 bowels from mechanical causes. 
 
 (1) The following are the principal symptoms that 
 
Chap. XXIII.] Errors in Diagnosis. 407 
 
 indicate the accession of diffuse peritonitis in a case 
 of intestinal obstruction. There may be, in the first 
 place, a rise of temperature. This symptom is by no 
 means constant, and the development of the serous 
 inflammation may be associated with a normal or even 
 with a subnormal temperature. Indeed, I have found 
 cases on record and in hospital reports where the tem- 
 perature, which was sinking when peritonitis set in, 
 has continued to fall after the development of that 
 inflammation. The pulse becomes smaller and more 
 thready, and increased in frequency. The abdomen 
 becomes more distended, and it is especially to be 
 noted that the distension is uniform. If any coils of 
 intestine were visible before the peritonitis set in, 
 then, on the appearance of the serous inflammation, 
 they will cease to be seen. The liver dullness disap- 
 pears, there is very often increased dyspnoea and 
 other evidences of pressure upon the thoracic viscera. 
 The abdominal parietes, hitherto flaccid, become hard 
 and tense, unless the patient be much collapsed or 
 deeply narcotised. There is great tenderness on pres- 
 sure all over the abdomen, and the patient, who has 
 probably been restless and tossing to and fro in bed, 
 now lies very still, and often with the knees drawn 
 up. In cases associated with much effusion there will 
 be evidences of the presence of fluid in the more 
 dependent parts of the abdomen. While there is a 
 distinct and very grave increase in the amount of ten- 
 derness (which may, indeed, have been absent before 
 the peritonitis) there is not usually a great increase in 
 the amount of pain. Owing to the paralysis of the 
 intestine, due to the effects of the peritonitis, the pain 
 depending upon irregular peristaltic movements abates, 
 such suffering as there is becomes less paroxysmal, and 
 the pain, therefore, is more continuous. In many in- 
 stances, therefore, the appearance of peritonitis has 
 been attended by increased tenderness but hy a 
 
4o8 Intestinal Obstruction. [Chap. xxiii. 
 
 diminislied amount of paiii. In some cases tlie vomiting 
 becomes moi-e severe, in other examples it is mode- 
 rated, and, if feculent, may become again non-ster- 
 coraceous. The appearance of singultus is often asso- 
 ciated with the onset of peritonitis. 
 
 (2) The differential diagnosis of peritonitis and 
 intestinal obstruction. 
 
 The most usual form of peritonitis to be mistaken 
 for a case of mechanical obstruction is that acute form 
 due to perforation. Duplay, in an excellent mono- 
 graph upon the subject, has collected no less than 
 fourteen recorded examples of this error in diagnosis."^ 
 
 In each instance the case was considered to be one 
 of acute strangulation of the bowel. In several of the 
 examples an operation was performed with the inten- 
 tion of relieving a supposed obstruction and the error 
 only discovered wdien the abdomen had been opened. 
 The great majority of the cases concerned j^erforative 
 peritonitis following upon some mischief in the caecum 
 or appendix. In two instances the cause of the mis- 
 chief was a perforation of the gall-bladder. In a case 
 of peritonitis due to this latter cause, reported by M. 
 Herbelin, laparotomy was performed under the im- 
 pression that the case was one of mechanical obstruc- 
 tion, t 
 
 The reseml)lancc between the cases of perforative 
 peritonitis and those of acute strangulation is often 
 close. In both the symptoms may develop suddenly 
 during apparent health or after certain vague ab- 
 dominal troubles, in both there is early and severe 
 pain, in both there is constipation, vomiting that may 
 become stercoraceous, and great prostration. 
 
 The following points may be noticed in the differ- 
 ential diagnosis. 
 
 * Archives gen. de M^J., vol. xxviii., 1876, page 513; and 
 ibid., 187!), page 709. [See aho Henrot's monograph.) 
 fBull. de la Soc. Anat., July, 1878. 
 
Chap. XXIII.] Errors in Diagnosis. 409 
 
 Mode of onset. — In both it is usually sudden and, 
 in the case of the obstruction, more commonly without 
 any definite preliminary symptoms. As already noted, 
 most of the instances of perforative peritonitis that 
 have been the cause of error have followed upon a 
 typhlitis, or some trouble in the appendix. Now, in 
 these cases the perforation may take place without 
 any marked intestinal symptoms having been noted. 
 In the majority of instances there are symptoms. 
 The bowels are irregular, there are attacks of severe 
 indigestion, there is tenderness over the region of the 
 csecum. The csecum, distended with fsecal matter, 
 may form a distinct tumour that is the seat of pain, 
 and is also tender on pressure. There may have been 
 vomiting, and very possil>ly some rise of temperature. 
 In more distmct cases there will be some oedema of 
 the abdominal parietes about the csecum. When 
 these symptoms have existed there should be little 
 difficulty in recognising the condition of things when 
 at last a perforation of the bowel occurs. 
 
 A rigor may usher in acute peritonitis, which will 
 not be the case in acute obstruction. 
 
 The tem2')erature in acute peritonitis is usually high 
 at first, falling again as prostration advances. In 
 certain examples attended by profound collapse tlie tem- 
 perature may be subnormal from the first, but such 
 cases are rare, and are not likely to be confounded 
 with acute strangulation. In those instances where 
 this confusion is apt to occur there will be almost 
 always a distinct elevation of temperature at the com- 
 mencement of the case, and this elevation may be 
 maintained through the further progress of the malady, 
 only sinking to or below normal at the termination. 
 In acute diffuse peritonitis death may occur while the 
 temperature is still at its height. The earliest rise of 
 temperature may reach 104, althougli it is more 
 usually not above 102, and throughout the progress of 
 
4IO Intestinal Obstruction. [Chap, xxiii. 
 
 the case the temperature is apt to show marked remis- 
 sions. In acute obstruction the temperature is low 
 at first, usually subnormal, and remains subnormal 
 throughout the progress of the case. 
 
 Pain. — In the inflammatory affection the pain, 
 which may be very severe, is attended by extreme 
 tenderness upon pressure. This tenderness, which 
 may be at first local, soon becomes diffused. In the 
 earlier stages of the obstructive affection there is also 
 very severe pain, but there is no marked tenderness, 
 and, indeed, the suffering is often to be relieved by 
 pressure. 
 
 Vomiting. — In both maladies vomiting appears 
 early, but in acute strangulation it is a much more 
 prominent symptom than in peritonitis. In the latter 
 affection it rarely becomes feculent, and then only 
 towards the conclusion of the case. Among the four- 
 teen cases of acute peritonitis collected by Duplay there 
 was feculent vomiting in three instances only. In 
 these fourteen cases, as already observed, the diagnosis 
 of acute obstruction had been in each instance made. 
 
 Constipation is absolute in the obstruction cases. 
 In peritonitis it may be absolute also, but not infre- 
 quently a slight motion may be passed or flatus may 
 be discharged by the anus. 
 
 The quantity of urine passed in both the condi- 
 tions may be very small. 
 
 The abdominal j^cirietes are tense and hard from 
 the first in diffused peritonitis. In acute obstruction 
 they are flaccid at first, and often remain so until peri- 
 toneal inflammation has set in. 
 
 The 7neteorism may be localised at first in the 
 obstruction cases. It is diffused from the commence- 
 ment in peritonitis. 
 
 Cases of tubercular peritonitis have been 
 mistaken for cases of obstruction of the bowels. This 
 error can but very rarely occur, for in the most usual 
 
chnp. XXIII.] Errors in Diagnosis, 411 
 
 form of tubercular peritonitis the symptoms have but 
 little resemblance to those due to occlusion. The 
 manifestations of the disease develop very gradually, 
 and the patients are usually first seen when suffering 
 from great debility and ascites. 
 
 There is, however, an acute form of the malady 
 which may be, and has been, a cause of error. In 
 this form the disease commences acutely with a pain 
 in the abdomen, cither at a circumscribed spot or over 
 a larger area. Associated with it are repeated vomiting, 
 constipation, and meteorism. In a while all the symp- 
 toms may disappear, and then repeated attacks occur 
 at irregular intervals. In this form there is no fluid 
 effusion."^ M. Lionville has given a good example of 
 mistaken diagnosis in this variety of tubercular perito- 
 nitis. The subject was a man, aged twenty-three, 
 who was taken suddenly with symptoms so severe, and 
 so like those of intestinal obstruction, that an opera- 
 tion for his relief was proposed. In four days the 
 bowels were opened spontaneously ; the vomiting, 
 which had been almost feculent, disappeared, and the 
 patient returned to what seemed to be a condition of 
 health. In fifteen days, however, the symptoms of in- 
 testinal obstruction appeared again, and again was an 
 operation seriously considered. The symptoms, how- 
 ever, passed off. The patient died in three months, 
 and the autopsy revealed nothing but the ordinary 
 evidences of tubercular peritonitis. f 
 
 In the differential diagnosis of these affections it is 
 especially to be noticed that the tubercular disorder is 
 attended by fever, and by early and usually distinct 
 tenderness of the abdomen. These symptoms are 
 absent in the obstruction cases. After the attack 
 there is usually a sense of undue resistance over the 
 
 * Bauer, Diseases of the Peritoneum. Ziemssen's Cyclopaedia 
 of Medicine, vol. viii., page 328. 
 
 t Bull, de la Soc. Anat. de Paris, 1875, page 726. 
 
412 Intestinal Obstruction. [Chap. xxiii. 
 
 spot that lias been especially the seat of pain and 
 tenderness. 
 
 During the progress of any case of tubercular 
 peritonitis, genuine intestinal obstruction may occur 
 from matting together of the coils of intestine, or from 
 bending or kinking of such loops as are adherent. 
 
 Diseases tliat liave been niistakeu for 
 obstruction of the bowels.— Under this heading 
 I propose merely to enumerate a few of the maladies 
 that have been mistaken for cases of intestinal ob- 
 struction ; but not to discuss the differential diagnosis 
 in each instance, since many of these examples of mis- 
 taken diagnosis have been already referred to, and the 
 symptoms of each variety of occlusion have been, on 
 the other hand, fully discussed. 
 
 Cholera. — This disease has been imitated by the 
 most acute forms of intestinal obstruction. In these 
 cases the patient has fallen rapidly into a condition of 
 cholera-like collapse ; the extremities have become 
 cool, the surface cyanosed, the pulse thready and 
 almost imperceptible, the voice has sunk to a whisper, 
 and the countenance has presented all the features ob- 
 served in cholera. At the same time there has been a 
 violent vomiting, cramps in all the limbs, suppression 
 of urine, and extreme prostration. The cases that 
 have most closely resembled cholera have been cases of 
 very acute sti'angulation of a considerable portion of 
 the small intestine es2)ecially of the upper parts of 
 that bowel. The strangulation may have been pre- 
 ceded by profuse diarrhoea, or the gut below the ob- 
 struction may have been emptied by diarrhoea after 
 the strangulation had occurred."* In many instances 
 the cases had been met with during an epidemic of 
 cholera. 
 
 Another form of obstruction that may resemble 
 
 * Fournier and Ollivier ; Gaz. Med. de Paris, 1868. The 
 motions were not arrested until two days before death. 
 
Chap. XXIII.] Errors in Diagnosis. 413 
 
 cholera is ultra-acute intussusception associated pro- 
 bably with much purging.* 
 
 Dr. Barlow mentions an instance where the patient 
 was thrown into a choleraic condition from obstruction 
 due to masses of undigested food.f A like case of a 
 more severe character is quoted in Dr. Servier's 
 treatise. In this instance the patient, a soldier, lived 
 only sixteen hours after the commencement of the 
 attack. \ 
 
 An excellent discussion of the chief features in the 
 diagnosis of these cases has been afforded by M. Felix 
 Refrege. § He deals with fourteen cases of error in 
 diagnosis, and refers to other but less defined examples. 
 
 In only four of the fourteen cases were cramps in 
 the limbs noticed, and in all, save in two examples, 
 there was absolute constipation. 
 
 There can be little real difficulty in the diagnosis 
 if too hurried an opinion be not arrived at. The ob- 
 struction attacks are associated with intense pain at 
 the commencement attended by constipation. In 
 cholera there is an absence of pain and profuse diar- 
 rhcea. The abdomen becomes soon retracted in cholera, 
 but meteoristic in acute strangulation. In cholera 
 vomiting does not set in quite so early as in cases of 
 acute obstruction. In many cases it is entirely absent, 
 and when present is non-feculent, and has the peculiar 
 whey-like appearance so often described. 
 
 Error is most likely to occur when an example of 
 ultra-acute occlusion is met with during an epidemic 
 of cholera. 
 
 * Dr. Todd; Med. Times and Gazette, vol. ii., 1865, page 195. 
 M. Fernet ; Bull, de la Soc. Anat., 1863, page 296. 
 
 t Med. Times, vol. i., 1866, page 443. 
 
 t L'Union Med., 1867, i^age 100. 
 
 § Le Diagnostic de I'Etranglement intestinal a Symptomes 
 choleriformes. These de Paris, 1867. See also art. by M. Berger, 
 Bull, et Mem. de la Soc. de Cliir. de Paris, vol. ii., 1876, page 
 698 ; and Yassor, These de Paris, 1862 ; and Savopoulo, These de 
 Paris, 1854. 
 
414 Intestinal Obstruction. [Chap, xx hi. 
 
 Lead colic. — A case is reported by Dr. Fagge"^ of 
 a man, aged twenty-nine, who had a blue line on the 
 gums, but whose intestinal symptoms were due not 
 to lead-poisoning, as at first supposed, but to partial 
 obstruction from shrinking of the mesentery. 
 
 Poisoning by arsenic. — In several instances cases of 
 acute strangulation have excited suspicions of poisoning 
 by arsenic, and the doubt has only been cleared up at 
 the autopsy. Leichtenstern alludes to several examples. 
 
 HejKttic or renal colic may be imitated by acute ob- 
 struction in the upper portion of the small intestine 
 associated with profuse non-feculent vomiting, intense 
 paroxysmal pain, collapse, and a retracted condition of 
 the abdomen. 
 
 Meningitis. — Dr. Fagge alludes to a case of acute 
 obstruction of the jejunum where meningitis was sus- 
 pected on account of the delirium, the vomiting, and 
 the retracted abdomen. 
 
 Cirrhosis of the liver. — Dr. Lusseau reports a case 
 where cirrhosis of the liver was taken for an example 
 of obstruction of the commencement of the colon by a 
 neoplasm. The autopsy, however, revealed, in addi- 
 tion to the cirrhosis, some old adhesions about the 
 caecum and sigmoid flexure, as well as a compression of 
 the third part of the duodenum by an old cicatricial 
 band, f 
 
 Cancer of the omentu7u has simulated true ob- 
 struction. X 
 
 A cyst of the mesentery has been mistaken for an 
 intussusception tumour, § and an intussusception 
 tumour for a new growth or a mass of faecal matter. 
 
 Tumours formed by faecal masses have been mis- 
 taken for a number of affections {see page 354), and 
 
 * Guy's Hospital Reports, vol. xiv., page 272. 
 
 + Progres Medical, 1879, page 545. 
 
 X De rOcclusion Intestinale. These de Paris, 1879, No. 303. 
 
 § Lull, de I'Acad. de Med., page 831. Paris, 1880. 
 
Chap. XXIV.] The Trea tment : Feeding. 415 
 
 notice has already been taken of tlie numerous diseases 
 which liave been confused with chronic intussuscep- 
 tion. {See page 237.) 
 
 The confusion between acute or subacute intus- 
 susception and dysentery or enteritis has been of fre- 
 quent occurrence. 
 
 CHAPTER XXIV. 
 
 THE TREATMENT. 
 
 The subject of the treatment of cases of intestinal 
 obstruction, with its extensive bearings and its many- 
 vexed questions, may be most conveniently considered 
 under two general headings : 
 
 1. The methods of treatment available for intestinal 
 
 ohstruction. 
 
 2. The special treatment of individual forms of ob- 
 
 struction. 
 
 THE METHODS OF TREATMENT AVAILABLE FOE INTES- 
 TINAL OBSTRUCTION. 
 
 ]¥on-operative measiu^es : the feeding of 
 the patient. — This is matter which demands a little 
 more attention than it has at present received. In many 
 examples of acute obstruction the progress of the 
 case is so rapid, and death appears so early, that the 
 question of supporting the patient by food does not 
 require to be entertained. In less rapid cases, how- 
 ever, this question becomes a prominent one, and in 
 subacute cases it obtains a very considerable degree 
 of importance. Certainly in not a few instances one 
 of the factors in the exliaustion that leads to death 
 depends upon the patient's inability to take or to 
 retain food. When the case has lasted four or five or 
 
41 6 Intestinal Obstruction. [Chap. xxiv. 
 
 six days the patient's prospect of recovery is com- 
 promised by the debility induced by want of nourish- 
 ment, and this debility may seriously modify the 
 result of any operation. In not a few instances, 
 more especially in cases of intussusception, a process 
 of spontaneous relief is found to be nearly complete 
 at the time of death and to have been arrested by 
 a fatal exhaustion, to the production of which an 
 inability to take food has no doubt contributed. The 
 position of acute and subacute cases of obstruction 
 with reference to the question of feeding is as follows : 
 The patient is very sick, he not only vomits every- 
 thing that he takes, but will vomit at other times 
 than after the ingestion of food. In many subacute 
 cases, where the sickness is not so marked, the taking 
 of nourishment excites the act of vomiting after the 
 symptom has abated, and the patient may for 
 awhile only be sick after he has taken food. 
 
 It is obvious that it is worse than useless to 
 attempt to feed these patients by the mouth. There 
 is usually an entire lack of aj^petite, and a disgust of 
 food quite apart from the circumstance that every 
 mouthful swallowed is apt to aggravate one of the 
 most distressing of the symptoms. Moreover, even 
 if it be supposed that the food can be retained, it is 
 scarcely possible to imagme that it can be digested 
 and absorbed. The stomach is not improbably occu- 
 pied by matters regurgitated from the bowel. The 
 small intestine above the obstruction is more or less 
 congested, is distended, is occupied by putrifying 
 contents and much flatus, and is certainly not in a 
 condition to further elaborate or even to absorb any 
 food matters that may reach it from the stomach. 
 These is still one other aspect of the question. In 
 some cases of subacute intussusception food may 
 occasionally be swallowed without causing sickness. 
 That such food is digested and al)Sorbed is not very 
 
Chap. XXIV.] The Treatment : Feeding. 417 
 
 probable. Whether it is or not is a little apart from 
 the question, since clinical experience shows timt the 
 matters, if not rejected, will excite increased peri- 
 staltic action in the intostineS; and will decidedly 
 aggravate the condition of tlie invagination. It is 
 obvious^ thei'efore, that if food is to be administered 
 in these cases, it nmst be administered by eiiemata 
 and never by the month. By ineans of nutritive 
 enemata the patient may be greatly relieved an(^ 
 his strength to no small extent supported. The dis- 
 tressing thirst that is often so conspicuous in cases of 
 acute obstruction is much abated by copious injections 
 of fluid into the rectum, and when more substantial 
 nourisliment needs to be administered, it can be 
 introduced by means of small and repeated enemata 
 of peptonised foods. In the majority of the cases of 
 acute obstruction, the small intestine is the p,ii-t 
 involved, and the colon, therefore, is free and capable 
 of receiving injections. Even in cases of acute ob- 
 struction involving the colon (as in volvulus of the 
 sigmoid flexure), enemata may be retained by the 
 rectum, althoug-h in many of these cases there i,^ so 
 much tenesmus that feeding by this method is im- 
 possible. On the other hand, it must be remembered 
 that the vomiting in cases where the colon is involved 
 is usually much less severe than it is when the ob- 
 struction implicates the lesser bowel. 
 
 There are many circumstances, however, besides 
 the one already mentioned, under which the admini- 
 stration of food by enemata is not possible. In 
 many examples of intussusception it is not possible. 
 The invagination has reached the lower colon, there is 
 tenesmus, the contents of the bowel are being fre- 
 quently rejected by a species of diarrhcea, and enemata 
 merely aggravate the peristaltic movements of the 
 tube. In these cases, however, that are associated 
 with diarrhcea, there is oftexi comparatively little 
 B B — 12 
 
4l8 IXTESTINAL OBSTRUCTION. [Chap. XXIV. 
 
 vomiting, and the patient is not infrequently able to 
 take a little nourishment by the mouth without in- 
 convenience being caused. 
 
 There are other cases of obstruction apart from 
 intussusception, where the administration of enemata 
 has been undesirable on account of the disturbance 
 produced, the mere injection having caused in such 
 instances an increase in the vomiting, and in the pain 
 depending upon peristaltic movements. 
 
 In acute and subacute cases of obstruction, the 
 question of feeding the patient resolves itself to this : 
 the patient may have ice to suck to relieve the sense 
 of distressing thirst, but apart from this all food 
 should be administered, if possible, by the rectum, and 
 in any case this method of taking nourishment should 
 be persevered with so long as it can be carried out. 
 
 In chronic intestinal obstruction, and especially 
 in cases where the small intestine is the part in- 
 volved, the feeding of the patient becomes a matter 
 of extreme importance, and one demanding consider- 
 able attention. 
 
 In this form the lumen of the intestine is only 
 partially occluded. Matters can pass readily througli 
 it so long as they are fluid, or at least of quite soft 
 consistence ; but any large solid particles passing along 
 the bowel will certainly, if of sufficient magnitude, 
 plug the stenosed part and produce severe symptoms. 
 This circumstance is repeatedly illustrated in the 
 clinical history of stricture of the intestine. Indeed, 
 the earlier symptoms of stenosis of the small intestine 
 depend upon an occasional entire occlusion of the tube, 
 and this occlusion is, in the majority of cases, due, 
 directly or indirectly, to the presence of masses of 
 undigested food. The earlier treatment of stricture 
 of the small intestine resolves itself almost solely into 
 a question of diet. So long as the patient exercises 
 extreme care in the selection of his food, so long will 
 
Chap. XXIV.] The Treatment : Feeding. 419 
 
 he remain free from severe trouble until such time as 
 the condition of the stricture will not permit the free 
 passage of even well-digested matters. In examples 
 of stenosis of the colon the sam^i importance attaches 
 to diet, although it may be not quite so manifest. 
 In these cases there may be no aggravation of sj^mp- 
 toms shortly after food, the connection between the 
 taking of certain foods and the appearance of certain 
 symptoms may be not so direct as in cases of stricture 
 of the lesser bowel, but the relationship still exists. 
 The more solid the contents of the colon become, the 
 more trouble does the stricture produce, and it is 
 needless to point out the connection between the state 
 of the colic contents, and the nourishment that has 
 been ingested. In the long period that xisually 
 elapses between the commencement of symptoms and 
 the time when operative interference has to be con- 
 sidered, a very great deal may be done by a careful 
 dieting of the patient. Indeed, during this period 
 the treatment of the case is in the main a pure 
 question of dieting. 
 
 These observations apply of course to feeding by 
 the mouth, and refer to cases of stricture as well as to 
 others allied to that condition. In the later stages of 
 these forms of obstruction, when vomiting becomes a 
 more frequent and prominent symptom, the question 
 of administering some or (for a while) all of the food 
 by enemata again arises. 
 
 In no case, however, do I think that operative 
 measures should be delayed on account of the cir- 
 cumstance that the patient's general strength can 
 be fairly supported by nutrient enemata. When 
 operation is desirable on account of the condition of 
 the bowel it should be carried out, and the more 
 favourable the patient's general state at the time of 
 the operation, the greater degree of success may be 
 expected to attend the procedure. 
 
42 o Intestinal Obstruction, rch.-ip.xxiv. 
 
 In not a few examples of chronic intussusception 
 tlie patient dies of marasmus and exha,ustion. This 
 termination is in great part brought about by the 
 enfeebling effect of persistent vomiting and frequent 
 pain, but it depends also in a large degree upon the 
 malnutrition, consequent upon the inability to take or 
 to retain food, or to absorb nutritive matters from the 
 disordered bowel above the invagination. In many of 
 these cases the general strength may be supported by 
 peptonised enemata, and the patient's life greatly 
 prolonged in instances where operative interference 
 is not considered as necessary. In cases where an 
 operation may be performed, the success of the pro- 
 cedure is likely to be rendered more certain by the 
 improved state of nutrition consequent upon feeding 
 by the rectum. There are, of course, cases of chronic 
 intussusception in which the repeated use of even 
 small injections would not be tolerated. 
 
 Opiiiiii. — There is certainly no one drug of more 
 use and value in cases of intestinal obstruction than 
 opium. The precise action of opium upon the intesti- 
 nal movements may be still a matter of some scientific 
 speculation, although its gross effects in cases of intes- 
 tinal disorder are, from a clinical point of view, obvious 
 enough. The latest experimental investigations upon 
 this subject are those conducted by Nothnagel. The 
 following abstract from an article in the Lancet* gives 
 tlie general result of these experiuients in a very brief 
 and complete manner. Nothnagel " discovered in 
 his earliest experiments that a sodic salt placed in 
 contact with the outer surface of the intestine of a 
 rabbit causes a local contraction which passes upwards. 
 This effect was found to be prevented by a preceding 
 subcutaneous injection of a small quantity of morphia, 
 one to four centigrammes. Even bicarbonate of 
 soda, which under normal circumstances causes a very 
 * Leading article, I/ancet, Oct. 2lst, 1882, pa§e 672, 
 
Chap. XXIV.] The Treatment: Opium. 421 
 
 energetic contraction, no longer produces the effect. 
 Nothnairel ascribes the effect to the stimulation of 
 a nervous mechanism antagonistic to that which is 
 excited by the sodic salt. If, however, a much larger 
 quantity of morphia was injected (ten centigrammes, 
 for instance), not only does the sodic salt produce its 
 customary effect, but the contraction is much more 
 energetic than under ordinary circumstances. Tliis 
 anomalous effect seems to indicate, that while small 
 doses of morphia stimulate, larger doses paralyse the 
 inhibitory nervous mechanism. Morphia appears thus 
 to exert on the intestinal apparatus an action compa- 
 rable to that which digitalis exercises on the innerva- 
 tion of the heart, which consists in a stimulation or 
 paralysis of the inhibitory fibres of the vagus, accord- 
 ing to the dose employed. Other experiments seem to 
 show that the action of morphia on the intestine is 
 exerted through the splanchnic nerves. The consti- 
 pation produced by morphia is assumed to be the re- 
 sult of a stimulation of the inhibitory fibres contained 
 in the nervous trunk, aided by a diminution in the in- 
 testinal secretion." 
 
 As to how far these experiments are confirmed or 
 refuted by clinical experience in the human subject it 
 is needless here to enquire. The general efi'ect of 
 opium in cases of intestinal obstruction is very marked, 
 and very fairly constant when the conditions under 
 which its action is observed are equal. It allays pain. 
 It can dull or remove the severe agony that often 
 marks the earliest stasfes of acute strano'ulation. It 
 can quiet the constant sense of distress that attends 
 upon a case of chronic obstruction. 
 
 Pain, moreover, may often be taken as a mea- 
 sure of shock, especially in examples of collapse 
 depending upon intestinal lesions, and with the sub- 
 sidence of pain the more striking manifestations of 
 shock commonly disappear. Thus in acute cases the 
 
42 2 Intestinal Obstruction. [Cba?. xxiv. 
 
 effect of opium in moderating and even removing 
 the more conspicuous symptoms of shock is often 
 very pronounced. It not only affects the pain, 
 but it influences the pulse and temperature. One 
 of the cases reported by Leichtenstern in his mo- 
 nograph maybe taken in illustration of this. "A 
 few days ago I saw," he writes, " an unusually severe 
 case of obstruction by gall stones ; the patient was 
 covered with cold sweat, had cool extremities, muffled 
 voice, choleraic countenance, vomited freely, and pre- 
 sented a board-like tension of the abdomen. The 
 temperature in the rectum was 95|^° ; a thermo- 
 meter j^laced at the same time in the axilla, and 
 compared with the one in the rectum, marked only 
 92S; the pulse was small, its frequency 48 in the 
 minute. After an injection of morphia, the tension of 
 the abdomen diminished, the skin filled with blood, 
 the pulse rose gradually to 76, the temperature in 
 the rectum, after the patient had passed an hour of 
 comparative comfort, was 99-6^."^ Besides all this, 
 in such cases the expression of the face returns more 
 to its normal condition. The pinched appearance is 
 gradually lost, the eyes appear less sunken, and the 
 lips less blue. The dry tongue becomes moist, the 
 sweat ceases to pour from the face, the intellectual 
 faculties revive, and the patient passes from a state of 
 intense terror and anxiety to a condition of compara- 
 tive repose. I have no doubt that in many severe 
 cases a death early in the case from shock has been 
 averted by the timely injection of morphia. Upon the 
 quantity of the urinary secretion the effects of opium 
 aA-e often very marked, as many reported cases testify. 
 Before the administration of the drug, and during the 
 presence of the collapse symptoms, there may be 
 oliguria or apparent suppression of urine, but after the 
 administration of the narcotic a copious secretion of 
 * Ziemssen's Cyciopicciia oi Medicine, vol. vii. , page 49U. 
 
Chap. XXIV.] The Treatment : Opium. 423 
 
 urine is one of the commonest evidences of its bene- 
 ficial effects. 
 
 Some of the symptoms of intestinal obstruction, 
 such as violent and disordered peristaltic movements 
 and vomiting, depend in a great degree upon reflex 
 nerve action. Opium has large powers as an inhibitor 
 of reflex movements. Thus it happens that under 
 the influence of the drug the vomiting, especially in 
 acute cases, often exhibits a singular improvement, 
 and the movements of the bowels become almost 
 stilled. In chronic cases, where the intestinal move- 
 ments can be observed through the parietes, the in 
 fluence of the narcotic upon those movements is very 
 conspicuously displayed. If one considers the serious 
 part that peristalsis takes in the development of 
 intestinal obstruction it will be understood that any 
 moderation in this movement is likely to be attended 
 by great improvement. This circumstance is strik- 
 ingly illustrated by the following case placed upon 
 record by M. Le Fort : A young man received a 
 kick upon the belly from a horse. Some days after 
 he developed symptoms of internal strangulation. 
 Opium was at once administered every one or two 
 hours. The symiptoms passed away. The patient's 
 appetite returned ; his bowels were freely opened ; 
 he got up. Before long, however, gurgling would 
 begin in the abdomen associated with energetic move- 
 ments of the intestine and subsequently with much 
 meteorism. These symptoms were soon followed by 
 vomiting, pain, and the other evidences of intestinal 
 obstruction. Under the influence of opium all these 
 symptoms subsided and the patient was soon well 
 again. Within two months the patient had three 
 attacks of internal strangulation which yielded to 
 opium. The fourth attack was associated with perito- 
 nitis, of which he died. The autopsy revealed two 
 hernise of the small intestine through two rents in the 
 
42 4 Intestinal Obstruction. [Chap. xxiv. 
 
 great omentum, whicli rents were no doubt produced 
 at the time of the accident. Here it would seem that 
 while the intestines were still, and their contents 
 quietly jDropelled, the narrowing of the gut was not 
 sufficient to cause obstruction. But when the peri- 
 staltic movements became active and the contents were 
 hurried along, the involved coils became obstructed 
 and symj)toms were immediately produced.* 
 
 The value of opium in the treatment of intussus- 
 ception can scarcely be over-estimated. In this con- 
 dition the very origin of the invagination as well as 
 its progress depend upon disordered peristaltic move-: 
 ments. Some of the most distressing symptoms of the 
 affection are due to those movements. Opium arrests 
 them. When the patient is fully under the influence 
 of the drug the intestines would appear to be still, an 
 increase of the intussusception is scarcely possible, and 
 the troubled parts have all the advantages of phy- 
 siological rest. When once the irregular peristaltic 
 movements are brought into abeyance a most favour- 
 able opportunity is offered to the part to return to its 
 normal condition. I have not the least doubt that 
 many cases of acute intussuscejjtion have yielded to 
 the early administration of opium, and it is not im- 
 probable that many of the examples of the " cure " of 
 acute strangulation by opium Ijelong really to this 
 pathological division. 
 
 Not a few instances, however, are reported of cases 
 of obstruction that have spontaneously yielded under 
 the ejQTects of opium, in which there is no reason to 
 suppose that the cause of the obstruction w^as an inva- 
 gination. As examples of this may be cited the fol- 
 lowing : Mr. Brewer records the case of a man, aged 
 forty-nine, who presented the symptoms of acute ob- 
 struction. The condition was ascribed to a too 
 hearty meal of steak-j)udding. Aperients were at first 
 * Bull, et 3Iem. de la Soc. de Chir. de Paris, 1879, page 635. 
 
Chap, xxiv.i The Treatment : Opium. 4^^ 
 
 administerecl, but only with the effect of increasing 
 the trouble. The subsequent treatment consisted of 
 opium, the use of enemata, and poultices. The 
 enemata had no effect, and, indeed, provoked vomit- 
 ing. The action of the poultices may be con- 
 sidered as nil, and the treatment therefore is reduced 
 to rest and opium. The man had all the symptoms of 
 internal strangulation, the vomiting was severe and 
 became stercoraceous. There was absolute constipa- 
 tion for eleven days. At the end of that time a 
 motion was passed spontaneously and the patient 
 made a rapid recovery.* 
 
 In another case, less fully reported, a female, aged 
 thirty-nine, after long-continued pain in the epigas- 
 trium began to vomit and to suffer from complete 
 constipation. The vomiting was severe and was for 
 seventeen days stercoraceous. Indeed, one note during 
 the progress of the case states that the patient vomited 
 four to live pints of feculent matter every twenty- 
 four hours. Xo aperients were given. The only treat- 
 ment adopted consisted in the use of opium and the 
 administration of enemata. The latter produced no 
 effect. At last the bowels, after having been absolutely 
 obstructed for nineteen days, were opened sponta- 
 neously and the patient made a good recovery.! 
 
 The immense quantity of morphia that can be 
 tolerated in some chronic cases is surprising. Dr. 
 Blake reports the case of a man whose bowels were 
 absolutely confined for no less a time than eighteen 
 weeks. He began early in the case to take morphia, 
 and before its conclusion was taking twelve grains of 
 the alkaloid every day. The bowels were sponta- 
 neously relieved before death, which occurred seven 
 days after this relief of the obstruction. 
 
 While opium is of great value in relieving the more 
 
 * Lancet, vol. ii., 1874, page 726. 
 
 t Ibid., vol. i., 18G8, page 284; case by JIi-. Moses. 
 
426 Intestinal Obstruction. [chap. xxiv. 
 
 urgent and distressing of the symptoms, it must also 
 be observed that its use may seriously obscure the 
 diagnosis in an obscure case of acute strangulation. 
 It may so modify the symptoms and so aifect the 
 general aspect of the case that the more characteristic 
 manifestations of the malady are put entirely in abey- 
 ance. If the pain be modified or relieved, if the 
 symptoms of collapse be but dimly marked, if the 
 vomiting be slight and of little moment, and if the 
 patient appear to be in a state of comparative ease, 
 some of the chief factors in a proper differential 
 diagnosis will be wanting. This is well illustrated in 
 cases of strangulated hernia, especially in old persons. 
 The symptoms may in these cases be at first typical 
 enough, but when opium is administered they become 
 not only obscured but misleading. The evidences of 
 pain and prostration become indistinct, the dry tongue 
 becomes moist, the pulse improves, the excretion of 
 urine is normal, the abdomen is the seat of no severe 
 pain, the hernia is not especially tender, the vomiting 
 has ceased or has become very much diminished. In 
 short, the patient's symptoms have apparently im- 
 proved, while the state of the herniated bowel has be- 
 come worse and worse. I have twice had under my 
 care in the London Hospital, elderly patients with 
 strangulated herniae, who had been freely drugged with 
 opium before admission, and who had lost most of the 
 more conspicuous evidences of strangulation. In both 
 there was great prostration, in both there was an 
 absence of pain, in both the vomiting had become 
 much less marked than it had been, and in both the 
 hernial tumour was becoming soft through gangrene. 
 
 In like manner, in cases of internal strangulation, 
 the symptoms may be so improved and so modified 
 by the free administration of opium that the clinical 
 outline of the case may become greatly blurred and 
 serious errors in the diagnosis result in consequence. 
 
Ch::p. XXI V.J ThE TREATMENT : APERIENTS. 427 
 
 I think that in acute cases the use of opium should 
 be conducted with the greatest possible caution before 
 a definite diagnosis has been made, or before a definite 
 plan of treatment has been decided upon. When once 
 the drug has been given the clinical aspect of the 
 case may become greatly altered without any corre- 
 sponding beneficial change taking place in the involved 
 portion of intestine. No better rules can be adopted 
 in this matter than those that guide the surgeon in 
 the use of opium in strangulated hernia. 
 
 Aperients. — There are comparatively few cases 
 of intestinal obstruction, in the sense in which the 
 term is used in the present volume, that are not 
 greatly aggravated by the use of aperient medicines. 
 In all cases of acute and of subacute strangulation 
 their use is to be absolutely condemned without 
 reservation. They merely excite increased peristaltic 
 action in such cases, and aggravate all the symptoms, 
 increasing the pain, rendering the vomiting more 
 severe, and producing without doubt a more grave 
 condition of strangulation. 
 
 Fortunately, in most of the acute cases the aperient 
 is at once vomited when taken; but when it is retained, 
 or when croton oil is used, or when the aperient drug 
 is administered by an enema, it can only be said that 
 it does unmixed harm. In a great many instances 
 the symptoms have not become severe until after the 
 administration of a purge. Vomiting that had been 
 moderate and merely bilious has become profuse and 
 feculent after the use of an aperient. Profound 
 collapse, from intense pain, has also followed this 
 treatment, and it has in many instances, I think, 
 brought about a threatening perforation of the bowel. 
 Aperient medicines in these maladies have rendered 
 subacute cases acute, and have caused chronic forms 
 of obstruction to take on an acute development. 
 Indeed, among the indirect causes of dea,th in stoppage 
 
42 S Intestinal Obstruction. [Cbap. xxiV. 
 
 of tlie bowels purges Would occupy a very prominent 
 position, if all the cases where they have been used 
 could be brought to light. The evil effect of aperients 
 in cases allied to those now under notice is well sho^vn 
 in an instance of injury to the abdomen reported by 
 Mr. Simon.* A man, aged sixty, was ridden over, 
 and, as an autopsy showed, his jejunum was partially 
 ruptured. No extravasation, however, appears to 
 have taken place at or immediately after the accident. 
 For seventy hours the patient remained free from any 
 symptom of abdominal trouble. He had then several 
 doses of ajDerient medicine. Symptoms of perforative 
 peritonitis very rapidly developed, and the j^atient 
 died. In this case the death of the individual may 
 be fairly ascribed to the effect of the treatment. 
 
 In acute and subacute forms of intussusception, 
 also, aperients can do little but harm. They simply 
 excite increased peristaltic movement and greatly 
 aggravate the local condition. In not a few instances 
 that have been reported the use of an aperient has 
 evidently determined the strangulation of an intus- 
 susception, and has very seriously compromised the 
 future prospects of the case. 
 
 In volvulus of the sigmoid flexure and of other parts 
 it is needless to say that aperients do infinite harm, 
 and tend to increase rather than to diminish the dis- 
 tortion of the bowel. 
 
 In obstruction, however, due to fnecal accumula- 
 tion, aperients are of especial value, particularly when 
 combined with enemata and administered with proper 
 caution. In cases also of chronic obstruction depend- 
 ing upon partial mechanical occlusion of the bowel, 
 laxatives cautiously administered are often of the 
 greatest service. They render the intestinal contents 
 fluid and prevent accumulations above the obstruc- 
 tion. Violent aperients are, however, often almost as 
 * Path. Soc. Trans., vol. iv., 1853, page 151. 
 
Chap, xxiv] The Treatment : Aperients. 429 
 
 obnoxious in these cases as they are in examples of 
 acute strangulation. They hurry along the contents 
 and rapidly plug the stenosed segment, at the same 
 time that they roughly disturb the disordered bowel 
 above the obstruction. It must be noted that the in- 
 testine above the obstruction is often hypersemic and 
 in a condition far from healthy, and that a violent irri- 
 tation applied to such a segment of bowel may lead 
 to serious changes within its walls. Indeed, in the 
 following case I think it may not be unjust to ascribe 
 the patient's death to the aperients that she took, 
 A woman, suffering from long- continued constipation, 
 depending upon a non-malignant stricture of the 
 sigmoid flexure, took castor-oil and other powerful 
 drastic purgatives. This treatment led to no improve- 
 ment, but induced a profuse diarrhoea attended by 
 great prostration and soon followed by death. The 
 autopsy revealed the circumstance that the greater 
 part of the anterior wall of the ascending colon had 
 sloughed, faecal extravasation being only prevented by 
 the adhesion of the omentum over the necrosed part."^ 
 In many cases of chronic intussusception the 
 occasional and cautious use of gentle laxatives is of 
 much service as a palliative measure. The aperient 
 in these cases can render fluid the intestinal contents 
 and can clear the bowel more or less efficiently 
 without leading to an amount of peristalsis that may 
 do harm to the invaginated part. Dr. Wilks has 
 recorded a case which he reports as an example of 
 intussusception cured by purging. The patient was 
 a girl, aged thirteen, who suffered for some forty 
 days wdth intestinal symptoms associated with ths 
 presence of a tumour in the right hypochondrium. 
 Purges were administered, the bowels were evacuated, 
 the tumour gradually disappeared, and the patient 
 
 * Case by Dr. Moiion : Path. Soc. Trans. , vol. xx. , 1869, page 
 181, ^ 
 
43° Intestinal Obstruction. [Chap. xxiv. 
 
 recovered.* With every respect for the authority of 
 so eminent a physician, I would submit that the symp- 
 toms in this case do not very clearly point to chronic 
 intussusception. Indeed, the whole circumstances of 
 the case could be more readily associated with the 
 notion of a faecal accumulation, a diagnosis that Dr. 
 Wilks especially repudiates. The conception of an 
 invagination that could be actually cured by purga- 
 tives invoh'ing a great increase in the peristaltic 
 movements is not consistent with the usually accepted 
 ideas as to the pathogenesis of the disease. 
 
 Metallic iiiercHry.— The use of metallic mercury 
 in large doses is of very ancient date, and the metal was 
 at one time regarded as a most important and certain 
 remedy. In those days little was known of the patho- 
 logy of intestinal obstruction ; most of the acute cases 
 were put down to " volvulus," and the mercury was 
 supposed by its mere weight to undo some twist of the 
 bowel that was causing obstruction, or to force open a 
 passage that had been temporarily closed. Many cases 
 are reported where patients suffering apparently from 
 severe ileus were immediately relieved by a large dose 
 of quicksilver. It is needless to say that this mode of 
 treatment has gone more or less out of use, and the 
 subject would hardly have merited a notice were it 
 not for a very able monograph recently published by 
 M. Matignon, wherein this mode of ■ treatment is once 
 more advocated.! Under any circumstances M. 
 Matignon's paper cannot fail to be read with consider- 
 able interest, and it is from this production that the 
 remarks that follow are in the main adduced. 
 
 The cases for which this mode of treatment are 
 best adopted are cases of obstruction due to stercoral 
 tumours and some exaxnples of obstruction depending 
 
 * Lancet, vol. i,, 1870, page 731. 
 
 t Du Traitement de I'Occlusion intest, jiar le Mercure m^tal- 
 lique a Haute Dose. These de Paris, No. 340, 1879. 
 
Ciiap. XXIV.] The Treatment: Mercury. 431 
 
 upon the accumulation of fsecal matters above a stric- 
 ture or stenosed part. In all cases of acute and sub- 
 acute strangidation, in all cases of intussusception, and 
 in all cases of complete mechanical occlusion of the 
 bowel, it is, as may be supposed, absolutely useless. 
 In cases, however, of ileus following f?ecal accumula- 
 tion its effects have often been very remarkable and 
 very decided, an evacuation having been at once pro- 
 duced in severe cases after repeated enemata and 
 aperients have failed. The modus operandi is as 
 follows : The mercury does not act by its weight, but 
 in its passage along the intestine it becomes very finely 
 divided, and on reaching the stercoral tumour appears 
 to insinuate itself among the parts of the fsecal mass 
 and between the mass and the bowel wall, and so to 
 loosen the obstructing matter as to restore the normal 
 passage. This mechanical action is aided, no doubt, by 
 some peristaltic action that the foreign substance may 
 excite in the intestinal wall as it passes along. In 
 any case the metal appears to have been passed in a 
 state of extremely fine division and not in a coherent 
 mass as when swallowed. In cases of acute and of 
 complete mechanical obstruction the quicksilver has 
 been found after death to have collected into a single 
 mass above the obstruction, the separated particles 
 having in such instances cohered again. In no instance 
 was any evidence of mercurial poisoning produced. 
 In several of the cases where this treatment was 
 adopted the vomiting and pain were immediately sub- 
 dued after the mercury had been swallowed, and this 
 result is supposed to be due to the interference with 
 the movements of the stomach that the metal may 
 effect by its mere weight. 
 
 The dose of the metal administered varies from 50 
 to 300 grammes, and in most cases the dose, whether 
 large or small, has been many times repeated. 
 
 jM. Matigiion rcpoi-ts several cases of relief by this 
 
432 Intestinal Obstruction. [Chap. xxiv. 
 
 treatment in obstruction clue to faecal accumnlation. 
 In these exaniples purges and enemata had failed, the 
 symptoms had become very grave, and in some the 
 vomiting had become feculent. Metallic mercury was 
 administered, with the result, that the vomiting and 
 pain were immediately relieved, and the bowels were 
 caused to act after a few hours. In each of the cases 
 quicksilver was passed in a finely-divided state for 
 some three or four days after the first evacuation, and 
 in one instance, where nearly 1,000 grammes of mer- 
 cury had been given in several doses, the metal was 
 noticed in the motions for seventeen days after the 
 administration of the last dose. 
 
 M. Matignon's cases appear so clear that in any 
 case of faecal accumulation that has resisted the action 
 of aperients, enemata, massage, electricity, etc., the use 
 of metallic mercury in large doses would appear to be 
 worth trying, especially as the mode of treatment 
 appears to be attended by no especial risk. 
 
 Ice. — In any case, and especially in those that are 
 of an acute character, the patient often derives much 
 comfort from sucking ice. It allays the thirst, it 
 moistens the parched mouth, and it certainly in many 
 cases moderates the sickness a little. In what is 
 known as GrissoUe's method the use of cold is more 
 extensively adopted, and the method professes to be 
 not merely palliative but also curative. In this pro- 
 cedure the patient is encouraged to take as much ice 
 by the mouth as possible ; ice is at the same time 
 freely applied to the surface of the abdomen and 
 enemata of iced water are administered at frequent 
 intervals. The precise modus operandi of Grissolle's 
 method in cases of internal strangulation is not quite 
 evident, and I can find no definite account of any in- 
 stance where cure can be said to have followed this 
 plan of treatment. 
 
 Enemata of iced weiter are apt to excite consider- 
 
Chap. XXIV.] The TreaTiMenT : Electricity. 433 
 
 able peristaltic movement, and may therefore in many- 
 cases do more harm than good. The treatment is pro- 
 bably more adapted for the relief of obstruction due 
 to paresis of the bowel than to that due to mechanical 
 causes. 
 
 Electricity has beeti extensively used in the treat- 
 ment of intestinal obstruction, and has been in recent 
 times strongly advised by eminent authorities. Many 
 remarkable cases of cure have been ascribed to this 
 method. Some of these cases are so scantily reported 
 that they are of little or no value, since they furnish 
 no data upon which to base any independent criticism 
 of the diacjnosis. 
 
 So far as I can ascertain, the cases of cure by elec- 
 tricity have been wholly, or for the most part, examples 
 of ileus depending upon faecal accumulation. In these 
 cases, in which a paresis of the gut takes so conspi- 
 cuous a part, the mode of treatment is intelligible, and 
 may be expected, h priori, to be of benefit. 
 
 Electricity may also be of use in some cases of 
 obstruction due to foreign substances of various kinds. 
 It may also prove of service in some instances of stric- 
 ture or of stenosis where an accumulation has taken 
 place above the narrowed part, which the unaided con- 
 tractions of the bowel are unable to relieve. 
 
 It is very difficult, however, to understand how 
 electricity can have the least curative effect in acute 
 strangulations as by bands or through slits and aper- 
 tures. If it acts by increasing peristaltic movements, 
 then its use in cases of this kind would appear to be 
 peculiarly undesirable. The same observations ap})ly 
 to acute or subacute intussusception and to volvulus. 
 In these affections a moderation of intestinal move- 
 ments is a condition to be desired, and if the main 
 effect of electricity is to stimulate those movements, 
 then the measure is calculated to do harm rather than 
 good. I have met with accounts of a large number of 
 c c — 12 
 
434 InTESTI.VAL ObSTRUCTIO:^. [Chap. xxiv. 
 
 cases of intestiiial obstruction treated by electricity, 
 and ill all such of these cases as were not due to fecal 
 accumulation or to temporary obstruction in cases of 
 incomplete stenosis, the treatment appears to liaA'e 
 been of no avail. Some examples of supposed cure 
 are, I think, a little fanciful. The following may ser-se 
 as an instance : " Dr. Clemens, of Frankfort, states 
 that he has successfully treated invagination by first 
 administering one or two tablesjioonfuls of metallic 
 mercury, which settled down to the seat of the invagi- 
 nation. The negative electrode was applied over the 
 supposed seat of the disease and the positive in the 
 rectum. Voltaic alternatives were used.'""^ In con- 
 nection with this case I might point out that post 
 mortem examinations do not support the belief that 
 metallic mercury, when taken by the mouth, will 
 arrange itself above an invagmation, as here described. 
 Ill many cases of fsecal accumulation causing ob- 
 struction symptoms electricity has given relief, and 
 has caused a motion to be passed after aperients and 
 enemata had entirely failed. Of its power in affording 
 relief in cases of stricture, the following case may be 
 taken as an example : A man, aged oQ, had had occa- 
 sional slight attacks of intestinal obstruction from time 
 to time during the twelve months that immediately 
 preceded his death. The last attack had lasted already 
 seventeen days when the patient was admitted into 
 hospital. He vomited everything, and the abdomen 
 was greatly distended. Aperients and enemata, in- 
 cluding enemata of seltzer water, had no effect. On 
 the twenty-second day galvanism was applied, and had 
 the immediate result of causing the patient to pass a 
 copious motion. He was much relieved. The symp- 
 toms, however, returned, inguinal colotomy was per- 
 formed on the right side, and the patient died on the 
 
 * Medical and Bwrgical Electricity, by Beai-d and Rockwell, 
 page 484. New York, iS71. 
 
Chap. XXI v.] The Treatment : Electricity. 435 
 
 following day. The obstruction was due to an epitlie- 
 liomatous stricture of the sigmoid flexure.* 
 
 There have been a fcAv cases reported of internnl 
 strangulation where electricity gave some slight tem- 
 porary relief without, however, affecting the actual 
 obstruction. Thus, M. Terrier records the case of a 
 woman, aged twenty-one, who was suffering from 
 strangulation of a portion of the intestine beneath a 
 band connected Avith the Ijroad ligament. On the- 
 third day electricity was used, and is said to have re- 
 lieved the pain and to have moderated the vomiting. 
 The symptoms, however, persisted and laparotomy was 
 performed on the fourth day with success, f 
 
 There are several methods of applying electricity in 
 these cases of abdominal obstruction. 1. Both elec- 
 trodes are placed upon the abdomen = abdominal 
 method. 2. One pole (the negative) is placed upon the 
 abdomen, the other just within the anus — ano-abdo- 
 minal. 3. One electrode (the negative) is placed over 
 the dorsal spine while the other is introduced some 
 distance up the rectum = recto-spinal. 4. The nega- 
 tive pole touches the abdomen while the positive is 
 applied within the rectum — recto-abdominal. In the 
 two last-mentioned methods the electrode is made of 
 a copper ball mounted on an isolating handle, so that 
 the current may pass to the gut direct without involving 
 the anus and lower part of the rectum. In all cases 
 and in all forms the faradic current is advised. The 
 method most particularly advocated by those who have 
 written upon the subject is the recto-abdominal. The 
 effects that have been demanded for this form of elec- 
 tric application are the following : The abdominal 
 muscles contract ; the intestines contract and propel 
 forwards their contents ; flatus disappears from the 
 intestine without being either expelled from the mouth 
 
 * Archives Gen. cle Med. , 1879. vol. ii. , page 207 ; M. Diiplay. 
 t Bull, et Mem. de la Roc. de Chir. de Paris, 1879, page 5(34. 
 
43^ Intestinal Obstruction, tchap. xxiv. 
 
 or the anus ; and the symptoms of collapse are relieved 
 if they exist. * 
 
 Massage. — Massage of the abdomen has been 
 somewhat extensively tried in many forms of intes- 
 tinal obstruction, especially in France. Its action is 
 very vague and its general effects uncertain and un- 
 satisfactory. It has often been used with much suc- 
 cess in constipation and in obstruction due to faecal 
 masses, to gall stones, and to foreign substances. In 
 these cases the manipulation of the abdomen probably 
 not only excites peristaltic movement but also directly 
 dislodges the obstructing matter. As an illustration 
 may be cited a case reported by Martin. The patient, 
 a woman aged seventy-eight, was suflfering from symp- 
 toms of severe obstruction due to the impaction, 
 probably in the terminal part of the ileum, of a large 
 gall-stone. Aperients had had no effect and the 
 vomiting had become stercoraceous. A tumour could 
 be detected in the right iliac fossa. On the sixth day 
 massage was employed ; relief followed, and on the 
 next day a large gall-stone with ten smaller stones 
 were evacuated.! 
 
 Massage has been frequently used in cases of intus- 
 susception. I can, however, find no case where cure 
 can be said to have followed this treatment alone. In 
 the cases of reputed cure the massage was usually sub- 
 sequent to, or coincident with, the administration of 
 copious cnemata,J and the morbid anatomy of invagi- 
 nation would lead us to suppose that the injection 
 would have more effect than the manipuhition, I ima- 
 gine that massage in these cases would tend to excite 
 an undesirable amount of peristaltic action, although 
 it is quite reasonable to suppose that it might prove of 
 
 * See L'Occlusion Intcstinale, by A. Bulteau. Thfese de Paris, 
 1878, No. 427. 
 
 t Bull, dela Soc. Anat. de Paris, 1875, page 195. 
 
 X See cane by Dr. Gillette, JVew York Med. Joiwn. , 1882, page 
 261. 
 
Chap. XXIV.] The Treatment : Massage, 437 
 
 service if applied when the patient was under the in- 
 fluence of an anaesthetic or a narcotic. 
 
 In other cases of acute obstruction I imagine 
 that this mode of treatment would probably do more 
 harm than good. It could never be applied with any 
 scientific precision. 
 
 In several of the reputed examples of cure by mas- 
 saii'e other modes of treatment had been adopted to 
 which some share in the cure may possibly be ascribed. 
 This is well illustrated in a remarkable case reported 
 by M. Bitterlin. The patient, a man aged fifty-six, 
 was seized with symptoms of acute intestinal ob- 
 struction. The obstruction lasted ten days and the 
 symptoms Avere very severe. During these ten days 
 the following therapeutic measures were adopted for 
 the relief of the unfortunate patient. Morphia was 
 administered, followed by large doses of castor-oil, 
 and subsequently by large doses of croton-oil. Ene- 
 mata of water, of senna, of sulphate of magnesia, and 
 of tobacco were injected at different times. Poultices 
 were first of all applied to the abdomen, and these 
 were in time followed by frictions with belladonna. 
 Electricity was used. All these means were without 
 effect. At last massage was tried, an almost immediate 
 relief followed, and the patient recovered in spite of 
 treatment."^ 
 
 The various mechanical methods adopted for the 
 relief of constipation in what is usually known as the 
 " Swedish movement cure," seem to have met with a 
 very encouraging degree of success. The machines 
 employed are of different descriptions. In one the 
 patient lies upon the abdomen over an opening, and in 
 this opening rollers move which exercise a kneading 
 action over the whole of the belly. In another machine 
 two rollers are caused to rotate along the course of 
 the large intestine. 
 
 * L'UniouMedicale, 1882, page 433. 
 
438 Intestinal Obstruction. [Chap. xxiv. 
 
 In other machines, passive rotation of the lower 
 part of the trunk and passive oscillation of the pelvis 
 are brought about, with the effect, it is said, of 
 stimulating peristaltic movements in the intestine. 
 In still other machines the patient sits upon a saddle, 
 and is subjected to movements which imitate more or 
 less the movements incident to horse exercise."^ 
 
 EiieiiiatR.. — Copious enemata of water are of con- 
 siderable service in cases of intestinal obstruction. 
 Beyond the fact that an enema may excite peristaltic 
 action in a large segment of the small intestine they 
 are of use only when the obstruction involves, in 
 whole or in part, the large intestine. In the cadaver, 
 water forcibly injected at the anus can occa- 
 sionally be made to pass through the ileo-csecal 
 valve. There is often no difficulty in this. In the 
 living subject, however, there is every reason to 
 believe that the valve does not yield, and that the 
 direct action of the enema ceases abruptly at the 
 ileo-c£ecal junction. 
 
 There are morbid circumstances in the living 
 subject, how^ever, under which it may be possible for 
 the valve to become insufficient. Thus there are good 
 reasons for believing that when the patient is under 
 the influence of an anaesthetic water may sometimes 
 be made to pass beyond the colon into the ileum. In 
 cases, too, of obstruction associated with paral3^sis of 
 the ileo-c?ecal segment of the bowel the valve may 
 prove to be insufficient, esjiecially when the activity 
 of reflex action has been moderated by opium. Mere 
 distension of the colon would appear to increase rather 
 than to diminish the competency of this internal anus. 
 
 There are ditl'erent methods of administering 
 enemata. In the great majority of cases th'e ordinary 
 
 * Diagrams of most of these machines are given in Mecha- 
 nical Exercise a Means of Cure, the work being a descrij^tion of the 
 Zander Institute in London, lb83. 
 
Chap. XXIV.] The Treatment : E-nemata. 439 
 
 enema-pump or syringe is all that is required. A 
 somewhat better instrument than this, even for 
 ordinary purposes, is the syphon apparatus. This 
 consists essentially of a large funnel, to which is 
 attached a long indiarubber pipe ending in a more 
 solid tube for introduction into the rectum. Between 
 the two tubes is a tap. In the administration of 
 enemata by this means the patient should be placed 
 in such a position as to reduce the abdominal pressure 
 as much as possible. The knee-and-head, knee and- 
 elbow, and lateral abdominal positions are the best. 
 The water enters by gravitation, and the pressure of 
 the entering column can be increased or diminished 
 by raising or lowering the funnel containing the 
 injection material. This method has great advantages 
 over the ordinary syringe. The fluid is introduced in 
 a constant and easily regulated stream, and not in 
 intermittent gushes. The bowel being more tolerant 
 of the former method^ it follows that much larger 
 quantities of fluid can be introduced by this means 
 than by the common syringe. The jDi'essure, more- 
 over, that is exercised upon the walls of the bowel is 
 uniform and can be slowly and regularly increased. 
 
 Enemata as administered by one or other of these 
 methods are of infinite service in many cases of 
 obstruction. By their means the large intestine may 
 be cleared. In cases of obstruction due to f^cal 
 accumulation enemata constitute the principal active 
 treatment. By the use of frequent and copious 
 injections a distended colon may be gradually emptied 
 of its contents from the rectum to the caecum. When 
 used for the purpose of evacuating the colon different 
 fluids have been recommended. In most cases warm 
 water is all that is required. When a more stimu- 
 lating injection is needed a little turpentine is added. 
 In some instances an alkali is mixed with the water, 
 under the impression that bv such admixture the 
 
44 o Intestinal Obstruction. [Chap. xxiv. 
 
 impacted fseces are more readily acted upon. The 
 alkali usually is introduced by uiixin*.;; soap with the 
 water. With a like object in view enemata of oil or 
 of mixtures containing oil have been made use of. 
 
 In other instances some aperient has been used 
 as the enema-material, and solutions of senna or of 
 sulphate of magnesia have been thrown up the bowel. 
 Here the ordinary action of the injection is supple- 
 mented by the absorption of purgative drugs. 
 
 Enemata are also of considerable use in relieving 
 obstructions due to accumulation above a stricture or 
 stenosis in the colon. In many cases it has been 
 found that water can be made to enter the narrowed 
 gut from below, while the part remains impervious to 
 water introduced from above. A stricture of the 
 colon may long be prevented from causing a complete 
 and final obstruction by the frequent and patient use 
 of enemata. Injections have also been of much 
 service in relieving accumulations that have taken 
 place above chronic invaginations occupying the large 
 intestine. 
 
 In cases of volvulus of the colon enemata would 
 appear to be of no use as curative measures, and the 
 same observation apj^lies in a still more marked 
 degree to examples of acute intestinal strangula- 
 tion. 
 
 Enemata, however, can be used in obstruction 
 cases for other purposes than the simple evacuation of 
 the colon. They have proved of considerable service 
 in reducting intussusceptions that occupy the large 
 intestine, i.e. such as are colic, ileo-colic, or ileo- 
 csecal. To effect this reduction large quantities of 
 fluid, and in such cases only warm water is used, are 
 injected with considerable force ("forcible enemata," 
 " monster clysters "). The ordinary syringe or pump 
 may be used for this purpose, the return of the water 
 being prevented by an assistant who presses the sides 
 
Chap. XXIV.] The Treatment: Enemata, AcAc'i- 
 
 of the buttocks and the margins of the anus as close 
 as possible against th(} tube. This apparatus, how- 
 ever, is ol)jectionable. The fluid is introduced spas- 
 modically, and it is difficult to estimate what amount 
 of force is being used. 
 
 A. far better method is by the syphon apparatus. 
 If the tube of this enema be made very long, and the 
 funnel be placed at a considerable height, the fluid can 
 be caused to enter the rectum, not only with great 
 force, but also with a uniform and easily regulated 
 pressure. In both forms of enema there is much 
 difficulty in retaining the injected fluid. This diffi- 
 culty can, however, be well met by adapting to the 
 rectal tube of the syphon-apparatus the very 
 ingenious elastic ring and handle devised by Mr. 
 Lund for his air- inflation instrument (Fig. 57). 
 
 In many cases the injection has been administered 
 while the patient was partly inverted. This position 
 has, however, I think, no peculiar advantage. If it 
 facilitates the passage of fluid along the descending 
 colon it must at the same time hinder its passage 
 along the ascending colon. The best positions for the 
 purpose are those already referred to, viz. the head- 
 and-.'knee, knee -and -elbow, and lateral abdominal 
 positions. I think it extremely important that the 
 injected fluid should be forcibly retained for a con- 
 siderahle time. Its reducing action upon the in- 
 vaginated bowel must be slow and gradual, and the 
 bowel should therefore be kept distended for at least 
 fifteen minutes. Dr. Eastes has recorded an in- 
 teresting case where an intussusception was quietly 
 reduced by means of a forcible enema, Avhich was not 
 allowed to escape for a quarter of an hour. "^ Many 
 examples may be given of the ready reduction of an 
 invagination by means of enemata only, both with 
 and without the assistance of chloroform. This 
 * Lancet, vol. ii., 1869, page 669. 
 
442 Intestinal Obstruction, [Chap. xxiv. 
 
 subject will be further considered in dealing with the 
 treatment of invagination. 
 
 Enemata of a mixture of tobacco-juice and water, 
 and even insufflations of tobacco-smoke, were at one 
 time in great repute among the therapeutic measures 
 available for intestinal obstruction. It was supposed 
 that the tobacco subdued spasm and relaxed the 
 muscular contraction of the bowel. The measure was 
 used at a time when spasmodic stricture of the 
 intestine was considered to be a fairly common 
 affection. Experience has shown this treatment to 
 be not only useless but also to be obnoxious in many 
 ways. If an anti-spasmodic be required it can be 
 administered in a more satisfactory manner than by 
 introducing tobacco-juice into the rectum. 
 
 Insufflation. — The forcible injection of air into 
 the colon has been used to excite peristaltic movements 
 in cases of chronic constipation and obstruction by 
 stercoral masses. It is, however^ not so efficacious as 
 an injection of fluid, and has no advantages over that 
 method of treatment. Insufflation has, however, been 
 extensively used in cases of intussusception for the 
 purpose of reducing the invagination. Air-inflation 
 acts in precisely the same way as the forcible enema, 
 and it might be said at once that, as a means of 
 reducing an intussusception, it is inferior to the 
 injection. Before it can be used the bowel must be 
 emptied by enemata, and there are no cogent reasons 
 why in the further treatment these enemata should be 
 replaced by insufflation. Indeed, instances can be 
 given where insufflation has failed but where in- 
 jections have been successful in reducing an invagi- 
 nation."^ There are at the same time not a few 
 examples of the cure of intussusception by air- 
 inflation only. 
 
 The procedure is usually carried out by means of a 
 
 * Sec case by ]\Ir. "Waren Tay : Lancet, vol. i., 1S7G. page 13. 
 
Chap, xxiv.j Ti IF. Treatment : Insufflation. 443 
 
 common bellows, to which an indiarubber pipe and a 
 rectal tube have Ijeen attached.* 
 
 By far the best instrument, however, for the 
 purpose is that designed by Mr. Lund of Manchester 
 (Fig. 57). It consists of an air-syringe and a rectum- 
 tube. "The merit of the invention," writes Mr. 
 Lund, " consists in a particular mode of securing an 
 air-tight contact around the margin of the anus, l)y 
 the use of a hollow elastic ring e placed over the 
 tube, which is compressed and flattened against the 
 
 Fig. 57.— Lnnd's Inflator. 
 A,airsyrin£?o ; ti, Blionlderonond of liandlec ; i), point wbero air enters tliorcrtnm 
 tube ; E, liollow clastic ring ; v, a long narrow rectum tube for cases of rectal 
 stricture, etc. 
 
 shoulder b on the handle c, when firmly pressed 
 against the part by an assistant. This method of 
 preventing the return of the air as it is pumped into 
 the bowel is more effective than anything of the 
 nature of a plug or tamj)on introduced within the 
 rectum, even if it be carefully adjusted to the size of 
 that cavity, for the air so injected is sure to escape 
 by the side of the plug, the anus and rectum being 
 immensely expansible. . . . With the apparatus, 
 when the hollow ring is compressed, the central hole 
 
 * yStec art. by Dr. Trastour ; Bull, g^n de Thf'rap., 1874, page 107. 
 
444 Intestinal Obstruction. [Chap. xxiv. 
 
 in it is diminished in size, tlie skin around the anus, 
 to which the indiarubber clings Avith gi'eat tenacity, 
 is drawn inwards towards this centre, and the tight- 
 ness of the air-joint thus formed can be well sus- 
 tained."* 
 
 Mr. Lund's instrument was more especially de- 
 vised for distending the colon in lumbar colotomy. 
 
 Eiieinata of carbonic acid.— Distension of the 
 colon by carbonic acid may be effected in two ways. 
 In the first method the gas is derived from an ordinary 
 " syphon " of seltzer or soda-Avater. A tube is passed 
 up the rectum as far as it will go. To the end of 
 this tube an indiarubber pipe is attached which is 
 connected by its other extremity with the nozzle of a 
 " syphon." The syphon should be of large size, 
 capable of holding a quart. An assistant presses the 
 margins of the anus against the tube, and, everything 
 being in readiness, the button of the syphon is 
 pressed and its contents pass into the rectum, f 
 
 In the second method the distension is effected by 
 mtroducing first a solution of bicarbonate of soda and 
 then a solution of tartaric acid into the rectum, so 
 that the gas is generated within the bowel. A long 
 rectal tube is used, which is connected by an india- 
 rubber pipe with a glass funnel. The two drugs are 
 introduced in solution, one being poured in after the 
 other has had full time to find its way into the 
 intestine. When the two solutions have been in- 
 troduced a certain quantity of Avater is rapidly 
 poured in. The escape of the gas is prevented by 
 forcibly pressing the buttocks together about the 
 tube, escape also being proA^ented along the tube 
 itself. Ziemssen, who has wi'itten in high praise of 
 this mode of distending the boAvel, says that for 
 complete dilatation of the colon in an adult tAventy 
 
 * Lancet, vol. i. , 1S8.3, page 588. 
 
 t See Bull. gen. de Th^rap., 1877, page 223 ; Dr. Gamier. 
 
Chap. xxv.i The Treatment : Puncture. 445 
 
 grammes of bicarbonate of soda are required and 
 fifteen grammes of tartaric acid. He recommends 
 that the solutions should be introduced grcxdually, or 
 at least in three parts. He points out that the ileo- 
 csecal valve remains firm even against strong pressure, 
 but states that under the influence of the carbonic 
 acid it may yield a little so as to allow gas to reach 
 the small intestine."^ 
 
 Ziemssen asserts that this form of enema is of 
 great value in reducing intussusceptions, and that it 
 is superior to the ordinary injection of water. He 
 regards it also as a very efficient aperient, and states 
 that it induces intense peristaltic action. Previous 
 authors have stated that carbonic acid acts as a 
 sedative to tlie intestine, and that injections of it may 
 be used to allay the pains of colic. Ziemssen believes 
 this form of enema to be of diagnostic value as a 
 means of ascertaining the dilatability of the colon, 
 and also as demonstrating possibly the position of an 
 obstruction in the bowel. 
 
 CHAPTER XXV. 
 
 THE TREATMENT — OPERATIVE MEASURES. 
 
 Puncture of the toowel with a liuc 
 trochar. — In this procedure an aspirator needle or 
 a fine trochar is thrust into the abdomen over some 
 prominent coil of intestine, and relief is sought to be 
 afforded by the escape of matters, flvdd and gaseous, 
 from the distended bowel. 
 
 It cannot be said that this is a very scientific 
 operation, nor one that can be adopted with any preci- 
 sion or carried out witH any very definite purpose. 
 
 * Archiv fur Klin. Med., bd. ;iS, 3 and 4. 
 
44^ Intestinal Obstruction. [Chap. xxv. 
 
 It must be regarded as a palliative rather than as 
 a curative measure. 
 
 In many forms of obstruction great distress is 
 occasioned by the distension of the abdomen, much 
 dyspnoea may be produced, the pain increased, and the 
 vomiting rendered more troublesome. Indeed, in 
 some cases of rapid and extreme distension, such as 
 may be met with in volvulus of the sigmoid flexure, 
 the meteoristic bowels may so press upon the dia- 
 phragm and the thoracic viscera as to cause more or 
 less sudden death. In cases of distension puncture 
 usually affords very considerable relief. The punctures 
 may be repeated many times or made in many parts 
 of the abdomen at once, and the amount of flatus and 
 occasionally of fluid matter that may be in this way 
 removed is often considerable. The procedure, more- 
 over, has been advocated as a valuable measure in 
 diagnosis. By its means distended coils may be 
 emptied and a tumour or other condition be revealed 
 that had been hitherto hidden from view. 
 
 It has been recommended also as a preliminary to 
 laparotcray by surgeons who, in performing this 
 operation, have been troubled by the premature escape 
 of the distended coils. 
 
 With regard to puncture as a curative measure 
 one must note that several cases of obstruction have 
 been recorded which have been apparently cured by 
 this procedure and by it alone. In illustration, I 
 might take an example of an acute case and then an 
 example of a chronic one. 
 
 M. Le Fort mentions the case of a man with 
 symptoms of acute internal strangulation upon whom 
 he was about to perform laparotomy. Before, how- 
 ever, proceeding to this measure he punctured the ab- 
 domen with a capillary trochar once in the right 
 hypochondrium and twice in the site of the transverse 
 colon. Some flatus and fluid f<eces escaped. The 
 
Chap. XXV.] The Treatment : Puncture. 447 
 
 next day the man passed a copious motion, and a rapid 
 and complete recovery followed.* 
 
 Mr. AVorthino-ton details a case of chronic consti- 
 pation ending in an acute attack in the person of a 
 man aged twenty-eight. The symptoms were severe, 
 there was great meteorism and stercoraceous vomitino-. 
 On the seventh day a fine trochar was introduced and 
 retained thirty minutes. Much fluid and flatus escaped. 
 Next day a stool was passed, and the patient made a 
 good recovery.! 
 
 Without discussing the probable nature of these or 
 of like cases "we may proceed to consider what form or 
 forms of obstruction are likely to be benefited by this 
 m.ode of treatment. 
 
 Puncture of the involved coil has been suggested 
 as a means of cure in volvulus of the colon. It is true 
 that at autopsies it has often been found impossible to 
 reduce a volvulus until it had been emptied by a 
 trochar, but I am not aware that the emptying alone 
 has been suflicient in any case to effect reduction. 
 Indeed, I can refer to cases both of volvulus of the 
 sigmoid flexure | and of the caecum § where capillary 
 puncture was resorted to during life without any 
 enduring benefit. 
 
 Evacuation of the contents of the upper segment 
 of the bowel may completely relieve obstruction due 
 to kinking, or to acute bending of the intestine. It 
 may also allow of the spontaneous reduction of a coil 
 that is lightly held under a band or is involved, with- 
 out severe strangulation, in some abnormal aperture. 
 It may afford marked and long-continued relief in 
 cases of temporary complete obstruction depending 
 upon stricture, upon any form of stenosis, upon faecal 
 
 * Biill. et M€in. de la Soc. de Cliii-. de Paris, 1879, page 641. 
 i- Bi'it. Med. Journ., vol. ii., 1882, page 167. 
 :J:Coiitrib. a TEtude de I'Occlus. intes., by J. M. Le Moyne. 
 These de Paris, 1878. 
 
 § Dr. Hilton Fagge ; Guy's Hosp. ReiDorts, vol. xiv. , page 27:?, 
 
44^ Intestinal Obstruction. [Chap. XjCV. 
 
 accumulation, or upon the impaction of a foreign sub- 
 stance. It may give decided relief in cases of chronic 
 "stoppage" Avhere symptoms of acute obstruction 
 have developed suddenly as a result of changes follow- 
 ing upon great distension of the bowel. 
 
 But even should a correct diagnosis be made in 
 such cases as the above, it must still remain an open 
 question whether relief should be sought by this 
 means. It is true that in most instances the little 
 operation is associated with no evil results, even if it 
 does not give relief, but its application is attended by 
 great uncertainty. The proper coil of intestine may 
 be hit, or it may not be. In any case it is probable 
 that the trochar would enter a distended loop, but it 
 may be one so far away from the seat of obstruction 
 that the evacuation of its contents is attended by no 
 real benefit. In the great majority of cases, there- 
 fore, the puncture must be made purely at hazard and 
 blindly, and its chances of hitting the exact spot are 
 about those of the arrow from the bow " drawn at a 
 venture." In not a few cases the trochar has entered 
 the bowel below the obstruction. Thus, in one ex- 
 ample of stricture involving the terminal part of the 
 ileum a trochar Avas thrust into the transverse colon 
 and retained there during the night. About forty 
 ounces of fluid faeces escaped, but no relief was 
 afforded.* 
 
 Even when the trochar strikes the proper segment 
 of the intestine an amount of distress may be occa- 
 sioned by the instrument which is not counterbalanced 
 by any relief following the evacuation of intestinal 
 contents. Thus^ in a case of chronic obstruction due 
 to a lesion involving the lower ileum a fine trochar 
 was introduced. It was proposed to retain it for some 
 time. The instrument was, however, carried round 
 and round by the peristaltic action of the bowel, and 
 * Lancd, vol. i. , 1883, page 42 : by Dr. Wm. Piatt. 
 
Chap. XXV.] The Treatment : Puncture, 449 
 
 so much pain was occasioned that it had to be removed 
 at the end of two hours."^ 
 
 Before conchiding this subject it must be pointed 
 out that puncture of the intestine is not quite so en- 
 tirely harmless a procedure as is sometimes supposed. 
 The punctured gut is much distended and often in a 
 state of temporary paralysis ; so that after the trochar 
 is withdrawn the little hole is not eihciently closed, 
 and faecal extravasation may follow. The more 
 minute the trochar the smaller the hole to be closed, 
 but at the same time the amount of matter evacuated 
 by very slight instruments is so trifling that the opera- 
 tion has no raison d'etre. Then, again, the puncture 
 may involve a friable piece of gut on the point of 
 gangrene, and faecal extravasation may again ensue. 
 Mr, Hulke, in performing a laparotomy, punctured 
 the distended intestine. The gut so treated was in a 
 precarious condition. The hole did not close, attempts 
 to close it made it larger, until at last it had to be 
 converted into an artificial anus.f 
 
 One other point may be noticed. I have met with 
 several instances where perforation of the bowel that 
 had been previously threatening took place imme- 
 diately after the relief of a distended coil. In one of 
 these cases I had performed left lumbar colotomy for 
 the relief of a stricture of the sigmoid flexure. Little 
 faeces escaped at the time of the operation. During 
 the night there was a copious evacuation through the 
 wound. Shortly afterwards the patient developed 
 evidences of perforative peritonitis, of which she died. 
 The autopsy showed extensive ulceration of the caecum 
 and a perforation at the base of one of these ulcers. 
 Dr. Bristowe describes a case of stricture of the sigmoid 
 
 * Dr. Hilton Fagge, loc. cit, 
 
 t Medical Times and Gazette, vol. ii., 1872, page 482. See also 
 Paper by Prof. G. Macleod ; Glasgoio Med. Journ. , March, 1884, 
 page 167' 
 
 DD— 12 
 
450 Intestinal Obstruction. [Chap. xxv. 
 
 flexure associated with great distension of the abdo- 
 men, to relieve which he used a trochar. In thirty 
 minutes acute peritonitis set in, of which the patient 
 died next day. The autopsy revealed the trochar 
 punctures perfectly closed. Fsecal exti*avasation had 
 taken place through a perforation in the lower ileum, 
 the aperture being at the base of an extensive nicer. "^ 
 In these cases, and I could allude to others, it would 
 appear that some disturbance in the amount of pres- 
 sure brought to bear ujion various segments of the 
 bowel follows from the sudden relief of distension, and 
 a potential perforation is thereby rendered an actual 
 one. 
 
 In favour of the liarmlessness of puncture of the 
 abdomen the case reported by Dr. Blake may be again 
 alluded to. In this case, during a constipation that 
 was absolute for eighteen weeks, the abdomen was 
 punctured no less than 150 times, about half a pint of 
 intestinal contents, in addition to some flatus, being- 
 drawn off each time. 
 
 Eiitei'ocentcsis. — This operation was devised 
 by Dr. Larguier des Bancels.f It merely consists in 
 puncturing the intestine with a large trochar, the 
 instrument to be retained as long as necessary. 
 
 Dr. Larguier uses a tro.'*har with a diameter of 
 five to six mm., and leave.s it in the intestine at 
 least two or three days. In one case the procedure 
 led to a fjecal fistula, which, however, closed in time. 
 Dr. Larguier gives an account of five cases in which 
 this puncture was adopted. Three recovered, one was 
 relieved, and one died. The cases were of a chronic 
 character, and in one instance of obstruction due to 
 ftecal accumulation the relief w^as certainly marked 
 and immediate. The operation can^ however, in 
 
 * Path. Soc. Trans., vol. xxiii., page 1|9. 
 t Sur le Diag. et le Trait, chiriu-g. des Etrang. internes. These 
 de Paris, No. 142, 1870. 
 
Chap. XXV.] The Treatment : Laparotomy. 451 
 
 no way be advised. It must be done blindly. Its 
 chances of failure are not equalled by its chances of 
 success. In many cases it must leave the real cause 
 of the obstruction untouched. It must expose the 
 patient to a great risk of faecal extravasation when 
 the trochar is withdrawn. The operation is in itself 
 dangerous, and at the most resolves itself, if success- 
 ful, into an enterotomy performed in the dark. 
 
 L:Bp:ii'otoiny. — This is one of the most important 
 operations concerned in the treatment of intestinal 
 obstruction, and is a procedure that is likely in the 
 future to occupy a still more conspicuous position than 
 it does at i)resent. 
 
 It consists essentially in making an opening into 
 the cavity of the abdomen. It has been adopted in 
 cases of obstructioD witli many different purposes. 
 Laparotomy may be performed merely as an explo- 
 ratory operation and as a means of diagnosis. 
 As a measure in treatment it has Ijeen applied to 
 cases of acute strangulation of all kinds. It has been 
 used as a means of dividing constricting bands and 
 ligaments, of reducing portions of intestine that have 
 become strangulated through holes and apertures of 
 various kinds, of treating every species of internal 
 hernia, of reduction en masse after external hernia, of 
 strangulation by the diverticulum, and by an adherent 
 appendix vermiformis and the like. It has been 
 applied for the relief of cases of volvulus and for 
 the reduction of all forms of intussusception. By its 
 means relief has been aftbrded in examples of obstruc- 
 tion by impacted foreign })odies, and in occlusion of 
 the bowel by tumours situated without the intestine. 
 
 It has been made a preliminary to other operations 
 such as enterotomy, enterectomy, colectomy, and the 
 like. 
 
 The principal details of the operation will be dis- 
 cussed when dealing with the forms of obstruction to 
 
452 Intestinal Obstruction. [Chap.xxv. 
 
 which it may be considered to be applicable. In this 
 place it will be convenient to consider the general 
 features of the procedure. 
 
 The first question that arises is as to the position of 
 the incision. Is it to be made in the middle line or 
 ovei' the seat of the supposed obstruction % In answer 
 to this question it may be said that in all cases it 
 is better for the incision to be made in the middle 
 line, and this applies as well to exploratory as to 
 curative procedures. The incision made in the linea 
 alba is a simple one ; no important structures are 
 cut through ; no vessels of any magnitude are divided ; 
 the abdominal cavity is readily reached ; the wound 
 is not a deep one, and after the operation its edges 
 can be easily apj)roximated. If the incision be 
 made over the supposed seat of obstruction it 
 is probable that the abdominal muscles will have to 
 be cut through ; important planes of connective tissue 
 will thus have to be opened up ; vessels that may 
 cause troublesome bleeding are apt to be divided ; by 
 the time the abdomen is oj^ened the wound will 
 be a deep one and will have to be relatively larger 
 than the median wound in order to obtain an 
 equally extensive display of the interior of the belly. 
 Moreover, wounds through muscular layers are not so 
 easy to adjust, and in the case of the abdomen are 
 more likely to lead to hernia than is a median wound 
 through a dense fibrous structure. Moreover, the 
 incision over the supposed seat of obstruction involves 
 a very accurate diagnosis, and failing this accuracy 
 many serious errors have been made. Thus tumours 
 have been cut down upon which have proved to be in 
 no way connected with the obstruction. An incision 
 has been made in the left iliac region when the 
 intestinal stoppage has been in the right iliac district. 
 
 In one case of laparotomy for intussusception tlie 
 operation had to be practically abandoned because the 
 
Chap. XXV.] The Treatment: Laparotomy. 453 
 
 incision had been made in a lateral segment of the 
 abdomen, and the surgeon's manipulations were in 
 consequence seriously restricted. The operator in 
 this instance (Mr. George Brown) expressed a resolve 
 in his report of the case to operate for the future by 
 a median incision."^ 
 
 Even in cases where the obstruction is supposed 
 to depend upon some morbid condition in the loop of 
 gut reduced from an external hernia it is better as a 
 rule to make the cut in the middle line than over the 
 seat of the hernia. A cut into the abdomen through 
 the region of the inguinal canal is apt to seriously 
 weaken a part already weak and render very probable 
 a subsequent ventral hernia. It moreover greatly 
 limits the surgeon's sphere of action and may render 
 the operation useless should an error have been made 
 in the diagnosis. 
 
 Thus in cases supposed to depend upon an ex- 
 ternal hernia an incision has been made over the 
 sac ; nothing has been found of note ; the wound has 
 been closed, and a second cut made in the linea alba.f 
 
 Through a median incision made between the 
 umbilicus and the pubes all parts of the abdomen can 
 be reached and all parts of the intestine explored. 
 If the obstruction is not in the situation in which it 
 was expected to be found, it may be searched for 
 elsewhere. Any part of the small intestine may be 
 resected through a median wound. I have shown 
 that a part of the colon can be excised through a like 
 incision. % 
 
 The most varied forms of intussusception have 
 been reduced through a cut in the linea alba, and 
 enterotomy has been performed at the same situation. 
 It has been shown, moreover, that a primary median 
 
 * Lancet, vol. ii., 1882, i^age 1036. 
 
 t Bee case by Mr. Bradley ; Lancet, vol. i., 1878, page 493. 
 
 X Med.-Chir. Trans., vol. Ixvi., 1883. 
 
454 Intestinal Obstruction. [Chap. xxv. 
 
 incision does not compromise the success of a sub- 
 sequent lumbar colotomy.* Lastly, in cases where a 
 laparotomy has been performed when no such pro- 
 ceeding should have been undertaken (and of this 
 there are not a few examples), it must be owned that 
 the median incision inflicts the less serious lesion upon 
 the patient. 
 
 Some surgeons have suggested that the abdomen, 
 when distended, should be punctured before the 
 operation. The evacuation of distended intestines 
 certainly greatly simplifies the procedure, and in cases 
 of extreme meteorism this preliminary tapping should 
 be adopted. In less severe cases of distension and in 
 cases where there is reason to expect a much damaged 
 state of the gut the puncturing may very well be 
 left until the intestines have been themselves exposed. 
 After such exposure the puncture may be made with 
 more precision, even if over a somewhat more limited 
 area. On two occasions I have introduced my hand 
 into the belly as soon as the incision was large 
 enough, and have punctured through the skin dis- 
 tended coils that I could feel but that were out of 
 easy reach through the incision. 
 
 The length of the wound must depend upon the 
 merits of the indi^ddual case. In most instances it 
 should be at least large enough to allow of the 
 introduction of the hand. 
 
 The bladder should be emptied before the opera- 
 tion, and in some cases of pelvic adhesions it is well 
 to make out its precise position with a sound. 
 
 In one reported case, in a male patient, the bladder 
 was cut into during the preliminary incision and urine 
 escaped into the peritoneal cavity. The j^atient died, f 
 
 * See, for example, case by Mr. Pitts ; St. Thomas's Hosp; Re- 
 ports, vol. xi;, 1882, page 75, 
 
 t Case by Dr. Atherton ; Boston Med. and Surp. Jonrn., 1883, 
 page .5S1 . 
 
Chap. XXV.] The Treatment : Laparotomy. 455 
 
 When the abdomen has been opened great care 
 must be taken to prevent the protrusion of the dis- 
 tended viscera. I am convinced that such protru- 
 sion very seriously compromises the success of the 
 operation, and I think that this fact is demonstrated 
 by the recorded cases. 
 
 The practice of allowing the bowels to escape for 
 the purpose of more readily finding the obstruction is 
 absolutely bad. The protrusion should be prevented 
 by an assistant provided with one or more large flat 
 sponges that have been soaked in warm carbolic water. 
 When these sponges become cool they should be 
 changed. Some surgeons appear to have used flannels 
 wrung out in hot water for this purpose. A more un- 
 suitable material could hardly be imagined, since the 
 hairy particles of the flannel adhere to the intestine 
 with the greatest readiness and are only to be got rid 
 of with, difficulty. 
 
 The hand should be introduced into the abdomen, 
 and before such introduction greatly distended coils 
 miay be evacuated by a fine capillary trochar if deemed 
 advisable. I would strongly urge that the examina- 
 tion should now be conducted on the following syste- 
 matic principles, even in cases where the diagnosis is 
 considered to be fairly certain. The hand should first 
 be passed to the csecum. If this part of the intestine 
 be found to be greatly distended the obstruction may 
 be taken to be in the colon ; but if it be found to be 
 empty, or only moderately filled, then it may be con- 
 cluded that the stoppage is in the lesser bowel. Thus 
 with very little disturbance of parts a considerable 
 step may be made towards a cori-ect diagnosis. 
 
 The csecum may not be found, either because it is 
 the subject of congenital malposition, or because it has 
 become involved in an intussusception or a volvulus. 
 
 If from the condition of the csecum it is sur- 
 mised that the obstruction is in the colon, then the 
 
456 Intestinal Obstruction. [Chap. xxv. 
 
 hand must be passed along the whole length of that 
 intestine, from its commencement to the beginning of 
 the rectum. The rectum itself will, of course, have 
 been explored previous to the operation. 
 
 If the condition of the caecum points rather to an 
 obstruction in the lesser bowel, then a somewhat more 
 difficult examination has to be undertaken. Some 
 operators have avoided the difficulty by allowing the 
 intestine to protrude and by then searching in the ab- 
 domen for the obstruction. Such a procedure is very 
 strongly to be condemned. Another plan is to expose 
 in the depth of the wound the length of the small in- 
 testine inch by inch until the part occluded is reached. 
 The serious difficulty in this case is usually a lack of 
 knowledge of the precise portion of bowel first exposed. 
 Without this knowledge the surgeon may proceed 
 with his examination in the wrong direction and find 
 himself at the end of a tedious inspection at the duo- 
 denum. Quite recently Mr. Rand of Liverpool has 
 advised an examination of the root of the mesentery 
 as a means of recognising any given portion of intes- 
 tine exposed.* It is well known that the attached 
 edge of the mesentery is only about six inches in 
 length, and that it extends along the spine from the 
 left side of the second lumbar vertebra to the right 
 sacro -iliac synchondrosis. Mr. Rand advises that the 
 mesentery of the exposed piece of gut be examined, 
 and claims that by this examination it would be pos- 
 sible to find which was the upper and which the lower 
 end of the coil, and also to form some idea as to whether 
 it belonged to the higher or to the terminal parts of 
 the lesser bowel. This plan may succeed in a few in- 
 stances, but in many it would be of little avail, as in 
 cases where many adhesions exist, or where there is 
 m uch shrinking of the mesentery, or where a volvulus 
 has occurred. By far the readier way out of the 
 * British Med. Journ., Dec. 22nd, 1883, page 1235. 
 
Chap. XXV.] The Treatment : Laparotomy. 457 
 
 difficulty is to commence the examination, not with 
 the distended coils that present in the wound, but with 
 the empty and collapsed coils below the obstruction. 
 When the obstruction is complete there should be 
 no difficulty in recognising such coils. In cases 
 of strangulation involving the lower ileum these 
 emjjty loops of intestine should be sought for in 
 the ciecal region. When the obstruction is higher 
 iij) in the bowel the collapsed loops are extremely 
 apt to hang down into the pelvis. It is well, there- 
 fore, that a search for the obstruction in the small 
 intestine should commence with a search for non- 
 distended coils in the region of the c?ecum, or about 
 the brim of the pelvis, or within that cavity. This 
 method of investigation was first proposed, so far as I 
 can ascertain, by Mr. Hulke in 1872. In describing a 
 case of laparotomy he says, "I passed in my hand 
 and felt for an empty piece of small intestine, by 
 tracing which I hoped to be led to the obstruction." "^ 
 In another case of Mr. Hulke's, reported by Dr. 
 J, K. Fowler, this i^rocedure was carried out, and Dr. 
 Fowler makes a point of strongly advocating the 
 method.! As he observes, the collapsed gut can be 
 examined with ease and rapidity, the distended and en- 
 gorged bowel above the obstruction is not exposed to 
 an extensive handling, and the risk of rupturing these 
 dilated coils, a risk by no means slight, is thus avoided. 
 Certainly by this means the danger of peritonitis is re- 
 duced to a minimum. A third case of laparotomy by 
 Mr. Hulke serves to illustrate indirectly the value of 
 this method. In this case pains were taken not to 
 allow the bowels to protrude. The small intestine 
 was drawn to the wound and examined inch by inch, 
 and the loop so inspected reduced after its exposure. 
 Unfortunately the examination Avas in the wrong 
 
 * Med. Times and Gazette, vol. ii. , 1872, page 482. 
 \ Lancet, vol. i., 1883, page 1119. 
 
458 Intestinal Obstruction. [Chap. xxv. 
 
 direction, and after a time the duodenum was reached, 
 and before the obstruction was found the whole process 
 of examination had to be reversed.* 
 
 In any case where hernia is suspected the various 
 hernial orifices should be examined from within. They 
 can all be readily reached by the hand introduced 
 through the median incision. 
 
 The special treatment to be adopted when the ob- 
 struction has been found will be considered subse- 
 quently, when dealing with the treatment of the 
 varieties of obstruction. 
 
 After the operation the peritoneal cavity should be 
 well sponged out. The wound should be united in the 
 same manner as the wound after ovariotomy. The 
 best suture material is " Chinese twist." For conve- 
 nience of introduction each suture should be threaded 
 at either end to a long straight needle. Deep sutures, 
 to include the peritoneum, should be placed at inter- 
 vals of about half an inch. The intermediate parts of 
 the wound may be adjusted by superficial sutures. 
 With regard to the draining of the peritoneal cavity 
 after the operation, the matter remains in the same 
 position somewhat as the question of drainage after 
 ovariotomy. Some advise, others condemn. 
 
 I think that in cases where peritoneal inflammation 
 is to be expected a drain should certainly be intro- 
 duced. 
 
 In the above observations I have presumed that the 
 operation is performed under the strictest antiseptic 
 precautions. It would certainly appear that lapar- 
 otomy has been attended with greater success since 
 the introduction of Listerism. At the same time it 
 must be remembered that with every year our know- 
 ledge of the diagnosis of these cases has become more 
 accurate. 
 
 There are many possible fallacies in the operation. 
 
 * Path. Soc. Trans., vol. xxxiii., page 146. 
 
Chap. XXV.] The Treatment : Laparotomy. 459 
 
 In several instances there has been no real obstruction, 
 bat the symptoms have been all clue to acute perito- 
 nitis."^ In one case, at least, no cause of obstruction 
 was found, the patient had no peritonitis. The wound 
 was closed and the patient recovered.! In other in- 
 stances there has been an obstruction but it has been 
 overlooked and the patient has died unrelieved. ± In 
 man J examples of the operation the obstruction was 
 found but was of a nature not to be relieved and the 
 case was practically abandoned. Some of these were 
 cases of volvulus of the colon, others were examples of 
 extensive cancer, and others of stricture. § 
 
 In many instances also the obstruction was of such 
 a nature that it could be only relieved by some further 
 operation such as enterotomy or colotomy. 
 
 When two forms of obstruction exist in the same 
 case one is very apt to be treated and the other to be 
 overlooked. In several examples where two bands 
 have obstructed the intestine at the same time, only 
 one band, and that causing the less amount of trouble, 
 has been divided and the patient has died uni^elieved. 
 
 The pathology of intestinal obstruction also reveals 
 cases where obstruction due to stricture has been as- 
 sociated with a less important obstruction due to slight 
 entanglement of a loop beneath a band. [| Had these 
 cases been treated by laparotomy it is more than prob- 
 able that the false ligament would have been divided 
 and the stenosis overlooked. 
 
 With regard to the general mortality of the 
 operation, I have here collected 155 examples of the 
 
 * For cases see Duplay's monograph ; Archives Gen. de M^d. , 
 vol. xxviii. , 1876, page 513. 
 
 t Lancet, vol. i., 1871, page 776. 
 
 X Brit. Med. Journ., 1882, page 166. 
 
 § For cases see Billroth ; Archiv f. klin. Chirug. Langenbeck, 
 b. i., s. 485 ; Lawson, Med. Times, vol. i., 1861, page 675 ; Spencer, 
 ibid., 1879; Maunder, Med. Press, 1867. 
 
 II For examples of such cases see Path. Soc. Trans,, vol. iv., 
 page 156 ; and Le Progres Medical, 1882, page 12. 
 
460 
 
 Intestinal Obstruction. (Chap. xxv 
 
 operation. M. Peyrot had collected in 1880 125 cases.* 
 In my list I have omitted, for various reasons, 
 several of M. Peyrot's cases, and have added forty- 
 five new ones. 
 
 Laparotomy for Intestinal Obstruction exclusive of 
 
 Intussusception. 
 
 Internal hernia 
 
 Strangulation after tlie reduction of hernia ■< 
 
 Strangulation by bands of all kinds . . -j 
 
 Volvulus ■< 
 
 Strangulation through slits or apertures . -j 
 
 Stricture, etc \ 
 
 Tumour compressing the bowel . . \ 
 
 Strangulation by diverticula . . . •< 
 
 Obstruction by foreign bodies . . . ■< 
 
 Obstruction due to unknown causes . ■] 
 
 Total number of laparotomies 
 Total number of [recoveries . . 
 Total number of deaths 
 
 "Koi-talxt-^f 63*1 per cent. 
 
 3 Recoveries. 
 
 6 Deaths. 
 
 7 Recoveries. 
 6 Deaths. 
 
 15 Recoveries. 
 31 Deaths. 
 
 2 Recoveries. 
 15 Deaths. 
 
 1 Recovery. 
 
 3 Deaths. 
 
 6 Recoveries. 
 5 Deaths. 
 
 2 Recoveries. 
 
 Death. 
 
 3 Recoveries. 
 
 8 Deaths. 
 
 4 Recoveries. 
 
 1 Death. 
 
 2 Recoveries. 
 2 Deaths. 
 
 122 
 
 45 
 
 . . 77 
 
 9 
 
 13] 
 46 
 17 
 
 4 
 11 
 
 2 
 11 
 
 5 
 
 4 
 
 Ages op the Patients. 
 
 2 years and under. 
 
 3 to 10 years. 
 
 11 to 15 years. 
 
 16 to 20 years. 
 
 Recoveries . 
 Deaths . . 
 
 Recoveries . 
 Deaths . 2 
 
 Recoveries . 2 
 Deaths . 7 
 
 Recoveries . 4 
 Deaths . 9 
 
 Total . . 
 
 Total . . 2 
 
 Total . . 9 
 
 Total . . 13 
 
 21 to 40 years. 
 
 41 to 60 years. 
 
 Over 60 years. 
 
 Age not Stated. 
 
 Recoveries . 20 
 Deaths . 23 
 
 Recoveries . 8 
 Deaths . 18 
 
 Recoveries . 5 
 Deaths . 5 
 
 Recoveries . 6 
 Deaths . 13 
 
 Total . . 43 
 
 Total . . 26 
 
 Total . . 10 
 
 Total . . 19 
 
 * De rintervention chirurgicale dans I'Obstruction intestinale. 
 Paris, 1880. 
 
Chap. XXV.] The Treatment: Laparotomy. 
 
 461 
 
 Laparotomy for Intussusception. 
 
 Total uuniber of cases .... 
 Total numbex* of recoveries 
 Total number of deatlis .... 
 Mortolity, 72'7 per cent. 
 
 Two years old and under ... 18 cases 
 
 33 
 9 
 
 24 
 
 Three to fifteen years old 
 
 Over fifteen years old . 
 
 'Rcdi.uciion easy. 
 Total cases .... 
 Recoveries .... 
 
 Deaths 
 
 Mortality, 30 per cent. 
 
 10 
 
 7 
 3 
 
 ^5 
 
 Jlecoveries. 
 
 6 months. 
 
 7 „ 
 9 „ 
 
 2 years. 
 I 33 „ ■ 
 134 „ 
 L50 „ 
 
 Deaths. 
 Infant. 
 9 months. 
 17 .. 
 
 4 cases 
 11 cases 
 
 f 4 recoveries. 
 1. 14 deaths, 
 f recoveries. 
 ( 4 deaths. 
 ( 5 recoveries. 
 ( 6 deaths. 
 
 Reduction difficult or impossible. 
 Total cases . . . "-- , 23 
 Recoveries .... 2 
 
 Deaths 21 
 
 Mortality, 91*3 per cent. 
 Bccovevies. Deaths. 
 
 '20 years. 12 Aveeks. 
 
 
 28 years. 
 
 L 
 
 14 
 
 4 months. 
 5 
 
 9 „ 
 1 year. 
 16 months 
 6^- years. 
 
 (2 cases.) 
 (3 cases.) 
 
 12 
 14 
 16 
 
 36 
 43 
 50 
 
 "Ay 
 
 , (2 cases.) 
 
 ouug man. 
 
 Duration of disease at the time 
 
 laparotomy was performed in the 
 
 cases that ^ver6 reduced easily. 
 
 18 hours. 
 
 2 days. 
 
 "A few days." 
 
 4 days. 
 
 5 days. 
 
 10 cases. 
 
 14 days. 
 18 days. 
 One month. 
 Not stated 
 (2 cases). 
 
 Duration of disease at the time 
 
 laparotomy was performed in 
 
 the cases that aucrc irreducible 
 
 or difficult of reduction. 
 
 48 hours. 
 
 3 days (2 cases). 
 
 4 days (2 cases) . 
 
 5 daj's (3 cases). 
 "Under 7 days." 
 7 days. 
 "Some days" 
 
 (3 cases). 
 
 10 days (2 cases). 
 
 11 days. 
 17 days. 
 30 days. 
 One month. 
 4 months. 
 Not stated 
 
 (3 cases). 
 
 Since the preparation of this table Dr. Schramm * lias 
 published statistics of 193 laparotomies for intestinal 
 obstruction, including twenty-seven for intussusception. 
 
 *■ Langenbeck's Archiv., band xxx., heft. 4. 
 
462 Intestinal Obstruction. [Chap. xxv. 
 
 The mortality of this series is 64*2 per cent. The 
 mortality of the operation in the various forms of ob- 
 struction is practically the same as in the above table. 
 
 Out of my one hundred and fifty-five cases 
 there were fifty-four recoveries and one hundred 
 and one deaths. I believe that these statistics are 
 quite useless as a means of ascertaining the real mor- 
 tality after this operation. Probably the recorded 
 cases bear to those that are unpublished the proportion 
 of one to ten, and it may be surmised that the great 
 bulk of these unpublished cases ended in death. It is 
 scarcely possible to find any hospital sui'geon of expe- 
 rience who cannot allude to two or three unsuccessful 
 laparotomies for obstruction in his practice. On 
 looking through the published cases one is struck with 
 the fact that they have been published for the most 
 pai-t with one of two objects, either because they were 
 successful or because they j)resented some interesting 
 pathological feature. Cases that end fatally and liave 
 no pathological interest in the eyes of the operator 
 are not reported. 
 
 I have no doubt, therefore, but that the mortality 
 after laparotomy is a very great deal higher than that 
 shown in the above statement. 
 
 The high mortality need be no matter for wonder. 
 In the majority of the cases the operation was 
 performed at a period antecedent to the introduction 
 of antiseptic measures in surgery, and previous to the 
 great advances that have been of late years made in 
 abdominal operations. 
 
 Thus Dr. Schramm has shown that the cases of 
 laparotomy reported prior to the year 1873 show a 
 mortality of 73 per cent., while those reported since 
 that date present a mortality of only 58 per cent. 
 
 A large number of the recorded cases were 
 totally unfit for operation. Some of the patients 
 were almost moribund at the time the laparotomy 
 
Chap. XXV.] The Treatment : Laparotomy. 463 
 
 was performed, others were in a condition of pro- 
 found exhaustion. In some there was general acute 
 peritonitis, in others fsecal extravasation had already 
 occurred before the abdomen was opened. Lapar- 
 otomy has been done in cases where treatment had 
 been so long delayed that the gut was gangrenous 
 and became ruptured when handled. Laparotomy has 
 indeed been looked upon as a last resource instead of 
 as a primary measure, and in the face of the above 
 facts it can hardly be wondered that the mortality 
 after the operation has been high. 
 
 Dr. Schramm has given a table in the monograph 
 above referred to, to show the influence that the time 
 of performing the operation has upon the result. 
 This table shows in a graphic manner how serious is 
 the delay, even of twenty-four hours, when lapar- 
 otomy is concerned. 
 
 An examination of the recorded cases shows very 
 clearly that in proper instances, and especially in those 
 where the operation is undertaken early enough, lapar- 
 otomy is by no means so very fatal a procedure. The 
 one great fact that aifects the issue of the operation is 
 not so much the age of the patient, nor the seat of the 
 obstruction, nor the period in the disease when the 
 procedure was carried out, but the state of the gut j 
 and since pathology can give us precise teaching upon 
 this latter point, there is no reason why laparotomy 
 should not be rescued from the somewhat ignominious 
 position it now occupies in surgery. 
 
 There is no reason why in the future, with a fuller 
 knowledge of the technical details essential to the ope- 
 ration, with a surer acquaintance with the clinical 
 aspects of obstruction, and with the exercise of a 
 sounder judgment in the selection of cases, the proce- 
 dure of laparotomy should not have a mortality but 
 little higher than that of the operation for the relief of 
 strangulated hernia. 
 
464 Intestinal Obstruction. [Chap. xxv. 
 
 liaparotomy during: peritonitis.— The gene- 
 ral question may now be considered as to how far peri- 
 tonitis is a bar to operation in cases of obstruction of 
 the intestines. 
 
 It may be at once said that when peritonitis occurs 
 in connection with intestinal obstruction its appearance 
 usually coincides with so serious a condition of the 
 gut that the case is unfit for any kind of operation. 
 The intestine under such circumstances maybe intensely 
 inflamed or gangrenous, or, as is frequently the case, 
 perforated. Thus it happens that laparotomy per- 
 formed during peritonitis has been in nearly every case 
 fatal, and the same applies to other operations for the 
 relief of obstruction, such as enterotomy. 
 
 Duplay has collected several cases of laparotomy 
 performed for a peritonitis, the symptoms of which were 
 mistaken for those of acute strangulation. These were 
 all instances of perforative peritonitis, and all led to a 
 fatal result. I have been able to add several other 
 cases to Duplay's list, and they collectively serve to 
 show that (at the present time at least) abdominal 
 incision does not delay the fatal issue in cases of per- 
 forative peritonitis, and that all operations performed 
 during that condition are entirely hopeless. 
 
 The occurrence, however, of local peritonitis, and 
 even of acute general peritonitis, when not due to per- 
 foration, is not an absolute bar to the performance of 
 laparotomy for the relief of obstruction, as some recent 
 cases show. 
 
 I have found two recorded instances of laparotomy 
 performed during acute general peritonitis, in both of 
 which the obstruction was relieved, and the patients 
 made an excellent recovery. It is significant that in 
 both these cases the operation was carried out under 
 strict antiseptic precautions. The first case w;is re- 
 corded by M. Terrier. It concerned a female, aged 
 twenty-one, who was operated upon, upon the third 
 
Chap. XXV.] The Treatment : Laparotomy. 465 
 
 day of the symptoms, for the relief of a strangulation 
 by a band. Much sero-sangiiinolent fluid escaped from 
 the peritoneal cavity, the serous membrane was red, 
 and the intestines extensively adherent by soft recent 
 adhesions. The band was found and divided without 
 diliiculty.'^ The second case was by M. JuUiard. The 
 patient, a woman aged forty-eight, had an ovarian 
 tumour, and developed symptoms of obstruction. 
 Laparotomy was performed on the second day. The 
 ovarian growth was removed and the o])struction, 
 which was due to oldish adhesions, was relieved. The 
 peritoneum was in about the same condition as in the 
 previous case.f 
 
 Apropos of this subject it may be observed that the 
 practice is gaining ground of treating many cases of 
 peritonitis by free incision and drainage. This treat- 
 ment has been applied to inflammatory effusions into 
 another large serous cavity, that of the pleura, and 
 why not to the peritoneum % The cases that appear to 
 be best suited for such treatment are cases of chronic 
 peritonitis and especially of local peritonitis. So far 
 as I can ascertain, the first serious proposal that ab- 
 dominal section should be performed for peritonitis 
 was brought forward by the late Mr. Hancock in a 
 paper read before the Medical Society in 1848. Mr. 
 Hancock opened the abdomen in a case of chronic local 
 peritonitis depending upon some disease in the ap- 
 pendix, and the patient recovered. In his comments 
 upon the case Mr. Hancock remarks : "I trust the 
 time will come when this plan will be successfully em- 
 ployed in other cases of peritonitis." Mr. Lawson 
 Tait has performed abdominal section in several cases 
 of chronic peritonitis, with a good result in each in- 
 stance. | Dr. Savage reports eight cases of pelvic 
 
 * Bull, et Mem. de la Soc. de Chir. de Paris, 1879, page 564. 
 t Ibid,, page 665. 
 
 Ij: Brit. Med. Journ., Feh. 17th, 1883, page 300. 
 E E — 12 
 
466 InTES TINA L ObS TR UC TION. [Chap . XX V. 
 
 peritonitis treated by laparotomy, and all followed by a 
 successful issue. "^ In a case of chronic puerperal 
 2)eritonitis Dr. Playfair made an abdominal incision 
 and freely drained the serous cavity under antiseptic 
 precautions, with a perfectly successful result, f 
 
 One of the most interesting cases, however, that 
 can be mentioned in the present category is placed on 
 record by Dr. Buchanan of Glasgow. A woman of 29 
 years of age was suddenly seized with severe abdominal 
 pain, soon followed by vomiting. The attack came on 
 on Feb. 18th, at 2 a,m., after eating a hearty supper. 
 The pain and vomiting became more severe, and at 
 4 a.m. on Feb. 20th the ejected matters were stercora- 
 ceous. There was absolute constipation, and enemata 
 gave no relief. On Feb. 21st the patient was greatly 
 l)rostrated, the eyes were sunken, the voice husky, the 
 limbs cold. The case was considered to be one of 
 obstruction. Median laparotomy was performed (non- 
 antiseptic). One pint of turbid serum containing 
 curd-like iiocculi escaped. There were extensive recent 
 adhesions invohdng all the intestines. No obstruction 
 was found. The pelvis was sj)onged out and the 
 wound closed. The patient made an excellent 
 recovery. \ 
 
 Eiitei'Otoniy. — This operation was first proposed 
 and carried out by Nelaton, by whose name it is also 
 very usually called. The procedure is as follows : The 
 seat of the operation is the iliac or inguinal region, 
 preference being given to the right side. An incision 
 is made through the abdominal parietes parallel to 
 and a little above Poupart's ligament, and to the 
 outer side of the epigastric artery. The skin incision 
 is advised to be about 7 cm. in length. The deep 
 
 * Brit. Med. Journ., March 4th, 1884. 
 
 t Ibid., INIarch 10th, 1883. See also account of Dr. Moloden- 
 koff' s fatal case in au annotation in the same journal, Feb. 10th, 
 1883. 
 
 X Lancet, vol. i., 1871, page 776. 
 
Chap. XXV.] The Treatment : Enterotomy. 467 
 
 incision whereby tlie peritoneum is opened being about 
 4 cm. in lensrtli. The first distended coil of bowel 
 that presents itself is gently seized and drawn into the 
 wound. If the operation be performed upon the right 
 side it is found that the segment of intestine opened is 
 nearly always the terminal part of the ileum. The 
 gut is then fixed to the wound by a double line of 
 sutures which transfix the intestinal walls. An opening 
 is finally made into the bowel between the two lines of 
 suture and the operation is completed. 
 
 In chronic cases, where time may be no great object, 
 the operation can be divided into two stages. In the 
 first stage the gut is fixed to the sides of the incision 
 by a series of sutures that do not traverse the entire 
 thickness of the intestinal wall. Three or four days 
 are allowed to elapse in order that adhesions may form 
 between the bowel and the parietal peritoneum, and 
 then by a second slight operation the gut is opened 
 and secured, if necessary, by more substantial ligatures. 
 The first stage [in the procedure may be conducted 
 under antiseptic precautions. 
 
 Enterotomy is an operation that can be very 
 readily performed and that is fairly certain of success 
 so far as making an opening in the gut above an 
 obstruction is concerned. It involves no more expo- 
 sure of the peritoneum than pertains to the operation 
 of kelotomy when the sac is opened. 
 
 The procedure has been carried out in nearly every 
 form of intestinal obstruction, and has certainly been 
 more popular upon the continent than in this country. 
 
 It has been done for internal strangulation, for 
 volvulus, for intussusception, both acute and chronic, 
 for the many forms of obstruction due to adhesions, 
 for fsecal accumulation, for stricture, and for obstruc- 
 tion by foreign bodies. It has also been performed, 
 owing to an error in diagnosis, in a case of tubercular 
 peritonitis. In some instances the opex^ation has been 
 
468 Intestinal Obstruction. LChap.xxv. 
 
 secondary to another procedure. For example, a 
 laparotomy lias been performed to relieve a supposed 
 strangulation. The case has proved to be incap- 
 able of relief by the means intended, and an enter- 
 otomy has then been performed. Messrs. Morris and 
 Coupland, in their monograph upon stricture of the in- 
 testine, advise that when a lumbar colotomy has been 
 performed, and it is found that the colon has been 
 oj3ened heloio the obstruction, the peritoneum should 
 be incised, and a coil of small intestine pulled into the 
 lumbar wound and opened. 
 
 I cannot avoid the conclusion that a primary en- 
 terotomy is not to be advised. The operation is at the 
 best but a palliative measure ; it is not founded upon 
 sound surgical principles ; it is a procedure that is 
 carried out more or less independently of diagnosis ; 
 it is an operation done in the dark, and it leaves the 
 cause of the disorder untouched. It is true that it does 
 not show so high a mortality as does laparotomy, but 
 the disadvantages of the procedure are many. In the 
 first j^lace, as already stated, it leaves the real malady 
 itself untouched. To this statement there are a few 
 exceptions. There are some forms of obstruction that 
 are in great measure jDroduced and maintained by dis- 
 tension of the bowel ; among such are certain forms of 
 volvulus (which are very rare), some cases of occlusion 
 by kinking, by adhesions, and by changes in the visceral 
 peritoneum or mesentery. Such cases iniay be cured 
 by enterotomy, and a closure of the artificial anus may 
 follow the oi)eration. Some cases also of fa3cal accu- 
 mulation and of obstruction by a foreign substance may 
 be so far relieved by enterotomy that the artificial 
 anus may close in time, or be closed by some plastic 
 measure. But how stands the matter in other cases % 
 The obstruction remains. If it be an example of acute 
 strangualtion, or of volvulus, or of intussusception, 
 then the gut may become in time gangrenous, and the 
 
Chap. XXV.] The Treatment : Enterotomy. 469 
 
 patient die practically of the direct effects of an unre- 
 lieved, or imperfectly relieved, obstniction of the bowel. 
 If the obstruction be due to cancer, the cancer is left 
 untouched, and the operation merely gives some tem- 
 porary relief. Suppose, however, that after the enter- 
 otomy no farther changes of a destructive or malignant 
 character take place about the seat of obstruction ; 
 what is the condition of the patient ] There is a per- 
 manent fsecal fistula in the groin. This leads into the 
 small intestine, and may be the cause of wasting, and, 
 if higher up in the bowel than usual, of death from 
 marasmus. There may be, moreover, a considerable 
 portion of intestine between the artificial anus and the 
 obstruction, and the accumulation of fa3cal matter in 
 this part of the bowel may lead to the greatest distress. 
 The ileum has actually been opened to relieve a case, 
 not diagnosed at the time, of simple stricture in the 
 upper part of the rectum, and in other examples of 
 enterotomy the seat of the obstruction has been in the 
 descending colon and the sigmoid fiexure. 
 
 An operation that would present examples such as 
 these cannot be said to be based upon proper surgical 
 principles. 
 
 Against secondary enterotomies there is nothing to 
 be said. If in performing a lumbar colotomy it is 
 found that the colon has been exposed at a point below 
 the obstruction, then it is clearly better to open the 
 small intestine at the seat of the colotomy, if the case 
 be urgent, rather than to make a second attempt upon 
 the colon in another place. These remarks refer in 
 the main to lumbar colotomy of the ascending colon, 
 in cases where the stricture is in the csecum or in the 
 terminal part of the ileum. 
 
 Moreover, when a laparotomy has been performed, 
 there are many cases in which nothing can be done to 
 give relief save by enterotomy or enterectomy, and by 
 some secondary enterotomies it is certain that life has 
 
47 o Intestinal Obstruction. [Chap. xxv. 
 
 been spared and the patient's existence has been greatly 
 prolonged. 
 
 The following statistics deal with the mortality 
 after enterotomy. The cases are divided into two sets, 
 those in which the operation was done for cancer, and 
 those in which it was done for obstruction due to non- 
 malignant disease. The total number of cases is 109. 
 Of these, ^^ are taken from Peyrot's tables, the 
 remaining 23 I have collected myself, mainly from 
 reports subsequent to the date of Peyrot's monograph. 
 They serve to show the great mortality of enterotomy 
 in cancer, and also demonstrate the fact that in the 
 fatal cases death does not follow so soon after the 
 operation as it does in fatal cases of laparotomy, where 
 the great majority of the deaths fall within the first 
 twenty -four hours. 
 
 Sixty-one operations .... j 20 ^re^described as cured. 
 
 j'24 died within 2 days of the operation. 
 Of the fatal cases . •< 7 ,, ,, 2 to 5 „ „ 
 
 ( 6 „ „ 6 to 10 
 
 Four patients survived the operation respectively 11 days, 15 days, 
 22 days, and 2 months. 
 
 Enterotomy in Cases of Malignant Strictuke. 
 
 Forty-eight operations .... | J are^described as cured. 
 
 ("28 died within 2 days of the operation. 
 Of the fatal oases , ■? 6 „ „ 2 to 5 ,, „ 
 
 (. 1 „ » 6 to 10 
 
 Seven patients survived the operation respectively 12 days, 28 days, 
 2 months, 4 mouths, 6 months (two cases), and 7 months. 
 
 { 3 are described simply as " cured." 
 
 Ot a. cases of .' cure" . \\Z ^tSdofthroiiratio.." 
 
 C.1 lived for 4 years after the enterotomy. 
 
 €oIotoiiiy.— This procedure is applicable only 
 to obstructions in the colon, and consists in estab- 
 lishing an artificial anus in the gut above the point 
 of occlusion. There are two forms of colotomy : 
 lumbar colotomy, commonly known as Amussat's 
 
Chap. XXV,] Z//^ Treatment: Colotomv. 
 
 471 
 
 operation, and inguinal colotomy, usually referred to 
 as Littre's operation. In the former, the ascending 
 or descending colon, as the case might be, is reached 
 through an incision made in the loin. An opening is 
 made in the gut behind the peritoneum, and the 
 serous cavity is not opened. In the latter, the colon 
 is reached by an incision in the iliac region placed a 
 little above Poupart's ligament and external to the 
 epigastric artery. The cavity of the peritoneum is 
 opened and an incision is made into the gut through 
 its peritoneal covering. The two modes of operating, 
 therefore, differ considerably. From Erckelen's "^ very 
 extensive statistics of colotomy, an abstract of which 
 is appeDded, it will be seen that Amussat's operation 
 is the safer of the two, there being a difference of 
 nearly ten per cent, between the mortality after the 
 two procedures. 
 
 Lumbar Colotomy (Erckelen's Statistics). 
 
 ToiaX operations, 262 = Amussat's method, 165 ; Littre's, 84 ; Method 
 unknown, 13. 
 
 Indications. — Cancer, 100 cases ; fistulse, 16 caises ; atresia, 44 cases ; 
 stricture, 49 cases ; obstruction, 43 cases. 
 
 Age. 
 
 Age^. 
 
 Cases. 
 
 Recoveries:. 
 
 Deaths. 
 
 
 1 to 10 years. 
 
 47 
 
 21 
 
 25 
 
 1 result unknown. 
 
 10 to 20 „ 
 
 5 
 
 4 
 
 1 
 
 
 20 to 30 „ 
 
 30 
 
 21 
 
 9 
 
 
 •60 tu -iO „ 
 
 27 
 
 12 
 
 15 
 
 
 40 to £0 „ 
 
 40 
 
 26 
 
 14 
 
 
 50 to 60 „ 
 
 38 
 
 23 
 
 15 
 
 
 60 to 70 „ 
 
 27 
 
 20 
 
 7 
 
 
 70 to 80 „ 
 
 4 
 
 1 
 
 3 
 
 
 UurecordeJ. 
 
 44 
 
 23 
 
 20 
 
 1 result unknown 
 
 Sea;.— Male, 128 ; Female, 96 ; Unknown, 38. 
 Death took place : 
 
 In first week in 70 cases, including 43 on first or second day. 
 In second week in 15 cases. 
 In third week in 8 cases. 
 Time not recorded, 15 cases. 
 
 * Arcliiv f . Klin. Chir. Langenbeck, 1879, page 41. 
 
472 Intestinal Obstruction. ichap. xxv. 
 
 In tlie total of 262 tlie operation ended : 
 
 Favourably in 152 (58 i per cent.), i.e. the patient survived 21 
 
 days. 
 Unfavourably in 108 (54-2 per cent.), i.e. the patient did not 
 survive 21 days. 
 
 Eesult unknown in 2. 
 
 Of the 165 by Amussat's method: 
 
 101 recovered 63*0 i)er cent. 
 
 63 died 38-J- „ 
 
 1 result unrecorded. 
 
 Of the 84 by Littre's method : 
 
 44 recovered 52*4 per cent, 
 
 39 died 46-4 „ 
 
 1 result unrecorded. 
 
 Of the 13 cases by unrecorded methods, 7 recovered and 6 died. 
 
 Cavcmoma., 
 110 cases . . 68 ended favourably 42 unfavourably. 
 
 813 by Amussat's . 52 (639 per cent.) ended favourably 31 ,, 
 
 23 by Littre's . 14 (61-0 „ ) „ „ 9 „ 
 
 4 by unknown methods ... 1 died, 3 recovered. 
 
 10 cases . . 13 (81'0 per cent.) ended favourably 3 unfavourably. 
 
 44 cases . . 20 (452 per cent.) ended favourably 24 unfavourably. 
 
 49 cases . . 29 (59*2 per cent.) ended favourably 20 unfavourably. 
 38 by Amussat's . 25 ,, ,, 13 „ 
 
 9 by Littre's .3 „ „ 6 „ 
 
 2 result unrecorded. 
 
 Obstrwclioti. 
 43 cases . . 22 ended favourably 21 unfavourably. 
 
 20 by Amussat's . 10 „ ,, 10 ,. 
 
 18 by Littre's . 10 „ „ 8 
 
 5 result unrecorded. 
 
 In the lumbar operation the gut may be more 
 readily and more safely reached ui)on the right than 
 upon the left side. The descending colon is less 
 movable than the ascending, and has also a more ex- 
 tensive non-peritoneal surface. A meso-colon is more 
 often found upon the right than upon the left side, 
 and the presence of this condition would involve an 
 opening into the sac of the peritoneum. Moreover, in 
 malformations of the colon the abnormal condition is 
 more frecjuently found upon the right than upon the 
 left side. It may be possible to attempt a right 
 
Chap. XXV.] The Treatment : Colotomy. 473 
 
 lumbar colotomy and find no colon at all in the usual 
 position. Indeed, the ascending colon may be entirely 
 absent. The question of a right versus a left lumbar 
 colotomy will be discussed further when dealing witli 
 the treatment of obstructions in the colon. 
 
 In Littre's procedure the incision may be made 
 either upon the left or the right side. In the former 
 case the sigmoid flexure is the part opened ; in the 
 latter case the csecum becomes the seat of the artificial 
 anus. The left operation is limited to cases of stric- 
 ture of the rectum or terminal part of the sigmoid 
 flexure. The right operation is the one concerned in 
 the present subject. 
 
 There are many excellent reasons for selecting the 
 caecum in these cases. It is usually much distended 
 and very prominent. In long-standing cases it is a 
 part much in need of early relief, since the great 
 strain of the accumulation falls upon its walls, and its 
 mucous membrane not infrequently becomes ulcerated. 
 Perforation by one of these ulcers is a common cause 
 of death in stenoses of the colon. I could refer to 
 several instances where this perforation has taken 
 place after a colotomy performed on another part of 
 the colon, and where it may be said that the caecum 
 has been relieved too late. It must be remem- 
 bered, however, that the caecum is liable to many 
 abnormalities due to congenital defect, and that 
 the right iliac region may be opened up and 
 no trace of the ct^cum found. In both forms of 
 colotomy much distress is often occasioned by the 
 accumulation of faeces that usually exists between the 
 artificial anus and the occluded part. The greater 
 the distance between these two points the more 
 serious is the trouble likely to be."^ As soon after the 
 operation as the condition of the wound will permit, 
 
 * See illustrative case by Mr. Bryant; Lancet, vol. i., 1878, 
 page 743. 
 
474 Intestinal Obstruction. [Chap, xxv 
 
 steps should be taken to relieve the gut of this ob- 
 struction. 
 
 In both Amussat's and Littre's operation, the pro- 
 cedure may be divided into two parts, when the 
 demands of the case are not urgent, and the first and 
 more important part of the operation may be per- 
 formed under antiseptic precautions. In this first step 
 the gut is exposed and stitched to the edges of the 
 wound by sutures that do not pass entirely through 
 the thickness of the intestinal wall. A few days are 
 allowed for the bowel to contract firm adhesions to the 
 margins of the incision. When all the parts are 
 firmly sealed with lymph the operation is completed 
 by opening the intestine. In Littre's procedure this 
 plan makes the opening of the peritoneum a 
 comparatively harmless proceeding, and renders the 
 chance of escape of faecal matter into the serous 
 cavity practically impossible. In the lumbar opera- 
 tion the plan is equally valuable. It minimises the 
 evils that may follow from an accidental wound of 
 the peritoneum, and tends, moreover, to prevent suppu- 
 ration in the loose subserous tissue that is opened up 
 when the gut is exposed. I have seen a case of left 
 lumbar colotomy where this suppuration had extended 
 do^\ai along the colon to the rectum and had ulti- 
 mately caused death. 
 
 After a lumbar colotomy has been f>erformed a 
 gi'eat deal of inconvenience is often experienced by the 
 patient owing to the accumulation of faecal matter 
 between the artificial anus and the seat of obstruction. 
 Madelung has recently proposed "^ a modification of 
 the operation which should prevent this complicatioiL 
 Madelung does not content himself with merely open- 
 ing the colon, but he cuts the bowel entirely across. 
 He stitches the upper end of the divided intestine to 
 
 * Deutschen Gesellsliaft fur Chirurgie, April, 1884 ; Central, 
 f. Chir., No. 23, 1884. 
 
Chap. XXV.] The Treatment : Colotomv. 475 
 
 the edges of the abdominal wound, and so establishes 
 an artificial anus. He then empties the lower seg- 
 ment of the bowel of its contents, and having entirely 
 closed its divided end reduces it into the abdominal 
 cavity (behind the peritoneum), and closes the skin 
 incision over it. This procedure is only proposed for 
 cancer of the rectum or of the sigmoid flexure. It 
 could be applied, however, to any form of obstniction 
 involving these parts which may be considered to be 
 quite beyond relief by further treatment. The measure 
 would prevent the evils arising from the irritation of 
 the cancerous surface by faecal matter, and should 
 greatly minimise the tendency to prolapse of the gut 
 at the seat of the operation. 
 
 Colotomy has been performed for all varieties of 
 obstruction of the colon, but especially for such as are 
 of a chronic character. The selection of the place of 
 operation depends, of course, upon the correctness of 
 the diagnosis ; and in many cases where the diagnosis 
 has been in error a useless operation has been per- 
 formed. Thus, in a case of volvulus of the ascending 
 colon and c£ecum, left lumbar colotomy was performed. 
 By chance the extreme point of the greatly distended 
 and displaced ascending colon was opened, but without 
 relief to the patient."^ 
 
 In many cases the artificial anus has been made 
 below the seat of the obstruction in the colon ; f and 
 the descending colon has even been opened for an oc- 
 clusion that involved the small intestine. J 
 
 Mr. Lockwood § has given an account of two cases 
 of attempted lumbar colotomy, in neither of which was 
 the colon found, owing to a congenital deformity of 
 the large intestine. 
 
 *Path. Soc. Trans., vol. ii., page 222. 
 f For instances see Dr. Fagge's Monograph. 
 J Path. Soc. Trans., vol. xii., page 111. 
 
 § St. Bart. '3 Hosi). Reports, vol. xix. See also A Manual of 
 Surgical Anatomy, by the author, page 314. 
 
47^ Intestinal Obstruction. ichap. xxv 
 
 Resection of intestine.— In tliis operation a 
 diseased portion of intestine is entirely cut away and 
 removed from the body. The term enterectomy is 
 applied to the procedure when it involves the small 
 intestine, the term colectomy when it concerns the 
 colon. 
 
 Enterectomy may be performed for the following 
 conditions : 1. Strictures of the small intestine both 
 simple and epitheliomatous. 2. Occlusion of the 
 bowel by adhesion, and matting of the coils of such a 
 character that the deviation of the gut cannot be cor- 
 rected. 3. Obstruction by neoplasms other than 
 epitheliomata. 4. Gangrene of the bowel due to any 
 of the manifold forms of strangulation. 5. Irredu- 
 cible intussusceptions. 6. For the closure of faecal 
 fistulse situated in the small intestine. 
 
 The great bulk of the ojjerations of enterectomy 
 have, up to the present time, been performed for the 
 removal of gangrenous bowel following strangulated 
 hernia, and for the closure of fascal fistuloe. 
 
 It will be convenient to consider, in the first place, 
 the data upon which the value of the procedure is based 
 in the various conditions above named. 1. In cases 
 of stricture of the small intestine, the patient may be 
 relieved, and may be saved from immediate death from 
 obstruction, by an operation other than the one under 
 notice ; but by the present procedure alone can the 
 patient be cured. Enterotomy may give relief, but 
 enterectomy is the only means of cure. Enterotomy 
 leaves the patient with the obstruction still untreated, 
 and it renders, moreover, an artificial anus an absolute 
 necessity. If this fistula be in the lower ileum, the 
 patient's life may be indefinitely prolonged ; but if it 
 be situated in the upper parts of the lesser bowel, 
 then a more or less rapid death from marasmus is in- 
 evitable. In addition to this, and as a matter of 
 less moment, the artificial anus involves a grave and 
 
c^inp. XXV.] The Treatment : Resection. 477 
 
 abiding source of inconvenience, and leaves the 
 patient exposed to the troubles that occasionally arise 
 from the presence of retained feecal matter in the bowel 
 below the seat of the obstruction. By means of enter- 
 ectomy the cause of the trouble may be removed^ and 
 the integrity of the intestinal canal restored. 
 
 Tf the stricture be carcinomatous, the condition is 
 still more serious. Enterotomy may relieve the patient 
 of obstruction symptoms, but it leaves untouched 
 within his body a growth that will assuredly increase, 
 and will at no distant time inevitably lead to death. 
 It happens that the form of cancer that is usual in 
 the intestine is a form that is peculiarly well adapted 
 for treatment by excision, and by enterectomy not 
 only may death from obstruction be averted, but the 
 patient may be relieved of a fatal malady. 
 
 2 and 3. To the conditions that fall under these head- 
 ings the same remarks apply as have been used in 
 speaking of enterectomy in simple stricture. In cases 
 of obstruction by the matting together of many coils, 
 the propriety of the operation must be influenced by 
 the length of intestine involved. In the light, how- 
 ever, of Koeberle's very successful case, where over 
 two yards of the lesser bowel were removed,"^ it is 
 evident that liberal views may be entertained upon 
 this point. 
 
 4. The value of resection in instances of gangrene 
 is obvious. To liberate a piece of bowel that is stran- 
 gulated by a band and gangrenous in consequence, and 
 then to leave that loop in the abdomen, is to undertake 
 an operation that had better have been left alone. It 
 would appear obvious also that it would be better to 
 resect the damaged loop than to simply draw it out 
 of the abdominal wound, and allow it to slough off, if for 
 no other reason than that during the process of separa- 
 tion the intestinal obstruction would be maintained. 
 
 * Bull, et Mem. de la Soc. de Chir. de Paris, 1881, page 99. 
 
478 Intestinal Obstruction. '[Chap. xxv. 
 
 5. If, in a case of intussusception, non-operative 
 treatment has failed, and the abdomen has been opened 
 and the invagination found^to be irreducible, the opera- 
 tion of enterotomy affords the only means of relief 
 if resection be not performed. Enterotomy, however, 
 performed under these circumstances, offers even less 
 jjrospects of success than it does in cases of simple 
 stricture. Not only does the obstruction remain 
 unrelieved, but a portion of gut is left in the abdomi- 
 nal cavity that may cause fatal mischief. The 
 unreduced intussusception may, in spite of the 
 artificial anus above it, become gangrenous ; or its walls 
 may ulcerate ; or the imflammation existing in its 
 tissues may lead to a fatal peritonitis. It is only 
 by an excision of the involved segment that these evils 
 can be obviated. 
 
 6. Resection for faecal fistula has little direct con- 
 cern with the present subject. Enterectomy performed 
 for the cure of artificial anus is of the nature of 
 a plastic operation. The piece of gut the seat of the 
 fistula is excised, and the two divided ends having 
 been united by suture, the bowel, whose integrity 
 has thus been restored, is reduced into the abdomen, 
 and the wound in the parietes is closed. A large 
 number of resections have been performed under these 
 circumstances, and the results obtained are of consider- 
 able moment in estimating the value of certain details 
 in resection procedures which are more fully dealt 
 with below. 
 
 Colectomy has been so far limited to cases of stric- 
 ture chiefly of an epitheliomatous character, and to arti- 
 ficial anus. The operation could, however, be adopted 
 for other conditions of disease in the large intestine 
 that are of like character with those just named in 
 connection with the lesser bowel. Colectomy cannot 
 be considered to present the same claims that may 
 be advanced on behalf of the operation as applied to 
 
Chap. XXV.] The Treatment : Resection. 479 
 
 the small intestine. An artificial anus in the colon is 
 hy no ni(!ans so inconvenient nor so detrimental to 
 health as is a fsecal fistula in the lesser bowel, and 
 colotomy as a moans of relief in colic stenoses must 
 be regarded as a very successful operation. Colotomy 
 of course leaves the cause of the obstruction untouched, 
 and renders a permanent artificial anus necessary, 
 whereas colectomy removes the disease entirely, and 
 allows the normal lumen of the bowel to be restored. 
 In cases of simple stricture, colotomy, as compared with 
 resection, concerns mainly the convenience of the 
 patient, and not a question of life and death. Such 
 being the case, the mortality of the two operations 
 should be as nearly as possible upon a par, and it must 
 be owned that at present this position cannot be 
 claimed for the resection operation. In instances of 
 epithelioma of the colon, however, the claims of 
 colectomy can be advanced with much greater point. 
 In such cases, the establishment of an artificial 
 anus but relieves the patient for awhile, and leaves 
 untouched a malignant growth that by means of 
 colectomy may be entirely and freely removed. 
 
 Speaking generally of the operation of resection of 
 intestine, it should be noted that the procedure involves 
 no new surgical principle, and embodies no revolution 
 in treatment. It merely implies the tardy application 
 to abdominal disorders of modes of cure that have for 
 centuries been applied to other parts of the body. 
 In principle it simply involves the removal of diseased 
 parts that cannot be treated by other means, the 
 excision of malignant cjrowths that cannot be got rid 
 of by milder measures, the separating of gangrenous 
 tissues from contact with the living body that cannot 
 be so separated by natural means. 
 
 The TYiodus operandi. — There are two different 
 methods of resecting the intestine. In the one, the 
 diseased segment is excised ; the divided ends of the 
 
480 Intestinal Obstruction. [chap. xxv. 
 
 bowel are then carefully united by many points of 
 suture; the parts so adjusted are reduced into the 
 abdominal cavity, and the wound in the parietes is 
 closed. In the other, after the necessary portion has 
 been removed, the divided ends are stitched to the 
 edges of the skin incision, and an artificial anus is 
 established. After a varying interval of time, a second 
 resection operation is performed upon the portion of 
 intestine involved in the faecal fistula, the lumen of 
 the tube is restored by suturing the two ends, and the 
 parietal wound is closed. The details of these two 
 procedures may now be described, so far as they refer 
 in the first instance to the small intestine. 
 
 1. A laparotomy is performed, and preferably by 
 an incision in the middle line. The advantages of a 
 median incision have been referred to in speaking of 
 laparotomy. Through such a cut, any part of the 
 small intestine may be reached, and the surgeon is 
 rendered independent of a precise knowledge of the 
 locality of the obstruction. If any certain evidence 
 exists to point to the precise seat of the lesion, 
 then the incision may be made over that spot, or over 
 the semi-lunar line that is nearest to it. The segment 
 of bowel to be excised is then drawn out of the 
 abdominal wound. Before proceeding further, steps 
 should be taken to prevent any blood or faecal matter 
 set free by the operation from entering the peritoneal 
 cavity. This occurrence can be prevented either by 
 closing the abdominal wound by sutures as far as the 
 protruding loop of bowel will allow, or by plugging that 
 wound carefully with warm carbolised sjDonges. The 
 next step is to occlude the bowel, both above and below 
 the part that is to be excised. For this purpose, some 
 surgeons content themselves with the pressure that 
 can be exercised by the fingers of an assistant, while 
 others secure the bowel by elastic or silk ligatures. 
 Both of these methods are open to objection. In 
 
Chap. XXV.] The Treatment : Resection. 
 
 481 
 
 adopting the first plan, it will be found that the 
 hands of the assistant will probably become tired out 
 before the operation (which must always be of long 
 duration) is completed. Moreover, if the assistant 
 has to relax his hold at any time to accommodate 
 himself to the manoeuvres of the surgeon, the intestinal 
 contents may escape, and in any case two additional 
 hands in the precincts of the wound greatly narrow 
 the area of the operation. Ligatures of all kinds are 
 objectionable on account of the damage they must 
 
 Pig. 58.— Treves' Clamp for Enterectomy or Colectomy. 
 
 almost of necessity inflict upon the delicate walls of 
 the intestine. It is evident that assistance must be 
 sought from some species of clamp. A clamp that I 
 have devised for this purpose, and the use of which 
 I have fully described elsewhere,"^ seems to meet, I 
 venture to believe, some of the chief requirements 
 demanded of such an instrument (Fig. 58). This 
 clamp is made in two parts, one for the upper and 
 one for the lower end of the intestine. These two 
 portions are quite separate, are readily applied, and 
 
 * Mecl.-Chir. Trans., vol. Ixvi., page 55. 
 F F — 12 
 
482 
 
 Intestinal Obstruction. [Chap. xxv. 
 
 occupy very little room. The compressing surfaces 
 are covered with indiarubber, and are brought 
 together by means of screws. When the gut has been 
 resected, and the two di^dded ends require to be 
 carefully approximated in order that the sutures may 
 be introduced, the two portions of the clamp are fixed 
 by means of connecting rods, so that a rigid frame- 
 work is formed, the length of which can be regulated 
 by a slight and easy adjustment of these little rods. 
 
 Fig. 59.— Bishop's Clamp for Eutereitomy. 
 A the claraps ; b, the sprcws l)v means nf wbicb the blades of the clamps are ap- 
 proximated ; c, the acrcw by means of which the clamps are adjusted. 
 
 A clamp of a more ingenious construction has 
 been introduced by Mr. Bishop, of Manchester.* In 
 this instrument the two portions of the clamp are 
 connected by means of a sccew, by one movement of 
 which they can be approximated, and by another 
 moved apart (Fig. 59). One slight disadvantage in 
 Mr. BishojVs instrument is its size and weight, and 
 the inconvenient dimensions and position of the con- 
 necting screw. It is, however, much more readily 
 applied than is the clamp to which I have just referred. 
 The clamps having been applied, the diseased 
 * BriU MuL Journ., Nov. 3, 1883. 
 
Chap. XXV.] The Treatment: Resection. 483 
 
 segment of gut between tliem is excised with scissors, 
 a certain portion of sound intestine being allowed to 
 intervene between the proposed line of sutures in each 
 case and the line of compression by the clamps. The 
 bowel should be divided upon a sponge, so that nothing 
 may escape into the peritoneal cavity ; and if the dis- 
 eased segment has been well emptied of its contents 
 before the clamps are applied, the amount of matter 
 that could escape should be slight. Attention must 
 now be turned to the mesentery, from which a 
 triangular piece must be cut, the base of the tiiangle 
 corresponding to that part of the membrane that is 
 attached to the resected segment of bowel. When a 
 large portion of intestine has to be removed, the apex 
 of this triangular gap in the mesentery may have to 
 be carried to its very root. 
 
 The mesenteric vessels are usually distinct, 
 especially as in cases demanding resection they are 
 apt to be engorged. This being the case, the most 
 conspicuous of them can be secured and ligatured 
 before the membrane is cut. In resection experi- 
 ments performed upon living animals, I have never 
 found any difficulty in dealing with these vessels.* 
 Having removed both the intestine and its mesentery, 
 the two cut edges of the latter should be carefully 
 approximated by sutures. I hold that the resection 
 of a triangular piece of the mesentery and the sub- 
 sequent closure of the gap so made by sutures is of 
 vital importance. If the membrane be not so treated, 
 the gut, when united and reduced, is almost certain to 
 become occluded by kinking at the suture line, a 
 catastrophe that has occurred in some of the recorded 
 cases in the human subject. The mesentery should, 
 if possible, not be divided quite up to the line of 
 division in the bowel, in order that the nutrition of 
 
 * It is necessary to state that none of the vivisection experi- 
 ments alluded to in this work were performed in this country. 
 
484 Intestinal Obstruction. [Chap. xxv. 
 
 the cut edge of the intestine be not interfered with 
 more than is possible. It is obvious that the sound 
 and rapid healing of the intestinal wound will depend 
 upon the nutritive activity of the divided ends, and it 
 is fortunate that the anatomical arrangements of the 
 vessels, both in the mesentery and in the walls of the 
 bowel, prevent this activity from being greatly inter- 
 fered with in the resection operations. 
 
 In cases of epithelioma of the gut, the excision of 
 a large triangular piece of the mesentery will usually 
 permit, at the same time, of the removal of any en- 
 larged glands in the immediate vicinity of the 
 disease. 
 
 The two divided ends of intestine are now to be 
 brought into close contact with one another, and if 
 either of the two clamps described above are used, 
 this object can be readily effected. The sutures have 
 next to be introduced. They should be introduced in 
 a double row, the first series bringing the edges of the 
 mucous membrane together ; the second or external 
 series uniting the serous surfaces of the bowel. When 
 the intestine is divided, the muscular coat retracts, 
 carrying with it the serous coat. By this contraction 
 the mucous layer is freely exposed, and the introduc- 
 tion of the inner row of sutures is a matter of no 
 difficulty (Fig. 60, a). 
 
 With regard to the outer line of sutures, the most 
 convenient stitch is that known as Lembert's. It is 
 readily applied, and brings the serous surfaces into 
 close contact. It is well known that the union of the 
 divided ends of the intestine will be first effected and 
 chiefly maintained by the fusion of tlie serous siirfaces. 
 This union is, however, slight in character, and not 
 sufficiently substantial to withstand much strain. 
 The use, therefore, of the inner row of sutures is most 
 important : they serve to strengthen the union, while 
 they help greatly to protect the healing wound on 
 
Chap. XXV,] The Trea tment : Resection. 
 
 485 
 
 the serous surface from contact with the septic 
 matters within the lumen of . the bowel. 
 
 By means of Gussenbauer's stitch the mucous and 
 serous layers of the bowel may be brought together 
 by one suture. This mode of using the needle is, 
 however, not to be advised. It is complicated, and 
 does not save any time in the operation (Fig. GO, b). 
 
 The needle used in the process of suturing shoidd 
 be very small, should be so curved as to represent 
 
 A B 
 
 Fig. 60.— A, Czeruy-Lembert sixture. B, Gussenbaner's suture. 
 ((, iiuK'oui^ coat ; h, iiuiscular coat ; c, serous coat. 
 
 half a circle, should be perfectly round on section, and 
 of the same thickness from the "eye" to within a 
 short distance of the point. The best material for 
 the stitches is the finest Chinese twist. It is much 
 more easy to manipulate than catgut or horsehair or 
 silk-worm gut, or even than fine silk. 
 
 In all, some forty points of suture are required, 
 fifteen for the inner row, and twenty -five for the outer. 
 The most difficult sutures to introduce are those 
 applied at the line of the attachment of the mesen- 
 tery j and it is significant that in cases of yielding of 
 
486 Intestinal Obstruction. [Chap. xxv. 
 
 the sutures the occurrence has been most often noted 
 at this spot. 
 
 The two divided ends of intestine that have to be 
 united are, of course, limp and non-resistant, and 
 render the introduction of the sutures a matter of 
 some difficulty. The need is felt of some firm sub- 
 stance upon which the bowel may rest while the 
 stitches are being introduced. To fulfil this object 
 some surgeons have proposed the introduction into the 
 ends of the divided intestine of a cylinder of gelatine, 
 wdiich would, after the operation, be dissolved and 
 disappear. Hohenliausen has made use of a cylinder 
 or plug of dough,* and ISTeuber of a tube of decalcified 
 bone.f These various substances, however, are very 
 apt to act as foreign bodies, and to cause an undesir- 
 able obstruction at the suture line. To meet the 
 purpose sought by the use of these plugs I have 
 employed a thin indiarubber bag of sausage shape. 
 This bag is introduced into the two approximated 
 ends of the intestine in a flaccid state, and is then 
 inflated in situ. It forms a firm basis for the intro- 
 duction of the sutures, and is in no danger of being 
 pricked if the stitches are properly introduced. 
 Before the last sutures are inserted, the air is 
 allowed to escape from the bag, which is then with- 
 drawn. "When empty, the bag is so thin that it can 
 be drawn through a hole that would not admit the tip 
 of the little finger. I have used this bag in vivisec- 
 tion experiments and on the human subject, | l)ut 
 have now discarded it as unnecessary. 
 
 After the divided ends of the l)owel have been 
 united, the clamps are removed, and the loop having 
 been replaced into the abdominal cavity, the wound in 
 the parietes is closed. 
 
 * Deutsche med. Wochens, Sept. -5, 1883. 
 t Central, fur Chirurg., No, 23, 1884. 
 JMed.-Chir. Trans,, vol. lx\-i., page 55. 
 
Chap. XXV.] The Treatment : Resection. 487 
 
 Schede* has suggested that the sutured segment 
 should not be at once reduced, but should be fixed 
 outside the peritoneum. This modification has for its 
 object the prevention of extravasation at the suture 
 line. The method, however, has little to commend it, 
 and is open to all the objections that have been urged 
 against the extra-peritoneal treatment of the pedicle 
 in ovariotomy. 
 
 In the operation upon the colon, the proceeding is 
 practically identical with that just described. In 
 dealing with the colon, however, the great difficulty 
 is the position of the incision through the abdominal 
 parietes. There is no doubt that in attempting to 
 resect a portion of the ascending or descending colon, 
 there is no better incision than that used in lumbar 
 colotomy. This incision affords plenty of room for 
 the operation, and it is surprising how much of the 
 vertical part of the colon, and especially of the de- 
 scending colon, can be drawn out and exposed in a 
 wound in the loin. When, therefore, the seat of the 
 obstruction is diagnosed for certain to be in either 
 the ascending or descending colon, the usual incision 
 for colotomy should be selected for the resection 
 operation. 
 
 If there should be distinct evidence to localise the 
 disease in the transverse colon or sigmoid flexure, then 
 the preliminary incision should be made through the 
 parietes, directly over the involved part of the intes- 
 tine. When, however, any doubt exists as to the 
 situation of the obstruction, it is safer to open the 
 abdomen in the middle line. This incision may be 
 made for diagnostic purposes, and a second incision 
 then made over the seat of the disease as soon as it 
 has been ascertained. It is far better, however, to 
 perform the resection through the median wound 
 when possible. When impossible, as it has been 
 * Quoted by Reichel. 
 
483 Intestinal Obstruction. [Chap.xxv. 
 
 shown to be in several cases, the median incision 
 should be closed, and a second cut made over the seat 
 of the obstruction. In some cases where a median 
 incision has been made, and the disease found to be 
 in one or other loin, the original wound has been con- 
 tinued into the loin by means of a transverse cut.* 
 This procedure is certainly to be condemned. Indeed, 
 so far as the reports of cases at present go, this com- 
 plicated wound appears to have been always attended 
 by unfortunate results. 
 
 In more than one instance the parts resected 
 were so extensive, and the involved gut so fixed, that 
 it was found impossible to unite the two ends of the 
 divided bowel, and a permanent fsecal fistula was 
 thtrefoixj inevitable, f 
 
 The most extensive statistics of this operation are 
 those collected by Keichel. \ He has brought together 
 121 reported ca,ses of gut resection, with subsequent 
 suturing of the divided ends. Out of this number 
 58 died, 58 are described as cured, and 5 recovered 
 with a permanent faecal fistula. 
 
 r 21 recovered. 
 37 cases for the relief of arti- \ 2 recovered with permanent 
 ficial anus , • = j fistulas. 
 
 ( 14 died. 
 / 24 recovered. 
 56 cases for gangrene after \ 3 recovered with pennanent 
 hernia . . • ^^= ) fistulae. 
 
 I 29 died. 
 8 cases for occlusion of the { 2 recovered. 
 
 howel . . . = \ 6 died. 
 10 cases for cancer of the \ 5 recovered. 
 
 bowel . . .= I 5 died. 
 
 10 cases for injury to the 1 6 recovered. 
 
 bowel . . . i=r I 4 died. 
 
 * Gussenbauer, Aichiv fiir Klin. Chir., 1878, page 233. Baum, 
 Centralbl. fiir Chir., 1879., page 169. 
 
 fSchede, Berlin. Klin. Woch., 1878, page 326. Martmi, 
 Zeitsoli. f. Heilkunde, 1880, page 208 ; and others. 
 
 t Deutsche Zeitsch. fiir Chir., 1883, page 230. 
 
Chap. XXV.] The Treatment : Resection. 489 
 
 The causes of death in the 58 instances are as 
 follows : 
 
 Collapse 
 
 Marasmus after fcecal fistula 
 Diseases not connected with the original malady 
 Yoniited matters entered trachea cliuing opcia 
 tion ....... 
 
 Intestinal ohstruction following the sutnre . 
 
 Peritonitis . 
 
 Causes not known . • . • • 
 
 6 
 1 
 3 
 
 1 
 
 3 
 
 34 
 
 9 
 
 The three cases of fatal obstruction inchided two 
 instances of contraction at the suture line, and one 
 case of kinking, due to improper application of the 
 suture. 
 
 It will be seen that the chief cause of death in 
 these operations is peritonitis, and it must be owned 
 that this peritonitis usually depended upon some flaw 
 in the details of the operation. In some instances 
 fsecal matter escaped into the peritoneal cavity during 
 the operation. In other cases the sutures were insuf- 
 ficient and allowed the escape of contents after the 
 parietal wound had been closed. In another set of 
 examples the gut sloughed at the suture line, or union 
 did not take place, or what union had occurred broke 
 down after a time. 
 
 It is not, tlierefore, too much to expect that the 
 mortality of the operation may be very greatly 
 diminished by improvement in the details of the 
 operation. 
 
 2. In the second method of performing resection a 
 temporary artificial anus is established. 
 
 The modus operandi in this procedure is practi- 
 cally identical with that first described, short of 
 suturing the intestine and closing the abdominal 
 wound. 
 
 The abdomen having been opened, and the diseased 
 loop exposed, the clamps are applied, and the jjortion 
 
490 Intestinal Obstruction. [Chap. xxv, 
 
 of intestine excised in the manner already described. 
 A triangular piece of tlie mesentery should also be 
 removed in the operation when it concerns the small 
 intestine. The gap thus formed in the membrane 
 should be closed by a few points of suture. This 
 mode of treating the mesentery renders the subse- 
 quent closure of the artificial anus a much more easy 
 matter to effect. The clamp having been removed 
 from the lower and usually collapsed end of the 
 bowel, the margins of the divided intestine are care- 
 fully secured to the edges of the abdominal wound. 
 Since the bowel above the obstruction is usually 
 greatly distended, much caution should be exercised 
 before the upper clamp is removed, lest any faecal 
 matter enter the peritoneal cavity. Before the 
 removal of this clamp the abdominal wound should be 
 closed as far as possible. The wound in the vicinity 
 of the upper segment of the bowel should be well 
 plugged, and before the clamp is actually taken off, 
 this end of intestine should be drawn well forward out 
 of the wound. After the contents of the bowel have 
 escaped, the margins of the intestinal wound and of 
 the parietal wound should be joined, as in colotomy. 
 
 After a while, the duration of which must depend 
 upon the circumstances of each case, the artificial 
 anus thus formed is closed by a further resection 
 operation, associated with suturing of the bowel. 
 
 Of these t\vo methods of performing resection 
 there is no doubt that the last described is by far the 
 better and the safer. 
 
 It may be that the operation of suturing the in- 
 testine immediately after the resection may be im- 
 l^roved as surgery advances, but, as the matter at 
 present stands, everything points in favour of the 
 operation that demands the establishment of a tem- 
 porary artificial anus. 
 
 The comparative value of these two procedures 
 
Chap. XXV.] The Treatment : Resection. 491 
 
 has been fully discussed by Reicliel in the monograph 
 above alluded to, and tliis surgeon has shown clearly 
 that the chief element of success in resection operations 
 depends upon the formation of a temporary fsecal 
 fistula. 
 
 It must be borne in mind that the patients who 
 are the subjects of resection operations are suffering 
 from obstruction, and often from acute obstruction. 
 Their lives are threatened by reason of this obstruc- 
 tion, and any operation performed should give imme- 
 diate and entii"e relief to the distended bowel above 
 the site of the occlusion. In the second of the two 
 methods above described this relief is afforded. The 
 engorged intestine can empty itself at its leisure. If, 
 however, the divided ends of the bowel be at once 
 united after the excision of the diseased segment, the 
 distension, to a great extent, remains, the obstruc- 
 tion is but imperfectly relieved, the gut at the suture 
 line is paralysed, peristaltic movements must be in- 
 terrupted at this point, and free circulation of the 
 intestinal contents is thus rendered practically impos- 
 sible. The fact must not be lost sight of, that in re- 
 section operations the relief of an obstructed intestine 
 is of more immediate moment as regards the patient's 
 life than the removal of an epithelioma or neoplasm 
 from the walls of the bowel. 
 
 Then, again, the operation requiring immediate 
 suturing of the intestine is long and tedious, and the 
 state of the patient upon whom these ojoerations are 
 performed is usually such as to render a prolonged 
 narcosis most undesirable and most dangerous. The 
 procedure that postpones the suturing of the bowel to 
 a future period is readily performed, and, indeed, is 
 almost as simple as an ordinary enterotomy or colo- 
 tomy. 
 
 In all resection proceedings there is a great risk of 
 death from fsecal extravasation, and it is needless to 
 
492 Intestinal Obstruction. [Chap. xxv. 
 
 point out that this risk is infinitely reduced by a 
 perfect evacuation of the bowel above the obstruc- 
 tion. 
 
 In many examples of resection, especially when 
 undertaken for gangrene, the bowel is not in a con- 
 dition to ensure sound and perfect healing. For the 
 success of the primary suture operation this ready 
 healing is essential, and it will be obvious that in ex- 
 cising the bowel, with this fact before him, the 
 surgeon would be apt to remove too much. 
 
 Owing to the disturbance of the mesentery the 
 margins of the divided intestine are apt to slough a 
 little. In the latter of the two procedures now 
 under notice this would prove a matter of no 
 moment ; in the former it would probably lead to 
 fsecal extravasation and death. 
 
 It may be said, therefore, that in resecting the 
 intestine a temporary artificial anus should always be 
 established, and the suturing of the bowel left to a 
 future period. 
 
 To this rule one exception may be made In 
 cases of resection of small intestine high up in the 
 jejunum, the divided ends should be at once brought 
 together with sutures whenever the state of the in- 
 testine will permit. The mortality attending fiscal 
 fistulas in the upper part of the jejunum is well known. 
 
 The literatiu'e of resection operations. — 
 Among the more important contributions the following 
 may be noted : Reichel, loc. cit. ; Bouilly and As- 
 saky, Re\^ie de Chir., 1881 and 1883; Petit. Bull. 
 G^n. de Therap., Med. et Chir., Dec. 1882 ; Koberle, 
 loc. cit, ; John Marshall, Lancet^ vol. i., 1882 ; Karl 
 Jafi'e, Volkmann's Sammlung, 1881, No. 201 ; Made- 
 lung, Yerh. d. d. Ges. f. Chir., 1881 ; Czerny, Berl. 
 Klin. Wochenschr, 1880, No. 45 ; Kocher, Centralb. 
 f. Chir., 1880, No. 29 ; Gussenbauer, Prager Zeitschr. 
 £. Heilk, i. bd., 1880; Bryant, Med. -Chir. Trans.,' 
 
Chap. XXVI.] Acute Obstruction: 493 
 
 1882; Pv-ydygior, Berlin. Klin. Wochen., 1881, Nos. 
 41, 42, 43; ydiede, Verb, der deutsch Ges. f. Chir., 
 1879. 
 
 CHAPTER XXVI. 
 
 THE SPECIAL TREATMENT OP INDIVIDUAL FORMS OF 
 OBSTRUCTION.* 
 
 It only remains to mention in the briefest possible 
 manner the particular treatment suited for each of the 
 various forms of intestinal obstruction. 
 
 In discussing this subject the classification that is 
 the most convenient is that based upon clinical evi- 
 dences, and that has been adopted in the chapter upon 
 difujnosis. This classification consisted essentially in 
 dividing the various forms of obstruction into two 
 great classes, the acute and the chronic, and then in 
 making certain subdivisions in each of these two great 
 classes. 
 
 1. ACUTE OBSTRUCTION. 
 
 Let it be suj)posed that a given case has been 
 diagnosed to be one of acute obstruction. By a further 
 step in the diagnosis let it be supposed that it has been 
 classed under one of the four following headings : 
 
 A. Strangulation by bands, or through apertures. 
 
 B. Volvulus. 
 
 C. Acute intussusception. 
 
 D. Obstruction by foreign bodies, etc. (certain cases). 
 
 A. Sfraiagrwiatioiii toy bands, or tlarougli 
 apertures, etc. — Under this heading may be in- 
 cluded the following pathological conditions : (1) 
 Strangulation by peritoneal bands ; (2) by omental 
 
 * This chapter must be regarded as little more than an index 
 to the matter contained in the chapters on the forms of ixQ&,%- 
 went. 
 
494 Intestinal Obstruction. [Chap. xxvi. 
 
 cords ; (3) by the diverticulum ; (4) by an adherent 
 appendix, or Fallopian tube, etc. ; (5) strangulation 
 through slits and apertures. As rarer conditions it 
 would also include (6) strangulation over a band ; (7) 
 acute kinking of the small intestine ; (8) some cases 
 of vohiilus of the small intestine ; and (9) of occlu- 
 sion by pressure of a tumour outside the gut. 
 
 In the treatment of the case the patient should in 
 the first place, of course, be kept absolutely at rest. 
 The lower bowel should be emptied by an enema. 
 The patient should be allowed ice to suck, but no food 
 should be given by the mouth. The strength should 
 be supported, if thought fit, by nutrient enemata, 
 although it must be remembered that such enemata 
 may cause distress and may have to be discontinued. 
 Opium should be given when the pain is very severe, 
 and the vomiting marked, and especially in cases asso- 
 ciated with collapse. It should be administered in 
 the form of a hypodermic injection of morphia. Great 
 care should be used in the giving of morphia in these 
 cases. It must be remembered that while opium may 
 give considerable relief, it is apt, on the other hand, 
 to mask the symptoms, to alter the clinical aspect of 
 the case, and to give the surgeon an erroneous notion 
 of its gravity. At the best the drug can only be re- 
 gai'ded as a i^alliative, and not as a curative measure. 
 Indeed, it should be given in these cases with the 
 same caution that it is administered in cases of stran- 
 gulated hernia. Should the patient become fully 
 narcotised the main symptoms may become so modified 
 that the surgeon may imagine the malady to be under- 
 going cure, while the involved gut is becoming hourly 
 more and more hopelessly disorganised. It should be 
 borne in mind that the main use of the drug in these 
 cases is to combat collapse. 
 
 With regard to the curative treatment in the 
 present forms of obstruction, the only measure is 
 
Chap. XXVI.] Acute Obstruction. 495 
 
 laparotomy. It has been shown, that in the first five 
 at least of the above-mentioned conditions spontaneous 
 cure, while not absolutely impossible, is yet so exceed- 
 ingly improbable that it cannot be considered when 
 discussing the treatment of the case. In the remain- 
 ing four conditions spontaneous relief of the obstruc- 
 tion is certainly not so improbable, but it must be re- 
 membered that these conditions cannot be diagnosed 
 from the rest, unless in the last-mentioned form a dis- 
 tinct tumour exist, and that even if diagnosed they 
 can be better treated by laparotomy than by any other 
 known means. When once, therefore, the general 
 nature of the case has been diagnosed, laj)arotomy 
 should be performed without delay. It is worse than 
 useless to temporise with aimless enemata, with elec- 
 tricity, with massage, with applications of ice, and the 
 like. The condition of the gut is identical with the 
 condition in strangulated hernia. In a case of stran- 
 gulated hernia no surgeon, after the taxis had failed, 
 would think of delaying kelotomy until he had tried 
 galvanism, enemata of tobacco, metallic mercury, and 
 other measures of like character. Kelotomy is in 
 itself an operation of small magnitude. It is only 
 serious when delayed, and its success depends not so 
 much upon the technical details of the procedure as 
 upon the condition of the gut at the time of operation. 
 The present series of cases are even more urgent than 
 are any cases of strangulated rupture, for no taxis can 
 be applied, and relief can only be expected from oper- 
 ation. Laparotomy, therefore, should be performed 
 at once. It must be remembered tliat the average 
 duration of life in these cases is only six days. Lapar- 
 otomy at present appears to be a very serious measure, 
 but when one comes to examine the fatal cases the 
 seriousness is soon explained. Other things being 
 equal, the success of the measure depends little upon 
 the precise species of obstruction, and still less upon 
 
496 Intestinal Obstruction. [Chap. xxvi. 
 
 the modus operandi^ the age of the patient, and the 
 site of the operation. It depends upon the condition 
 of the gut ; and, with very few exceptions, in the cases 
 of death the operation had been delayed until the con- 
 dition of the parts was such as to render any inter- 
 ference hopeless. 
 
 It has been shown clearly enough that a simple 
 incision into the abdomen is, with certain precau- 
 tions, a comi:)aratively trifling measure ; but that in- 
 cision appears as one of the very gravest and most 
 dangerous when in cases of obstruction its application 
 is delayed. If any treatment is to be adopted at all, 
 let it be adopted at once. I would urge that lapar- 
 otomy should be performed as soon as the diagnosis is 
 fairly clear, and if possible within the first twenty- 
 four hours after the appearance of the symptoms. 
 The operation is usually regarded as a last resource. 
 It should be the first resource, especially as it certainly 
 is the only resource. Moreover, in cases of doubt, all 
 recent experience in abdominal surgery would speak 
 in favour of an exploratory incision. A simple cut 
 into the peritoneal cavity, made with proper caution, 
 cannot be so calamitous a circumstance as an un- 
 reduced strangulation, or even as a case of intestinal 
 obstruction treated absolutely in the dark. 
 
 I could allude to several instances where an 
 exploratory laparotomy has been performed, where 
 the obstruction has been found to be in the colon, and 
 where after closure of the median wound a lumbar 
 colotomy has been performed with success. "'*■ In any 
 case, therefore, of acute obstruction diagnosed (surely 
 or even incorr-ectly) to be of the character with 
 which we are now dealing, an early laparotomy is, 
 I venture to think, without doubt the most appro- 
 priate, as it is indeed the only, treatment. 
 
 * See Lancet, voL i., 1875, page 369, case by Mr. Teale; and 
 St. Thomas's Hosp. Reports, 1882, page 75 ; case by Mr. Pitts. 
 
Chap. XXVI.] Acute Obstruction. 497 
 
 Tlie details of the operation have been ah-eady 
 described. It only remains to say a few words as to 
 the treatment of the obstruction when found. Slender 
 " bands " may be torn through with the finger ; while 
 larger ones should be secured by a double ligature, 
 and divided between the two threads. It is well 
 subsequently to cut off these bands close to their 
 attachments, as they may give further trouble if left 
 free in the abdomen. Large omental cords may be 
 clamped, then cut, and the individual vessels secured 
 with the finest catgut. This treatment especially 
 applies to the larger omental bands, which are oftea 
 supplied with many blood-vessels. Indeed, such 
 " bands " may consist of the whole or one-half of the 
 omentum rolled up into a large cord. 
 
 In cases of strangulation by Meckel's diverticulum, 
 the process when large, and especially when disposed to 
 become gangrenous, had better be excised near its 
 point of origin from the intestine, and the wound 
 carefully closed by Lembert's suture, or any other 
 suture that will bring the peritoneal surfaces in 
 contact. It is unwise to leave a diverticulum still 
 attached to the bowel, since it is very likely to 
 become again a source of trouble. The narrower 
 diverticula may be divided after having been secured 
 by a ligature. In some cases the cut end has been 
 clamped and fixed in the wound after the manner of 
 treating the pedicle in a form of ovariotomy. 
 
 If the trouble be due to the appendix, the 
 adhesions holding down that process may .be divided, 
 or the end of the appendix itself may be cut off, and the 
 wound closed carefully with several points of suture. 
 
 In cases of strangulation through slits and 
 apertures, it is well (whenever possible) to close the 
 abnormal aperture with a few points of suture after 
 the gut has been reduced. 
 
 After an obstructing band has been relieved, care 
 G G — 12 
 
49^ Intestinal Obstruction. [Chap. xxvi. 
 
 should be taken to ascertain that there is no other 
 occluding cord. I might refer to two instances where 
 there were two bands causing obstruction in one case. 
 In each instance laparotomy was performed, one band 
 was divided, and in each instance it was the wrong 
 band, or the one causing the least serious obstruction. 
 Both patients of course died,"^ 
 
 The amount of gut involved in the forms of acute 
 occlusion now under notice is on an average fifteen 
 inches. It is very commonly much less, and often a 
 mere knuckle. 
 
 If the strangulated gut be gangrenous, the 
 damaged pai-t should be resected, and the divided 
 ends of the bowel attached to the edges of the 
 abdominal wound. The artificial anus so established 
 may be closed by a subsequent operation, as already 
 pointed out. 
 
 If a volvulus be found it may be reduced, but if 
 irreducible by the usual means, the question of re- 
 section or of enterotomy must be considered. 
 
 Cases of obstruction due to the pressure of a 
 tumour must be treated according to the indications 
 in each es])ecial case. 
 
 B. Volvulus. — The morbid condition concerned 
 in this form of obstruction is for the most part that 
 known as volvulus of the sigmoid flexure. To this 
 variety of volvulus the following observations are in. 
 the main directed. Under* the same clinical heading, 
 however, are classed volvulus of other parts of the 
 colon, and occlusion of the colon by acute bending. 
 
 In the matter of treatment the patient may be 
 brought early under the influence of opium, and the 
 rectum may be emptied by an enema. There is no 
 evidence to show that a complete and well-defined 
 volvulus of the sigmoid flexure can ever spontaneously 
 
 773. 
 
 * Lo/ncetf vol. i., 1876, page 773; and ibid., vol. i., 1873, page 
 
Chap. XXVI.] Acute Obstruction. 499 
 
 untwist itself. Indeed, the longer the case lasts the 
 more tight does the twist become. If unrelieved, no 
 other than a fatal issue is to be anticipated. Attempts 
 at relief by enemata or by rectal tubes are useless, if 
 not actually harmful. 
 
 The treatment of these cases is most unsatisfactory. 
 As the symptoms produced by the volvulus are acute, 
 the operative measure adopted for its relief has as a 
 rule been laparotomy, the cases having been probably 
 mistaken for acute strangulation of the lesser bowel. 
 Laparotomy, however, is not likely to prove other 
 than useless. The huge coil formed by the distended 
 sigmoid flexure cannot be dealt with through the 
 small incision permitted by an ordinary laparotomy. 
 If the gut be punctured it may be reduced, but the 
 volvulus would probably reappear as soon as the 
 abdominal wound was closed."^ At the same time 
 some treatment must be promptly adopted, since the 
 progress of the case is rapid and peritonitis is apt to 
 develop very early. In the first place, the distended 
 coil may be tapped through the parietes, and failing 
 relief from that measure a left lumbar colotomy 
 should be at once performed. In these cases the 
 colon is usually much distended with fiieces above the 
 seat of the volvulus, and the lumbar colotomy would 
 give very efficient relief if performed early enough. 
 If postponed for too long a time the distorted sig- 
 moid flexure may have become gangrenous, or peri- 
 tonitis may have developed to a grave extent. Left 
 inguinal colotomy would probably be impracticable. 
 The incision would merely expose the distended and 
 obstructed coil, and would not permit the surgeon to 
 reach the gut above the occlusion. 
 
 In cases of occlusion of the colon by kinking, 
 
 *In one case of laparotomy that I performed for volvulus, I 
 could not reduce the twist tlirough the wound, nor could 1 rediice 
 it at the autopsy, until after much distiu-bance of the parts. 
 
500 Intestinal Obstruction. [Chap. xxvi. 
 
 permanent relief may be given by puncturing the 
 colon and by keeping the bowel for the future clear 
 by the judicious use of aperients and by dieting. 
 Should puncture fail, colotomy would be the best 
 method of treatment, provided that the seat of the 
 obstruction had been diagnosed. 
 
 Volvulus of the right part of the colon (a rare 
 condition) may be relieved very possibly by lapar- 
 otomy, and failing that an enterotomy should be done 
 at the laparotomy wound. 
 
 One surgeon, who is perhaps a little in advance of 
 the times, has suggested that an irreducible volvulus 
 should be removed by resection ; but at present there 
 would appear to be but slender bases for the support 
 of this plan of treatment. 
 
 C. Acute iiitiissiisception. — The administra- 
 tion of opium is absolutely essential in these cases. 
 By its means peristaltic movements are stilled, and 
 any increase in the invagination is probably prevented. 
 At the same time, it must be remembered that the 
 drug may mask the symptoms and may thus arouse 
 in the surgeon's mind a false impression as to the im- 
 provement effected in the case. As has been already 
 pointed out, there are substantial reasons for believing 
 that under the influence of opium, administered early, 
 an invagination may undergo cure by spontaneous re- 
 duction. I think, therefore, that in all cases, both in 
 the young as well as in adults, the administration 
 of this drug should be adopted as early in the case as 
 l)0ssible. Presuming, as is very probable, that no 
 marked improvement follows upon its use, the next 
 measure in the treatment consists in an attempt to 
 reduce the invagination by means of enemata or by 
 insufiiation. These modes of treatment have been 
 already fully described. They have met with very 
 ei couraging success in a large and varied series of 
 cases, and are worthy of a patient trial. 
 
Chap. XXVI.] Acute Obstruction. 501 
 
 It will be obvious that enemata or insufflation will 
 be quite useless when once adhesions have formed, or 
 when the invagination has become for other reasons 
 irreducible. Moreover, should the intussusce2:)tum 
 have become gangrenous a forcible enema may cause 
 rapid death by separating the sloughing gut and per- 
 mitting the intestinal contents to escape into the peri- 
 toneal cavity. 
 
 Should these measures fail or be considered inad- 
 missible, there are substantial reasons for recommend- 
 ing an immediate laparotomy, especially in the young. 
 Against this operation many objections have beeii 
 urged. In the first place, it is pointed out that an 
 acute attack may become a chronic one, and the patient 
 may live if left alone for many months. This may be ; 
 but examples of the occurrence are comparatively few, 
 since the great majority of the patients die long before 
 they can enter upon the chronic disease. Moreover, 
 chronic intussusception is itself fatal in time, as has 
 already been fully shown. Indeed, out of fifty-nine re- 
 corded examples of chronic invagination there are no 
 less than fifty-one deaths. 
 
 As a further objection, it is said that spontaneous 
 cure may take place by elimination of the gangrenous 
 intussusceptum. But how does this matter really 
 stand % Elimination of the gut by gangrene occurs in 
 about 42 per cent, of all cases, but when it has 
 occurred it by no means follows that the patient re- 
 covers. In fact, no less than 40 per cent, of the 
 subjects of spontaneous elimination die of the imme- 
 diate results of the process of separation. Moreover, 
 during the first year of life spontaneous elimination 
 occurs in only 2 per cent, of the cases, and between 
 the ages of two and five in only 6 per cent, ; and 
 when it is remembered that more than 50 per cent, of 
 the total number of examples of intussusception occur 
 in children under ten, it will be seen that elimination 
 
502 Intestinal Obstruction. [Chap. xxvi. 
 
 by gangrene offers no very extensive prospects of 
 sj^ontaneous relief. It is true that the older the 
 patient the more chance has he of a recovery by this 
 means ; but it unfortunately happens that the older 
 the patient the higher is the mortality after the oc- 
 currence of the elimination, so that the chance of cure 
 becomes remarkably slight. 
 
 In favour of laparotomy in intussusception it must 
 be remembered that the general mortality of the 
 disease is 70 per cent., and that 80 per cent, of 
 the patients die before the seventh day. In quite 
 young children the mortality is terribly high ; death 
 occurs at an early period, the cases usually following 
 an acute course. In the young, therefore, laparotomy, 
 if done at all, should be performed within the first 
 forty-eight hours, and, if possible, within the first 
 twenty-four hours ; and Dr. Sands' well-known case of 
 laparotomy for invagination fully supports this advice."^ 
 In adults the question of operation may be left a more 
 open one, since the chance of spontaneous cure is cer- 
 tainly increased ; but that chance is too slender to 
 depend upon, and is more slender than that incurred 
 by a laparotomy performed in good time and under 
 properly selected circumstances. 
 
 In performing laparotomy in these cases the in- 
 vagination should be reduced if possible, and, failing 
 this, the mass should be resected by either of the two 
 methods that have been above described, but preferably 
 by that that establishes a temporary artificial anus. 
 
 D. Obstruction by foreign bodies, gall 
 stones, etc, — In cases of subacute or acute obstruc- 
 tion due to foreign substances in the intestine the 
 condition may in some instances be met by free doses 
 of opium followed in a while by a gentle aperient. 
 Li more grave cases laparotomy should be performed 
 and the foreign body extracted. The wound made in 
 * Nexo York Med. Journ., June, 1877. 
 
Chap. XXVI,]' Chronic Obstruction. 503 
 
 the intestine may be closed and the gut returned, or 
 an artificial anvis may be, for a while, established. 
 The selection of one or other of these methods will 
 depend ob\dously upon the state of the bowel at the 
 seat of the obstruction. Its condition will probably 
 be such as to forbid union of the wound and a return 
 of the gut into the abdomen. 
 
 2. CHRONIC OBSTRUCTION". 
 
 A. Stenosis of the small intestiiie. — Under 
 this heading are included a great many pathological 
 conditions which are all marked by a partial mecha- 
 nical occlusion of the lumen of the bowel associated 
 with the symptoms of chronic obstruction. 
 
 The conditions are the following : 1. Stricture. 
 2. Bendino- of adherent intestine. 3. Adhesion of a 
 
 o 
 
 coil in the form of a loop. 4. Matting of adjacent 
 coils by many adhesions. 5. Direct compression of 
 the gut by contracting adhesions. 6. Occlusion from 
 shrinking of the mesentery. 7. Stenosis from trac- 
 tion. 8. Some forms of volvulus. 9. Obstruction 
 by neoplasms. 10. Some cases of obstruction by gall 
 stones and foreign substances. 11. Pressure of a 
 tumour outside the gut. 
 
 In all these forms of obstruction the dieting of the 
 patient is a matter of the very gTeatest importance. 
 The food taken should be moderate in amount, should 
 be composed of only the most digestible substances, 
 and should be taken in small quantities at a time. 
 By observing a careful dietary, and by keeping the 
 bowels clear by enemata and gentle laxatives, the 
 patient's condition may be rendered endurable for a 
 considerable period of time. When these means 
 cease to be of use, and when the malady becomes 
 more grave in consequence of repeated attacks of ob- 
 struction and the mal-nutrition that follows upon 
 them, some operative measure must be adopted. In 
 
504 Intestinal Obstruction. [Chap. xxvi. 
 
 cases of stricture temporary relief may be afforded by 
 enterotomy, but more lasting and efficient relief can 
 only be obtained by resection of the diseased segment 
 of the intestine. In cases where the stricture is epi- 
 theliomatous, where the disease is still not extensive, 
 and where the glands are not seriously involved, the 
 operation of excision is very strongly to be advised. 
 Enterotomy or resection, and especially the latter, is 
 the proper measure to adopt in cases of stenosis as a 
 result of traction, and in cases of obstruction by neo- 
 plasms within the gut. Occlusions due to adhesions 
 may be relieved by laparotomy and division of the 
 adventitious bands, and in cases where the adhesions 
 are too extensive to be so treated enterotomy may be 
 performed to save life. In any such case the involved 
 coils may be removed by resection, provided that too 
 extensive a removal of intestine be not required, and 
 that the operation is upon other grounds possible and 
 desirable. In cases of obstruction by foreign sub- 
 stances time should be allowed. In the great majority 
 of instances the mass will be evacuated in time. 
 Slight aperients may be of some use, and massage and 
 electricity have also been credited with effecting a 
 cure. Failing these or other methods, the obstructing 
 body may Vje cut down upon and removed. 
 
 B. Stenosis of the larg^e intestine. — The 
 conditions in the colon that as regards treatment 
 maybe included under this title are : 1. Stricture; 2. 
 Bending of the adherent colon ; 3. Compression by 
 adhesions ; 4. Volvulus of the caecum ; 5. Obstruction 
 by neoplasms ; 6. Compression by a tumour outside 
 the gut ; 7. Some enteroliths. 
 
 In all these forms of obstruction the patient's con- 
 dition can be rendered more comfortable by careful 
 attention to diet and by ensuring as complete an 
 evacuation of the bowels as possible by means of 
 laxatives, and especially by means of enemata. In 
 
Chap. XXVI.] Chronic Obstruction. 505 
 
 the cases of obstruction due to pressure of a tumour 
 outside the gut some special treatment directed 
 against the tumour itself will probably be indicated. 
 When the obstruction is due to an enterolith (a com- 
 paratively rare condition) relief may be afforded by 
 repeated copious enemata, combined by cautiously 
 administered aperients. Some surgeons would be dis- 
 posed to rely, to some extent, upon electricity and 
 massage in these cases. 
 
 In the other forms of obstruction, as well as in 
 those just mentioned, when a distinct diagnosis is not 
 made, the usual means of aff'ording relief is by colo- 
 tomy. 
 
 In cases of stricture the site of the colotomy must 
 obviously depend upon the site of the obstruction, and 
 this latter matter is by no means easy to determine. 
 Statistics dealing with the position of strictures of the 
 colon show very clearly that in any case of doubt it is 
 better to open the colon in the right loin, or do in- 
 guinal colotomy in the right iliac region. If, after 
 attempting right lumbar colotomy, the ascending 
 colon be found empty, it has been advised that an 
 enterotomy should be done through the lumbar 
 wound. I have already alluded to instances where 
 the diagnosis has been made by means of a median 
 laparotomy, and where an opening into the colon in 
 the loin has been subsequently effected with success. 
 In several cases colotomy has failed, owing to the 
 presence of a double obstruction, one being above the 
 artificial anus. Thus in one case the rectum was 
 found to be partially occluded, left lumbar colotomy 
 was performed, but proved to be useless, since an ob- 
 struction existed also in the small intestine."^ It 
 must be observed also that colic strictures are often 
 multiple. Thus, in one case there existed a stricture 
 of the rectum, which had been diagnosed ; there also 
 * Path. Soc. Trans., vol. iii., page 108. 
 
5o6 Intestinal Obstruction. [Chap. xxvi. 
 
 existed two strictures of the transverse colon which 
 had not been suspected. Had left lumbar colotomy 
 been performed in this case it would have proved 
 abortive."^ 
 
 The relative merits of inguinal and lumbar colo- 
 tomy have been already discussed. 
 
 In cases of stricture where a more radical mode of 
 treatment is considered necessary, colectomy may be 
 performed. This procedure seems to be rather 
 prominently indicated in cases of epitheliomatous 
 stricture, where by an early performance of the 
 oj)eration the malignant growth may possibly be 
 entirely eradicated. The details of the measure have 
 been considered. 
 
 In cases of obstruction by neoplasms also colectomy 
 may be performed should the general conditions of the 
 case permit that procedure. 
 
 C. FsBcal acciiiiiulatiou. — In the treatment 
 of these cases is involved the varied and extensive 
 methods adopted for the relief of constipation. Into 
 the consideration of these it is unnecessary to enter in 
 this i^lace. 
 
 The only question that need be entertained is the 
 treatment of the case when actual and serious ob- 
 struction has occurred. In such condition aperients 
 are calculated to do harm rather than good. The 
 main reliance should be placed in copious and re- 
 peated enemata. jNIany continental surgeons strongly 
 advise carbonic acid enemata in these cases. Much 
 good has also been effected by massage, by electricity, 
 and even by the somewhat questionable mode of 
 treatment by metallic mercury in large doses. All 
 these measures and their application have been already 
 considered. In not a few cases that have resisted all 
 other treatment colotomy has Ijeen performed. I 
 think, however, that in the majority of these examples 
 * BuU. de la Soe. Anat., 1877, page 519. 
 
Chap. XXVI.] Chronic Obstruction. 507 
 
 a correct diagnosis was not made. The cases wherein 
 this operation is actually demanded are very few, and 
 the measure should not be entertained until every 
 other mode of treatment has had a patient and 
 repeated trial. Lumbar colotomy for faecal accumu- 
 lation must be regarded rather as a surgical mis- 
 fortune than as a recognised means of treatment. 
 
 D. Chronic iutuissiisccptioii. — The great 
 fatality that attends this form of obstruction demands 
 that it should be very carefully treated. Much relief 
 can in all cases be afforded by a careful attention to 
 diet, and in the most chronic examples benefit of a 
 temporary character has attended the use of laxatives. 
 In the less chronic cases, and in those associated with 
 occasional and slight acute attacks, the nse of opium 
 is now and then indicated. 
 
 Attempts may be made to reduce the invagination 
 by means of enemata and insuiflation, since it has 
 been shown that even in intussusceptions that have 
 existed for more than a month, reduction, and fairly 
 easy reduction, is not impossible. This measure, 
 however, can only be successful in extremely rare cases. 
 The only means of relief, in the event of failure of 
 non-operative measures, is by laparotomy, followed by 
 resection of the diseased mass in cases where re- 
 duction is found to be impossible. This question has 
 already been discussed in the preceding chapter. 
 
INDEX. 
 
 Abdomeu, state of, in intussuscep- 
 tion, 229, 241 
 , , in strangulation ■by- 
 bands, 76, 88 
 
 , , in stricture, 295, 303 
 
 , , in Yolvnliis of sigmoid 
 
 flexure, 147 
 AciTte intussusception, Diagnosis 
 of, 377 
 
 obstruction, Diagnosis of, 374 
 
 —— in cbronic cases, 388 
 
 in stricture, 296 
 
 , Treatment of, 493 
 
 Adenoma of intestine, 309 
 Adhesions, Anonialoiis forms of, 96 
 
 • , Complicated, 7 
 
 , Compression of the bowel by, 
 
 111. 
 
 , Diffused peritoneal, 120 
 
 , Effects of traction upon, 129 
 
 , Extensive forms of, 119 
 
 , Formation of, 4 
 
 , Occlusion by, 102, 119 
 
 , Strangulation througb slits 
 
 in, 55 
 Angioma of intestine, 310 
 Antiperistalsis and Tomiting, 363 
 Anuria and collapse, 369 
 
 in intestinal obstruction, 369 
 
 Aperients in intestinal obstruc- 
 tion, 427 
 Apertures, Bare forms of, 53 
 
 , Strangitlation through, 52 
 
 , Symptoms of strangulation 
 
 through, 62 
 Appendices epiploicae, Adhesions 
 of, 52 
 
 , Rings formed by, 54 
 
 Apj)endix, Strangulation by the, 
 
 50 
 Arsenical poisoning yersiis intes- 
 tinal obstruction, 414 
 Aspiration of the bowel, Treat- 
 ment by, 445 
 
 Auscultation of the colon, 398 
 Avenoliths, 338 
 
 Band, Strangulation over a, 97 
 
 Bands, Anomalous forms of ob- 
 struction by, 96 
 
 , Attachments of, 20 
 
 , Complicated, 7, 19 
 
 , Cousrenital, 37 
 
 , Double, 17 
 
 , Methods of strangulation by, 
 
 23 
 
 , Pathology of, 13, 14 
 
 , Strang ufation by, 13 
 
 , , Amount of gut involved 
 
 in, 59 
 
 , , Constipation in, 81 
 
 , , Diagnosis of, 374 
 
 , , Exciting cause of, 
 
 70 
 
 , , Frequency of the vari- 
 ous forms, 56 
 
 , , General constitutional 
 
 symptoms in, 84 
 
 , , Mechanism of, 59 
 
 , , Mode of onset in, 69 
 
 , , Pain in, 71 
 
 , , Portion of gut involved 
 
 in, 56 
 
 in, 93 
 
 Prognosis in, 91 
 Spontaneous recovery 
 
 , , State of abdomen in, 76, 
 
 88 
 
 , , of urine in, 86 
 
 , , Symptoms of, 62 
 
 , , Temperature in, 85 
 
 , , The previoiis history 
 
 in, 67 
 
 , , Yomiting in, 78 
 
 , Tlie formation of, 4 
 
 , Various forms of, 15 
 
 , Y-shaped, IS 
 
5IO 
 
 Intestinal Obstruction. 
 
 Bending of adherent colon, 108, 
 123 
 
 small ixitestine, 109 
 
 of the bowel, Occlusion by, 
 
 102 
 
 , Symptoms of, 108 
 
 Bishop's clamp for resection ope- 
 rations, 482 
 Broad ligament of uterus, Stran- 
 gulation by slit in, 55 
 
 Csecum.Ulceration of, in stricture, 
 280 
 
 , Volvulus of, 153, 155, 157 
 
 Calculi in the intestine, 336 
 Cancer of intestine, 269, 297, 304 
 
 of mesentery and intestinal 
 
 obstruction, 414 
 Carbonic acid enemata. Treatment 
 
 by, 444 
 Catarrhal ulcer, 258 
 Cholera vcv&ns intestinal obstruc- 
 tion, 412 
 Chronic constipation, 344 
 
 obstruction. Treatment of, 
 
 503 
 Cirrhosis of liver and intestinal 
 
 obstruction, 414 
 Clamps for resection operations, 
 
 481 
 Classification of intestinal ob- 
 struction, 1 
 
 , Clinical, 373 
 
 Colectomy, Treatment by, 478, 
 
 487 
 Colic intussusception, 170 
 Collnpse, Signification of, 355 
 Colloid cancer of bowel, 269 
 Colon, Adhesions affecting the, 
 122 
 
 , ascending, Volvulus of, 153 
 
 , Auscultation of, 398 
 
 , Bending of, by adhesions, 
 
 102, 107, 108, 123 
 
 , Distension of, from traction, 
 
 130 
 
 , Distortion of, 123 
 
 , Stricture of, 286, 300, 304 
 
 Colotomy, Inguinal, 471 
 
 , Lumbar, 471 
 
 , Mortality in, 471 
 
 , Statistics of, 471 
 
 , Treatment by, 470 
 
 Compression of the bowel by ad- 
 hesions, 111 
 
 by tumours, 315 
 
 Concretions in diverticiala, 43 
 of magnesia in bowel, 3;39 
 
 Congenital forms of intestinal ob- 
 struction, 1 
 Constipation, Chronic, 344 
 
 , , Causes of, 347 
 
 , , Symptoms of, 348 
 
 in intestinal obstruction, 368 
 
 in intussusception, 225, 239 
 
 in strangulation by bands, 
 
 81 
 
 in stricture, 294, 302 
 
 in volvulus of sigmoid flexure, 
 
 144 
 
 of unusual duration, 350 
 
 Cramps in acute strangulation, 87 
 Cylindroma, 268, 272 
 Czerny-Lembert suture, 48. 
 
 Diagnosis, DiflEerential, 371 
 
 , Errors in, 400 
 
 of acute obstruction, 374 
 
 of chronic cases that end 
 
 acutely, 388 
 
 of chronic obstruction, 3S0 
 
 of intestinal obstruction, 355 . 
 
 Diarrhoea as a cause of intussus' 
 ception, 212 
 
 in intussusception, 225, 240 
 
 Distension of intestine, Effects of, 
 
 8 
 Distortions of the colon, 123 
 Diverticula, False, 44 
 
 , , communicating with 
 
 bladder, 49 
 Diverticular cords, 35 
 
 knots, 41 
 
 Diverticulum, Attachments of, 33 
 
 in an invagination, 215 
 
 , Knots formed by, 41 
 
 , Strangulation by, 31, 37 
 
 , , Prognosis in, 91 
 
 , , Spontaneous recovery 
 
 in, 95 
 
 , The effects of traction on, 
 
 127, 131 
 
 , The true or Meckel's, 31 
 
 Double intussusception, 180 
 Duodenum, obstruction in. Diag- 
 nosis of, 395 
 Dysenteric ulcer, 255 
 Dysentery and intestinal obstruc- 
 tion, 415 
 
 Electricity, Treatment by, 433 
 Enemata as means of Diagnosis, 
 396 
 
 of carbonic acid, 414 
 
 , Treatment by, 438 
 
Index. 
 
 5" 
 
 Entevectomy, Treatment by, 476, 
 460 
 
 Eutcric intxTSSiisceptiou, 16S 
 
 Enteritis and intestinal obstruc- 
 tion, 415 
 
 Enteroceutesis, Treatment by, 450 
 
 Enteroliths, 336 
 
 Enterotomy, Mortality in, 470 
 
 , Statistics of, 470 
 
 , Treatment by, 466 
 
 Epithelioma and intussusception, 
 200 
 
 of the intestine, 268, 272 
 
 EiTors in diagnosis, 400 
 
 Etiology of intestinal obstruc- 
 tion, 3 
 
 Fsecal accumulation, Diagnosis of, 
 385 
 
 , Treatment of, 506 
 
 masses'. Obstruction by, 344 
 
 tumoiu', 352 
 
 Fallopian tube. Strangulation by, 
 
 p 51 
 
 False diverticula, 44 
 
 Fecnlent vomiting, 365 
 
 Feeding of patients in intestinal 
 obstruction, 415 
 
 Fibroma of intestine, 310 
 
 Fibro-myoma of intestine, 310 
 
 Fistula bimucosa, 115 
 
 Foramen of Winslow, Strangula- 
 tion at, 55 
 
 Forcible eneniata, 440 
 
 Forei.gn bodies. Diagnosis of ob- 
 struction by, 379 
 
 , etc., Treatment of ob- 
 struction by, 502 
 
 in the intestine, 277 
 
 , Obstruction by, 319 
 
 Fruit stones in the intestine, 277 
 
 Gall stones. Diagnosis of obstruc- 
 tion by, 379 
 
 , Obstruction by, 323 
 
 , Position of, wben im 
 
 pacted, 325 
 
 • , Prognosis in obstruc- 
 tion by, 334 
 
 , Symptoms of obstruc- 
 tion by, 327 
 
 , Treatment of obstruc- 
 tion by, 502 
 
 Gan^-rene in intussusception, '196, 
 2i7 
 
 in stricture, 281 
 
 Gussenbauer's suture, 485 
 
 Hepatic colic and intestinal ob- 
 
 striiction, 414 
 Hernia and omental bands, 30 
 
 as a cause of str'icture, 263 
 
 as an indirect cause of intes- 
 
 tinal.obstruction, 10 
 
 , Internal, 56 
 
 like strangulation, 13 
 
 Ice in intestinal obstruction, 432 
 
 Heo-caecal intussusception, 170 
 
 csecal valve, Stricture of, 262, 
 
 277, 286, 299 
 
 -colic intussusception, 170 
 
 Ileus paralyticus, 344 
 
 Impacted gall-stones, 323 
 
 Ina:esta as a cause of intussuscep- 
 tion, 213 
 
 Injuries as a cause of intussuscep- 
 tion, 214 
 
 of stricture, 265 
 
 Insufflation, Treatment by, 442 
 
 Intestinal calculi, 336 
 
 , Symptoms caused by, 
 
 341 
 
 coUs, Visible movements of, 
 
 370 
 
 concretions, 43 
 
 loops, Obstruction by, 113 
 
 stones, Obstruction by, 336 
 
 tunioui'S, 309 
 
 Intestine, small. Cancer of, 297 
 
 , , Stricture of, 285, 290, 
 
 291 297 
 
 — 1-, '-^, Volvulus of, 158, 165 
 
 , The effects of traction on, 
 
 126 
 
 Intestines, Matting together of, 
 113, 119 
 
 Intussusception, Abdominal tu- 
 mours in, 230, 241 
 
 acute. Diagnosis of, 377 
 
 forms of, 215, 220, 242 
 
 , Ti'eatment of, 500 
 
 and " spasms," 203 
 Artificial production of, 203 
 Changes in the gut above, 
 
 190 
 
 chronic. Diagnosis of, 386 
 
 forms of, 215, 236, 242 
 
 , Treatment of, 507 
 
 Clinical forms of, 215, 242 
 Colic, 170 
 
 Course and prognosis in, 242 
 Double and triple, 180 
 Enteric, 168 
 Epithelioma with, 200 
 Etiology of, 202 
 
512 
 
 Intestinal Obstruction. 
 
 Intussusception, Exciting causes 
 of, 210 
 
 , Frequency of, 216, 242 
 
 , , in ileo-ca3cal region, 209 
 
 , of various forms of, 171 
 
 , Gangrene in, 196, 247 
 
 , General pathologicarchanges 
 
 ii), 181 
 
 , symptoms of, 228 
 
 , Ileo-csecal, 170 
 
 , -colic, 170 
 
 , Immediate causes of, 203 
 
 ■ -, Irreducible, 187 
 
 , Mode of srrowth of, 172 
 
 , of onset in, 218, 236 
 
 , Mortality in, 243 
 
 , Obstruction and strangula- 
 tion in, 185 
 
 of the dying, 173 
 
 , Pathology of, 166 
 
 , Retrograde, 178 
 
 , Sex and age in, 216, 242 
 
 - — -, Spontaneous ciire in, 244, 
 245,246 
 
 , Subacute forms of. 215, 220, 
 
 242 
 
 , Symptoms of, 215 
 
 , The layers of, 167 
 
 , Ultra-acute forms or, 215, 
 
 220, 242 
 
 , Varieties of, 168 
 
 Intussusceptum, 167 ■i 
 
 , Changes in, 195 
 
 , Elimination of, 196, 247 
 
 , Signs of separation of, 251 
 
 Intussuscipiens, 167 
 
 , Changes in, 193 
 
 Invaginatio paralytica, 205 
 
 spasmodica, 203 
 
 Irreducible intussusception, 187 
 
 Jejuno-ileum, Volvulus of, 164 
 Jejunum, Diagnosis of obstruc- 
 tion in, 395 
 
 Kinkiug, Strangulation by, 43, 99 
 
 , , Symptoms of, 102 
 
 Knot formed by the appendix, 
 
 50 
 , Strangulation by, 24, 26, 38, 
 
 41 
 
 Laparotomy during peritonitis, 
 
 464 
 
 , Fallacies in, 458 
 
 for intussusception. Statistics 
 
 of, 461 
 
 Laparotomy for obstruction. Sta- 
 tistics of, 460 
 
 , Incision in, 452 
 
 , Mode of proceeding in, 455 
 
 , Mortality in, 459 
 
 , Treatment by, 451 
 
 Lipoma of bowel, 310 
 
 Littre's hernia, 37 
 
 Long tube as a means of diagnosis, 
 397 
 
 Loops, Intestinal obstruction by, 
 113 
 
 Limd's inflator, 443 
 
 Lymijho-sarcoma of bowel, 314 
 
 Magnesia, Concretions of, 339 
 
 Massage, Treatment by, 436 
 
 Matting together of intestines, 
 113, 119 
 
 Meckel's divei-ticulum, Attach- 
 ments of, 33 
 
 , Strangialation by, 31, 37 
 
 , Varieties of, 31 
 
 Meningitis and intestinal obstruc- 
 tion, 414 
 
 Mercury, Metallic, in intestinal 
 obstruction, 430 
 
 Mesenteric gland disease as a cause 
 of intestinal obstruction, 12 
 
 Mesentery, Part played by, in in- 
 tussusception, 181 
 
 , shrinking of, Obstruction 
 
 caused by, 133 
 
 , Strangulation by fixed por- 
 tion of, 51 
 
 , through slits in, 52 
 
 Meso-colon, Part played by, in in- 
 tussusception, 183 
 
 Mucous casts passed per anum, 
 342 
 
 Noose, Strangulation by, 24, 38 
 
 Oat stones, 338 
 
 Obstruction by compression, 315 
 
 by foreign bodies, 319 
 
 by gall stones, 323 
 
 by intestinal calculi, 336 
 
 by neoplasms, 309 
 
 , Diagnosis of site of, 391 
 
 in intussusception, 186 
 
 Occlusion due to shrinking of me- 
 sentery, 1:33 
 Oliguria in intestinal obstruction, 
 
 369 
 Omental cords, Formation of, 28 
 , Strangulation by, 28 
 
Index. 
 
 513 
 
 Omentum, Straugiilation tlirongli 
 slits iu, f 3 
 
 Omplialo-mesenteric vessels, Per- 
 sistence of, 35 
 
 Operative treatment of obstruc- 
 tion, 445 
 
 Opium in intestinal obstruction, 
 420 
 
 Ovarian cyst, Strangulation by 
 pedicle of, 52 
 
 Pain, Character of, in intestinal 
 
 obstruction, 359 
 in complete and incomplete 
 
 obstruction, 75 
 
 in intestinal obstruction, 
 
 357 
 
 iu intussusception, 220, 238 
 
 in strangulation by Taauds, 
 
 etc., 71 
 
 in stricture, 291, 300 
 
 in volvulus of sigmoid flexure, 
 
 143 
 
 , Localisation of, in acute ob- 
 struction, 72 
 
 , situation of, in intestinal ob- 
 struction, 360 
 
 Paralysis of the bowel, 401 
 
 Peptic ulcer, 258 
 
 Peritoueal false ligaments (see 
 Bands) 
 
 Pej-itonitis and l^parotomy, 464 
 
 as an indirect cause of ob- 
 struction, 3 
 
 deformans, 1:33 
 
 I'ersus intestinal obstruction, 
 
 406 
 
 Poisoning by arsenic versus intes- 
 tinal obstruction, 414 
 
 Polypi, 311 
 
 as a cause of intussusception, 
 
 212 
 
 Pseudo-strangulation, 400 
 
 Puncture of the bowel. Treatment 
 by, 445 
 
 Rectal tumour in intu ssusception, 
 
 233, 241 
 Resection of intestine. Causes of 
 
 death after, 489 
 
 , Clamps for, 481 
 
 , Modus operandi in 479, 
 
 487, 4S9 
 
 , Mortality in, 488 
 
 ■ — —, Sutures in, 484 
 
 ■ ■ , Statistics of, 488 
 
 , Treatment by, 476 
 
 H H 12 
 
 Retrograde intussusception, 178 
 Rigors in acute obstruction, 84 
 
 Sarcoma of bowel, 313 
 Sigmoid flexure and small intes- 
 tine. Volvulus of, 151 
 
 , Volvxilus of, 131, 151 
 
 , , Course of, 149 
 
 , Pathology of. 
 
 1:34 
 149 
 141 
 
 -, Prognosis in, 
 -, Symptoms of, 
 
 " Skins " passed per anum, 342 
 Spontaneous recovery in acute 
 
 strangulation, 93 
 Stenosis of adherent bowel, 130 
 of the colon. Treatment of, 
 
 504 
 Stenosis of the small intestine, 
 
 Treatment of, 503 
 
 the result of traction, 126 
 
 Stercoraceous vomiting, 365 
 Stercoral tumours, 352 
 Strangulation by a noose or knot, 
 
 24, 38, 41 
 
 by acute Mnldng, 99 
 
 by bands, Diagnosis of, 374 
 
 , Mechanism of, 59 
 
 , Pathology of, 13 
 
 , Prognosis of, 91 
 
 , Symptoms of, 62 
 
 , Treatment of, 493 
 
 by fixed mesentery, 51 
 
 by kinking, 43 
 
 by Meckel's diverticulum, 31, 
 
 37 
 
 by omental cords, 28 
 
 by pedicle of ovarian cyst, 
 
 52 
 by the appendix vermiformis, 
 
 50 
 
 by the effects of traction, 43 
 
 • by the Fallopian tube, 51 
 
 in intussusception, 185 
 
 over a band, 43, 97 
 
 through slits and apertures, 
 
 52 
 
 under a band, 23 
 
 Strictiu'e after hernia, 263 
 
 after injury, 265 
 
 after intussusception, 251 
 
 after ulceration, 254 
 
 , Cancerous, 267, 297, 304 
 
 , Cicatricial, 253 
 
 , General changes that result 
 
 from, 277 
 
514 
 
 IXTES TINA L ObS TR UC TION. 
 
 Stricture, its clinical beariugs, 
 
 282 
 • , Modes of causing deatli in, 
 
 283 
 of ileo-caecal valve, 262, 277, 
 
 286, 299 
 
 of the colon, Diagnosis of, 
 
 383 
 
 , Treatment of, 504 
 
 of the small intestine. Dia- 
 gnosis of, 380 
 
 ■ , Treatment of, 5(»3 
 
 , Pathology of, 352 
 
 , Prognosis in, 285, 298, 305 
 
 , sinii^le, Situation of, 261 
 
 , Symptoms of, 285 
 
 Suspensory ligament of liver, 
 
 Strangulation through slit in, 
 
 55 
 Sutures in resection operations, 
 
 4S4 
 Swedish movement cure, 437 
 Symptoms as modified by the site 
 
 of the obstruction, 391 
 Syi^hihtic ulcer of intestine, 258 
 Syphon enemata, 439 
 
 Temperature in strangulation by 
 
 bands, 85 
 in volvulus of sigmoid 
 
 flexure, 145 
 Tenesmus in intussusception, 226, 
 
 240 
 Traction of the intestine. Effects 
 
 of, 126 
 , Strangulation by the effects 
 
 of, 43 
 Treatment by carbonic acid ene- 
 mata, 444 
 
 by colectomy,. 478 
 
 by colotomy, 470 
 
 by electricity, 43^3 
 
 by enemata, 438 
 
 by enterectoiny, 476 
 
 by enterocentesis, 450 
 
 by enterotomy, 466 
 
 by insufflation, 442 
 
 by lajmrotomy, 451 
 
 by massage, 436 
 
 by non-operative means, 415 
 
 by operative means, 4t5 
 
 by puncture of the bowel, 445 
 
 by resection of intestine, 476 
 
 of acute intussusception, 500 
 
 obstruction, 493 
 
 of chronic intussuscei^tion, 
 
 507 
 obstruction, 503 
 
 Treatment of faecal accumulation, 
 506 
 
 of intestinal obstruction, 415 
 
 of obstruction by foreign 
 
 bodies, etc., 502 
 
 by gall stones, 502 
 
 of stenosis of the coloii, 501 
 
 of the small intestine, 
 
 503 
 
 of strangulation by bands, 
 
 etc. , or through apertures, 493 
 
 of stricture of the colon, 504 
 
 of the small intestine, 
 
 503 
 
 of volvulus, 498 
 
 , Special, of the various forms 
 
 of obstruction, 493 
 
 Treves' clamp for resection opera- 
 tions, 481 
 
 Triple intussusception, 180 
 
 Trochar, Use of, in intestinal ob- 
 struction, 445 
 
 Tubercular peritonitis and intes- 
 tinal obstruction, 410 
 
 Tubercular ulcer of intestine, 259 
 
 Tumours, Compression of the 
 bowel by, 315 
 
 formed of faecal masses, 352 
 
 of intestine, 309 
 
 Typhoid ulcer and stricture, 255 
 
 Ulcer, Catarrhal, 258 
 
 , Dysenteric, 255 
 
 , Peptic, 258 
 
 , Syphilitic, 258 
 
 , Tubercular, 259 
 
 , Typhoid, 255 
 
 Ulcers of the intestine, 254 
 
 Umbilical fistulae due to the open- 
 ing of Meckel's diverticulum, 
 31 
 
 Uiine, Amount of, passed in ob- 
 struction, 369 
 
 , State of, in acute strangula- 
 tion, 86 
 
 , , in volvulus, 143 
 
 Valve, ileo-csecal, Stricture of, 
 
 262, 277, 286, 299 
 Vegetable concretions, 337 
 Volvulus, Congenital, 163 
 
 , Diagnosis of, 376 
 
 , Forms of, 134 
 
 of ascending colon and C8B« 
 
 cum, 153 
 
 of caecum, 153, 155, 157 
 
 of jejuno-ileuui, 164 
 
Index. 
 
 5^5 
 
 Volvulus of sigmoid flexure and 
 
 small intestine, 151 
 
 , Symptoms of, 141 
 
 , Causes of, 135 
 
 , Course of, 149 
 
 , Forms of, 136, 151 
 
 , Mechanism of, 137 
 
 , Pathology of, 134 
 
 , Peritonitis in, 140 
 
 , Prognosis in, 149 
 
 of small intestine, 158, 161, 
 
 165 
 , Treatment of, 498 
 
 Vomiting and antiperistalsis, 363 
 
 , Causes of, 362 
 
 in intestinal obstruction, 362 
 
 in intussusception, 223, 239 
 
 in strangulation hy bands, 78 
 
 in stricture, 293, 302 
 
 in volvulus of sigmoid flexure 
 
 144 
 
 , Stercoraceous, 365 
 
 , The initial, 366 
 
 "Worms and intestinal obstruction, 
 343 
 
 CASSELL & COMPANY, LIMITED, BELLE SAUYAGE WORKS, LONDON, B.C. 
 
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