quantities of magnesia have been found as a mass in the colon, and portions of string become impacted in like manner. Foreign bodies of considerable size sometimes pass through the whole intestinal canal without producing any injurious symptoms, as coins accidentally swallowed, stones taken by maniacs; in other cases they are retained at the sphincter and require mechanical assistance in their removal, as fish-bones, &c., placed across the intestine. In a remarkable instance in which a sailor swallowed claspknives, several were discharged from the bowels, and one was found fixed transversely in the rectum; the case is recorded by Dr. Marcet, in the Medico-Chirurgical Transactions,' and the thickened stomach, with the fragments of the blades found on examination after death, are preserved in the Museum of Guy's Hospital. The patient was an American sailor, aged 23, who, in June, 1799, swallowed four clasp-knives; three were discharged from the bowels. In March, 1805, he swallowed fourteen knives in two days; in December, 1805, he swallowed fifteen to twenty more; making thirty-five swallowed at different times. His health became impaired; he vomited the handle of one, and passed portions of the blades of others; and in March, 1809, he died in a state of extreme exhaustion. The oesophagus and stomach were dilated and thickened, and in the latter were numerous blades of knives partially dissolved. In the abdomen there was a general discoloration of the intestines; one blade was found perforating the colon opposite the kidney, but without extravasation of fæces; another blade was transversely fixed in the rectum. CHAPTER XIV. INTERNAL STRANGULATION.—INTUSSUSCEPTION. CARCINOMA OF INTESTINE. VARIED conditions, leading to insuperable constipation, have frequently been indiscriminately associated together, under the term ileus; and whilst we are willing to acknowledge, that very great difficulty is connected with the correct diagnosis of these cases, we believe that when a full history of the symptoms can be obtained, careful examination will enable us to divide them into several classes, and to make an approximative diagnosis, not only as to the character, but the position of the obstruction. Each minute circumstance is important in assisting the correct diagnosis of these cases, the accurate detail of previous symptoms, the mode of attack, the position of pain, the vomiting, the relative severity and period of commencement of these symptoms, the state of the abdomen, the general appearance of the patient, the quantity of the urine, &c. Dr. Barlow has drawn attention to several of these conditions, and has shown the importance of ascertaining the period of the commencement of the vomiting,* and the condition of the renal secretion. The causes of insuperable constipation are numerous : 1. Internal strangulation arises from bands of adhesion, which may be the result of inflammatory action; or from simple adhesion without constricting bands, as of the ileum to the uterus. 2. From congenital intestinal pouch becoming adherent to other parts, or from perforations in the mesentery, &c. 3. From the appendix cæci assuming a fixed and adherent position. Guy's Reports,' 1844. Clinical cases. Practice of Medicine. 4. From the twisting of the intestine, of which Rokitansky gives three forms-1, Upon its own axis; II, Upon the mesentery; and III, Upon other coils of intestine. Other causes are 5. The development of tumours in the mesentery leading to constriction. 6. Intussusception. 7. Cancerous disease of the intestine. 8. Contraction of cicatrices, as after dysentery; fever. Beside these, we must also enumerate : 9. Enteritis and peritonitis. -- 10. Impaction of fæces and of foreign bodies, as gall-stones, &c. 11. Obscure forms of hernia, as into the obturator foramen, &c. 12. Prolapsus ani, and inflamed hæmorrhoids. 13. Abdominal and pelvic tumours. Abercrombie describes cases of ileus in which no cause of strangulation nor obstruction was detected after death, and he believed them to arise from distension, or "simple derangement of action" of the intestine; thus he states, "that distension appears to constitute a morbid condition which may be fatal without passing into any farther state of disease;" and again, that "ileus does not appear to be necessarily connected with obstruction in any part of the canal; for we have seen it fatal without obstruction, and we have seen everything like obstruction entirely removed without relieving the symptoms." He mentions other instances in which adhesions had formed without sensible diminution of the area of the intestine, and which were followed by the symptoms of insuperable obstruction; in the former we believe that either enteritis was present, or the bowel was twisted; in the latter that spasmodic contraction rendered a partial impediment complete; and the author just mentioned writes, "I admit, however, that there may be irregular contractions of portions of the intestine, analogous to that to which the term spasm is usually applied, and that these may form the first step in that chain of derange* Abercrombie on Diseases of the Stomach and Intestine.' Third edition. ments of the harmonious action of the canal which leads to an attack of ileus." Internal strangulation.-The general symptoms of this condition are pain sometimes very slight, but occasionally very severe, gradually increasing distension of the abdomen, constipation, generally of an insuperable character, vomiting at first bilious, afterwards stercoraceous; and after a longer or shorter period peritonitis, prostration, and death. Pain. In many cases of internal strangulation there is a sudden catch in the bowels, as of some displacement, and the patient can place the hand on the exact part, which generally indicates the seat of disease; although, if fatal, we may find that distension and other causes have led to considerable altera tion of position. When a portion of intestine has slipped under a band of adhesion, or into a hole of omentum or mesentery, this character of pain is observed, but when there has been a twist of the intestine the pain is more gradually developed, and for many days may be entirely absent. The most obscure cases are those of internal strangulation, in which there has been chronic partial constriction, and from indiscretions in diet, or other causes, slight enteric irritation has led to spasmodic constriction at the part; in these cases the pain closely resembles ordinary colic. Tenderness of the abdomen may be absent for many days; in some instances the peritonitis does not come on till nearly the close of life, from a state of continued and extreme distension of the intestine, and from ulceration of the mucous membrane extending to the serous coat; but where there has been sudden strangulation, the serous membrane is more quickly implicated, and the symptoms bear a closer resemblance to those of ordinary external strangulated hernia. If the strangulation be in the small intestine, either near the cæcum, or in the jejunum, the pain will generally be found to be in the region of the umbilicus; where the colon is involved the position of the pain is in the course of that part of the intestine, and often marks its precise seat; thus, in diseases of the sigmoid flexure, the pain will generally be found in the left iliac fossa or in the left groin. Its character in intussusception is often severe, paroxysmal, and resembles that of ordinary colic; in many instances a tumour can be felt in the abdomen, arising from the involution of the intestine, or adhesion between its coils. Tympanitis.-Unless the obstruction be very high in the alimentary canal, as in the case recorded with disease of the duodenum and of obstruction twenty inches from the pylorus, the abdomen gradually becomes distended, and tympanitic on percussion. The enlarged coils of intestine may be observed through the stretched parietes, and the peristaltic movements are often clearly perceptible, especially in obstruction of the colon. If the ileum, or the commencement of the ascending colon, be constricted, the distension is central in its character, and is less evident; but if the descending colon, sigmoid flexure, or rectum, the portions of the large intestine above the seat of disease become greatly distended; they may be observed in the peculiar outline of the abdomen, and the tympanitic resonance extends to the loins; where, however, the obstruction arises from portions of twisted large intestine, as of the cæcum or sigmoid flexure, we find that there is some deviation from the general character just mentioned; an enormously distended cæcum may be twisted over to the left hypochondrium, and constitute a prominence in that region. Vomiting. The character of the vomiting, and the period at which it has commenced, especially when irritating and powerful purgative medicines have not been administered, are important guides to our diagnosis. If the obstruction be sudden, and be situated in the small intestine, the vomiting comes on very quickly, in from half an hour to two or three hours; if it be high in the jejunum, the vomited matters are of a bilious character, but if near to the cæcum they may assume a fæcal odour, and be completely stercoraceous. In one instance, in which the obstruction arose from a band of adhesion high up in the jejunum, the vomiting was so sudden as to resemble that produced by cerebral disease; and this view of the case was favoured by the partial insensibility of the patient. In the case recorded of twisted cæcum; where the obstruction was near the termination of the ileum, so fully fæcal was the character of the vomited fluid that it was for a time supposed that a communication existed between the stomach and the transverse colon. When the large intestine is the seat of disease, as in cancer of |