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 where we have a history of the symptoms throughout, 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 shown their importance, especially the period of the commencement of the vomiting,* and particularly to the condition of the renal secretion.

The causes of insuperable constipation are numerous. As forms of internal strangulation we observe it :

1. Arising from bands of adhesion, the result of inflammatory action; or simple adhesion without constricting bands, as of the ileum to the uterus.

2. From congenital intestinal pouch becoming adherent.

3. From the appendix cæci assuming a fixed and adherent position.

4. From the twisting of the intestine, of which Rokitansky

Guy's Reports, 1844. Clinical cases. Practice of Medicine.

gives three forms-1. Upon its own axis; 11. Upon the mesentery; and 111. Upon other coils of intestine.

5. Tumours developed in the mesentery leading to constriction. From other allied causes are:

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, or 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 or pelvic tumours.

Abercrombie* describes cases of ileus in which no cause of strangulation was detected after death, and he believed them to arise from a spasmodic state of the intestine; in others, that only a portion of the walls of the intestine were strangulated in hernia, without the whole calibre being constricted, and that all the symptoms of insuperable obstruction were the result; 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.

The general symptoms of these conditions are pain in a greater or less degree, gradually increasing distension of the abdomen, constipation, generally of an insuperable character, vomiting; 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 has led to considerable alteration of position. Where 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 where there has been a twist of the intestine the pain is more gradually developed. The most obscure cases are those of internal strangulation, where there has been partial constriction, but slight enteric inflammation, as from indiscretions

* Abercrombie on Diseases of the Stomach and Intestine.

in diet, has led to spasmodic eonstriction at the part; in these the pain closely resembles ordinary colic. Tenderness of the abdomen may be absent for many days; in some the peritonitis does not come on till nearly the close of life, from the state of continued and extreme distension, and the 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 more 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.

Tympanitis.-Unless the obstruction be very high in the alimentary canal, as in the case recorded with disease of the duodenum, 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. If the ileum, or the commencement of the ascending colon, be constricted, the distension is central in its character; but if of 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 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. Where the large intestine is the seat of disease, as in cancer of the sigmoid flexure, or of rectum, &c., several days sometimes elapse before vomiting supervenes; the time is, however, much accelerated if powerful drastics are given. In the latter state also, the vomiting is more easily checked by the administration of remedies, as of ice, or opium, &c. As to the immediate cause of stercoraceous vomiting, Dr. Brinton, in his valuable remarks in the Encyclopædia of Anatomy, has clearly shown that the peristaltic action is not in itself reversed, but that the contents of the bowel are propelled onward sin their normal manner till the obstruction is reached, when the fluid assumes a central retrograde direction, thus producing a double current, a parietal or onward, and a central or reverse current; this retrograde movement continues till the vomited matters are of the same character as those found at the seat of stricture.

Hiccough is also more severe and more speedily produced in the strangulation of the small, than of the large intestine. It must be borne in mind, that the vomiting and hiccough are sometimes extreme in peritonitis, where the serous membrane of the stomach is involved.

Urine.—Dr. Barlow has drawn especial attention to the amount of urine excreted, as a sign of the seat of obstruction; that where the obstruction is high in the canal, as in the jejunum or ileum, absorption is partially checked, the renal vein receives a diminished supply, and a small quantity of urine is excreted; if on the contrary the rectum or sigmoid flexure be occluded, nearly the whole of the capillaries of the alimentary canal are free to absorb fluid, and thus the blood contains more watery elements.

and the urine is abundant. This is a symptom deserving our attention, but it is not a certain one; several cases among those illustrative of disease of the sigmoid flexure, had scanty urine among their earlier signs, and we shall find that the amount of urine may be measured by the quantity of fluid vomited; that if in obstructed colon powerful drastics have been administered, and speedy vomiting induced, or peritonitis quickly set up, the urine may be found to be small in quantity. However, it is as true that the urine is abundant when the obstruction is low down in the canal, as that the vomiting is late in its occurrence. The fluid character of the contents generally observed in the distended intestine above the seat of stricture is to be remarked, and is an indication that no remedies are needed in these cases to render them more watery, but that the spasmodic state of the diseased bowel, in addition to the mechanical impediment, often prevents a drop of fluid or any gas from passing the stricture.

State of the Rectum.-Dr. Barlow has here also added his diagnostic acumen to the elucidation of the symptoms presented. He has shown that in obstruction suddenly produced, the rectum retains its natural power of contraction, and will be found to be empty; if the disease be of gradual formation, that it is more patulous and readily yields to injections. To a certain extent this is the case, but it is not a symptom upon which we can rely. The intestine below the obstruction is generally contracted, and sometimes after the occurrence of the strangulation or other occlusion, a fæcal evacuation may take place, or be removed after injection merely arising from this cause, and giving a delusive hope. Mr. Moore has proposed the injection of fluid into the colon, regarding the varied dulness observed on percussion in the loins, as a sign of the position of the obstruction; and that in this way fluid may be forced into the ascending colon, and indicate that the disease is above that part.

The discharge of blood, or of offensive mucus, has been shown by Mr. Gorham* as a very frequent sign of intussusception; and it may be here remarked that it is important in all cases of this kind to make a careful manual examination of the rectum, as well as of all the parts in which hernia may occur.

* Guy's Reports.