lus may be referred to the back. In volvulus, high up in the small bowel, there may occur frequent evacuation from the bowels. This is unlike internal hernia from strangulation from bands, which are accompanied by absolute constipation. Rectal tenesmus is an indication of volvulus, being the cause of obstruction rather than strangulation from other causes. Fecal vomiting is not common in volvulus, but it is common in strangulation from entanglement under bands and in openings. Volvulus is more likely to be preceded by habitual constipation, and causes less intense collapse than strangulation from bands. If the patient has had a history of peritonitis, this would indi diagnosis cannot be established with a fair degree of accuracy within twenty-four hours, or, at most, forty-eight hours, then open the abdomen aseptically and examine the contents." I will report the following case, which is a typical one in so far as the history and symptoms are concerned, but which is very unusual as to causation: C. M., aged nineteen, a college athlete, was brought to the City Hospital the evening of December 28, 1906, by Dr. C. B. Trout, of Duncan's Falls. The patient's family history is good. He had always been in the best of health, except that about a year previous to the present attack he had had an attack of appen dicitis and was confined to his bed for probably a week, and was not well for several weeks after. Since that time he had apparently been in perfect health. When admitted to the hospital his condition was very unpromising. He had taken suddenly ill with pain and vomiting and complete obstruction of the bowels four days previous to his admission. When he arrived at the hospital, having been brought thirteen miles to the city, his pulse was 120, temperature subnormal, abdomen enormously distended with gas, and stercoraceous vomiting. His condition was so serious that operation was postponed twelve hours with the hope of improving his condition by lavage of the stomach and rectal enemas. This treatment relieved, to some extent, the grave symptoms, and operation was performed by the writer early next morning. Not knowing where the obstruction might be located, the incision was made in the median line, and, following the enormously distended ileum, the obstruction was finally located in the ileum about three or four inches from where it entered the cecum. A firm band was tightly drawn across the gut and was adhered to it. Upon further investigation, this band proved to be Meckel's diverticulum, which was firmly adhered to an enlarged appendix. The band was grasped above the bowel with forceps and ligated and cut. In separating the diverticulum from the intestines it was found that necrosis and a perforation existed, which allowed quite a large amount of gas and fecal matter to escape into the abdominal cavity. This rent in the bowel was quickly closed by silk sutures and the obstructive band, together with the appendix, was removed in the usual manner. On account of the infection from the escaping contents of the bowel into the abdomen, another opening was made over the appendix near the crest of the ilium and a cigarette drain inserted. The median incision was closed at the completion of the operation. Aside from considerable shock, the patient made a rapid and complete recovery. In searching the literature I was unable to find a similar case. Of course, it is quite common for the diverticulum to be the cause of intestinal obstruction in various ways, but this is the only instance that I have known that it was adhered to the appendix, causing an obstructive band. The adhesion had evidently formed at the time of his attack of appendicitis, which occurred a year previous. A renewal of the attack at the beginning of his illness caused a tightening of the band sufficient to cause complete obstruction. (For discussion see p. 253.) INTERNAL STRANGULATED HERNIA, OR INTERNAL INTESTINAL STRANGULATION.* BY EDWARD M. BROWN, M. D., I am aware that I am using the term hernia in connection with this paper in not a strictly scientific sense. A hernia must always include a peritoneal sac, and in this paper I mean to speak of intestinal strangulation within the abdominal cavity caused not only by protrusion of bowel through visceral canals, congenital slits. and weak points in the mesentery, etc., but of strangulation due to the slipping of bowel through loops caused by adhesions between the intestines themselves and between the intestines and visceral or parietal peritoneum. Intestinal strangulation is of interest because of the treacherous na ture of the condition, as evidenced by the large mortality in such cases. This high This high mortality is due to the lateness with which a positive diagnosis is usually made, or the lateness with which it is even looked upon as a serious condition by the attending physician, in a great many cases. It is my purpose to emphasize some points in the early diagnosis of these cases, to urge early operation in all, even suspected cases, to report three or four interesting and somewhat unique cases which have occurred in my own practice, and to refer to some others occurring in the practice of Dr. Alex. Hugh Ferguson, with whom I am associated. Time does not permit me to more than categorically mention the etiological classification of internal hernia. Hernia and intestinal strangulation within the abdomen are caused by the slipping of a loop of bowel into or through 1. The visceral canals or fossæ, such as (a) foramen of Winslow; (b) duodenojejunal fossa; (c) congenitally or trau * Read before the Mississippi Valley Medical Association, Columbus, O., October 8-10, 1908. matically weakened points in the mesentery, omentum, diaphragm, omphalo-mesenteric vessels and diverticulæ, and visceral or parietal peritoneum. 2. Loops or openings caused by adhesions due to peritoneal infection and inflammation, such as (a) pelvic peritonitis; (b) appendicitis; (c) gall-bladder disease; (d) typhoid ulcer and perforation; (e) tubercular peritonitis and enteritis; (f) post-operative or traumatic adhesions; (g) tumors and abnormal growths in the abdo men. SYMPTOMS AND DIAGNOSIS. Symptomatically, there are practically two classes of cases: 1. Acute, or those in which the symptoms are sudden, severe and violent, and in which the seriousness of the condition is never overlooked. 2. Subacute, or those in which the symptoms are very much less marked, and the seriousness of which is often overlooked until too late. In the acute cases the symptoms are: 1. Abdominal pain; sudden, severe, violent, and regularly paroxysmal. 2. Vomiting; prompt, frequent, severe, and early becoming stercoraceous in char acter. 3. Collapse marked; pulse small and feeble; skin cold and bathed with sweat. 4. Temperature absent or subnormal. 5. Tympanites absent or only slight early in the attack. Excretion of urine. less than normal, often very scanty, or even suppressed. 6. Complete obstruction to flow of feces. 7. No point of special tenderness or resistance. 8. At first, no tumor or swelling. The higher up in the small intestine, the more marked are all these symptoms, except fecal vomiting, which, when obstruction is near duodenum, cannot well occur. When, on the other hand, the abdomen is greatly distended, vomiting is less frequent. Longer interval before stercoraceous vomiting occurring, indicates involvement of the large intestine, which brings us to the second class of symptoms, or subacute cases, in which the 1. Pain is less severe. 2. Vomiting less urgent. 3. Collapse at first not present, but the patient feels that he is seriously and dangerously ill, a point which is frequently not given sufficient weight by his physician. 4. Tympanites often marked, which in dicates again that the strangulation is in the large bowel. In fact, the subacute cases are those in which usually the strangulation is in the large bowel. 5. Fecal obstruction is not always complete, except when obstruction is low down; gas is often passed. These subacute cases are the most dangerous. They are the ones in which he diagnosis is doubtful and delayed, and in which surgical interference comes too late and the patients die. In the first class of symptoms we are usually not in doubt, but, on the contrary, recognizing the seriousness of the condition readily, feel that we are dealing with a case of intestinal strangulation. In the second class of cases, because of the much less violent early symptoms, we are liable to mistake the colicky pain, nausea, etc., for that of acute indigestion, flatulent colic or impacted feces. It is a noteworthy fact, however, and one which should never be lost sight of in diagnosis, that the abdominal facies is nearly always present, even early, and that the patient himself feels that there is something seriously wroug. He often informs his physician that he feels that if he had a free bowel movement he would be well. The physician is led to believe the same, and here is where the dangerous waste of time occurs. Medication and other efforts to empty the bowel are instituted, only to find the patient next day with all the symptomis more marked. Perhaps it is the secend, third, or even the fourth day before the patient is found in violent pain, collapse, great abdominal distention, absolute stoppage of the flow of feces, temperature, rapid pulse, auto-intoxication and peritonitis. Physicians often do not see nor profit by the early symptoms and signs. Though somewhat subdued early in the case, when the involvement is in the large bowel or low in the intestinal tract, the positive symptoms are always present, and should not be overlooked. It is then only that the diagnosis can be made, if made at all. There is often a dangerous lull in the symptoms between the onset and ensuing conditions, which is dangerous and misleading. The regularly paroxysmal pain, vomiting, meteorism, and complete stoppage of gas and fecal flow, either sudden or coming on within a few hours, cannot be mis taken. It is by no means always possible before laparotomy to differentiate between internal hernia or intestinal strangulation due to protrusion of bowel into or through congenital slits, adhesive bands, loops, etc., and the obstruction of the bowel due to other causes. The symptom-complex the result of obstruction due to intestinal strangulation, with its involvement of blood-vessels, nerves and lymphatics, is always more severe than that of simple obstruction due to other mechanical causes. The most difficult to differentiate is perhaps intussusception and volvulus, but a careful study of the anamnesis, fecal flow and local findings, tumor, etc., will aid in clearing this point considerably. The other conditions offering difficulty of differentiation are appendicitis, gall-bladder disease, acute pancreatitis, perforating ulcer of the bowel or stomach, and thrombosis and embolism of mesenteric arteries. Here, again, the history, presence of fever, local peritonitis, local tenderness, etc., will serve to assist in making a diagnosis within a high degree of probability. Such conditions and diseases as flatulent colic, lead colic, arsenical poisoning and Asiatic cholera should be thought of and eliminated. Examination of the blood and urine offers little of value in the diagnosis. of the obstruction of internal hernia or intestinal strangulation. It is true that a leucocytosis may develop as the disease progresses. So, also, may indicanuria be found. The quantity of urine is often less or its secretion practically suspended in the onset of the attack. A microscopic study should be made of the fluid found in the abdomen and contents of the strangulated loop, with the endeavor to associate these with symptoms and signs present before operation. The usual sites of internal hernia are the diaphragm, duodeno-jejunal fossa, foramen of Winslow, intersigmoid fossa (not always present), ileo-colic and ileo-cecal fossæ, and sub-cecal region. These should be thought of before opening the abdomen, with a view to locating the site of strangulation, if possible. When we have failed to clear up the case by all means of investigation at our command, exploration of the abdominal cavity should be made. Sometimes, as in the acquired varieties of diphragmatic hernia, symptoms referable to the thoracic cavity are so marked as to make the diagnosis easy, if thought of and looked for before obscured by the rapidly fulminating symptoms in the abdomen. I must admit, however, that in but few of these cases has the diagnosis of diphragmatic hernia been made during life. In only 7 out of 266 cases reviewed by Lachner was the diagnosis made ante-mortem. It is usually congenital in origin, and is due to imperfect development of one or both halves of the diaphragm, and is most common on the left side. In Winslowian hernia the bowel passes through the foramen of Winslow into the lesser sac of the peritoneum. The hernia may be composed of small bowel (Treitz), transverse colon (Majoli), cecum, or the entire ascending colon and part of the transverse colon (Treves). In three-fourths of the recorded cases the strangulated mass contained small intestine, the remaining fourth transverse colon, part of the ascending colon and even the cecum. The only important symptom in regard to the diagnosis of the localization of the strangulation is the presence of a swelling in these regions (Faure Jeanbrau and Riche, Bulletin et Mem. de la Soc. de Chir. de Paris, No. 12, 1906). The tumor occurs in the epigastrium in the center or toward the right side, and always below the costal arch. In none of the cases reported was the diagnosis correctly made before the operation. Hernia into the intersigmoid fossa has occurred only four times up to 1899 (Treves), and its treatment, laparotomy, is the only way of making the diagnosis. What has been said of diaphragmatic and Winslowian hernia as regards diagnosis can also be said of the rare forms, ileocolic, ileo-cecal, and, in fact, all other forms of internal strangulated hernia. Secord (Annals of Surgery, November, 1906) reports the first case of ileo-colic hernia to be recorded. The patient was operated upon and recovered. Hernia into the duodeno-jejunal fossa (fossa of Treitz) is comparatively rare. Two varieties are described-right, having the superior mesenteric artery in front of the sac, and left, having the superior mes enteric vein in front of the sac. Bingel (Archiv f. Pathol. und Anatomie, No. 1, 1902); L. L. McArthur (Surgery, Gynecology and Obstetrics, January, 1906); L. Freeman (Transactions American Surgical Association, 1903), and Ferguson ("Modern Operations for Hernia") report very interesting cases. As regards diagnosis, it is interesting to quote Ferguson's case: "The patient had not been well for a number of years, but complained most of recurrent attacks of pain over the gall-bladder. She said that she felt as though something was slipping away behind the stomach. Inspection of the abdomen was negative. Palpation elicited tenderness over the gall-bladder and also over the appendix. The gallbladder was enlarged. On the whole, the physical examination did not furnish much evidence upon which a diagnosis could be made." This hernia consisted of a loop of the upper portion of the jejunum, extending behind the stomach above the duodenum into the lesser cavity of the peritoneum. The sac was formed of the posterior layer of the transverse mesocolon. Strangulation of bowel in congenital or acquired apertures or fissures, as in omphalo-mesenteric vestiges, or slits in the omentum and mesentery, are much more frequent than such cases as those just described. I wish to report a very interesting case of meso-colic hernia with strangulation occurring in my own practice a short time. ago: "Mrs. E., Belle Plains, Ia., referred to me by Dr. S. M. Cook. Aged thirty-five, married two years; no pregnancies. Personal history negative, except that she complained of backache, pain referable to pelvis and right side. Physical examination revealed a retroflexed uterus, tender tubes and ovaries, and a floating kidney on the right side. Otherwise everything was in a normal condition. I operated on her early in November, 1905, at the West Side Hospital, Chicago, doing a ventro-suspension of the uterus, plastic work on the tubes and ovaries, and a nephropexy on the right side. She recovered beautifully until three weeks after her operation, when, on a Sunday morning preceding the day on which she expected to return to her home, she was seized with sudden, violent paroxysmal pain in the epigastrium, severe and frequent vomiting, becoming fecal early; apparent complete obstruction of the fecal flow, with considerable shock. I saw her a few hours after the onset of the attack, diagnosed internal intestinal strangulation, and opened the abdomen within twelve hours from the inception of the symptoms. I found little or no tympanites, and no peritoneal exudate. Examination of the pelvis showed no adhesions. Examination of the kidney previously operated upon showed everything normal. I next explored the region of the duodeno-jejunal fossa, and found a loop of jejunum protruding through a slit in the mesocolon about two inches to the left of that fossa. I easily withdrew the bowel, which was in good condition, obliterated the slit by one or two catgut sutures, and closed the abdomen. The slit in the mesentery admitted the tips of the first two fingers. The patient made an uneventful recovery, and returned to her home two weeks after the operation. Congenital and traumatically produced holes or slits in the omentum are frequently the cause of intestinal strangulation. The symptoms are, of course, the same as strangulation elsewhere, and positive diagnosis as to location is little less difficult than the other cases mentioned. By far the most frequent cause of intestinal strangulation within the abdomen is post-operative adhesions, loops and bands caused by trauma of previous operations and local peritonitis. While many of the cases which occur in women because of the frequency of tubal disease. and pelvic peritonitis, etc., adhesions the result of appendicitis and gall-bladder disease are also responsible for obstruction; still, the post-operative adhesions contribute many more. The diagnosis here is easy, as a rule, because of the history which it would be unpardonable to overlook. Out of an experience of about twentyfive, I select the following two most interesting and instructive cases as best illustrating that which I wish to impress: "Mrs. R., aged thirty-two; housewife; married seven years. Gave a history of one miscarriage early in married life; no later pregnancy. Gonorrhea in the husband, and repeated attacks of pelvic peritonitis. On October 25, 1900, she was taken with pain resembling that of flatulent colic. Cathartics did not act well, though some feces and gas escaped with enemata. An internist of national reputation saw her on the second day, but did not make a diagnosis of intestinal strangulation. On the third day, the pain and tympany increasing, she was sent to the hospital, but the obstruction not being complete, she was not operated upon until the fourth day. The symptoms then exhibited were severe, dragging abdominal pains, beginning stercoraceous vomiting, great abdominal distension and tenderThe temperature, which up to this time. was little above normal, registered 103.4°; pulse 100. The patient had a distressed and anxious face, and complete obstruction of the fecal flow had developed. Physical examination revealed ness. |