Source: Snow, John. London Med. Gazelle, vol. 38, Dec. 18, 1846, pp. 1049-1052.
Case of strangulation of the ileum in an aperture of the mesentery
Paper read at the Royal Medical and Chirurgical Society, 23 June 1846
By John Snow, M.D.
(Read at the Royal Med. and Chir. Society, June 23d, 1846.)
The subject of the following case was the patient of Mr. Marshall of Greek Street, and I am indebted to him for the following account of her illness, having seen her during life myself only at his last visit.
Mrs. Oliver, 24 years of age, of good constitution, in the 8th month of her first pregnancy, was seized early on Saturday morning, March 21st, 1846, with rather severe pain, extending over the whole of the belly, of an intermitting character, being increased at intervals varying from a quarter of an hour to half an hour. There were sickness and vomiting, but little or no tenderness on pressure of the abdomen. The pulse was about 80: the bowels had been moved by castor oil. She thought her labour was coming on, but the os uteri was not at all dilated. Supposing that the pain depended on irregular spasmodic action of the intestines, a grain and a half of opium, and a carminative mixture, were administered. In the evening the pain had somewhat abated, and the vomiting had nearly ceased.
22d.--She had slept very little during the night; the pain was as severe as on the previous morning, with shorter intervals of intermission, and the vomiting had returned. Opiates were continued at intervals, and effervescing and cathartic draughts. In the evening the breathing was accelerated, and the pulse was upwards of 100: there was slight distension of the bowels from flatulence. An enema was administered, and was followed by what the nurse considered to be a copious and healthy motion, but it was not seen by me. She now complained of thirst.
23d.--She had passed another restless night. The pulse was now 120, and full;the breathing extremely hurried, and the thirst very great. The countenance was anxious. Sixteen ounces of blood were abstracted from the arm, to the great relief of the dyspnœa; the pulse was not diminished in frequency. To take calomel and opium, and effervescing draughts. The clyster was repeated, but no fecal evacuation followed.
24th.--The vomiting continued, and during the night a considerable quantity of dark green liquid was brought up; not, however, having a fecal odour. There was a little tenderness on firm pressure, and great tympanitic swelling of the abdomen. The countenance was somewhat improved since yesterday, but the pulse was very rapid--140. A repetition of the clyster, and a continuance of the calomel and opium, and the fomentations which had been employed throughout, were directed. She died four hours after this visit, on the 4th day of her illness.
Examination 24 hours after death.--The abdomen was tympanitic and very much swollen, and a great quantity of dark green liquid, similar to that which had been vomited, had flowed out. The stomach and small intestines were extremely distended with flatus; the only lymph observed was a little of a creamy consistence between two folds of small intestine in the center of the abdomen; this part of the intestine exhibited a reddish surface externally: the rest of the intestines were nearly of the natural pale colour, except the last portion of the ileum, about 18 inches of which were of a deep purple, approaching nearly to black, and lay in folds in front and to the right side of the ascending colon. The contents of the uterus being removed in order to bring this part more clearly into view, these folds of ileum were seen to be bound down hust in front of the junction of the cœcum with the colon, and constricted as closely as if a thread had been twitched tightly round them. The band which held them down did not seem thicker than the smallest hempen twine; one end of it was continuous with the peritoneum covering the vermiform appendix at about three-fourths of an inch from its commencement, and the other with [1049/1050] the peritoneum covering the ileum, about an inch from its termination. The appendix vermiformis was doubled on itself at the junction of this band, and the process of peritoneum inclosing it was dragged upwards, so as to give the appearance of a tight ligament, extending from that point to the upper edge of the pelvis, in front of the right sacro-iliac symphysis. On Mr. Marshall's attempting to pass his finger under the band, it gave way, and liberated the strangulated ileum, but the parts still remained in an unnatural position; the ascending colon was twisted on itself, so that the cœcum was turned with its inner edge outwards, the ileum entering on the outerside, and the origin of the vermiform appendix being on the anterior and external side; these intestines, however, were readily removed into their natural places. The coats of the dark-coloured portion of ileum which had been strangulated were much swollen from the great congestion. The stomach was pale externally; its mucous membrane was ashy brown, and gave way under the fingers. This viscus, and the duodenum, contained dark green fluid, and the jejunum and the ileum, down to the strictured portion, contained a good deal of yellow liquid feces; the colon was empty. The head of the fetus was closely fitted to the cavity of the pelvis, and the os uteri was dilated to the size of a half-penny, the membranes being unruptured.
On examining the preparation* (*now in the possession of Mr. Marshall) which accompanies this paper, it will be found that the vermiform appendix is enclosed within a double layer of peritoneum, which forms a kind of broad ligament, which is attached above to the cœcum and ilium, and was attached externally and inferiorly to the iliac fossa and brim of the pelvis.
The hand could be passed behind this expansion. On the external side of the vermiform appendix there is an aperture in this membrane, with defined edges, through which the thumb can be passed, and behind the portion of it which extends with a curve from the vermiform appendix to the ileum, there is a pouch into which a finger can be passed for about two [1050/1051] inches. The thin membrane passing from the appendix vermiformis cœci to the ileum, and leaving the aperture through which the strangulation took place, forms an extension of the above-mentioned curve. It has been tied at the spot where it was broken.
The symptoms in this case were such as usually arise from any mechanical obstruction in the bowels. There was nothing to indicate the cause, or even the situation, of the obstruction; for there was not more pain at one part of the abdomen than another. The enlargement of the uterus, by displacing the small intestines upwards and to each side, was probably the immediate cause of the insinuation of the ileum through the aperture. This opinion is confirmed by the circumstance that, in the first of the two cases quoted at the end of this paper, in which the band causing the strangulation was, in size and situation, very much like the one in this case, the immediate cause of the strangulation was evidently a particular posture of the patient. The twisted state of the ascending colon was, no doubt, a consequence of the strangulation, or of the distenstion which followed it: a twisted state of the bowels has been met with in several cases of intussusception and strangulation by membranous bands. There are many cases on record of strangulation of the bowels in an aperture made by morbid adhesion of the vermiform appendix of the cœcum with neighbouring parts; but the appearance of the membrane in this case, the absence of evidences of old inflammation in the abdomen, and the circumstance that the membranous band appears to be a natural continuation of a larger fold, lead me to consider it as a congenital production of peritoneum, leaving an aperture on the inner side of the appendix vermiformis similar to the one we see on its outer side.
The recorded cases which I have been able to find that most resemble this just detailed, follow as an appendix, but the authors do not offer any opinion as to whether the apertures were congenital or not: there is, however, one case of strangulation from a congenital malformation related by M. Moscati, p. 468, of the 3d vol. of the same Mémoires. In that case the ileum gave off a branch 2 ½ feet previous to its termination, in the form of a funnel, terminating in a ligamentous band about 5 inches in length, and attached by its other extremity to the mesentery, leaving an opening through which some loops of the ileum became strangulated. This branch, I conclude, was the remains of the ductus omphalo-mesentericus.
Mr. Thomas Morton and Mr. Prescot Hewett have informed me that they have seen the appendix vermiformis enclosed in a fold of peritoneum forming a kind of broad ligament.
I subjoin two cases translated from the Mémoires de l'Academie Royale de Chirurgie:-
"M. de la Faye informed us in 1750 of a strangulation of the intestine by a similar band. Being invited to assist at the opening of a body in order to make a report in concert with the surgeon in attendance, he learned that the subject, who was newly married, had experienced on the night of his nuptials a very severe pain of colic, such as had occurred to him for the last seven years every time that he had lain with a women. On this occasion it was more violent than before, and followed by all the symptoms which accompany a volvulus. The patient died in thirty-six hours, notwithstanding all the assistance that could be rendered him in that short interval. The belly was swelled out like a balloon: on its being opened the cause of death was evident. On going over the intestines with care, there was remarked, at an inch from the termination of the ileum in the cæcum, a band of the thickness of a strong thread, and of three finger-breaths in length, attached on one side to the appendix cæci, and on the other to the part of the mesentery nearest to that intestine. The ileum had passed under that band to the extent of a foot: the strangulated portion was collapsed and inflamed. From the stomach to the seat of strangulation the intestinal canal was very much distended, and the part beyond the stricture was in the ordinary state. The band must have been vascular, for it was black and already gangrenous, so that it required only the slightest effort to break it. If the patient could have lived till the rupture of this band had taken place, he might possibly have recovered."-M. Hevin on Volvulus, in [1051/1052] the Mém. De l'Acad. Roy. de Chirurgie, p. 237, vol iv. quarto edition.
"On the 16th April, 1765, M. Sancerotte, Surgeon in Ordinary of the late King of Poland, Duke of Lorraine, opened the body of a man who had been brought to the hospital the evening before. He had been ill nine days with the usual symptoms of strangulated hernia, although there was no appearance of it externally. The pulse had always been small, with severe pain in the right lumbar region. There was an annular opening in the mesentery of a ligamentous consistence, through which had passed the cæcum with a part of the colon, and a greater extent of the ileum. The swelling which came on, having changed the relative proportions, these parts of the intestine became strangulated, and not being able to disengage themselves they mortified, after having occasioned first bilious and then stercoraceous vomiting, as usual in such cases. These parts could be withdrawn through the aperture, after evacuating by a puncture the air which distended them."-Ibid. p. 239.
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