Incomplete intestinal rotation

INCOMPLETE

INTESTINAL ROTATION

BERNHARD NEWBURGER, M.D. CINCINNATI,

A

DISEASED vermiform appendix Iying in the Ieft haIf of the abdomen, as it may, as a resuIt of a

0.

to his “ Hernia Retro-peritoneaIis ” described four such cases. We have found in our search of the Iiterature reports by four authors38r151,163,181antedating Treitz, though none of these descriptions was so unequivoca1 as his. The embryoIogy of the condition was known forty years before Treitz’s pubIication. It is most surprising that so sensationa an anomaIous entity as sinistrocoIia shouId have escaped the notice of generations of observers from the earIiest times to the first of the Iast century. EspeciaIIy is this true in view of the presence of an homoIogous condition in some of the Iower mammaIs which is known to have been described by the ancients and even dissected in viuo by some of the medieva1 French Schoo1143 and of the fact that other anomaIies not more striking were earIy observed and recorded, such as the doubIe avian cecum77 and the occurrence of viscera1 mirror transpoBition in animaIs.’ On the other hand, one’s astonishment at the apparent Iack of the ancients’ acuity is IargeIy mitigated by the realization that no mention of the condition was made in twenty-three standard FIG. I. continenta textbooks1g0 of the nineteenth century and that as Iate as Igo an articIe emanating from a continenta surgica1 transverse position, dispIacement of the cecum by intra-abdomina1 tumor, faiIure of cIinic, exhausting the other possibiIities of Ieft-sided appendicitis, ignored incompIete peritoneal fusion resuIting in cecum mobiIe coIonic rotation. or mesenterium commune, situs transverThe medieva1 anatomists and barber sus totaIis or abdominis, or incompIete were cognizant of certain of surgeons rotation of the coIon, carries with it an the abdomina1 dispIacements. CorneIius enhanced operative risk. The impression Gemma,7g Fabricius ab Aquapendente,63 has been gained in the present study that Johann Schenk von Graefenberg,178 Bonthe Iast mentioned cause of Ieft-sided etus15 and Morgagni 145a11gave descriptions appendicitis is perhaps not so uncommon of either situs transversus totaIis or abas the reported cases might Iead one to dominis. Pierre Franco74 noted the presence beIieve. According to Stieda,lgO the first record of of the cecum in an enterocoeIe. Shortly after Morgagni’s opus was pubincompIete migration of the coIon shouId be Iished, Caspar Friederich WoIff211 in his attributed to Treitz,lg7 who in an appendix 474

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“De Formatione Intestinorum” Iaid the groundwork for a11 subsequent investigative work in this fieId by his epoch-making

FIG.

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portrayal of the deveIopment of the intestine in the chick. Within the next fifty years a group of men, most prominent of whom were 0ken,ls2 FIeischmann67 and J. F. MeckeI,140 to a Iarge extent cIarified the question of rotation of the abdomina1 viscera and brought to Iight anomaIies due to interference with that mechanism, and MeckeI, at any rate, reaIized that “ Mehrere FaeIIe, wo sich diese fruehere anordnung des Grimmdarms mehr oder weniger such in spaetern Perioden erhaIten hatte, findet man von FIeischmann zusammengesteIIt, und richtig aIs Wesen derseIben ein StehenbIeiben auf einer fruehern BiIdungsstufe nachgewiesen.” Koch12’ Iater hroughi phyIogenyto bear on the probIem. This Dioneer achievement has been succeeded by many sporadic reports of germane material IargeIy necroscopic, some operative and recentIy roentgenographic.

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The two Iatter sources have been, perforce, incomplete in detai1 and could not have particularized as to vesse1 relationships

FIG.

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mesenteric and intestinai or omenta1, minutiae. In a consideration of this condition, the muItipIicity and compIexity of genericaIIy reIated abnormaIities must not be overlooked. RiseIlG5 in a compiIation and anaIysis of 49 cases of situs inversus partiaIis abdominis is abIe roughIy to cIassify them into groups, but the borderland between groups is extremeIy extensive and the overIapping confusing. The gaI1 bladder, for example, with or without Iiver anomalies may be Ieft-sided, possibIy associated with tota absence of the spleen or with the stomach in the right hypochondrium and the Iarge gut whoIIy behind or to the right of the smaI1. Then, too, the gastric half of the umbiIica1 Ioop may rotate with its appended anIagen (pancreas, Ii\,er, spIeen) in a direction opposite to that taken by the dista1 half. Further, abdominal viscera1

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disIocations may or may not be associated with thoracic anomahes. CertainIy the possibihties seem aImost Iegion and a singIe abnormaIity the exception though pure cases of sinistrocoIia occur as do cases of mere dextrocolia. Though the criteria of incompIete rotation are suff&ientIy rigid, observation of the detaiIs has not been thorough-going, in some, at Ieast, of the probabIe cases; it has been said thaV6 “actuaIIy not a singIe case exists in which a11 these eIements (the situation of the duodenum, smaI1 and Iarge intestine, pancreas, and the reIation of the vesseIs) have been observed.” Cases of reverse rotation such as StrehIe’s,gl or Peignaux and Fruchaud’s;155 compIete absence of rotation as in TandIer’slg3 first case, in Tscherning’s,lgg Thompson’s1g4 and Braeunig’s17 fourth case; faiIure of fixation of the mesentery, beautifuIIy differentiated from true faiIure of rotation with retention of a mesenterium commune in Langerhans’ case; such a case as that described by Drechse156 in which aIthough the duodenum is crossed by the normaIIy pIaced coIon, the duodenojejuna1 angIe is to the right of the superior mesenteric artery at the origin of the common mesentery; and the termina1 stages of incompIete rotation known as subhepatic ceca have not been incIuded in this study. The embryoIogy of intestina1 deveIopment need not be detaiIed here. NOSOLOGY

Of the various cIassifications* of anomaIous positions of the intestines, some are devoted whoIIy to restraint of rotation and none is thoroughIy comprehensive. The most attractive are the etioIogica1 arrangement of Dott and the rather arbitrary one of Hecker, GrunwaId and KuhIman. The former faiIs to consider a dextroposition of the coIon while the Iatter assigns to absence of rotation a condition which Dott with much more reasonabIeness classifies as reversed rotation of the midgut. There is a growing unanimity as to the causa* See References 12, 17. 46, 47, 52, 92-94.

MARCH. 1933

Rotation

tion of these states, but the nomencIature stiI1 Iacks standardization. The anatomica grouping of DeQuervain has the cIinica1 advantage of extreme simpIicity. PATHOLOGY

Hurst and Johnsonlo enumerate the anomaIies subsidiary to incompIete rotation as foIIows: I. The coIon occupies the Ieft haIf or Iess of the abdomina1 cavity whiIe the smaI1 intestine Iies to its right side. 2. The duodenum is eIongated and its mesentery usuaIIy persists. 3. The coIon does not cross ventra1 to any part of the smaI1 intestines. 4. The whoIe of the coIon retains its mesentery and no part of this mesentery is bIended with the great omentum. 5. The superior mesenteric artery Iies dorsa1 to the duodenum. The rami intestini tenuis arise from its right side and the coIic branches from its Ieft, and, 6. As Heckerg2sg4 points out, if 90 degrees of rotation occur in a norma direction, that is countercIockwise, so that the spIenic ffexure is defined, the duodenojejuna1 fIexure is to the right of, and on the same IeveI with, the superior mesenteric artery. Of these items, the first is the most obvious, the basis of the roentgenographic detection, and, as a ruIe, the first intimation in the course of Iaparotomy of the existence of incompIete rotation. The mesenteric artery-duodena1 reIationship is crucia1 but frequentIy not determined cIinicaIIy. The retention of a mesenterium commune is often obscured by secondary fusion of the colonic serosa to the parietes or by adhesion of the ascending to the descending Iimb of the coIon resuIting in the “doubIe barreIIed appearance,” so that it may be impossibIe to disIocate the cecum to any great extent. As to the fourth secondariIy derived anomaIy there is an interesting variabiIity. In two of Braeunig’s17 cases, in Judd’s,llO and in LeConte, Lee and Downs’12’ rudi-

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mentary omenta were dependent, but without connection with each other, from both the greater curvature and a coIonic segment. Eggers,5g South,18’ Corlette,34 DeIatour*4 (III), Ludington,135 and Schrup*O encountered no omenturn, not even rudimentary. MaIcoIm,136 Hammesfahr8g and H arrisg” describe short, free omenta attached to the stomach, the Iatter describing the omentum in his case as “very short (2 inches) .” In the cases of Janker,lo7 Eddy, 6i Lemesic and KoIisko,12g HoImes,go and m Braeunig’s17 second case the omenturn hung free without colonic fusion. In Treitz’slg7 first specimen an omentum a hand’s breadth in size was drawn into the hypochondrium and attached to the spIenic ffexure. RainerlGo found the mesogaster united to the mesentery. These bizarre omenta1 states are not restricted to faiIure of norma rotation but occur in dextrocoIia (DeQuervain46,47), ptosis of the spIenic ffexure (Loubat and Jonchures18”), and so on (ScheIenz,17’ ToIdt,lg6 Virchow,203 and RiseI16”). ObviousIy, as Lemesic and KoIisko say, “The large gut then can undergo its reguIar fusion with the omentum onIy if a mesocolic segment of the transverse coIon of normal cases remains in a suitabIe position.” That even minor abnormaIities are not common is evident from the observation of Poynter, 158who found no case in 200 bodies “in which the omentum was not adherent to the transverse coIon.” ToIdt cites a femaIe infant three days old described by H. L. F. Robert16* in which there was no trace of omentum; also the case of HIavagg reported by Epstein@ with absence of both great omentum and gastrocoIic Iigament. In this case of a five weeks oId gir1 the stomach assumed a vertica1 embryonic position. He further points out that fusion of the omentum with the coIon and transverse mesocoIon does not occur normahy under certain conditions : “The conditions for this Iie in extraordinary positiona reIationships of the stomach to the large gut . . . ” He calIs attention to the anaIogy of the Iower

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mammaIs and the human embryo of the third month in respect to coIonic-omenta1 reIationship. The mesenteric radix, which, especiaIIy in those cases with obstruction from voIvuIus is extremeIy narrow, is described in some of the reports as assuming a. downward course from right to Ieft, the inverse of the usua1 insertion. ETIOLOGY

Theories as to genesis of positional, anomaIies of the intestinal tract, and specificaIIy of incompIete coIonic migration, have advanced from the beIief that “the situs rarior [is] the resuIt of God’s punishment, [or] the work of demons”‘22 to a mechanistic expIanation which is currentIy accepted. PhyIogeny and ontogeny both shouId make one anticipate an incidence of faiIure of compIete aduIt human deveIopment even greater than indicated by the numerous reports of subhepatic ceca and cecum mobiIe. W. H. Flower”” found that the human intestina1 pattern “is perfectIy exceptiona among mammaIs.” Koch’?l correIated some human intestinal anomaIies with the norma state of birds and fish. According to Fredet? “torsion is normallv lacking in a great number of mammals.” Cuvier40 noticed the ahnost universa1 absence of intestina1 rotation in the carnivora whose intestina1 canal in the main resembles that of the bat. Some have thought that the mere Iengthening of the tube shouId account for the norma presence of rotation in the relativeIy few species in which it does occur, but as this lengthening takes pIace both in animaIs which are normaIIy devoid of intestina1 migration and in humans who are aIso without the twist, it obviously cannot serve as an etioIogica1 factor. Again, the right-sided position of the duodena1 Ioop and the Iiver mass has been assumed as the obstacle to rotation in the clockwise direction, but such cases ha\-e been recorded. EkehornGo felt that the rapid duodena1 deveIopment might influence

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rotation. KIaatschl’g attributed the determining roIes in the deveIopment of the aduIt’s situs abdominis to the Iiver and spIeen. The theory of embryonic peritonea1 adhesions as the source of restraint of rotation was Iong in vogue and was advanced, seemingIy with good reason, by many of the Scotch-EngIish schoo1. Dott52 has cIearIy pointed out the faIIacy here. Serres quoted by J. Reid1’j3 attributed the position of the caput cecum in the right iIiac fossa to the descent of the testis or pvary. Persistence of the right rather than the Ieft omphaIo-mesenteric vein has been hinted at by Lochte ~2 as the cause of nonrotation; this might occasionaIIy account for an isoIated case but atypica1 deveIopment of the porta system is certainIy no constant concomitant of incompIete coIonic migration though extremeIy frequent in otherwise norma peopIe. In short, unti1 ‘915, no greater success attended the attempts at expIanation of non-rotation, and its norma counterpart rotation of the intestines, than had simiIar efforts in the domain of situs transversus totaIis and partiaIis. At that time Frazer and Robbins’ passive mechanica theory was advanced and has received widespread acceptance through its Iucidity and its IogicaI attack on the problem of rotation. AIthough this hypothesis is intrinsicaIIy most diffIcuIt of proof some formidabIe indirect evidence is at hand to Iend it great credibiIity. Their theory is briefly as foIIows: Rotation is initiated through downgrowth of the right hepatic Iobe and the consequent depression of the proxima1 Iimb of the intestina1 Ioop to the right in the physioIogica1 hernia by the above conditioned descent of the secondary Ieft umbiIica1 vein which runs diagonaIIy across the ventra1 aspect of the proxima1 Iimb from the Ieft side of the umbiIica1 opening to the right Iobe of the Iiver. AIso, in this first stage, the two fixed points, the duodenum, with its bow-causing pancreas, the “coIic angIe” with its transient retention band, and the duodenocolic isthmus are deIimited.

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In the second, critica1, stage, during which the intestines return from the extraembryonic to the intra-embryonic ceIom and definitiveIy assume their position, the proxima1 Iimb of the Ioop reenters the reIativeIy enIarged abdomina1 cavity, with its decreased pressure, first. This happens for two reasons: the crucia1 items of the theory. First, because the intestines cannot re-enter en masse, being hindered by the rather rigid waIIs of the umbiIica1 orifice (recti abdominis and the centra1 hepatic notch) ; and, second, because the iIeoceca1 region, especiaIIy the cecum, forms a definiteIy Iarger and Iess fIexibIe and ductiIe mass than the smaI1 intestina1 coiIs (proxima1 Iimb) and “that this shape of the coIon must operate against its passage through the narrow neck of the sack.” Hence, the proxima1 Loops of the smaI1 intestine return to the right of the median mesocoIon, which forms a sagittaIIy pIaced septum. This they push up, to the Ieft and dorsaIIy. Further, these coils are directed beIow and to the Ieft of both the temporariIy fixed mesenteric trunks and the dista1 Iimb (coIon), causing rotation. When the cecum, foIIQwing the smaI1 intestines, returns, it at first Iies on them and Iater, due to pressure, behind them near the dorsa1 waI1, though not adhering. As wiI1 be noted, the intestines do not rotate about the mesenteric axis, but the first returning coiIs pass beneath it. The third stage comprises fixation of the mesocolon and mesentery and extension of the cecum from a subspIenic or subgastric position to its aduIt Iocus. Dott52 on the basis of this theory says that “a departure from this sequence of return is the onIy possibIe expIanation of perversion of the second stage of rotation” and that “the factors which wouId derange this order are such as wouId render the smaI1 intestine more diffIcuIt of rotation or the cecum or the umbiIica1 orifice so Iarge that they couId be reduced with equa1 faciIity “; and further, specificaIIy, in regard to the cause of incompIete rotation of the midgut Ioop that “it appears most

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IikeIy that the colon and cecum return first through a Iax umbilical ring, carrying with them the Iower end of the iIeum and superior mesenteric artery. The smaII intestine immediateIy foIlowing on wiII not tend to pass behind the artery since the Iatter is not now heId forward to the umbiIicus, but rather to dispIace it and the Iarge intestines to the Ieft.” AIthough this and the derived expIanations are most attractive, the suspicion of a more basic disturbance as the cause of faiIure of rotation is contained in RiseI’s statement that no compIete inversion of the abdomina1 viscera has been authoritativeIy reported without some accompanying abnorma1 thoracic feature; and, too, the almost interrupted series of transitiona forms between situs solitus and situs transversus, as indicated in his coIIected cases as well as those of ToIdt:

as incomplete acting factors not impossibIe have premised

Es kann ferner aIIein der Magen mit seinem AnhangsgebiIden (Mesogastrium, MiIz, Duodenum, Pancreas) verkehrt geIagert sein, dadurch dass sich die Magenschleife ToIdts in entgegengesetztem Sinne gedreht hat, oder such aIlem der Duenn-und Dickdarm infoIge von umgekehrter Drehung der NabeIschIeife. Diese, wenn man so sagen darf, reinen Formen koennen sich untereinander kombinieren. Mit der Umkehrung der MagenschIeife kann eine soIche der Leber oder eine soIche des Darmes verknuepft sein (bei sonst normaIer Lage der Brustorgane und der grossen gefaesse der BauchhoehIe), oder endIich konnen such aIIe drei Formen zusammen vorkommen. Martinotti’38 is quoted as having marked the frequency with which inversion of the cecum and coIon was associated with malposition of the other abdomina1 organs and having concluded that “the position of a11 these organs might be attributabIe to one and the same cause.” There can be but IittIe doubt but that these cases of situs inversus abdominis to which Rise1 and Martinotti refer are cIoseIy aIIied to, if not of identical order of pathogeny with, instances of coIonic non-rotation. However, ToIdt was of the opinion that in isoIated deviations of aIimentary segments, such

American Journal 01 Surgt~v

coIonic rotation, wouId be the cause that Frazer and them.

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IocaIIv I and it is Robbins

INCIDENCE

The relative rarity of incompIete intestina rotation is difficuIt to confirm but is vouched for by Mayo,‘“” J. B. Murphy,14g E. W. Andrews, 5 ScheIenz,j7 Hurst’ol and others. RiseI, on the other hand, says of the cIoseIv reIated cases of situs ‘inversus abdominis that their number is by no means so restricted as one wouId judge from the majority of reports. An idea of the frequency of its occurrence may be arrived at by a consideration of ratio: A search of the Iiterature of the Iast four or five years had disclosed some twenty-six pubIished cases of this sort (complete transposition). Their number in a few years compared with the number of other kinds of mispIaced appendices reported during a period of a hundred .~ears makes it apparent that the latter condition must be very much more unusua1 than the former.lvO At the time of Mayo’s report of 4 cases of appendicitis associated with faiIure of the coIon to rotate, 3 cases had been operated on at the Mayo clinic which were compIicated by complete viscera1 transposition. Warren Cole reports no cases of incompIete intestina1 rotation in ~S,OOO admissions to the St. Louis ChiIdrens HospitaI. Larimore on the basis of 10,000 gastrointestina1 roentgenoIogica1 studies pIaced the incidence of anomaIous intestina1 rotation, presumptiveIy incIuding non-rotation, maIrotation and reversed rotation, at less than >fO of I per cent and thought it of almost as rare occurrence as compIete transposition of which he has seen but 2 instances. of 12,072 observations in A compiIation* which the authors were interested primariIy in the position of the appendix, furnished an incidence of incompIete rotation of 0.041 per cent. Treveslg8 found a subhepatic position of the cecum in 2 per * See References

I, 93, IOO, 144,

184,

189, 205.

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cent. Liertz’s’sl figures are not incIuded as it is impossibIe to specifIcaIIy account for his 0.7 per cent Ieft-sided appendices. A survey of the Iiterature reveaIed 15 I cases of incompIete rotation not incIuding 14 doubtfu1 cIinica1 instances and 12 in which the incompIete rotation was combined with other major viscera1 abnormahties. Of this tota of 177 cases, 40 were instances of appendicitis. In 1926 Herrmang6 found 3 Ig cases of situs inversis totaIis. RoughIy, then, incompIete rotation is about one-haIf as frequent in occurrence as tota viscera1 transposition. The extremeIy high proportion of appendicitis in the recorded cases is most suggestive of a much higher incidence of the condition than the reported cases wouId indicate. Foerster’O made the observation that the midgut in cases of extroversion of the bIadder compIicated by intestina1 openings often remained at the three or four week embryonic IeveI. In 6 cases of situs transversus totaIis* the additiona anomaIy of incompIete rotation was present, resuIting, of course, in a dextrocoIia. In a group of 111 cases of incompIete rotation in which the sex was mentioned, 5g were maIe and 52 femaIe, showing, as wouId be expected in a Iarger series, a tendency to equaIization as compared to “about three maIes to one femaIe” as found by Dott in 48 cases of a11 types of anomaIies of rotation. In the group with appendicitis the distribution as to sex was equaI. In g2 of the reported cases the age of death or operative interference was as folIows: 7 a few days premature to three months; 16 from three months to fifteen years; 49 from sixteen to forty-five, and 20 from forty-six on. The extremes of age are represented from prematurity to eightyfour years. Appendicitis in the abstracted cases occurred from the fifth to the eightyfourth year. Dott, in the more cathoIic group in&ding ma1 and reversed-rotation and faiIure of peritonea1 fusion, found a * See References 24, 98, 171, 183, zoo, 203.

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Iarge group (6 of 13) with the occurrence of symptoms of obstruction within a few days of birth. CASE REPORT MaIe, aged fourteen, white. Family History: IrreIevant except that

four sisters had been operated on for appendicitis. Past History: Unimportant. Review of systems negative. No aIimentary compIaints of any nature, except as noted under Present Illness. Present Illness: Onset November 29 with sIight pain in the right Iower quadrant. This pain was bareIy perceptibIe and the patient continued at schoo1. The foIIowing day shortIy after noon the pain became increasingIy severe and coIicky in character. There was no radiation. About 3~30 P. M. severe persistent vomiting began; each bout of vomiting being foIIowed by some reIief. This is the fifth simiIar attack the patient has had during the Iast year. They have each Iasted about two days, forcing the patient to remain in bed. Each has been accompanied by pain restricted to the right Iower quadrant, nausea, vomiting, and during the first attack in December, 1927 a frequent desire to go to stoo1. Physical Examination: That of a poorIy

nourished boy Iying in bed compIaining of sIight abdomina1 pain and nausea. Temperature 98.6%.; puIse 78; respirations 20. Tongue coated. P.M.I. 7.5 cm. from midIine in fifth interspace. Abdomen soft, scaphoid, and tympanitic throughout. No masses or rigidity noted. There is moderate tenderness over McBurney’s point and over the bIadder region. There is hyperesthesia over McBurney’s point. The findings are otherwise negative, no anomaIies such as poIydactyIism or syndactylism being noted. Laboratory Findings: UrinaIysis: acetone positive, few pus ceIIs. BIood count: W.B.C. 21,600; P.M.N. 90 per cent; S.L. IO per cent. Operation (Nov. 30, 1928): McBurney’s incision. DiIated and injected Ioops of smaI1 bowe1 seen on opening peritoneum. No cecum or coIon found, nor was any encountered on Iooking up under the liver, where the smaI1 intestina1 coiIs were coIIapsed and not injected. Incision enIarged to a Weir. Retraction to the Ieft uncovered the cecum Iying about 5 cm. to the Ieft of the midIine and on a IeveI

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with the iliac spine, pointing caudad and to the right. It was rather IirmIy fixed and did not permit mobilization. The appendix was free, normally attached to its mesentery, acutel\~ inflamed and covered with patches of fibrin. There were about 50 C.C. of cIear, straw-colored fluid in the peIvis. The omentum was seen in the upper Ieft half of the abdomen, but its relation to stomach and colon was not determined. Appendectomy was performed according to the usua1 carboIic-aIcoho1 technique and the stump inverted with a Runion silk stitch, and the mesenterioIar stump coverecl with ceca1 waI1 with two mattress sutures. The coIon ran up and to the left. No further exploration. The postoperative course was smooth, heaIing per primam. The maximum temperature \v:lS IOO.fi’F. on the third day. Discharged on December 9, 1928. Since then no abdomina1 complaint up to March, 1932. X-ray hIms taken postoperativeIy show the course of the duodenum (Fig. I) and coIon (Figs. 2 and 3). Case reports of appendicitis with incomplete migration abstracted from the literature: LeConte, and Johnston lo1 Lee and Downs, 1%7 Hurst Malcolm,‘“” PIeth,‘“’ Eggers,5g BaumgartneC,l” Walther ?06 SokoIova 185 Corner,36 Case,28 St. CIair,1’4 ’ South,‘s7 Ki~pp,‘~O Ashhurst,g Mayo, CorIette,34 G. R. 4 cases, 139 DeNancrede,45 FowIer,7Z R. H. FowIer,73 DeIatour, second and third cases,14 Sturgis,1g2 Johnson,lO* Brewer,‘” Blake,‘” BIoch, second case,14 Lefebvre,“!” WeiI and Detre ?OgGiIIen ,83 Schrup,lsO Harris,g1 and fourth ’ case, lo7 Ostroumow Waugh, Kremer,‘j” Edington,% Brouet,rg WooIsey, 2 clses ?l? ‘Q’t’ues tonable cases qfappendicitis with possible incomplete rotation: FowIer, 2 cases,72 Harris,go

Dowd, j3 VazeIIe %02Fournier,‘r Gerster,*O Proust first case,l15 Eliot,“’ and Paris,‘jg Karewski, Walther, first case,2o6 Damianos,43 Crook,37 Raw-son. 161 Cases complicated by other congenital positional anomalies not associated with appentwentieth case,24 dicitis: Lochte, 13L Bujalski,

Schelenz,“’ Moser,14’ PerIs,156 Marchand,13’ first and second GeipeI, 2 cases, 78 Hickman, cases, 9: Ssobolew, fifth case,1*8 VaIIiex, ninth case.?O@ Case oj incomplete intestinal rotation not associated with appendicitis and derived from x-ray, postmortem and operative material: I. Necropsy :

Reid,

two

cases,163 Simpson’s

twenty-ninth

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481

case,183 Neugebauer, 151Chiene,“O Fagge, fiftyseventh case,64 Lockwood,133 Willis,?“’ Berry, l1 Jukes,“’ Farabeuf,66 Young,“” Schiffendecker, I” Groenroos,86 Stieda, 1~0 Treitz, four cases,rg7 Gruber, two cases,87 Rostowzew, 172 HoImes,‘O’ RiecheImann,r64 Sencert, I81 Casariego, 27Rainer, two cases,rGo Reid,‘“” Descomps,48 Ingebristen,‘05 Lemesic and Kohsko, three cases, lzg Hamann, 88 Huntington, four cases,‘“” FIick,‘j8 Smith, five cases,184 Eddy,57Morosoff,146 Jaboulay, lo6 Sauerbeck, second and third cases, 1’s Sawin, first case,‘76 TandIer, second and third cases,lg3 Johnston,10g His,g8 FaItin,“” CIement,31 CruveiIhier,38 MoIe,*4’ Borukhin,‘” MicheI,14’ Curschmann,3g Pan.l”,’ 2. Roentgenogram: CorIette,35 Doehner,“’ Altschul, two cases,2 Roberts,16g Keaton,rL6 Nessa,l”O Hurst and Johnston, second case,lo4 Janker, fourth case,‘O’ LeWaId, four cases,‘“O d’Amato,4 AItschuI,3 DiIIenseger,4g GiIbert,8” DiocIes 5oVasseIIe,201 Darbois and SobeI.41 3. Oljeration : DeQuervain,47 Armstrong,* BuIman,25 Judd,“0 Hecker et aI., first case,g3 Arce and CassineIIi,6 Dowries,““” Janker, third case,lo7 Waugh, first and second cases,2n8 fourth case,ls9 HammesVogIein, 204 Mayo, fahr,8g Rixford, first, second, and third cases,rfi7 Downes,54 Brouet and CaroIi Ln CorkiII,33 Grant,R4 Ludington,13j Grant,ha Gibson,8’ Thomson,lg5 Robineau,lrO Hecker et aI., second case,g3 Kiffer,“s Davis.42 COMMENT Besides those cases Iisted as questionable in this report (incIuding Hamann,** Morosoff, 146 and Sauerbeck, second case”j), Fredet considers those of Cruveilhier, His, ToIdt (not incIuded in this series), Moser and WiIks as doubtfu1 as regards incompIeteness of rotation. The median position assumed by the descending coIon in the roentgenograms of the barium enema is probabIy due to free mobiIity resuIting from an extension of the common mesentery to the Iower rectosigmoid. This position was not observed in roentgenograms accompanying other articIes reviewed. In the cases of appendicitis a most infrequent correspondence between the ectopia and signs were found. No expIanation of this capriciousness can be found in

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the work of KuIenkampff,‘23+124 Bruening, 21-23 or Kappis.l12-114 The findings of SengIar,ls2 Chauveau,2g MueIIer, 148 BIoch,14 Hornicke, lo2 FowIer,72 and KeIIy”’ are of the same tenor. Waugh’s sign of emptiness of the right iIiac fossa was not confirmed. A mortality of about IO per cent in the group with appendicitis in a11 IikeIihood faiIs to reflect the true state of affairs, as aImost one-fourth of those dated from Igo7 on, were comphcated by either a genera1 or IocaIized peritonitis, indicating possibIe difEcuIty in arriving at a diagnosis with consequent late intervention.

Rotation

MARCH,1933

about go degrees to approximateIy I 35 degrees have been embraced in this series, as Iesser or greater degrees of rotation result in either compIete non-rotation or subhepatic or subpyIoric ceca. One hundred and seventy-seven cases, of which at Ieast 15 are dubious, are abstracted from the Iiterature. Of these about one-quarter are comphcated by appendicitis and one-tenth by intestina1 obstruction. The approximate frequency of incomplete rotation in proportion to compIete transposition is estimated. The difficuIty of diagnosis of appendicitis in incompIete rotation of the coIon is noted. The impression is gained that the condition is uncommon but not rare.

SUMMARY

A case of sinistrocoha proved by operation and roentgenography to be due to incompIete normaI rotation of the intestines to about go degrees is recorded. OnIy cases of incompIete norma rotation from

Since this articIe went to press two further cases of incompIete intestinal rotation have b een seen by the author in von Haberer’s Clinic in KoeIn. Both were aduIt males, one operated on for gastroduodena1 uIcer and the other for peritonitis of unknown origin.

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