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Intussusceptions
GENERAL ARTICLES.
bovine ongm; in others, on the contrary, its virulence is so much weakened as to appear null, particularly if used on bovine subjects. 4. Human bacilli of attenuated virulence always cause, at least in the lung, after intravenious injections,lesions visible to the microscope, which sometimes tend to rapid fibrous transformation. 5. It is therefore impossible to give an opinion on the failure of an inoculation without a microscopic study of the lung and of the principal parenchymatous viscera. 6. The variability of the virulence of the bacillus accounts for the apparently negative results which led Koch and Schlitz to believe in duality. 7. The identity of human and bovine tuberculosis ought to be maintained, and the prophylactic measures which result from it ought also to be maintained, notably with regard to the use of milk. INTUSSUSCEPTIONS.
By EDREDD M. CORNER, B.SC. (London), M.A., M.B., B.C. (Cambridge), F.R.C.S. (England), Demonstrator of Anatomy, late Resident Assistant Surgeon, St. Thomas' Hospital. DURING.the years 1901 and 1902 a number of cases of intussusception passed through my hands, and from observations that were made upon them I became convinced that the present state of our knowledge of the pathology of this condition was erroneous. In a paper in the St. Thomas' Hospital Reports, 1901, I raised this question, embodying also my reasons for the attitude taken up and the reports of five clinically interesting cases. If the histories of the sister sciences of anatomy, physiology, etc., are examined, the fact at once becomes patent that although the knowledge gained from mere dissection was continually increasing, no advance of importance was made until the introduction of the comparative method. This comparative method has been used in physiology, medicine, and pathology, and to a less extent in surgery. But observers are much hampered here by reason of their lack of knowledge of the physiological limits of the animals experimented on. Veterinary surgery and medicine have only of recent years been pursued with true scientific spirit, and in this respect are still far behind their corresponding human sciences. As a result, they are as yet scarcely ripe for accurate comparisons; yet, on account of the larger size of the parts that may be observed, and the still greater frequency of post-mortem observations, a great deal may be learned. In 1898 I made use of this method in an enquiry into the influence of the quadrupedal and bipedal positions on fractures and dislocations in man and animals. 1 The interest of suSh a comparison has caused me to examine the records of intussusception in animals to see how thfiY shed light upon the .pathology. The knowledge gained from this enquiry forms the subject matter of this paper, and I have added a short introductory account of the present views on the pathology of intussusceptions and the alterations that I have suggested. Before proceeding, I would like to offer my thanks to Prof. Hobday for his scientific interest in my work and the readiness with which he placed his knowledge at my disposal. 1
"Lancet," 1898 ,and 1899, "Veterinarian," 1899.
GENERAL ARTICLES.
INTUSSUSCEPTIONS IN MAN.
By intussusception is meant the inversion of a piece of bowel into the part immediately below it, the former being called the intussusceptum and the latter the intussuscipiens or receiving layer. The invaginated portion then acts like a foreign body to the part of the bowel that receives it, and is consequently passed on by peristalsis. The invaginated portion or intussusceptum naturally consists of two layers, which it is needless to distinguish with names. Thus every intussusception consists of two parts, the intussusceptum and the intussuscipiens. The invagination may occur in any part of the alimentary tract except the <:esophagus and stomach. When it originates in the small intestine it is termed enteric, and is most common in the ileum, then in the jejunum, and very rare in the duodenum. The most favourite site for intussusceptions to start at is about the ileoc
Iftfu ~3U~ '
Clpl lJU,s . . .. ... .
Two loyers
_. of' themfu3S_
" us ceptum
Another form, which is said to be rare in man, starts in the ileum just above the valve, through which it becomes prolapsed. As'it originates in the small intestine, it is primarily enteric, and its mere prolapse through the valve in no way constitutes a second intussusception. This form may be recognised as a subvariety of the enteric, and .is called ileocolic. Occasionally the inversion begins in the C
GENERAL ARTICLES.
Table showing the Present Views on tile Relative .Frequency of tile Different Varieties of Intussusception. --------------,-----~------~------~------~--------
Entaic. Percentage.
Treves 1 Sargent 2 M'Adam Eccles 3 Limits of variation
Ileocolic. p e;·centage.
- ---
I
30
II
4
4-3 0
8
I
-
-
Colic.
Pe)-centage.
Double Intus·
susception, dc.
I
-- - - - - - -
PCJ'ceatage. - ---_.-
9
9
5 5
10
~
44 69 87
2-8
44- 8 7
5-9
2-10
I
I
IleocQ3ccLl. Percentage.
5
2
The only point on which these figures agree is that over 90 per cent. of cases are examples of single intussusception, and that the ileoca!cal variety is by far the most common, whilst the ileocolic is by far the most uncommon. Omitting from consideration such varieties as invagination of the appendix, or a Meckel's divesticulum, the above may be taken as the view accepted by human pathologists. Thirteen successive cases of which I made particular notes, showed that 10, or 77 per cent., were double intussusceptions, and that 3. or 23 per cent., were single! Either I have run across a most remarkable series, or former observers have either from lack of time or scanty examination arrived at a wrong diagnosis. The latter suggestion is recommended by the following considerations : I. The reduction of an intussusception is the operation in surgery where speed is most requisite, on account of the tender ag-es of the patients, etc. 2. I have often seen intussusceptions reduced and returned to the abdomen without examination, and finally called ileoca!cal. 3. This variety of intussusception has been diagnosed over and over again in cases in which reduction has been accomplished by inflation, injection of water, or manipulation, and where there has been no autopsy in unreduced cases. 4. Examination per rectum reveals the fact that the apex of the invaginated part or intussusceptum feels like the ileoca!cal valve. In reality I believe this to be merely the false impression that may be given by the redematous intussusceptum of any part of the gut. Similar points might be multiplied, but sufficient has been said to show that the great frequency of single and ileoca!cal intussusceptions may largely depend on the lack of observation of the surgeon, or negative evidence rather than positive. To the truth of the statement just made, as to the conditions of the invaginations in my thirteen cases, I am prepared to adhere, and the chief points upon which I have based my opinion may be briefly given. For a fuller account I would refer to my paper in the St. Thomas' Hospital Reports, 1901, XXX., p. 355. J_ A great deal of the invagination is reduced before any smaIl bowel is expressed from t~e ca!cum; a fact suggests that the colic part of the invagination -alone has been reduced. 1
Treves, "Intestinal Obstruction."
2 Sargent, "St. Thomas' Hospital Report," 1900. B Oompiled from three papers in the" St. Bartholomew's
Hospital Reports."
154
GENERAL ARTICLES.
2. The difficulty of reducing the last part of the intussusception is due to the prolapse of the ileum through the ileoca:cal valve. 3. If traction on the small bowel is not used, a little enteric intussusception may be often expressed from the ca:cum. 4. A lateral dimple frequently seen on the side of the ileum after reduction, just above the valve, may represent the origin of the invagination. 5. Examination after reduction reveals the fact that the last halfinch of the ileum is of a much darker colour than the contiguous bowel, and the limits of the discolouration are fairly sharp. Such an appearance suggests that this terminal half-inch has been strangulated, such as through the ileoca:cal valve. This is more frequently to be noticed when traction has been employed to reduce the last part of the invagination, whilst if expression only is used a small enteric intussusception or lateral dimple also is seen. The real anatomy of the parts may be easily hidden during the reduction unless a careful watch is kept. Thus, allowing for the fact that a man's observation s may be warped by his own personal equation, there seems ample evidence for the fact that double intussusceptions are of far more frequent occurrence than is generally supposed. And, on the other hand, there are reasons to doubt the accuracy of the diagnosis in a large number of cases reported or recorded as single, and especially those regarded as ileoca:cal, whose diagnosis really rests more on negative than positive evidence. The veterinary literature was examined as thoroughly as possible for recorded examples, and over twenty-five were found. To these may be added four specimens that Professor Hobday has allowed me to see. The first fact that becomes patent is that observers have not recognised what are known humanly speaking as "intussusceptions of the dying," and which occur ' during the death agony. The characters by which they may be recognised are: (a) their multiplicity; (b) they are easily reduced; Cc) they are frequently ascending, i.e., reversed peristalsis; Cd) there are no signs of inflammation or change about them; (e) always in the small bowel, etc. It is thus impossible to say whether the intussusceptions of the dying are a distinctive character of human pathology or not. Some of the features described as occurring in dogs' intussusceptions seem t o possess similar characteristics. NOTES OF THE RECORDS OF VETERINARY CASES. 1. Williams. Principles and Practice of Veterinary Medicine, p. 675. " Intussusceptions may involve both large and small bowel in all the domesticated animals." He bears out what I have suggested for man, namely, that the origin is either in the large or small intestine and not at the i1eoc:ecal valve. He mentions a cow who passed the intussusceptum as a slough on the seventh day of the illness, and mentions Aitken of Dalkeith who records a similar event in a cowan the fifth day. The anatomy of the slough is not given in either case, and so there is no suggestion as to the possible variety for either case. 2. E. M. Jarvis. Journal of Comparative Pathology, 1894, p. 380. Mare, twelve years old, suffered from colic, etc. Death in forty-eight hours. Post-mortem- The whole of the c:ecum was invaginated into the colon. Worms were present in both stomach and small gut. Variety, colic.
GENERAL ARTICLES.
155
3. Penberthy. Journal of Comparative Pathology, 1896, p. 48. Gelding, five years, colic for a week before seen, death on the sixteenth day. Post-mortem-" Complete intussusception of the ClEcum into the commencing portion of the colon." There was a large cyst containing three pints of fluid in connection with the crecum. Variety, colic. 4. M'Fadyean. Journal of COlilparatiz1e Pathology, Vol. XV., Part 11., J 902, p. 154. Mare, seven years old, severe abdominal pain. Post-mortem-Intussusception beginning in the ileum above the ileocrecal valve, and 3 feet were prolapsed into the ca!cum, whilst the ring marking the point of junction of the invaginated and receiving layers was 6 inches above the ileocrecal junction. Variety il eocolic (?). Had been ileocolic-colic. 5· Dewar. Veterinarian, 1895, LXVIII., p. 369. Intussusception "is a well-known although not very common cause of abdominal colic," "best known in the dog," "comparatively common in the ox and more rare in the horse." In the horse it is said to be most common that the ileum passes into the crecum-that is, ileocolic variety. The reported cases do not bear out this statement. Filly, one year old. Post-mortem-Double intussusception of the ileocoliccolic variety. 6. Power. Veterinarian, 1897, LXX., p. 648. Two enteric intussusceptions in dogs dosed with turpeth mineral. Cats apparently tolerate intussusceptions. (Extract of Hunterian Lectures.) 7. Power. Veterinarian, 1897, LXX., p. 648. Extract from Archiv.f Wissensc/l. und prakt. Thierheilkunde of paper by Rackow of Berlin. Horse, nine years of age, colic. passed per rectum inverted crecum on the tenth day, recovery. Variety, colic. 8. Dorn. Veterinarian, 1901, LXXIV., p. 548. Ox, 10 inches invaginated. ? small gut. Extract from the Wochenschrtjt fiir Tilierheilkunde, etc. Operation, reduction, recovery. 9. Allen. Veterinarian, 1901, LXXIV. p. 71. Dog, four months old, death three to four days. Post-mortem- Jejunal intussusception 6 inches long. Variety, enteric. 10. Macqueen. Veterinary Journal, 1892, XXXVI., p. 114. Also in Veterinarian of same year. Says that they usually consist of small gut (The reported cases confirm this, invaginated into small gut, i.e. enteric. though not so simply as would appear in dogs.) I I. "Hirudo." Veterinary Journal, 1895, XLI., p. 36. Mare, eight years old, death, crecum into colon. Variety, colic. 12. Veterinary Journal, 1902, LV., N. S. VI., p. 133. Chiefly affects crecum and colon. (Apparently only true of older horses.) 13. Webster. Journal of Comparative Medicine, 1896, XVII., p. 612. Gelding; pain, abdominal distension, etc. Death in forty-eight hours. Post-morte1ll- Three feet of ileum invaginated into itself and then through the ileocreci.l valve. Double intussusception, ileocolic-colic. 14. Michener. Journal of Comparative Medicine, 1897, XVII!., p. 779· Colt, three months old, colic etc. Operation, and 2 feet 3 inches of small intestine reduced fr()\ll invagination, recovery. Variety, enteric. IS. Lyman. Journal of Comparative Medicine, 1896, XVII., p. 55 0. Colt,. not three weeks old. ? of small gut, gangrenous, death. Variety, ? enteric. Collection of fluid between the layers of invagination. '16. Butlerfield. Journal of Comparative Medicine, r893, XIV. Devon ox, small gut apparently, easily reduced, recovery. Variety, ? enteric. ' 17. Archiv.fur Thierheilkunde, 1898, XXIII., P.336-339·
GENERAL ARTICLES.
Horse, nine years old, colic, passed crecum invaginated In the crecum. recovery, variety colic. 18. Receuil de Med. Veterinaire, Tome 7,8 ser., 1900. Long paper dealing with signs, symptoms, treatment, etc. Mentions five or six cases in dogs. 19. Petit. Receuil de MM. Veterinaire, Tome 8, 8 ser., p. 191, 1900. Several invaginations of small gut into the colon. Says that it is quite a common lesion in dogs. Seven observations recently found. Post-mortem. (? Intussusceptions of the dying). Cases show 10-20 cm. of small gut into the colon. Variety ileocolic. Extract from Bull. de Soc. Anat., Paris, 16th Nov. 1900. 20. Petit. Receuil de MM. Veterinaire, Tome 2, 8 ser., 1895, p. 569. Extract of Veterinary Magazine, 1895. Dog, small gut into small gut, then prolapsed into the large, and finally second colic intussusception super-imposed. Double ileocolic variety. 21. Mauri. Receuil de MM. Veterinaire, Tome I, 8 ser., 1894, p. 299. Revue Veterinaire, July. Horse, three years, small gut into crecum, variety ileocolic. Quotes as recording cases, Bouley Jeune, Reyual, and Mitant. Variety ileocolic. 22. Hobday. Unpublished. From litter of chow-chow puppies, four fatal cases of enteric intussusceptions. The results of this series may be summed up as follows : (I) Three recorded cases in cattle, nine in horses, eighteen in dog-so (2) Of these three are recorded as double, and eight or nine might very well have been so. (3) Records of over thirty cases, many of which cannot be consulted in the original, and many are scanty in anatomical details. (4) Seven cases were purely enteric-two in colts, and five in dogs. Ten cases were ileocolic-three in horses, seven in dogs. Five cases were purely colic, all in horses. (5) In seventeen cases the invagination arose in the small gut. In five cases the invagiNation arose in the large gut. And in no case did it begin at the ileoca!cal valve. (6) In dogs the intussusception always begins in the small gut. In horses, when very young, it starts in the small gut; when older, in the ca!cum. This is flO invariable rule, and may be only apparently true. lt is thus seen that the veterinary observations entirely confirm the suggestion that I made for human intussusceptions CSt. Thomas' Hospital Reports, I90r), that they do not begin at the ileocrecal valve, i.e., the ileocrecal variety, bnt in the small bowel above it. This small bowel becomes prolapsed through the ileocrecal valve, and finally engages in it, and, becoming tightly grasped, a second colic intussusception may be superimposed on the original ileocolic. Hence the commonest double intussusception in man and animals is the ileocoliccolic. But should the enteric intussusception begin far above the valve, its intussusceptum may become too cedematous to get through the valve, which will be pushed forward by it. The resulting double intussusception will be enteric-ileocrecal. The following tables may be arranged, the varieties being in order of the probable frequency.
I57
GENERAL ARTICLES.
Single Intu88U8ceptions. iI[am,.
Colic .Ileocolic Enteric. I1eoc::ecal Animals.
Ileocolic Enteric. Colic I1eoc::ecal
DouJJle I ntussu8ceptions. Man.
Definitim•.
Large gut into large gut. Small gut through the ileoc::ecal valve. Small gut into small gut. Origin at valve, which forms apex of intussusception. As above. As above, especially in dogs. As above. Undescribed. Dejinition.
The most common of all. Ileocolic as above, with secondary colic intussusception. Enteric-ileoc::ecal Next common. Rest uncommon except the colic·ileoc::ecal form.
Ileocolic-colic
Animals.
Ileocolic-colic
The only form described.
One of the chief distinctions between man and animals lies in the apparent proneness of ileocolic intussusceptions to take upon themselves a secondary colic invagination, whilst in animals this is not so marked. The result is that the double ileocolic-colic intussusception is most probably the commonest in man, whilst the single ileocolic seems the most common in animals. From examination of the recorded cases, it is impossible to say whether this distinction is real or only apparent. A small point may also be noted, that in animals, possibly on account of the larger size of the parts, e.g., horses, noticeable collections of fluid are found between the peritoneal layers of the intussusceptum or invaginated gut. In man there exists an uncommon but not unknown variety of double intussusception, which begins by the invagination of the c::ecum, and so blocks the ileoc
bovine ongm; in others, on the contrary, its virulence is so much weakened as to appear null, particularly if used on bovine subjects. 4. Human bacilli of attenuated virulence always cause, at least in the lung, after intravenious injections,lesions visible to the microscope, which sometimes tend to rapid fibrous transformation. 5. It is therefore impossible to give an opinion on the failure of an inoculation without a microscopic study of the lung and of the principal parenchymatous viscera. 6. The variability of the virulence of the bacillus accounts for the apparently negative results which led Koch and Schlitz to believe in duality. 7. The identity of human and bovine tuberculosis ought to be maintained, and the prophylactic measures which result from it ought also to be maintained, notably with regard to the use of milk. INTUSSUSCEPTIONS.
By EDREDD M. CORNER, B.SC. (London), M.A., M.B., B.C. (Cambridge), F.R.C.S. (England), Demonstrator of Anatomy, late Resident Assistant Surgeon, St. Thomas' Hospital. DURING.the years 1901 and 1902 a number of cases of intussusception passed through my hands, and from observations that were made upon them I became convinced that the present state of our knowledge of the pathology of this condition was erroneous. In a paper in the St. Thomas' Hospital Reports, 1901, I raised this question, embodying also my reasons for the attitude taken up and the reports of five clinically interesting cases. If the histories of the sister sciences of anatomy, physiology, etc., are examined, the fact at once becomes patent that although the knowledge gained from mere dissection was continually increasing, no advance of importance was made until the introduction of the comparative method. This comparative method has been used in physiology, medicine, and pathology, and to a less extent in surgery. But observers are much hampered here by reason of their lack of knowledge of the physiological limits of the animals experimented on. Veterinary surgery and medicine have only of recent years been pursued with true scientific spirit, and in this respect are still far behind their corresponding human sciences. As a result, they are as yet scarcely ripe for accurate comparisons; yet, on account of the larger size of the parts that may be observed, and the still greater frequency of post-mortem observations, a great deal may be learned. In 1898 I made use of this method in an enquiry into the influence of the quadrupedal and bipedal positions on fractures and dislocations in man and animals. 1 The interest of suSh a comparison has caused me to examine the records of intussusception in animals to see how thfiY shed light upon the .pathology. The knowledge gained from this enquiry forms the subject matter of this paper, and I have added a short introductory account of the present views on the pathology of intussusceptions and the alterations that I have suggested. Before proceeding, I would like to offer my thanks to Prof. Hobday for his scientific interest in my work and the readiness with which he placed his knowledge at my disposal. 1
"Lancet," 1898 ,and 1899, "Veterinarian," 1899.
GENERAL ARTICLES.
INTUSSUSCEPTIONS IN MAN.
By intussusception is meant the inversion of a piece of bowel into the part immediately below it, the former being called the intussusceptum and the latter the intussuscipiens or receiving layer. The invaginated portion then acts like a foreign body to the part of the bowel that receives it, and is consequently passed on by peristalsis. The invaginated portion or intussusceptum naturally consists of two layers, which it is needless to distinguish with names. Thus every intussusception consists of two parts, the intussusceptum and the intussuscipiens. The invagination may occur in any part of the alimentary tract except the <:esophagus and stomach. When it originates in the small intestine it is termed enteric, and is most common in the ileum, then in the jejunum, and very rare in the duodenum. The most favourite site for intussusceptions to start at is about the ileoc
Iftfu ~3U~ '
Clpl lJU,s . . .. ... .
Two loyers
_. of' themfu3S_
" us ceptum
Another form, which is said to be rare in man, starts in the ileum just above the valve, through which it becomes prolapsed. As'it originates in the small intestine, it is primarily enteric, and its mere prolapse through the valve in no way constitutes a second intussusception. This form may be recognised as a subvariety of the enteric, and .is called ileocolic. Occasionally the inversion begins in the C
GENERAL ARTICLES.
Table showing the Present Views on tile Relative .Frequency of tile Different Varieties of Intussusception. --------------,-----~------~------~------~--------
Entaic. Percentage.
Treves 1 Sargent 2 M'Adam Eccles 3 Limits of variation
Ileocolic. p e;·centage.
- ---
I
30
II
4
4-3 0
8
I
-
-
Colic.
Pe)-centage.
Double Intus·
susception, dc.
I
-- - - - - - -
PCJ'ceatage. - ---_.-
9
9
5 5
10
~
44 69 87
2-8
44- 8 7
5-9
2-10
I
I
IleocQ3ccLl. Percentage.
5
2
The only point on which these figures agree is that over 90 per cent. of cases are examples of single intussusception, and that the ileoca!cal variety is by far the most common, whilst the ileocolic is by far the most uncommon. Omitting from consideration such varieties as invagination of the appendix, or a Meckel's divesticulum, the above may be taken as the view accepted by human pathologists. Thirteen successive cases of which I made particular notes, showed that 10, or 77 per cent., were double intussusceptions, and that 3. or 23 per cent., were single! Either I have run across a most remarkable series, or former observers have either from lack of time or scanty examination arrived at a wrong diagnosis. The latter suggestion is recommended by the following considerations : I. The reduction of an intussusception is the operation in surgery where speed is most requisite, on account of the tender ag-es of the patients, etc. 2. I have often seen intussusceptions reduced and returned to the abdomen without examination, and finally called ileoca!cal. 3. This variety of intussusception has been diagnosed over and over again in cases in which reduction has been accomplished by inflation, injection of water, or manipulation, and where there has been no autopsy in unreduced cases. 4. Examination per rectum reveals the fact that the apex of the invaginated part or intussusceptum feels like the ileoca!cal valve. In reality I believe this to be merely the false impression that may be given by the redematous intussusceptum of any part of the gut. Similar points might be multiplied, but sufficient has been said to show that the great frequency of single and ileoca!cal intussusceptions may largely depend on the lack of observation of the surgeon, or negative evidence rather than positive. To the truth of the statement just made, as to the conditions of the invaginations in my thirteen cases, I am prepared to adhere, and the chief points upon which I have based my opinion may be briefly given. For a fuller account I would refer to my paper in the St. Thomas' Hospital Reports, 1901, XXX., p. 355. J_ A great deal of the invagination is reduced before any smaIl bowel is expressed from t~e ca!cum; a fact suggests that the colic part of the invagination -alone has been reduced. 1
Treves, "Intestinal Obstruction."
2 Sargent, "St. Thomas' Hospital Report," 1900. B Oompiled from three papers in the" St. Bartholomew's
Hospital Reports."
154
GENERAL ARTICLES.
2. The difficulty of reducing the last part of the intussusception is due to the prolapse of the ileum through the ileoca:cal valve. 3. If traction on the small bowel is not used, a little enteric intussusception may be often expressed from the ca:cum. 4. A lateral dimple frequently seen on the side of the ileum after reduction, just above the valve, may represent the origin of the invagination. 5. Examination after reduction reveals the fact that the last halfinch of the ileum is of a much darker colour than the contiguous bowel, and the limits of the discolouration are fairly sharp. Such an appearance suggests that this terminal half-inch has been strangulated, such as through the ileoca:cal valve. This is more frequently to be noticed when traction has been employed to reduce the last part of the invagination, whilst if expression only is used a small enteric intussusception or lateral dimple also is seen. The real anatomy of the parts may be easily hidden during the reduction unless a careful watch is kept. Thus, allowing for the fact that a man's observation s may be warped by his own personal equation, there seems ample evidence for the fact that double intussusceptions are of far more frequent occurrence than is generally supposed. And, on the other hand, there are reasons to doubt the accuracy of the diagnosis in a large number of cases reported or recorded as single, and especially those regarded as ileoca:cal, whose diagnosis really rests more on negative than positive evidence. The veterinary literature was examined as thoroughly as possible for recorded examples, and over twenty-five were found. To these may be added four specimens that Professor Hobday has allowed me to see. The first fact that becomes patent is that observers have not recognised what are known humanly speaking as "intussusceptions of the dying," and which occur ' during the death agony. The characters by which they may be recognised are: (a) their multiplicity; (b) they are easily reduced; Cc) they are frequently ascending, i.e., reversed peristalsis; Cd) there are no signs of inflammation or change about them; (e) always in the small bowel, etc. It is thus impossible to say whether the intussusceptions of the dying are a distinctive character of human pathology or not. Some of the features described as occurring in dogs' intussusceptions seem t o possess similar characteristics. NOTES OF THE RECORDS OF VETERINARY CASES. 1. Williams. Principles and Practice of Veterinary Medicine, p. 675. " Intussusceptions may involve both large and small bowel in all the domesticated animals." He bears out what I have suggested for man, namely, that the origin is either in the large or small intestine and not at the i1eoc:ecal valve. He mentions a cow who passed the intussusceptum as a slough on the seventh day of the illness, and mentions Aitken of Dalkeith who records a similar event in a cowan the fifth day. The anatomy of the slough is not given in either case, and so there is no suggestion as to the possible variety for either case. 2. E. M. Jarvis. Journal of Comparative Pathology, 1894, p. 380. Mare, twelve years old, suffered from colic, etc. Death in forty-eight hours. Post-mortem- The whole of the c:ecum was invaginated into the colon. Worms were present in both stomach and small gut. Variety, colic.
GENERAL ARTICLES.
155
3. Penberthy. Journal of Comparative Pathology, 1896, p. 48. Gelding, five years, colic for a week before seen, death on the sixteenth day. Post-mortem-" Complete intussusception of the ClEcum into the commencing portion of the colon." There was a large cyst containing three pints of fluid in connection with the crecum. Variety, colic. 4. M'Fadyean. Journal of COlilparatiz1e Pathology, Vol. XV., Part 11., J 902, p. 154. Mare, seven years old, severe abdominal pain. Post-mortem-Intussusception beginning in the ileum above the ileocrecal valve, and 3 feet were prolapsed into the ca!cum, whilst the ring marking the point of junction of the invaginated and receiving layers was 6 inches above the ileocrecal junction. Variety il eocolic (?). Had been ileocolic-colic. 5· Dewar. Veterinarian, 1895, LXVIII., p. 369. Intussusception "is a well-known although not very common cause of abdominal colic," "best known in the dog," "comparatively common in the ox and more rare in the horse." In the horse it is said to be most common that the ileum passes into the crecum-that is, ileocolic variety. The reported cases do not bear out this statement. Filly, one year old. Post-mortem-Double intussusception of the ileocoliccolic variety. 6. Power. Veterinarian, 1897, LXX., p. 648. Two enteric intussusceptions in dogs dosed with turpeth mineral. Cats apparently tolerate intussusceptions. (Extract of Hunterian Lectures.) 7. Power. Veterinarian, 1897, LXX., p. 648. Extract from Archiv.f Wissensc/l. und prakt. Thierheilkunde of paper by Rackow of Berlin. Horse, nine years of age, colic. passed per rectum inverted crecum on the tenth day, recovery. Variety, colic. 8. Dorn. Veterinarian, 1901, LXXIV., p. 548. Ox, 10 inches invaginated. ? small gut. Extract from the Wochenschrtjt fiir Tilierheilkunde, etc. Operation, reduction, recovery. 9. Allen. Veterinarian, 1901, LXXIV. p. 71. Dog, four months old, death three to four days. Post-mortem- Jejunal intussusception 6 inches long. Variety, enteric. 10. Macqueen. Veterinary Journal, 1892, XXXVI., p. 114. Also in Veterinarian of same year. Says that they usually consist of small gut (The reported cases confirm this, invaginated into small gut, i.e. enteric. though not so simply as would appear in dogs.) I I. "Hirudo." Veterinary Journal, 1895, XLI., p. 36. Mare, eight years old, death, crecum into colon. Variety, colic. 12. Veterinary Journal, 1902, LV., N. S. VI., p. 133. Chiefly affects crecum and colon. (Apparently only true of older horses.) 13. Webster. Journal of Comparative Medicine, 1896, XVII., p. 612. Gelding; pain, abdominal distension, etc. Death in forty-eight hours. Post-morte1ll- Three feet of ileum invaginated into itself and then through the ileocreci.l valve. Double intussusception, ileocolic-colic. 14. Michener. Journal of Comparative Medicine, 1897, XVII!., p. 779· Colt, three months old, colic etc. Operation, and 2 feet 3 inches of small intestine reduced fr()\ll invagination, recovery. Variety, enteric. IS. Lyman. Journal of Comparative Medicine, 1896, XVII., p. 55 0. Colt,. not three weeks old. ? of small gut, gangrenous, death. Variety, ? enteric. Collection of fluid between the layers of invagination. '16. Butlerfield. Journal of Comparative Medicine, r893, XIV. Devon ox, small gut apparently, easily reduced, recovery. Variety, ? enteric. ' 17. Archiv.fur Thierheilkunde, 1898, XXIII., P.336-339·
GENERAL ARTICLES.
Horse, nine years old, colic, passed crecum invaginated In the crecum. recovery, variety colic. 18. Receuil de Med. Veterinaire, Tome 7,8 ser., 1900. Long paper dealing with signs, symptoms, treatment, etc. Mentions five or six cases in dogs. 19. Petit. Receuil de MM. Veterinaire, Tome 8, 8 ser., p. 191, 1900. Several invaginations of small gut into the colon. Says that it is quite a common lesion in dogs. Seven observations recently found. Post-mortem. (? Intussusceptions of the dying). Cases show 10-20 cm. of small gut into the colon. Variety ileocolic. Extract from Bull. de Soc. Anat., Paris, 16th Nov. 1900. 20. Petit. Receuil de MM. Veterinaire, Tome 2, 8 ser., 1895, p. 569. Extract of Veterinary Magazine, 1895. Dog, small gut into small gut, then prolapsed into the large, and finally second colic intussusception super-imposed. Double ileocolic variety. 21. Mauri. Receuil de MM. Veterinaire, Tome I, 8 ser., 1894, p. 299. Revue Veterinaire, July. Horse, three years, small gut into crecum, variety ileocolic. Quotes as recording cases, Bouley Jeune, Reyual, and Mitant. Variety ileocolic. 22. Hobday. Unpublished. From litter of chow-chow puppies, four fatal cases of enteric intussusceptions. The results of this series may be summed up as follows : (I) Three recorded cases in cattle, nine in horses, eighteen in dog-so (2) Of these three are recorded as double, and eight or nine might very well have been so. (3) Records of over thirty cases, many of which cannot be consulted in the original, and many are scanty in anatomical details. (4) Seven cases were purely enteric-two in colts, and five in dogs. Ten cases were ileocolic-three in horses, seven in dogs. Five cases were purely colic, all in horses. (5) In seventeen cases the invagination arose in the small gut. In five cases the invagiNation arose in the large gut. And in no case did it begin at the ileoca!cal valve. (6) In dogs the intussusception always begins in the small gut. In horses, when very young, it starts in the small gut; when older, in the ca!cum. This is flO invariable rule, and may be only apparently true. lt is thus seen that the veterinary observations entirely confirm the suggestion that I made for human intussusceptions CSt. Thomas' Hospital Reports, I90r), that they do not begin at the ileocrecal valve, i.e., the ileocrecal variety, bnt in the small bowel above it. This small bowel becomes prolapsed through the ileocrecal valve, and finally engages in it, and, becoming tightly grasped, a second colic intussusception may be superimposed on the original ileocolic. Hence the commonest double intussusception in man and animals is the ileocoliccolic. But should the enteric intussusception begin far above the valve, its intussusceptum may become too cedematous to get through the valve, which will be pushed forward by it. The resulting double intussusception will be enteric-ileocrecal. The following tables may be arranged, the varieties being in order of the probable frequency.
I57
GENERAL ARTICLES.
Single Intu88U8ceptions. iI[am,.
Colic .Ileocolic Enteric. I1eoc::ecal Animals.
Ileocolic Enteric. Colic I1eoc::ecal
DouJJle I ntussu8ceptions. Man.
Definitim•.
Large gut into large gut. Small gut through the ileoc::ecal valve. Small gut into small gut. Origin at valve, which forms apex of intussusception. As above. As above, especially in dogs. As above. Undescribed. Dejinition.
The most common of all. Ileocolic as above, with secondary colic intussusception. Enteric-ileoc::ecal Next common. Rest uncommon except the colic·ileoc::ecal form.
Ileocolic-colic
Animals.
Ileocolic-colic
The only form described.
One of the chief distinctions between man and animals lies in the apparent proneness of ileocolic intussusceptions to take upon themselves a secondary colic invagination, whilst in animals this is not so marked. The result is that the double ileocolic-colic intussusception is most probably the commonest in man, whilst the single ileocolic seems the most common in animals. From examination of the recorded cases, it is impossible to say whether this distinction is real or only apparent. A small point may also be noted, that in animals, possibly on account of the larger size of the parts, e.g., horses, noticeable collections of fluid are found between the peritoneal layers of the intussusceptum or invaginated gut. In man there exists an uncommon but not unknown variety of double intussusception, which begins by the invagination of the c::ecum, and so blocks the ileoc