Eleven cases : roentgenographic and operative findings / by A. Judson Quimby and William Seaman Bainbridge.
- Quimby, A. Judson (Adoniram Judson), 1875-
- Date:
- 1914
Licence: In copyright
Credit: Eleven cases : roentgenographic and operative findings / by A. Judson Quimby and William Seaman Bainbridge. Source: Wellcome Collection.
Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.
6/34 page 4
![the colon, is done by such manipulative methods as are obviously necessary to sep- arate and move the folds and coils about. Mesenteric bands in many cases are so buried in the wall of the intestine between the haustrations, that we can only find them by deep palpation which will separate these segments. If we find these constricted fixed points, and at the same time observe delay at this place, we are safe in assuming that such conditions exist. Erect position may bring out the acute angle that is formed where the band has fixed the gut, the splenic flexure at deep inspiration may force the colon down so that the angulation is made manifest. If during the statis test, delay not directly traceable to pyloric obstruction was found, the duodenum is inspected, especially at the juncture of the first and second portion. To do this a meal is administered with the patient in the erect position, then sufficient time is allowed for it to reach the duo- denum; it is now watched under the fluoro- scope as it passes from the stomach. The conus-duodenalis will fill promptly, espe- cially if gastric peristalsis is active. If the gastric motility is slow, more time is allowed. After the first portion of the duo- denum is filled, if none escapes into the sec- ond portion or if it passes through exces- sively slow, the stomach is elevated by mod- erate pressure just Ijelow the greater curva- ture, and if there is a kink at this place, the tension is relieved by the upward pressure, and progress of the duodenal contents is un- interrupted. The patient is then placed in the prone position, the stomach permitted to drift upward, and the advance of the bis- muth through the duodenum watched Ijy the lluoroscope, posteriorly. The patient is then turned to the supine position, first lying- on their right side in order to fill the pyloric end of the stomach. The progress through the duodenum is watched for a moment, and the patient is asked to take a deep in- spiration; this will force the duodenum downward with the liver, so that the fingers may be pressed in above it, and when the lungs are emptied and the liver is carried upward, the duodenum also will be pulled upward if fixed, whereas if not adherent or retained by a band, it can be easily held down by moderate pressure. At the same time the degree of tenderness may be de- termined. Kinking at the duodenal-jejunal juncture may be difficult to find, but by filling the duodenum with pressure upward on the stomach, then rotating the patient to the left, the amount of retention in the duo- denum should tell us the degree of ob- struction. If we inspect the intestines in the vertical position, at varying periods and under dif- ferent conditions, wt find marked changes in the degree of ptosis. The factors that enter into this are the quantity and position of the intestinal contents. In general it may be said that the higher in the ab- dominal level the accumulations are, the greater degree of ptosis. A distended rectum and pelvic sigmoid will push the ileum upward, and under certain con- ditions, will also carry the cecum up. If the ileum is filled with gas or feces, the transverse colon and stomach are elevated; if a mobile cecum is loaded, it is very apt to be found in the pelvis because of the wedge-shape of this structure, but if empty, will contract and retreat to its normal posi- tion. If the cecum is al)ove the brim of the pelvis, and the rectum is distended with feces, a Lane l)and may not obstruct the terminal ileum, that is, providing this band does not fix the ileum too securely to the posterior wall. If a cecum rests in the jjeh'is, and there is no obstructing ileal l:)and, even with a patulous ileo-cecal valve, there will not be ileal stasis because the contents of the terminal ileum is theu favored by gravity. When a recent meal fills a mobile cecum, and it drops into the pelvis, and a redundant sigmoid liecomes filled with in- s])issated feces, it will so wedge the cecum iu the pelvis as to render it almost immov- al)le. I have observed this condition pro- duce very marked distress and have seen immediate relief extended to the patient by](https://iiif.wellcomecollection.org/image/b22463860_0008.jp2/full/800%2C/0/default.jpg)
