Clinical Lecture on Malignant Stricture of the Hepatic Flexure of the Colon
Authors: J. F. Goodhart
Journal: BMJ (1879)

THE case to which I invite your attention, gentlemen, to-day is one of stricture of the colon; but, in order that those of you who know little about such things may follow me the more readily, it will be advisable, in the first place, to mention the common symptoms of intestinal ob- struction, and also the various causes of the same.The symptoms are vomiting; griping abdominal pain; constipation; more or less distension of the abdomen; abnormally visible peristaltic action of the bowels; and possibly, in some cases, diminished quantity of urine.According as the obstruction is sudden and complete, or slow and for a long time incomplete, in its onset, you can readily understand that the symptoms will be likely to differ.Thus, in sudden cases, the vomiting and constipation are immediate, and the abdominal distension follows soon after.In the chronic cases, there is usually a history of paroxysmal colic for some time before the onset of more urgent symptoms.The abdominal distension slowly increases, and reaches an extreme degree, and the vomiting and absolute constipation come on at this late period.Moreover, throughout the illness, the visible muscular action is usually a prominent symptom.This is, I think, the simplest division of intes- tinal obstruction-into acute and chronic; and you will find that the various forms are readily classified in this way for clinical interpretation.It is not very elaborate, and therefore proportionately liable to error for exceptional cases; but it is correct for the majority of cases.Some writers attempt to classify according to the seat of the disease; this comes very much to the same thing, but is not quite so simple.The following causes are usually enumerated: I. Plugging of the intestine by foreign bodies and con- cretions.Acute.2. Internal strangulation.3. Vo1vulus.Acutne.o 4. Intussusception.Chronic. 5. Contractions. Strictures.Of these six, the first, except when due to a large gall-stone, is very rare, so that need not detain us.Nos. 2 and 3 are associated with very acute symptoms, early vomiting, pain, and distension of the abdomen.Intussusception occupies a somewhat intermediate position, as it is some- times acute, sometimes chronic; and five and six have usually chronic symptoms.The case is that of a man aged 27, admitted into the clinical ward on May 22nd, I878, and who died on May 3ist.He was an Irishman, born in Killarney, and had had no illness that he was aware of, with the ex- ception of measles, and, four years ago, of gonorrhoea.His father and mother are alive and healthy.He has drunk very freely of spirits and beer, being for some time a bottler of whiskey, when he used to imbibe more than a pint per diem.From Killarney, he went to a sugar-factory at Bristol, where he used to drink considerably more than three quarts of beer in the day.During the last twelve months, he has not drunk nearly so much, only taking spirits at long intervals, and about a quart of beer per day.During the last nine months, the patient has suffered from attacks of griping pain in his right side, more especially after taking beer; he has never noticed that the pain was increased by food; and he has been so little troubled by it as to take not much notice of it.About two months ago, he caught a bad cold, and was confined to his bed, and treated by a medical man.He then first noticed a hard swelling in his right side, just below the ribs.Previouslv, he had felt in good health, and had been able to work and eat well.He now began to have pain in this spot; and, though he got better of his cold, and began to work again, he felt weak, and his appetite failed.A month ago, he was seized with severe pain in his right side, and for two days his bowels were confined.This attack passed off, but only to be succeeded by another in a week's time.The pains generally came on in the evening, and, after lasting twenty-four or thirty-six hours, would go away.During the pain, he was always sick, and, in so doing, was relieved.The vomit was bilious, green or yellow.Sickness never came on immediately after food, nor has he ever thrown up any blood, but the ejecta have been of the nature of coffee-grounds.The vomiting has