"RMCS: T. B. Curling on a "Case of fatal internal strangulation""

(7 December 1846)

Royal Medical and Chirurgical Society

"Case of fatal internal strangulation caused by a cord prolonged from a diverticulum of the ileum, with observations"

The case presentation was made by T. B. Curling, Lecturer on surgery at the London Hospital. After a report of his clinical-pathological findings, Mr. Curling remarked "that this case affords an example of a very rare from of internal strangulation, and is an addition to a number of those cases in which no internal remedies are capable of affording relief. The best practical surgeons of the present day, he believes, entirely discountenance the proceeding once adopted by Dupuytren, of opening the abdomen at the supposed seat of obstruction, for the purpose of liberating the intestine. He has not, however, met with a case in which the symptoms, seat, and nature of the obstruction were so favourable for such an operation as in the one just related. The patient was a lean subject; the part strangulated was evidently small intestine; the pain and tenderness were confined throughout to one spot, and theat directly beneath the linea alba; and there were no symptoms, even to the last, of peritonæal inflammation. At the post-mortem examination, the obstructed intestine was found precisely at the site anticipated, and not deeply seated in the cavity. The cause of obstruction was a slender cord, in which a trifling incision would have set the intestine free; and there were no marks of peritonæal inflammation, with the exception of deep congestion of the portion of intestine directly implicated.

The author states that the museum of the College of Surgeons contains a preparation closely resembling the morbid specimen just described; but there is no history of the case. He is also indebted to Mr. Paget for the reference to another similar case, of which the parts are preserved in the museum of St. Bartholomew's Hospital. In this case, the intestine was strangulated by a ring formed entirely by the diverticulum; whereas, in the case related in the paper, and in the preparation at the College of Surgeons, the constriction was produced chiefly by a cord prolonged from the extremity of the diverticulum. This cord, he believes with Mr. Paget, consists of the remains of the obliterated omphalo-mesenteric vessels. In conclusion, the author notices two cases of gastrotomy successfully performed, in cases of obstructed bowels, by surgeons in the United States.

Dr. Snow said that there were other cases besides those to which Mr. Curling referred, of exactly the same nature as the one just related. In his paper on a case of strangulation of the ileum, read to the Society last session, he (Dr. Snow) had referred to a case related by M. Moscati in the "Memoires de l'Acad. Roy. De Chirurgie," which was, in every particular, even in the situation and dimensions of the parts, exactly like Mr. Curling's case; and that he had been lately informed by Mr. Robert Wade, that that gentleman once met with a fatal case of internal strangulation of the bowel by a fibrous band continued from an abnormal branch of the ileum, and attached by its other end to the mesentery. Although these cases were certainly rare, yet they formed a distinct class of internal strangulations, depending on a particular congenital malformation, which, as he (Dr. Snow) had stated in his paper, and as Mr. Curling had now stated, was a persistent state of the ductus omphalo-mesentericus. With respect to the question of operation in cases of strangulation by an internal band, the case he had related last session would not admit of it, for the patient had never been able to refer her pain to any spot in particular.

Mr. Curling replied that the case of M. Moscati had not escaped his memory; but in consequence of a wrong reference he had been unable to give an account of it" (665).

There was additional discussion until the meeting was adjourned.

"Royal Medical and Chirurgical Society," Lancet 2 (1846): 664-65.