TWISTING OR KNOTTING (VoLvuLus). —This form of obstruction is far more difficult to recognize. It presents the main symptoms of intestinal obstruction, including preliminary constipation; but there is, as a rule, no history of tenesmus or of muco-sanguineous stools. The acute symptoms appear .suddenly and are se vere from the start, abdominal distension and tenderness being especially marked. Vomiting is apt to come on late, however; it is rarely stercoraceous, the lesion, in the majority of cases, being situated at the sigmoid flexure. Constipation is ab solute and intestinal gases are retained. The usual position of the volvulus causes it to lie deep in the pelvic cavity, and it cannot, therefore, be felt through the abdominal walls. Occasionally' the intes tine is sufficiently weighted by accumu lated fces to bring it within reach of the finger in the rectum or through the vaginal wall. The passage of a flexible bongie or of fluids by injection is some times advised. Exploratory laparotomy is often necessary.
F.rECAL OBSTRUCTION.—FTCal obstruc tion is situated, in the g,reat majority of cases, in the rectum or the sigmoid flex ure: parts habituated to the pressure of more or less large masses of fTcal mat ter. It is, therefore, slow of develop
ment: a chronic form. After a pro longed period of constipation—following, perhaps, a period during which small, hard, rounded masses were voided (as described under chronic obstruction) —acute symptoms supervene, which may' be suddenly relieved by a copious pas sage. When this does not occur, how ever, abdominal pain, nausea and vomit ing, and gradually increasing distension follow in more or less rapid succession; and, when the vomiting becomes ftecal, collapse is imminent. Examination of the rectum by the finger or speculum quickly clears the diagnosis in most cases. Vag inal examination also assists when the impaction is somewhat high. Abdominal palpation is only of use when the accu mulation is very large. This form is often met with in the insane, especially in females.