T H E 
SURGICAL TREATMENT OF VOLVULUS. 
BY 
l 
N. SENN, M.D., Ph. D., 
MILWAUKEE, WISCONSIN ; 
ATTENDING SURGEON TO THE MILWAUKEE HOSPITAL ; PROFESSOR OF 
THE PRINCIPLES OF SURGERY AND OF SURGICAL PATHOLOGY IN 
THE RUSH MEDICAL COLLEGE, CHICAGO, ILLINOIS. 
FROM 
‘x 
THE MEDICAL NEWS, 
November 30, 1889. [Reprinted from THE Medical News, November 30, 1889.] 
THE SURGICAL TREATMENT OF VOLVULUS 
By N. SENN, M.D., Ph.D., 
MILWAUKEE, WISCONSIN ; 
ATTENDING SURGEON TO THE MILWAUKEE HOSPITAL ; PROFESSOR OF 
THE PRINCIPLES OF SURGERY AND OF SURGICAL PATHOLOGY IN 
THE RUSH MEDICAL COLLEGE, CHICAGO, ILLINOIS. 
Volvulus constitutes a well-defined and definite 
anatomical form of intestinal obstruction. This 
term is used to designate that form of imperme- 
ability of the intestinal canal which results from 
twisting or rotation of one or more loops of the 
bowel about its mesenteric axis. 
Frequency of its Occurrence.—Volvulus, as com- 
pared with some other forms of intestinal obstruc- 
tion, is quite rare. In 1541 cases of obstruction 
from different causes, collected by Leichtenstern 
(Ziemssen’s Cyclopedia of the Practice of Medicine, 
American edition, vol. iii.), and analyzed with spe- 
cial reference to the anatomical cause of the obstruc- 
tion, after deducting 178 due to carcinoma, 33 cases 
only were due to twisting of the bowel, includ- 
ing twists of both the sigmoid flexure and the ileum. 
Upon another page the same author gives the result 
of his examinations of 76 cases of volvulus which he 
has collected, and of this number the lesion was 
found in 45 cases in the sigmoid flexure, in 23 cases SENN, 
in the ileum, and in 8 cases in the jejunum and ileum 
combined. 
Predisposing Causes.—Volvulus can only occur 
where the mesentery of the bowel is of abnormal 
length, and is, therefore, most frequently met with in 
the segments of the intestinal tract normally pro- 
vided with a long mesentery, as the sigmoid flexure 
and the lower part of the ileum. That the relation 
of the length of the intestinal canal to the mesentery 
has something to do in the causation of volvulus has 
been well shown by Kiittner (“Ueber innere Incar- 
cerationen,” Virchow's Archiv, B. 43, S. 478), who 
has ascertained from his anatomical researches that in 
persons who subsist almost exclusively on coarse vege- 
table food, as is the case with most of the peasants in 
Russia, the small intestine measure from twenty to 
twenty-seven feet in length, while in persons of 
German birth the length varies between seventeen 
and nineteen feet. The same author has also shown 
that volvulus is much more frequently met with in 
Russia than in Germany. As the mesenteric attach- 
ment to the posterior abdominal wall must be nearly 
the same in all individuals, as far as its extent is con- 
cerned, the occurrence of volvulus will be favored 
in proportion to the length of the intestinal canal. 
The nearer the two bars of an intestinal loop ap- 
proach each other the narrower the mesentery, and, 
therefore, the greater the risk of rotation about its 
axis from causes which disturb the peristaltic move- 
ments. Sudden or gradual elongation of the intes- 
tinal canal from distention, as we observe it in cases 
of intestinal obstruction and peritonitis, furnishes SURGICAL TREATMENT OF VOLVULUS. 
one of the mechanical conditions upon which the 
production of volvulus depends, by disturbing the 
normal relations which exist between the length ot 
the intestines and their fixed points of attachment. 
It is not uncommon to find in post-mortem records 
of persons who have died of peritonitis, mention of 
volvulus as a secondary condition, and in cases of 
intestinal obstruction it is by no means rare to find 
the same condition as a secondary occurrence on the 
proximal side of the primary occlusion. I have met 
with volvulus in two of my abdominal sections, 
where this lesion could only be accounted for by 
attributing it to elongation of the intestines from 
distention. In one case it followed a strangulated 
hernia. The patient was a young man who had suf- 
fered for a week from a strangulated inguinal hernia. 
On opening the sac the strangulated loop was found 
to be gangrenous; the incision was therefore en- 
larged in an upward direction, and the bowel brought 
down until healthy tissue was reached. The part 
of the intestine leading downward was collapsed, 
while the portion on the proximal side was only 
moderately distended. As this amount of distention 
did not explain the general diffuse tympanites, it 
was deemed necessary to search for an additional 
cause of obstruction higher in the intestinal canal. 
The abdomen was opened by enlarging the incision 
in an upward direction. About one foot above the 
seat of strangulation, a mass of intestinal coils was 
found twisted upon their mesenteric attachments 
and firmly adherent. Above this secondary ob- 
struction, the intestines were enormously distended 4 
S E N N, 
and very much congested. In this case the disten- 
tion of the intestine, commencing at the internal 
inguinal ring, had caused elongation of the bowel, 
which in turn resulted in volvulus, giving rise to a 
speedy aggravation of the symptoms of obstruction. 
That the volvulus was not of long standing was 
evident from the fact that the adhesions were recent, 
and limited to the part of the intestine implicated 
in the twist. In the second case the volvulus formed 
after perforation of a typhoid ulcer. I examined the 
patient three days after the perforation had occurred, 
and at that time the symptoms pointed rather to vol- 
vulus than perforation and peritonitis. The abdomen 
was opened and the volvulus readily found. A num- 
ber of loops of the small intestine had undergone a 
complete twist around the mesenteric axis, and 
showed evidences of strangulation, and were at the 
same time enormously dilated. The diffuse septic 
peritonitis which was present had been caused by 
perforation of a typhoid ulcer a few inches above 
the ileo-csecal valve. The perforation was closed 
by suturing, the volvulus corrected, and the abdom- 
inal cavity flushed with a weak solution of salicylic 
acid. The patient never rallied fully from the 
shock and died a few hours after the operation. 
Nieberding (“ Beitrage zur Darmocclusion nach 
Ovariotomie,” Centralblatt f Gynakologie, No. 12, 
1889) has recently called attention to another cause 
of volvulus. He has reported a case which occurred 
in Bumm’s practice, where, after an ovariotomy, a 
volvulus of the small intestine occurred which proved 
fatal after a few days. During the operation the SURGICAL TREATMENT OF VOLVULUS. 
5 
omentum, which was adherent to the cyst, was sepa- 
rated and a portion excised. The necropsy showed 
that the raw surface of the omental stump had 
formed an adhesion to a loop of the small intestine, 
and above the fixed point a volvulus was found. He 
reported another and somewhat similar case which 
had come under his own observation. A large cysto 
sarcoma of the left ovary was removed, in a woman 
twenty-nine years of age. Before closing the wound 
it was noticed that the omentum was so short that the 
intestines could not be covered by it in the region of 
the incision. At the end of the second day symp- 
toms of acute obstruction set in, the temperature re- 
maining normal. As the symptoms increased in 
gravity and the ordinary treatment proved fruitless, 
the wound was opened and a loop of intestine was 
found adherent to the left margin of the incision, 
and after this was separated a volvulus was detected. 
The bowel was untwisted and its contents forced into 
the segment further down, beyond the seat of ob- 
struction, the detached loop pushed beyond the 
reach of the abdominal wound, and the abdomen 
closed. The day after the operation the intestinal 
canal appeared to be permeable, and gas escaped per 
rectum, but evidences of peritonitis set in and the 
patient died with symptoms of collapse. From the 
foregoing considerations it is apparent that the fol- 
lowing three mechanical conditions favor rotation of 
the intestine about its mesenteric axis: 
1. Long mesentery. 
2. Physiological or pathological elongation of the 
bowel. 
3. Intestinal adhesions to the abdominal wall. 6 
SENN, 
Exciting Causes.—Among the exciting causes of 
volvulus Kiittner mentions, as the most important, 
unequal distribution of intestinal contents and ex- 
aggerated peristalsis. He never observed peritonitis 
in any of his cases, even if life was prolonged for 
five or six days. He asserts that the complicated 
forms of knotting of the intestines, which are still 
described in the text-books as rare but distinct 
forms of obstruction, are only varieties of volvulus. 
Grawitz (Virchow u. Hirsch's Jahresbericht, B. i, 
1876, S. 284) asserts that the immediate cause of 
volvulus is to be found in an accumulation of in- 
testinal contents above a constricted portion of 
bowel; that the distended portion of intestine 
above the seat of constriction undergoes elongation, 
and that this elongated portion then rotates around 
its axis. Henning (“ Beitragezur Kenntniss der Pa- 
thogenese des Volvulus,” Dissertation, Berlin, 1883) 
firmly ligated the intestines of animals, and injected 
water above the seat of obstruction. In the small 
intestine, the distended and elongated coils above 
the ligature always showed a tendency to rotate upon 
their vertebro-mesenteric axes, thus producing a 
volvulus. In the large intestine, on account of the 
shortness of the mesenteric attachment, the same 
experiment caused rupture of the bowel before a 
volvulus could be produced. These experiments 
furnish positive evidence that volvulus of the large 
intestine cannot occur when the mechanical condi- 
tions described as predisposing causes are absent. 
Henning collected a number of cases of volvulus, SURGICAL TREATMENT OF VOLVULUS. 
scattered through the literature on this subject, 
where, in the post-mortem description of the twisted 
bowel, it was distinctly stated that the lumen of the 
intestine was narrowed by some form of acquired or 
congenital stenosis, which is only another proof in 
support of the statement that elongation of the 
bowel constitutes one of the most important con- 
ditions in the causation of this form of intestinal 
obstruction. 
Spontaneous Reposition.—We have reason to be- 
lieve that a violent peristalsis not infrequently pro- 
duces a volvulus, but when the bowel and its mesen- 
tery are of normal length spontaneous reduction 
occurs as soon as the peristaltic wave has passed. 
Such a condition gives rise to abdominal pain and 
a temporary disturbance of the fecal movement. 
In animals, when I produced volvulus artificially by 
twisting an intestinal loop completely around its 
axis and fixing it in this position by suturing, I was 
never able to produce obstruction, and usually 
found, subsequently, that partial reposition had 
been effected by gradual yielding of the sutures and 
adhesions. The conditions are entirely different 
when both the intestine and the mesentery are ab- 
normally long, under which circumstances spontan- 
eous reposition seldom if ever takes place. In such 
cases the mechanical obstruction caused by the 
twist is soon followed by dynamic obstruction in 
the segment of bowel constituting the volvulus, 
caused by the pathological conditions arising from 
the strangulation. The mechanical constriction 
which takes place at the point of rotation produces 8 
S E N N , 
paresis, venous engorgement, oedema, and gangrene. 
These secondary conditions are followed by disten- 
tion of the intestine and accumulation of intestinal 
contents, which cannot fail to aggravate the me- 
chanical difficulties which initiated the obstruction. 
Symptoms and Diagnosis.—Primary volvulus is of 
sudden occurrence, and when located anywhere 
above the ileo-csecal valve it is usually attended by 
severe pain and other symptoms of acute obstruc- 
tion. Vomiting is a prominent symptom in vol- 
vulus of the small intestine, but is often entirely 
absent when the colon is the seat of the twist. 
Poppert (“ Zur Frage der chirurgischen Behand- 
lung des Ileus,” Archiv f klin.'Chirurgie, B. 39, S. 
207) reports a case of volvulus of the sigmoid flexure, 
which had become twisted 180° around its mesen- 
teric axis, where vomiting never occurred from 
the beginning of the attack to the fatal termination. 
He also refers to the statement made by Roser, that 
in cases of volvulus of this portion of the colon 
vomiting is a late symptom, or may be entirely 
wanting. Treves found that this symptom was ab- 
sent in three out of twenty cases of volvulus which 
he collected. 
In Poppert’s case it was shown during life, by 
the introduction of an elastic tube through which 
the organ was washed out, that the stomach was 
empty or nearly so. In volvulus of the sigmoid 
flexure the pain is often referred to the umbilical 
region and not to the seat of the obstruction. A 
circumscribed area of tenderness over the surface 
corresponding to the circumference of the twisted SURGICAL TREATMENT OF VOLVULUS. 
9 
loop is an early and well-marked symptom. A vol- 
vulus once fully developed gives rise to complete 
obstruction, the violent peristalsis above the seat of 
obstruction only aiding in rendering the occlusion 
more complete. Diffuse peritonitis is never met 
with in cases of volvulus unless it has developed in 
consequence of gangrene or perforation. Localized 
plastic peritonitis is, however, of frequent occurrence, 
commencing in the twisted mesentery and extend- 
ing from here to the intestine. Such adhesions in 
cases where a number of loops are implicated in the 
volvulus, or where knotting of the intestine has 
taken place, frequently offer serious difficulties in 
effecting reposition, and after successful reposition 
tend to reproduce the volvulus unless provision is 
made by special measures against such an occur- 
rence. The occurrence of gangrene of the twisted 
loop is announced by a small, rapid, feeble pulse and 
other symptoms indicative of septic intoxication. 
Professor von Wahl (“ Ueber die klinische Diag- 
nose der Darmocclusion durch Strangulation oder Ach- 
sendrehung,” Centralblattf. Chirurgie, No. 9, 1889) 
has recently called special attention to an important 
diagnostic sign in cases of strangulation and volvu- 
lus. Schweninger’s experimental investigations have 
shown that meteorismus first takes place in the con- 
stricted or twisted loops of the bowel, and von Wahl 
has in a number of cases been able to make a posi- 
tive diagnosis of volvulus by percussion, by which 
he located a circumscribed area of tympanites, 
which, on opening the abdomen, was found to 
correspond to the site of the twisted and dilated SENN, 
intestinal coil. As this circumscribed tympanites 
is one of the earliest symptoms, it should be sought 
for and its significance recognized before general 
tympanites sets in, as at that time a correct diagnosis 
is most important in enabling the surgeon to adopt 
timely measures for successful treatment. As vol- 
vulus occurs usually in some portion of the colon or 
the lower portion of the ileum its exact location 
can be readily determined by rectal insufflation of 
hydrogen gas. This diagnostic measure is of the 
greatest importance and value before general tym- 
panites has set in. If the volvulus is located at the 
sigmoid flexure, only a small quantity of gas can be 
introduced, and after the distention of the colon 
below the seat of obstruction the localized tympanites 
due to the volvulus will be found a little higher up 
in the abdomen, the twisted loop of the bowel hav- 
ing been pushed in an upward direction by the dis- 
tended colon. If the caecum is the seat of the vol- 
vulus the insufflation can be continued until the 
entire colon is fully distended, but the gas cannot 
be forced into the small intestine. The effect of 
the insufflation under such circumstances will be 
to widen the abdomen without increasing its promi- 
nence. If the volvulus is situated above the ileo- 
caecal valve the gas will rush from the colon into 
the ileum with an audible blowing or gurgling 
sound, and the distention of the lower coils of the 
small intestine will cause the hypogastric region to 
become more prominent. In recapitulation it may 
be said that the most important symptoms and signs 
upon which a probable or positive diagnosis can be SURGICAL TREATMENT OF VOLVULUS. 
based are the following: i. Suddenness of attack. 
2. Absolute obstruction. 3. Localized area of 
tympanites. 4. Permeability of intestinal canal to 
rectal insufflation of hydrogen gas as far as he seat 
of obstruction. 
Prognosis.—A fully developed volvulus—that is, 
a half to two complete twists—occurring in a por- 
tion of the intestine predisposed to such an occur- 
rence by congenital or acquired causes, is never cor- 
rected without direct mechanical assistance, and, if 
left to itself, invariably results in death from intes- 
tinal obstruction, gangrene, or septic peritonitis in 
a short time. The acuteness of symptoms, and the 
immediate danger to life, increase as the volvulus 
approaches the upper portion of the intestinal canal. 
Death results either from exhaustion owing to the 
incessant vomiting and defective nutrition, or from 
the pathological changes which occur in the twisted 
portion of the bowel; the latter consisting in gan- 
grene affecting the entire loop, or from circum- 
scribed gangrenous spots at the point of greatest 
pressure, resulting in perforation and septic peri- 
tonitis. As the gangrene is the result of pressure or 
strangulation, its rapid occurrence may be expected 
when the twist is tight—that is, when the intestinal 
loop has been rotated once or twice around its 
mesenteric attachment. Death from any of these 
causes may occur in a few days, and life is seldom 
prolonged for more than a week. 
Treatment.—As violent peristalsis is not only one 
of the causes of volvulus, but seriously aggravates 
the local and general conditions after the accident 12 
SENN, 
has occurred, one of the first indications of treat- 
ment should be to place the bowel as nearly as pos- 
sible in a condition approaching physiological rest. 
No food should be introduced into the stomach, and 
thirst should be quenched by small pieces of ice. 
If the vomiting is severe, or if this symptom is ab- 
sent and there is reason to believe that the stomach 
is not empty, washing out of the organ by means of 
a flexible tube is indicated, and this simple proce- 
dure is often followed by immediate and great re- 
lief. The peristalsis is quieted by the administration 
of some preparation of opium, and if this is not re- 
tained by the stomach morphia is administered hypo- 
dermatically. The bowel below the volvulus is 
evacuated by copious injections, which should be 
given while the patient is placed in Hegar’s 
position. The patient is to be nourished exclu- 
sively by rectal enemata. Are there any known 
means by which reposition can be effected without 
opening the abdomen? Jonathan Hutchinson, 
whose views concerning the utility of laparotomy 
in the treatment of intestinal obstruction are, to say 
the least, exceedingly pessimistic, in a recent publi- 
cation (“ Records of Intestinal Obstruction, with 
Especial Reference to Symptoms and Treatment,” 
Archives of Surgery, vol. i., No. i) again calls atten- 
tion to the value of his method of performing ab- 
dominal taxis in the treatment of intestinal obstruc- 
tion, irrespective of a probable or positive anatomical 
diagnosis. His method is described as follows: 
“ The first point in abdominal taxis is the full use 
of an anaesthetic, so as to obliterate all muscular SURGICAL TREATMENT OF VOLVULUS. 
13 
resistance. Next (the bowels and bladder being 
supposed to be empty) the surgeon will forcibly and 
repeatedly knead the abdomen, pressing its contents 
vigorously upward, downward, and from side to 
side. The patient is now to be turned on his ab- 
domen, and in this position to be held up by four 
strong men, and shaken backward and forward. 
This done, the trunk is to be held uppermost, and 
shaking again practised directly upward and down- 
ward ; whilst in this position copious enemata are to 
be given. The whole proceedings are to be carried 
out in a bona fide and energetic manner. It is not 
to be merely the name of taxis, but the reality, and 
patience and persistence are to be exercised. The 
inversion of the body, and succussion in this posi- 
tion, are on no account to be omitted, for they are 
possibly the most important of all. I do not think 
that I ever spend less than half or three-quarters of 
an hour in the procedure.” 
As Mr. Hutchinson mentions no exceptions, as 
far as the nature of the obstruction is concerned, 
we have reason to believe that he advises taxis as 
above described in the treatment of volvulus. Taxis 
has a limited field of useful application in some 
forms of intestinal obstruction, but in the treatment 
of volvulus it must be looked upon not only as a 
useless, but also as an exceedingly dangerous, per- 
formance. It is difficult to conceive in what manner 
such gymnastic exercises could effect reposition, 
while it is easy to understand in what manner the 
different movements would increase the rotation. 
Furthermore, volvulus is rapidly followed by text- 14 
S E N N , 
ural changes which weaken, and, finally, destroy, the 
intestinal walls; and hence taxis, as advised and 
practised by Mr. Hutchinson, would expose the pa- 
tient to the imminent risk of producing a rupture of 
the bowel, without promising the shadow of a hope 
that reposition would be accomplished. Only one 
mechanical measure suggests itself to me as offering 
any inducements in effecting the reposition of vol- 
vulus, short of laparotomy. Rectal insufflation of 
hydrogen gas has already been referred to as a diag- 
nostic measure. In some cases of volvulus the rota- 
tion of the bowel around the vertebro-mesenteric 
axis is often less than one complete circle, and be- 
fore the loop has become considerably changed by 
the twist a reduction might be effected by dilating 
and elongating the bowel below the seat of obstruc- 
tion, thus bringing the same causes to bear which 
have produced the displacement, but in an opposite 
direction. This method of reduction should be 
practised with great care, in the manner described 
in my work on Intestinal Surgery, page 12, and is, 
of course, only applicable in recent cases, before the 
appearance of general tympanites and before the 
bowel has undergone serious tissuec-hanges in con- 
sequence of the strangulation. If this comparatively 
harmless procedure fails in accomplishing the de- 
sired object, laparotomy should be performed at 
once, as every hour of delay increases the danger 
and diminishes the prospect of a favorable issue by 
operative interference. Statistics show a fearful 
mortality of operations done for the relief of obstruc- 
tion from volvulus, simply because they were per- SURGICAL TREATMENT OF VOLVULUS. 
15 
formed too late. Oettingen (Dissertation, Dorpat, 
1888) has collected five cases of volvulus treated by 
the formation of an artificial anus, with the result 
that all the patients died. Of the cases treated by 
laparotomy, six recovered and thirteen died. The 
cause of death in these cases was generally due, not 
to the operation, but to pathological changes in the 
bowel, caused by deferring surgical interference too 
long. Laparotomy, undertaken early in the treat- 
ment of this form of intestinal obstruction, will show 
better results in the future. If reposition of the 
twisted bowel is accomplished by direct measures at 
a time when the general tympanites is not excessive 
and the twisted loop has not undergone irreparable 
tissue-changes, the prospects of a speedy recovery 
are as good as after any other intra-abdominal opera- 
tions which now present more encouraging statistics. 
Early diagnosis and early treatment by laparotomy 
are the requirements which will insure success in the 
treatment of volvulus. Treves, in his paper on 
“The Operative Treatment of Intestinal Obstruc- 
tion” (British Medical Journal, August 29, 1885), 
claims that this form of obstruction is only ag- 
gravated by forcible rectal injections, as such a 
procedure will tend to tighten rather than to relax 
the twist. Of the operative treatment, he says that 
simple laparotomy is an unpromising procedure, but 
that in the future he will make the incision in the 
median line, puncture the gut, and attempt its reduc- 
tion ; if this fails, or the result appears unsatisfac- 
tory, he will evacuate the involved gut through an 
opening in the summit of the flexure, unfold the 16 
SENN, 
volvulus, and establish an artificial anus, using the 
opening first mentioned for that purpose. The ad- 
vice here given I should like to modify by the fol- 
lowing suggestions: i. Never to puncture the gut. 
2. Substitute intestinal anastomosis for the formation 
of an artificial anus. 3. Evacuate not only the 
twisted loop, but also the bowel for some distance 
on the proximal side. The strictest antiseptic pre- 
cautions are urgently indicated in the surgical treat- 
ment of volvulus, more particularly if the operation 
is performed before gangrene or perforation have 
occurred, as in such cases the surgeon has to deal, 
in the majority of cases, with an aseptic peritoneal 
cavity. The stomach and intestine below the seat 
of obstruction should be thoroughly evacuated be- 
fore the anaesthetic is administered. 
Incision.—A median incision should always be 
preferred, even if it has been determined before- 
hand that the volvulus is located at the sigmoid 
flexure. The first incision is made sufficiently long 
to permit the introduction of the hand for the pur- 
pose of making a brief manual exploration of the 
abdominal cavity, with a view to determine the 
existence and exact location of the volvulus. It 
the caecum is found distended, it is proof positive 
that the volvulus is located at the sigmoid flexure. 
A brief examination of the sigmoid region, if the 
volvulus is located here, will show that the bowel 
composing the volvulus is more distended than the 
remaining portion of the colon, and the twist in the 
mesentery can usually be felt and recognized with- 
out any difficulty. In cases of volvulus above the SURGICAL TREATMENT OF VOLVULUS. 
ileo-caecal region, the colon will of course be found 
collapsed and empty. 
If the probable diagnosis of volvulus has been 
confirmed by this manual exploration, or if, after 
the examination of the most important landmarks 
in determining the location of the obstruction, no 
positive conclusions can be reached, no time should 
be lost in enlarging the incision sufficiently to per- 
mit of ready evisceration. As the intestines are 
usually found greatly distended, it is of the greatest 
importance to support them well and to keep them 
covered with moist warm aseptic compresses, so as 
to prevent injury, especially at the points where 
they come in contact with the sharp margins of the 
abdominal incision. The twisted portion of the 
bowel, on account of its greater degree of disten- 
tion, will be among the first loops to escape, and it 
is thus made easily accessible to direct treatment. 
Reposition of Volvulus.—Intra-abdominal reposi- 
tion of a volvulus is not a feasible procedure, hence 
the necessity of making a large incision and bring- 
ing the twisted bowel within reach of sight and 
direct manipulation for the purpose of dealing more 
efficiently and safely with the displacement. The 
danger incident to a few moments’ exposure of the 
intestines is more than counterbalanced by the risks 
which attend attempts at replacement through a 
small wound with the abdomen often distended to 
its utmost by dilated intestines with congested and 
fragile walls. Reduction is easily accomplished in 
recent cases without adhesions, and it is not difficult 
if the adhesions are of recent date. The intestinal 18 
SENN, 
loop is rotated in an opposite direction from that of 
the twist until the unfolding is completed. As a rule, 
the segment of bowel of which the volvulus is com- 
posed contains but little solid or fluid matter, but is 
distended to its utmost by gas which has been gen- 
erated within it by putrefactive or fermentative 
changes since the accident occurred. If there is 
any difficulty encountered in the unfolding of the 
distended loop it is advisable to empty the bowel by 
an incision at least an inch in length, made parallel 
to the intestine and on its convex side, as through 
such incision not only the twisted portion but the 
intestine above the seat of obstruction can be 
emptied of its contents—a matter of great impor- 
tance in such cases. After the bowel has been 
washed out with a warm solution of salicylated 
water further escape of intestinal contents is pre- 
vented by an assistant compressing the wound dur- 
ing the time the surgeon is engaged in correcting 
the twist. I believe it is absolutely necessary to in- 
cise the bowel in every instance where the abdomen 
is opened for the purpose of reducing a volvulus. 
Before the incision is made, it may be necessary to 
place the patient on his side to enable the operator 
to draw the bowel beyond the rest of the intestinal 
coils, so that after the incision has been made the 
intestinal contents can escape into a receptacle with- 
out coming in contact with the prolapsed intestines. 
This position is to be maintained until the intes- 
tinal contents which have accumulated about the 
seat of obstruction can be poured out through the 
incision. This pouring-out process is accomplished SURGICAL TREATMENT OF VOLVULUS. 
19 
by seizing the highest loop which it is deemed 
necessary to evacuate, and, by raising it, pouring the 
contents by the force of gravitation from loop to 
loop until the incision is reached. I even deem it 
an excellent plan not only to evacuate as much as 
posible of the intestinal contents, but also resort to 
irrigation of the bowel through the incision with a 
weak warm solution of salicylic acid. Such thorough 
evacuation of the bowel at and above the seat of 
obstruction accomplishes three desirable objects: 
i. It facilitates the replacement of the intestines 
into the abdominal cavity. 2. It directly unloads 
the distended paretic intestine, and thus favors the 
return of peristaltic action. 3. It exerts a potent 
influence in preventing putrefactive and fermenta- 
tive changes in the intestines after the operation. 
Before the bowel is returned the incision is closed 
in the usual manner by Czerny-Lembert sutures. If 
one or more circumscribed points of gangrene are 
found they should be buried by suturing over them 
healthy peritoneum when the bowel is returned, 
with a fair expectation that after removal of the 
strangulation the gangrene will not extend. If large 
portions of the intestines or the entire loop show 
evidences of gangrene, enterectomy has become an 
unavoidable evil. If, as is usually the case in such 
instances, the patient is in a collapsed condition, no 
time should be lost in the restoration of the contin- 
uity of the intestinal canal by circular enterorrhaphy, 
as the same object is attained in a much shorter 
time by closing both ends of the intestine, and mak- 20 
SENN, 
ing a lateral apposition by means of decalcified 
perforated bone disks. 
Intestinal Anastomosis.—Cases may occur where it 
will be found impossible to unfold the volvulus 
without tearing the bowel, and the question arises, 
Is it best to resect and suture the ends of the intes- 
tine, or to leave the volvulus and establish a com- 
munication between the intestine above and below 
the obstruction? Mr. Hutchinson (op. cit.) reports 
such a case. A soldier, aged forty-six, in good health, 
who was in bed in the hospital, after removal of a 
fatty tumor, two days after operation complained 
of pain in the back and abdomen. He had not 
left the bed since the operation. The following day 
the pain was less; slightly nauseated ; constipation ; 
injections and laxatives produced no effect, except- 
ing to increase the sickness. On the fifth day after 
the attack the retching and vomiting were persistent 
and distressing. On the seventh day the abdomen 
was distended and coils were visible. The symptoms 
became more and more threatening, until death oc- 
curred on the tenth day after the commencement of 
the attack. I will append the report of the autopsy 
and criticism as given by the reporter : 
"Autopsy.—Three inches above the ileo-csecal valve a 
coil of small intestine was found twice twisted round a 
portion of the mesentery, and the canal of the bowel was 
thus completely obstructed. There were no recent in- 
flammatory changes about this part of the intestine, but 
from the dense and contracted condition of the bowel 
where twisted, it must have been for some time narrowed 
at this point. When I moved aside the coils of intestine 
which lay in front of the obstruction, more or less adhe- SURGICAL TREATMENT OF VOLVULUS. 
21 
rent amongst themselves by means of old and tough 
peritoneal bands—and when I endeavored to, and after 
some sorting of the parts, succeeded in unrolling the 
twisted canal, I was glad not to have attempted the oper- 
ation during the life of the patient, for it would have 
been impossible. [Italics my own.] 
"Criticism.—It seems not improbable that in this case 
some old adhesions favored the formation of the twist. 
It may be alleged that an early operation would have 
found the unravelment not so difficult; but then it must 
be remembered that the early symptoms were but slightly 
marked. The case was not considered a serious one 
until seven days had passed. It is in order to illustrate 
the vagueness of the early symptoms that I have quoted 
this case.” 
I cannot appreciate the reasons for self-congratula- 
tion on the part of Mr. Hutchinson for not having 
made an attempt to save the life of this patient by 
surgical interference. The result might have been 
better, and certainly could not have been any worse. 
The time will come, and is not far distant, when as 
much blame will be attached to a surgeon who will 
look on as an idle spectator at the bedside of a pa- 
tient whose life is in danger from intestinal obstruc- 
tion, as now falls upon an obstetrician who permits a 
parturient woman to die undelivered. In the case 
above quoted I cannot see any cogent reasons why 
unravelment in the hands of such an able and careful 
surgeon as Mr. Hutchinson is known to be, would 
not have succeeded, if not equally well, during 
the life of the patient as in the post-mortem room. 
But supposing that unravelment would have been 
found impossible or impracticable, two plans of 
treatment were still left for the operator to pursue, 22 
SENN, 
and either of them might possibly have become a 
life-saving measure. As the bowel presented no 
evidences of gangrene, resection was not to be 
thought of, but the continuity of the intestinal canal 
might have been restored by intestinal anastomosis 
with permanent exclusion of the volvulus from the 
fecal circulation. Or, if the operator had no faith 
in this procedure, he could at least have made an 
artificial anus above the seat of obstruction. An 
intestinal anastomosis between the intestine above 
and below the volvulus by means of decalcified per- 
forated bone disks can be done in a few minutes, and 
at once restores the continuity of the intestinal canal. 
If such a procedure is chosen in the treatment of an 
irreducible volvulus, it becomes necessary to make 
provision for a permanent outlet of the contents of 
the isolated segment of the intestine which consti- 
tutes the volvulus, as the obstruction of both ends of 
this portion may prove to be permanent. This can 
be accomplished by making a second anastomosis 
between the apex of the volvulus and an adjoining 
intestinal loop in preference to a loop below the seat 
of obstruction. Such a procedure will establish with 
but little additional risk a permanent fistulous open- 
ing between the twisted portion of the bowel and 
the fecal circulation, and will prevent any danger 
that might arise from over-distention and perfora- 
tion should the obstruction caused by the volvulus 
remain permanent. In making intestinal anastomosis 
the lateral apposition with the bone-plates should be 
preceded by thorough evacuation and disinfection 
of the intestine. As a matter of precaution a con- SURGICAL TREATMENT OF VOLVULUS. 
23 
tinuous suture, embracing the serous and muscular 
coats, can be applied around the margins of the 
disks, thus obliterating the grooves between their 
margins. In order to hasten plastic adhesions the 
serous surfaces which are to be coaptated should be 
freely scarified. 
Shortening of Mesentery.—After the reduction of a 
volvulus has been accomplished by operative meas- 
ures, it is desirable to protect the patient in the 
future against a possible recurrence of the same 
accident in the same place. As an elongated mes- 
entery plays the most important role in the produc- 
tion of volvulus, this can be done in a few moments 
with certainty and safety by shortening the mesentery. 
Resection of the mesentery is out of the question, 
as such a procedure would in all probability result 
in gangrene of a corresponding portion of the intes- 
tine. Shortening of the mesentery, however, can be 
effected by folding the mesentery upon itself in a 
direction parallel to the bowel and suturing the apex 
of the fold to the root of the mesentery. By this 
method the floating bowel is firmly anchored and a 
recurrence of the volvulus is made impossible. The 
indications for flushing the abdominal cavity and for 
establishing drainage are the same as in laparotomy 
for other forms of intestinal obstruction. As a con- 
tribution to the statistics of the surgical treatment of 
volvulus I will append the following case : 
Volvulus of the sig?noid flexure; laparotomy; re- 
covery.—The patient was a man, sixty-three years of 
age, carpenter by occupation, who was placed under my care at the Milwaukee Hospital by his medical 
attendant, Dr. Walbridge, October 13, 1889. It 
was ascertained that he was of good habits, good 
general health, well nourished, but with no ten- 
dency to obesity. With the exception of occasional 
attacks of constipation, which readily yielded to 
mild laxatives, he had never been sick. The present 
attack was not preceded by constipation. In the 
morning of October 6th, while walking around in 
his room, he was suddenly seized with a severe pain 
in the middle and lower part of the abdomen. He 
sought rest in the recumbent position and the pain 
gradually subsided. At this time the appetite was 
impaired, but there was no nausea or vomiting. 
Toward evening he felt somewhat distressed in the 
abdomen, a circumstance which he attributed to 
flatulency, as he felt relieved after loosening his 
clothing. The following morning he awoke free 
from pain, but on rising the pain returned. He 
remained quiet all day and suffered only an occa- 
sional attack of colicky pain. He rested well during 
the night, and on the third morning he was again 
free from pain. He ate a light breakfast and started 
to resume work at his shop. On his way, however, 
the pain returned. On reaching his destination the 
severity of the pain increased and he returned home. 
The pain yielded to rest, but the abdomen became 
more distended. The fourth day he was again able 
to be about. As the bowels had not moved since 
the beginning of the attack he took a dose of rhubarb 
in the evening. As the cathartic did not act by the 
following morning he took an enema, which brought 
away a small quantity of fecal matter. The following 
two days the pain became more severe and the dis- 
tention of the abdomen greater, with nausea, but no 
vomiting. He did not consider himself sufficiently 
SENN, SURGICAL TREATMENT OF VOLVULUS. 
25 
ill to call a physician until October 1 2th, when Dr. 
Walbridge was called, who, after examination, 
diagnosticated some form of intestinal obstruction, 
and sent the patient to the hospital to be placed 
under surgical treatment. Examination at this time 
showed that the temperature was normal; pulse 90, 
soft, and compressible; copious eructations, but little 
nausea and no vomiting. According to his state- 
ment he had not had a proper movement of his 
bowels since the attack, and no flatus passed per 
rectum. Abdomen enormously distended and tym- 
panitic over the entire surface ; contour of intestinal 
coils visible at a number of places. It was evident 
that the obstruction was located low down in the 
colon, probably in the sigmoid flexure, and it was 
surmised from the history of the case and the symp- 
toms presented, that it was caused either by a 
volvulus or a circular carcinoma. Laparotomy was 
advised, and as the patient at once gave his consent, 
it was performed the following day, October 13th, 
about noon. After he came into the hospital the 
nurse administered two ounces of castor oil in one 
dose without any appreciable effect being produced. 
Operation.—As- the patient was suffering at the 
same time from a chronic bronchial catarrh, chloro- 
form was used in place of ether as an anaesthetic. 
The temperature of the room was kept at 85° to 90° 
F. The most careful antiseptic preparations were 
made, and during the operation rigid aseptic meas- 
ures were carried out. The abdomen was opened 
by a median incision half-way between the umbilicus 
and pubes, and sufficiently large to permit introduc- 
tion of the hand. Intra-abdominal manual explor- 
ation showed in the first place that the caecum was 
greatly distended, consequently the examination was 
continued by exploring the sigmoid region. Below 26 
S E N N, 
the sigmoid flexure the colon and upper portion of 
the rectum were found completely empty and col- 
lapsed. The sigmoid flexure could be distinctly 
felt, and was enormously distended and twisted 
around its mesenteric axis. The twist in the mesen- 
tery could be distinctly felt. No time was lost in 
useless attempts to effect reduction. The incision 
was enlarged in an upward direction to three inches 
above the umbilicus. As the intestines -escaped 
they were covered with hot, moist aseptic com- 
presses and carefully supported by two assistants. 
The small intestine was greatly distended and ex- 
tremely vascular; the visceral peritoneum had lost 
its glistening appearance. The colon had become 
so much distended and elongated that the transverse 
portion, in the shape of a horse-shoe, was found 
displaced in a downward direction to near the pubes. 
The sigmoid flexure was twisted around its mesen- 
teric axis one complete twist. The twisted portion 
of the mesentery was the seat of a limited plastic 
peritonitis which had resulted in adhesions. The 
part of the bowel constituting the volvulus meas- 
ured at least eighteen inches in circumference, and 
its walls appeared to be of the thinness of parch- 
ment paper. Reposition was very easily effected 
by simply turning the bowel in an opposite direc- 
tion to that of the twist until the normal position 
was restored. Peristaltic action appeared to be 
almost completely suspended, both in the large and 
small intestine. It would have been mechanically 
almost impossible to return the intestines into the 
abdominal cavity without producing serious injury, 
perhaps complete rupture of the bowel, hence an 
incision an inch in length was made into the colon, 
where the distention was the greatest. The incision 
was made parallel to the long axis of the bowel and SURGICAL TREATMENT OF VOLVULUS. 
27 
directly opposite its mesenteric attachment. The 
part of the bowel which had been twisted contained, 
besides gas, only a very small amount of fluid fecal 
matter. The incision did not empty more than this 
part of the bowel. As a large amount of fluid feces 
had accumulated above the seat of obstruction, this 
was evacuated by the 4 ‘ pouring-out process,” pre- 
viously described, and in this manner almost the 
entire colon was emptied. The incised portion of 
the bowel was drawn well forward, and held in this 
position by an assistant during the entire time re- 
quired for unloading the bowel, and thus soiling ot 
the intestines and abdominal cavity was prevented. 
As far as could be readily done the intestine was 
subsequently washed out with warm salicylated 
water. The wound was closed with two rows ot 
silk sutures. The mesentery of the volvulus was at 
least eight inches in length and was shortened more 
than one-half by the method described above. Re- 
placement of the intestines was now accomplished 
without any difficulty, and after drying the perito- 
neal cavity with sponges wrung out of warm steril- 
ized water the external incision was closed in the 
usual manner. No drainage. The customary anti- 
septic compress composed of iodoform gauze and 
salicylated cotton was applied and the abdominal 
walls well supported with adhesive strips. Outside 
of the adhesive strips a layer of common cotton was 
applied, and over this a snugly fitting binder. 
Duration of operation nearly an hour and a half. 
The patient recovered rapidly from the immediate 
effects of the operation. At 8 o’clock in the even- 
ing temperature was 100.5° F., pulse no. Free 
movement of bowels; feces liquid* dark colored, and 
of a very offensive odor. Complained of no pain 
but a sensation of soreness in the abdomen. 28 
October 14. Temperature 99.50 F., pulse 90. 
During the night had four fluid passages of the same 
offensive character. So far, the patient had not been 
allowed any food by the mouth. Thirst was relieved 
by giving water in small quantities and frequently 
repeated. In the evening the patient felt so well 
that during a brief absence of the nurse he got out 
of bed and walked around the room. 
15th. Temperature and pulse normal. Impru- 
dence on part of patient did not seem to have re- 
sulted in any harm. From this time on the patient 
was allowed liquid food, and after the lapse of 
another week was placed on the ordinary hospital 
diet. With the exception of a small parietal abscess 
the recovery was not marked by any untoward symp- 
toms. The patient left the hospital three weeks after 
the operation in perfect health. 
SENN, 
Conclusions. 
1. The predisposing causes of volvulus are either 
congenital or acquired, and consist in elongation of 
certain segments of the intestine, abnormal length 
of mesentery, and adhesions. 
2. Irregular distribution of intestinal contents and 
violent peristalsis are the most important exciting 
causes. 
3. Volvulus is most frequently met at the sigmoid 
flexure and the lower portion of the ileum. 
4. Secondary volvulus on the proximal side of 
other forms of intestinal obstruction is not a rare 
occurrence; it is also frequently developed during 
an attack of peritonitis. 
5. As a rule, the symptoms are more acute and SURGTCAL TREATMENT OF VOLVULUS. 
29 
intense if the volvulus is located above the ileo- 
caecal region. 
6. Vomiting in cases of volvulus of the sigmoid 
flexure is not a constant symptom. 
7. The most important physical sign of volvulus 
is a circumscribed area of tympanites which corre- 
sponds to the location of the volvulus, but this sign 
is only of value before general tympanites has set in, 
and, therefore, enables the surgeon in many cases 
to make an early and positive diagnosis. 
8. All cases of volvulus should be treated by 
laparotomy if reposition cannot be accomplished by 
rectal insufflation of hydrogen gas. 
9. Reposition should not be attempted without 
evisceration. 
10. Evacuation of intestinal contents by a free 
incision should be practised in every case where 
general distention of the intestines is present. 
11. Enterectomy becomes necessary if any con- 
siderable portion of the intestinal wall has become 
gangrenous. 
12. Irreducible volvulus should be treated by 
establishing intestinal anastomosis with permanent 
exclusion of the seat of obstruction from the active 
fecal circulation. 
13. Recurrence of volvulus can and should be 
guarded against by shortening the mesentery by 
folding it upon itself parallel to the long axis of the 
bowel and suturing the apex of the fold to the root 
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