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 {Reprinted from Ihe Montreal Medical Journal, October, 1896.) 
 
 If- 
 
 TWO CASES OF VOLVULUS OF SMALL INTESTINE. 
 
 ~ By ROBT. C. KiBKPATRICK, M.D. 
 
 Demonitrator of Surgery MoQill Uoiversityi Surgeon to Montreal Qeneral Hospital. 
 
 I have had under my care two cases of this unusual condition pre- 
 senting such widely difterent symptoms that I thought it would be of 
 interest to bring them before you to-night. 
 
 The tirst case, Lizzie M., aged 30, entered the Montreal General 
 Hospital November 16, 1894, complaining of pain in the abdomen 
 and vomiting. For a week previously she had had cramps in the 
 upper part of the abdomen. Two days before admission pain came on 
 in the epigastric and right inguinal regions, becoming more severe un- 
 til by evening the pain was constant and stabbing in character. The 
 next day vomiting came on and the following day she entered the 
 hospital. Smce the beginning of the trouble the bowels have not 
 moved. We found her condition on examination as follows : The 
 skin is of a subicteroid hue and the conjunctivae are yellowish. She lies 
 on the right side with legs d'.awn up, but is very restless. Abdomen 
 tense and a little distended, tenderness on pressure, especially in epi- 
 and hypogastric regions. McBurney's point painful, but not markedly 
 so. No tumour ; tympanitic note all over, but liver dulness not oblit- 
 erated. Temperature 100.6°, pulse 78, respiration 32. 
 
 The condition remained about the same until the 19th, when it was 
 decided to operate. The vomiting continued and no movement of 
 the bowels was obtained, although some flatus was passed. During 
 the whole time the distention of the abdomen did not become great, 
 nor w' '' hei'f anv tumour to be made out. 
 
 Tht -ation was an exploratory incision made in the middle line 
 above uie umbilicus. The gall-bladder was found normal, but on 
 withdrawing the small intestme from the abdominal cavity a curious 
 condition of affairs was found. The part first withdrawn was col- 
 lapsed, then came a deep constriction in the gut, then about three feet 
 of intestine and finally another deep constriction. There wei'e no biinds 
 or adhesions and the bowel was drawn out very easily from the abdo- 
 men. The large intestine was found much distended, therefore the 
 incision was extended downwards, passing to the left of the umbilicus, 
 in order to permit of the examination of the sigmoid flexure and 
 rectum. Nothing, however, was found to account for this condition 
 and the abdomen'was closed. The recovery was uneventful and the 
 
 * Read before the Montreal Medioo-Chirurgioal Society. June 28, 1895. 
 
2 
 
 patient left the hospital on December 19th, thirty clays after the 
 operation. 
 
 The second cose, Wm. R, aged 19, presented a very different 
 clinical picture. On April 21st he complained of a little uneasiness 
 in his bowels with some swelling of the abdomen. During the after- 
 noon he went to stool twice, but noticed nothing unusual. From 
 time to time he had had similar attacks, so did not pay much atten- 
 tion to his sen.sations. However, while at supper the .same evening, 
 about 5.45, he was suddenly seized with intense stinging pain in the 
 abdomen. His brother assisted him upstairs to his bedroom and 
 loosened his clothing. While doing so he noticed that the patient's 
 abdomen was swollen, hard and tender. There had been no vomiting 
 and no diarrh.mi. Dr. Drummond saw him soon after and sent for 
 me. When I saw him about 7 o'clock he was lying partly dressed on 
 his bed on the right side with his legs drawn up. His lips were livid 
 and his finger nails were also cyanosod. He was suffering severely 
 and was quite conscious. Any att(>mpt to move him gave great pain, 
 consequently the examination was rather supei-ficial. 
 
 The abdomen was greatly di.stended, very tense and tender. Liver 
 dulness apparent, but note tympanitic elsewhere. There was a his- 
 tory of having been shot in the left side, just below the heart, and 
 from this he date<l all his abdominal troubles. . 
 
 The patient was brought to the hospital and as soon as prepara- 
 tions could be made the abdomen was incised in the middle line below 
 the umbilicus. No signs of peritonitis were found, but the small 
 il)owel was collapsed. After withdrawing alumt three feet of this a 
 distended portion was come to — about eight inches in length — with a 
 deep constriction at each end ; beyond this the bowel appeared nor- 
 mal. The distended portion was dax-k in colour, but had not lost its 
 natural lustre, and hot cloths being applied it soon regained its nor- 
 mal appearance. The abdomen was closed and the patient made a 
 good recovery. 
 
 In giving his history he spoke of attacks to which he was subject 
 and which he referred to as fainting spells and attacks of dizziness. 
 Subsequent investigation showed these to be epileptic fits of the petit 
 mat variety, but at the time they made the history still more con- 
 fusing, as he referred them to some stomach disturbance and appeared 
 to think that the}' were connected with the attacks of abdominal 
 pain. 
 
 In neither of the cases had we any symptoms which might be 
 termed diagnostic, nor is it usual to have any such .symptoms in cases 
 of volvulus. The only symptom which they had in common, outside 
 
8 
 
 of the usual symptoms of obstruction, was the decubitus; both lay on 
 the right side with the legs drawn up. It is easy to understand how, 
 in a case of sigmoid flexure with a long mesentery, this condition 
 may occur, but in the small intestine, even with an elongated mesen- 
 tery, the mechanism is more difficult of explanation. The two ends 
 of the sigmoid flexure are not far apart and the looseness of its 
 attachments varies much in difterent subjects. If the loop of bowel 
 is long and loosely attached, one limb of the flexure may be twisted 
 over the other and so obstruction formed. This occurred in a case 
 which I saw some years ago at the General Hospital. 
 
 Taking into cnnsideration the frequency of hernia and the fact that 
 this condition must always be more or less accompanied by elonga- 
 tion of the mesentery and that consequently this state of the attach- 
 ments of the bowel is far from being uncommon, while according to 
 all writers on surgery volvulus of the small intestine is a veiy un- 
 common occurrence, we cannot attach much importance to this point. 
 In fact I have not come across any satisfactory explanation of why it 
 should occur. 
 
 It may be questioned whether thesu were cases of volvulus at all. 
 The total absence of bands or adhesions of any kind, the distinct 
 points of constriction and the absence of inflammatory conditions 
 practically rule out all other conditions. Besides this evidence by ex- 
 clusion, in the second case there was more direct }'roof — the twist 
 could be readily repioduced outside of the abdomen. 
 
 The happy result in these two cases, although I must admit the 
 diagnosis was not made initil the abdomen was opened, would en- 
 courage us to operate early in cases of obscure gastro-intestinal 
 disease where we have symptoms of obstruction. In the second case 
 the pronounced symptoms had only lasted four hours, yet the bowel 
 was already turning black and before long would have become gan- 
 grenous. The mere drawing out of the bowel loosened the twist and 
 no difficulty was experienced in returning the abdominal contents. 
 
 Up to the present time there has been no return in either case, 
 seven months and two months respectively. 
 
 In concluding I wish to thank Dr. Armstrong for his kind assist- 
 ance at both operations.