Acute Internal Strangulation, Twisting, etc.

When a portion of bowel within the abdomen is constricted, its circulation interfered with, and the passage of the contents of the bowel interrupted, it gives rise to acute internal strangulation. This condition is very similar to that of external strangulated hernia. The difference is, that one is inside and the other outside of the cavity of the abdomen.

Twisting of the gut upon its mesenteric axis, the passage of the bowel through some natural or unnatural opening, the encircling of one portion of bowel by another or by bands, false membranes, etc., may cause internal strangulation. It may happen at any age, and involves generally the small intestine or the more movable parts of the large bowel—viz. the sigmoid flexure and cæcum.

Twisting, or torsion, is not an unfrequent cause of intestinal obstruction, and may involve almost any portion of the intestinal tube. Its most common site is the sigmoid flexure, and next in point of frequency the cæcum. It sometimes, but rarely, involves the small intestines, and may occur as a simple twisting of one loop of intestines upon another. Several conditions are necessary for its production. First, the mesentery must be elongated. This change in the mesenteric root may have been caused by the dragging of an old and large hernia, or the mesentery may have been lengthened by relaxation of the abdominal walls from childbearing or by the disappearance of fat. However caused, before torsion of the gut takes place the mesentery is elongated, so that the two ends are approximated and something like a pedicle formed. Second, the portion of bowel attached to the lengthened mesentery may become filled with an enormous quantity of fecal matter and paralyzed by the great distension. In this paretic condition it may be displaced by the living, moving parts around it, and become bent and twisted, or the length of bowel belonging to the elongated portion of the mesentery may be the seat of inflammation, and, paralysis following, it becomes without resistance subject to the pressure and movements of the active vital parts surrounding it. A portion of bowel with its accumulated contents having a redundant mesentery and paralyzed by enormous distension or by inflammation, or by both, may readily be twisted more or less completely, and in some cases several times upon itself.

The weight of the bowel and its contents, along with the rapid distension of the intestine above, fixes the gut in this state of torsion and effectually prevents it from untwisting. A semi-rotation of the paretic and distended bowel about the mesenteric axis is sufficient to interfere with the supply and return of blood and provoke enteritis. Indeed, the rotation is rarely sufficiently great to produce complete obstruction, and the symptoms are frequently rather those of inflammation than of internal strangulation. For weeks before the final attack the patient usually has symptoms of intestinal disorder, such as flatulence, constipation, and spells of colic, due no doubt to the changes provoked by the elongated mesentery and bent or curved intestine. When torsion takes place the attack is sudden and the symptoms violent and urgent. Vomiting, meteorism, insuperable constipation, and frequently tenesmus, are soon followed by collapse and speedy death. The patient may die in twenty-four hours; he rarely lives beyond the fourth day. In some cases excessive tenesmus and bloody stools are seen in the early stages of torsion of the bowel. The condition may be mistaken for intussusception, but can usually be distinguished by the premonitory symptoms of twisting and by the more rapid course, the sudden meteorism, and quick collapse of the latter.

Still another way by which displacement of intestine may occasion obstruction to the passage of its contents is when a portion of the intestine has a long and narrow mesentery, and around this mesentery, which is like a pedicle, another portion of the bowel is thrown, encircling and compressing it. The accompanying figure, taken from Ziemssen's Cyclopædia, gives a good idea of this condition (Fig. 23). It represents a loop of the small intestine placed around the mesenteric pedicle of the sigmoid flexure. Leichtenstern calls this "intertwining or knotting of two intestinal loops."

FIG. 23. FIG. 24.

Anterior view of the strangulated intestine and stricture. a, gastric extremity; b, rectal extremity. Posterior view of the strangulated intestine and stricture. a, gastric extremity; b, rectal extremity.

In consequence of inflammation of the peritoneum and effusion of lymph, peritoneal surfaces are joined together, and before the lymph is fully organized these surfaces are separated by the constant movements of the organs and the change in the relationship of the parts, and strings and bands of various shapes and sizes are formed in which a portion of the intestine may become entangled and constricted. Sometimes the bowel accidentally becomes engaged in a loop or noose of false membrane, or becomes bound down under a band of fibrin; or, the peritoneal surfaces of some of the organs having been joined together or to the wall of the abdomen or pelvis, a loop of bowel may escape into a slit or opening and become incarcerated; or a fold of bowel may fall into a fissure in the omentum or mesentery or broad ligament of the uterus or suspensory ligament of the liver, and become constricted; or the appendix vermiformis may be twisted around the intestine in such a way as to cause ligation of the tube, or, by becoming attached to some neighboring part, it may form a loop through which the intestine may pass and become obstructed. In the same way the bowel may be constricted by a diverticulum. (This is well shown in Figs. 23, 24, and 25.) Bands entangling the bowel and causing strangulation may be attached to the fimbriated process of the Fallopian tube or the ovary or uterus. Indeed, it is impossible to describe in a limited space the almost infinite ways in which these bands and strings may engage and incarcerate the intestinal tube (Figs. 24, 25).

FIG. 25.

An appearance of the natural relations of the diverticulum to the intestine. a, gastric extremity; b, rectal extremity.

Internal strangulated hernia may result from the bowel falling into a pouch of the peritoneum and becoming ligated by the orifice of the pouch, or passing into the foramen of Winslow, of which there are three cases of strangulation recorded; or a retro-peritoneal hernia may be formed; or, more common still, a hernia of the intestine through the diaphragm.

In diaphragmatic hernia an opening is more frequently found in the posterior part of this muscle. Two hundred and fifty-two cases of this form of internal hernia have been collected by Leichtenstern, in which the diagnosis was made in only five cases. He found the oesophageal opening, a spot just behind the sternum, and a gap between the lumbar and costal parts of the muscle, the weakest points in the diaphragm.

Diaphragmatic and other forms of internal hernia may exist and not produce symptoms of strangulation either at the time of formation or subsequently, just as we so commonly see in cases of external hernia. When the bowel is constricted, however, and its circulation interfered with, symptoms of internal strangulation come on, and are exactly like the symptoms of external strangulated hernia. The attack is sudden, the symptoms acute and urgent, and the course and termination very rapid. Unless the constriction is relieved death may take place in twenty-four hours; life is rarely protracted beyond three or four days.

The patient has first eructations, soon succeeded by nausea and vomiting. The matter vomited consists of the contents of the stomach, then of gastric fluid, bile, and the contents of the intestines. When the last is ejected the vomiting is called fecal or stercoraceous. The patient complains of a sense of constriction about the abdomen, griping pains about the umbilicus, flatulence, tenesmus, and insuperable constipation. One or two free stools from the large intestine below the site of strangulation may be passed, but this should not deceive the practitioner. As a rule, peritonitis soon follows strangulation. The belly becomes tympanitic and tender, the pulse small and wiry, and the face anxious. When gangrene supervenes the pain subsides, the pulse becomes weak and intermittent, the surface cold and clammy, and the patient soon dies in a state of collapse. Slight delirium may precede death, or the mind remain unimpaired to the end. Very often, when gangrene sets in and pain disappears, the patient has a grateful sense of relief and is hopeful of recovery.