A clinical consideration of intestinal obstruction

NEW SERIES,

VOL. VIII

MARCH,

1930

No. 3

A CLINICAL CONSIDERA?ION OF INTESTINAL OBSTRUCTION* C. JEFF MILLER, M.D.,

F.A.C.S.

NEW ORLEANS,LA.

T

HE saIvation of human life,” says Lord Moynihan of Leeds, “is a greater thing than the estabIishment of a convincing, irrefutabIe cIinica1 diagnosis,” and Arthur Curtis remarks, in another connection, that “it is better to have a Iess accurate diagnosis and a more favorThere are possibiIities abIe prognosis.” of danger in these aphorisms, I admit, but if they were steadfastIy borne in mind we shouId see a prompt reduction in the mortaIity of at Ieast one cIinica1 entity. I have reference to intestina1 obstruction, a condition in which the lowest mortaIity is achieved not by the conservative surgeons who operate onIy on definite diagnoses and for whom, ordinariIy, we have onIy praise, but by that other group of surgica1 enthusiasts whose resort to the knife is immediate and for whom, ordinariIy and properIy, we have onIy condemnation. Their craftsmanship may be dubious, their surgica1 judgment is unquestionabIy dubious, but in this one contingency, at least, we would do we11 to emuIate them, for they Iose the fewest patients from this deadIy disease. For surgery is the one treatment, the onIy treatment, for intestina1 obstruction. ExpIoration is warranted on the barest suspicion that it exists. A properIy made expIoratory incision seIdom does harm, and sureIy it is a better thing to open the abdomen and find nothing than to open * Read before the Pan-Pacific

it after days of deIay, when a moribund patient carries his diagnosis on his face, and find pathoIogy which, because priceIess time has been Iost, no amount of surgica1 judgment and no exhibition of surgica1 dexterity can possibIy remedy. The Iogic of immediate operation is apparent if we reffect upon the true nature of intestina1 obstruction. Its pathoIogy is pureIy mechanica in origin, and mechanica1 fauIts can be rectified onIy by mechanica1 means. The spontaneous formation of a feca1 fistuIa or the spontaneous correction of the obstruction are possibiIities too remote to be seriousIy considered. The patient who is not operated on is going to die. He may die anyway, he wiI1 certainIy die if surgery is deIayed too Iong, but that is no reflection upon surgery. It is, however, a decided reflection upon the quahty of the surgica1 judgment that deferred its performance. You know the incidents of the sorry story so we11 that I need not Iinger upon them. The patient, seized with abdomina1 pain, resorts to purgation, the great curea11 of the Iaity. When he grows no better he caIIs in the medica man, who experiments with further purgation, with opiates, with fine-spun Iaboratory tests and other time-consuming measures. EventuaIIy the surgeon is summoned, the surgeon who is quite as prone to deIay as is his medica confrere but who escapes a good dea1 of opprobrium because in most instances

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he is not in at the start. FinaIIy operation is resorted to, and operation, Iate in this disease, is most often the gesture of despair. It is done, as LincoIn Davis vividIy says, not with any specia1 hope of saving the patient but simpIy because the ethics of the profession does not permit one to operate for “a batting average.” Even in the earIy stages of intestinaI‘obstruction the patient is much sicker than he Iooks, and in the Iate stages he is pIainIy so III that no medical knowIedge is necessary to assert that here is a human being beyond the hope of succor. At this point I am minded to refer, aIthough with considerabIe trepidation, to a tendency wideIy current in this age of research, the tendency to Iose sight of the cIinica1 aspects of this condition, as of many others, under the weight of laboratory details. I hope that you wiI1 not misunderstand me. I have onIy the highest praise for the work that has been done by such investigators as WhippIe, Stone, SchoIefieId, Hermann, Gatch, TrusIer, Haden and Orr. Ayres, Foster, It has been of incaIcuIabIe aid in determining pathoIogy and in estabIishing a therapeutic rationaIe, and almost without exception the men who have done it have preached and taught that nothing which they have discovered, nothing which they hope to discover, can obviate the necessity for speedy operation in every instance of intestina1 obstruction. But, consciously or unconsciousIy, much of their work has been distorted and made to seem a justification for procrastination. Certain of the profession, at Ieast, have tended to dweI1 on the experimenta work done on Taboratory animaIs, on the exact nature of the toxins eIaborated in the bower, on the precise causes of death, forgetting that in the fina analysis the onIy important aspect of this disease is its cIinica1 aspect. Our chief concern must ever be with the damaged bowe1 waI1. A knowIedge of the IethaI agents present may be important, but sureIy it is more important to dweI1 upon the earIy cIinica1 manifestations, the

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prompt recognition of which wiI1 remove any necessity for studying their termina1 resuIts. Moreover, conditions produced experimentaIIy in animaIs by no means paraIIe1 conditions actuaIIy present in humans, and it might be weI1, at Ieast occasionahy, to pay Iess attention to mice and more attention to men. FinaIIy, in this disease preeminentIy, the pathoIogy of the Iiving is a study of considerabIy more vaIue than the pathoIogy of the dead, and a deeper concentration on it wouId undoubtedIy mean that the autopsy room wouId furnish us with fewer exampIes of it. Th e protean character of intestina1 obstruction is very often overIooked. It is anything but a simpIe disease. It is true that in the beginning, unIess there is immediate circuIatory damage, the picture is one of a simpIe bIockage of the feca1 current by some mechanica obstruction. But once the pathoIogy has Iasted an appreciabIe time, even those cases which have begun as simpIe obstructions merge promptIy into the vascuIar type. Then, with interference to the circuIation, come damage to the bowel waI1, gangrene, necrosis, even perforation with consequent peritonitis, and the eIaboration of a toxemia which is perhaps the most serious feature of aI1. In short, intestina1 obstruction is a disease which remains IocaIized only a very IittIe whiIe, and in which constitutiona changes of the gravest sort come to pass within an amazingIy short space of time. It foIIows, then, that in a disease of such potential gravity the promptest diagnosis and treatment are essentia1. But this is not as simpIe as it sounds. The symptoms and physica signs are inconstant and variabIe, and diagnostic methods are far from conclusive. In practicaIIy no earIy case is the fuII cIassic syndrome apparent, and, as a matter of fact, when it does appear the patient is very IikeIy to be near his death agony. The surgeon who operates for obstruction onIy when the diagnosis is confirmed by

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the fuII complement of symptoms may achieve an enviable reputation for diagnostic acumen, but it wiI1 be in the autopsy room, for he wiI1 have few Iiving patients to his credit. Pain, the eariiest symptom and the most constant, is, I would say, the inevitabIe concomitant of intestina1 obstruction. I wouId remind you, however, that the abdomina1 viscera are IargeIy insensitive, even when they have become pathoIogic, and that a proper comprehension of the mechanism by which pain is produced is even more essentia1 in this case than it is in most other abdomina1 diseases. OnIy in rare instances is exact IocaIization possible. The pain most usuaIIy originates vagueIy about the umbiIicus, less often in the epigastrium, but finaIIy the whore abdomen is implicated. The character is quite definite. If the mesentery is invoIved the pain is continuous from the outset. Otherwise it begins in a coIicky and intermittent fashion, and it becomes continuous onIy when the disease has progressed beyond the first stages. Be not deceived, either, by its subsidence. That in itseIf may be a most misIeading thing, for it may portend the deveIopment of gangrene and not the abeyance of pathoIogy. Vomiting is by no means the constant symptom which pain is. In obstruction of the smaI1 bowe1 it is present from the start, at first as a reflex phenomenon, Iater because of a hypersecretory activity of this normaIIy very active portion of the intestine, an activity which may be increased, aside from the obstruction, by misguided efforts to force ffuids by mouth. In coIonic obstruction, on the other hand, vomiting is usuaIIy a Iate symptom and it may never appear. At first the vomitus consists of gastric contents, then of biIestained fluid, and finaIIy of true feca1 matter, unIess this Iatter development is prevented by the fact that the smaI1 bowel obstruction acts upward as we11 as downward. There is no more misIeading symptom than this same fecal vomiting,

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and I am in hearty accord with the writers who contend that the term shouId be removed from the vocabuIary of intestina1 obstruction. It is absoIuteIy diagnostic of obstruction, but it is Iikewise absoIuteIy prognostic of impending death, and for my own part, I have never seen a patient recover in whom true fecal vomiting had been exhibited. Since the very term intestina1 obstruction carries with it the impIication of a stoppage of the feca1 current, it might be expected that absoIute constipation wouId be a definite and immediate symptom. This is far from the truth. The hygher the obstruction, the Iess IikeIy is constipation to be evident promptly, and it must be remembered, too, that in intussusception and mesenteric thrombosis, frequent thin, watery, blood-stained stooIs are more IikeIy to be the ruIe. It is often urged, in this connection, that, as a diagnostic measure, two enemata be given, the first to empty the bowe1, the second to demonstrate the obstruction. Aside from the fact that this is a time-consuming procedure, it may not serve the purpose at aI1, for in a high obstruction even mechanica means may not fuIIy or promptIy empty an overIoaded Iower bowe1. Moreover, unIess there is compIete reIief of symptoms simuItaneousIy, the mere passage of feces cannot be accepted at its face vaIue. More to the point is the suggestion of Codman, that digita recta1 examination be done routineIy, which wiI1 revea1 an empty rectum in which the waIIs crowd around the finger, whiIe above is a sensation of tremendous intra-abdomina1 pressure. Quinn emphasizes the same point, decIaring that it is more important to insert a finger in the Iower end of the aIimentary tract than a thermometer in the upper. Distention is the promptest and most conspicuous physica sign, but again it is an inconstant manifestation and a Iate one, except in voIvuIus of the sigmoid, when it may be prompt and aIarming. Tenderness is never apparent unti1 after distention

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has occurred. Rigidity is evident onIy when IocaIized peritonitis has set in, and in marked toxemia, when the muscuIar defense is Iacking, it may not appear at aI1. is pathognomonic, VisibIe peristaIsis but it can be demonstrated onIy occasionaIIy and Iate. AudibIe peristarsis, however, is a different matter, and many agree with Deaver that auscuItation of the abdomen, either with the naked ear or with the stethoscope, shouId never be omitted. In the earIy stages, as he points out, there is a hyperactive, noisy, whirring peristaIsis, which ceases absoIuteIy at the point of obstruction. In the second stage there is a high-pitched, beII-Iike tinkle, due to gas and ffuid moving in a tubuIar space. And in the fina stage there is the “ominousIy siIent “abdomen, in which aIIactivity has ceased and in which the onIy sound is the puIsation of the aorta. BayIey of Los AngeIes describes another sign which I have nowhere else seen mentioned. He cIaims that in certain earIy cases, as the resuIt of free fluid under tension, the heart sounds may be transmitted through the abdomen and heard in any or a11 of its four quadrants. UnfortunateIy, whiIe this sign is aImost pathognomonic, it is inconstant and is therefore of vaIue onIy in conjunction with other findings. EIevations of temperature, as wouId be expected in a condition that is not primarily inff ammatory, are never apparent in the earIy stages of intestina1 obstruction, at which time norma or distinctIy subnorma temperatures are the ruIe. The puIse, on the other hand, tends to rise speedily, and this fact, taken in conjunction with the Iow temperature, is an important diagnostic point. Shock is apparent from the first when the circuIation is affected, is aIways associated with distention, no matter what the primary cause of the obstruction, and is aIways a part of the toxemic picture of the fina stages. The bIood pressure of these patients, therefore, must be carefuIIy watched from the outset. A routine urinaIysis is, of course, impera-

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tive, but otherwise the Iaboratory offers sma1 aid, except of a negative kind, in the earIy case. The bIood count, unless the circuIation is affected, remains within norma Iimits unti1 inff ammatory changes have set in. Continued vomiting eventuaIIy produces definite body changes, the most marked of which is a disturbance of the bIood eIectroIytes, depending IargeIy upon the Iocation of the obstruction. BIood studies wiI1 often show a Ioss of chIorides, a rise in the non-protein bIood nitrogen, and a rise, sometimes to extraordinary figures, of the co2 combining power of the pIasma. These changes, however, occur too Iate to be of diagnostic vaIue, and there is smaI1 ground for the suggestion, occasionaIIy advanced, that the indications for operation in intestina1 obstruction shouId be based upon repeated tests of this character. Rena1 damage is evident Iate, not onIy in the Iaboratory findings, but in the Iessened ffuid output, sometimes amounting to actua1 anuria. Indeed, in the absence of an adequate history, a patient in the Iast stages of intestinal obstruction couId, from the cIinica1 picture, quite IogicaIIy be treated for uremia, and I have more than once seen this happen, the true Iesion being discovered only at necropsy. AIthough I am strongIy opposed to the administration of a barium mea1 in any suspected intra-abdomina1 pathoIogy, I am heartiIy in favor of the use of the x.-ray as advocated by Case of Chicago. The patient is examined, preferably in the standing position, and the reIative IeveIs of gas and ffuid are studied as soon as the pIate can be deveIoped. This procedure takes but a short time, and in the hand of a skiIIed roentgenoIogist it can be very vaIuabIe in the eIucidation of obscure cases. The diagnosis of intestina1 obstruction, it is cIear, must be made with a very confusing array of symptoms and signs, and with very uncertain methods of diagnosis. Yet it must be made promptIy, for, as we have said, this is one disease in

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which IiteraIIy moments count, in which the deveIopment of the cIassic syndrome is an aImost certain sign that the patient has passed beyond morta1 aid. What shouId be our procedure in this grave hour? First, there must be a carefu1 history, with specia1 reference to past surgery and simiIar past attacks. IntestinaI obstruction is very often a boIt from the bIue, but it may have definite antecedents, the chief of which is a story of previous surgery especiaIIy for peIvic disease or for appendicitis with drainage, for these two types of operation are estimated to furnish from 20 to 40 per cent of a11 intestina1 obstructions. The history of the present attack, with the character and chronoIogy of the symptoms, is equaIIy important. Then must come a physica examination suffIcientIy genera1 to eIiminate intercurrent disease, suffrcientIy detaiIed to investigate a11 areas of the abdomen, a11 hernia1 openings, a11 recta1 pathoIogy, and, in a woman, a11 peIvic pathoIogy. A urinaIysis and a bIood count shouId be routine, and bIood may be taken for chemica1 study, though, as I have said, there is no justification for deIaying operation unti1 this type of investigation can be concIuded. FinaIIy, a11 of the findings must be carefuIly weighed and evaIuated, there being aIways, we11 to the fore, the recoIIection that any patient suffering from intra-abdomina distress may be suffering from intestina1 obstruction, and that the possibiIity is not such a remote one at that. The important thing is to recognize that an obstruction is actuaIIy or possibIy present, or that some other definitely surgica1 intra-abdomina1 pathoIogy which resembIes it is actuaIIy or possibIy present. A differentia1 diagnosis, whiIe desirabIe, is not essentiaI, for the reason that if cardiac, puImonary and renaI disease be eIiminated (and their eIimination is not difficuIt) any other intra-abdomina1 condition which can be confused with intestina1 obstruction is amenabIe onIy to surgery. It is a safe ruIe to foIIow that any ab-

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domina1 pain which Iasts more than six hours in a previousIy we11 person, especiaIIy if it is accompanied by any of the signs and symptoms we have enumerated, and if it is not permanentIy reIieved by a singIe smaI1 dose of morphia, is evidence of a pathoIogy which can be corrected onIy by operation. The Iocation and type of the obstruction are Iikewise of IittIe moment. The smaI1 bowe1 is more IikeIy to be impIicated than the Iarge, and it is Carson, I think, who points out that the higher the obstruction the more constant the symptoms, especiaIIy vomiting, whiIe the Iower the obstruction the more constant the signs, especiaIIy meteorism. Again, obstructions of the smaI1 bowe1 are more IikeIy to exhibit a sudden onset, aImost the onIy exception being voIvuIus of the sigmoid, whiIe obstructions of the Iarge bowel are more IikeIy to present a previous history of digestive disturbance. Herniae, at Ieast of the externa1 variety, carry their own diagnosis. The history of a previous operation is highIy suggestive of the existence of bands or adhesions. Impacted gaIIstones are aIways preceded by a typica history of digestive disturbance, and the same history, pIus Ioss of weight, suggests malignancy of the Iarge bower. This is probabIy the most common cause of obstruction in the aged, and it aImost aIways presents itseIf as an acute obstruction superimposed upon a chronic one. Rapid and enormous distention, sometimes to the point of respiratory embarrassment, is pathognomonic of volvuIus of the sigmoid. Mesenteric thrombosis is prone to occur in middIe-aged individuals, more commonIy men, of a phIethoric type, and to be associated with immediate shock and a raised Ieukocytosis. AI1 of however, though interesting and this, gratifying from the standpoint of diagnosis beside the point. The tic acumen, conviction of intestina1 obstruction, or the suspicion of it, is the one thing that is needfu1. WhiIe the diagnosis is being considered,

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the important thing is to stay one’s therapeutic hand, to restrain one’s “phiIocarthartic propensities.” Th is is not aIways easy. An anguished patient and an anxious famiIy may be insistent for reIief, but this is one set of circumstances in which nihilism is true wisdom. Opiates serve onIy to mask symptoms, and purgatives, as Haggard we11 observes, simpIy “compound the feIony of deIay.” By increasing a peristaIsis that is aheady too active they serve to augment the distention of the overtried boweI, and to increase its bacteria1 activity, whiIe if the stomach, and very properIy, refuses to toIerate them, the body, as the resuIt of increased vomiting, is stiI1 further depIeted of its fIuids. At operation three principa1 probIems arise: the correction of the actua1 obstruction, the management of the damaged bowe1, and the combating of toxemia. In most earIy cases, unIess an associated paraIysis compIicates the issue, simpIe reIief of the obstruction is sufficient, bit in advanced cases, as we have aIready pointed out, considerabIy more is invoIved than the interruption of the feca1 current. Moreover, we must guard against harming the patient by the very means we empIoy to reIieve him: in the Iate stages of the disease the mere reIief of the obstruction is fraught with danger, permitting, as it does, a rush of toxic substances into the hitherto intact bowe1 or the return of the circuIation to an aIready necrotic Ioop. FinaIIy, even if the patient be reIieved of his toxemia by drainage of the bowe1 and other adjuvant measures, he may stiI1 die of the unreIieved primary obstruction which, in his critica condition, it wouId be fata to attempt to rectify. It is pIainIy impossible to speak categoricaIIy of a disease in which each case must be judged upon its own merits. For working purposes, however, we can advantageousIy empIoy Sir WiIIiam TayIor’s very IogicaI cIassification of cases, based, as is so much in this dread disease, on its duration. The condition of the patient is the determining

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factor in deciding upon the type and extent of the procedure. In the first group he is seen earIy and operated on promptIy; his condition is good, and simpIe reIief of the obstruction most often suffices for a cure. In the second group he is seen Iater; his condition is stiI1 fairly good, but toxemia is either an actua1 or a strongIy probabIe compIication, and drainage of the bowe1 is done in addition to reIief of the obstruction. In the third group he is seen Iate, indeed often he is frankIy moribund, and his toxemia is so overwheIming that the primary obstruction is Iost sight of. Operation is done onIy because even a dying patient deserves his chance for Iife, sIender though that chance be. Drainage of the bowe1, through the first presenting Ioop of jejunum, is the onIy procedure warranted. If the patient survives, and most often he does not, the primary obstruction can be deaIt with at a Iater date. The high mortaIity reported after enterostomy, either aIone or combined with other procedures, is no more an argument against it than is the high genera1 mortaIity of intestina1 obstruction a reffection on its It is empIoyed surgica1 management. onIy in frankIy bad risks, and where contro1 series have been fairIy studied, a definite reduction in the mortaIity has aIways been noted. Moreover, jejunostomy, if done by the WitzeI technic, escapes the disadvantages usuaIIy attributed to it, the Ioss of digestive fluids and the deveIopment of fistuIae which require Iater tedious closures. As to other procedures, invagination and pIication of gangrenous or suspicious areas of the bowe1 waI1 is a dangerous operation (indeed, a gangrenous bowe1, whether drained or undrained, shouId never be Ieft within the abdomen) and its apparent conservatism resuIts in a higher mortaIity, in most instances, than the frankIy radica1 procedure of resection. The Iatter, many surgeons beIieve, is indicated in every case in which distention and toxemia, with their consequent paraIy-

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sis, pIay a part, but except in very high obstructions, when Ioss of the digestive fluids wouId be a serious consideration, the two-stage operation is better than immediate anastomosis. Operation for intestina1 obstruction, I need scarceIy point out, is anything but a simpIe procedure. The utmost manua1 dexterity is necessary, for, as BunneII says, every manipuIation, necessary or unnecessary, is “ a shove nearer the grave.” The Ieast that can be done is the safest for the patient. It may be a highly satisfactory thing to compIete a perfect operation, but it is a highly unsatisfactory thing to compIete it on a corpse, and these way of patients have a disconcerting dying on the tabIe, under one’s very hands. In short, surgica1 judgment here comes into its own. To speak very bIuntIy, onIy an experienced surgeon has a right to undertake operation for such a condition means as this, in which craftsmanship much, in which knowledge means much, but in which wisdom, which is the appIication of knowledge, means even more. Like Lord Moynihan, I stand amazed at the ready acceptance by patients “of the eager ministrations of incompetent when it wouId be quite as operators,” easy to secure adequate ski11 and experience, both of which are here taxed to the limit. In the average case of intestina1 obstruction there is no time for the rehabihtation of the patient, at Ieast as we commonIy understand the term. Two things, however, must not be omitted. Gastric Iavage must be instituted and must be repeated unti1 it returns cIear, and it is a wise precaution, too, to Ieave the tube in situ during anesthesia, Iest, when the gIottic reflex is obIiterated, the patient drown in his own secretions, or Iest, later, he deveIop an aspiration pneumonia. ParentheticaIIy, I might add that in spite of a11 the arguments against it and in spite of a11 the advantages cIaimed for other types, my own preference is stiI1 for genera1 anesthesia, even for ether, admittedIy the Ieast

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auspicious of them aI1. In both IocaI and spina anaIgesia, it seems to me, the inevitabIe prolongation of the operation and the inevitabIe additiona manipuIations and trauma, which increase the shock of an aIready badIy shocked patient, outweigh a11 the advantages claimed for them. In the second pIace, hypertonic saIt soIution must be promptIy given, preferabIy by infusion, to restore the ffuid baIance and to repIace the Iost chIorides, if this Ioss can be demonstrated; otherwise isotonic saIine, as suggested by SeIIing BriII, may be empIoyed instead. The use of saIine, aItogether with infusions of gIucose and insuIin, is continued after operation as Iong as the indications, based on the patient’s cIinica1 condition and the Jaboratory findings, warrant it. Other postoperative measures are empIoyed according to the exigencies of the specia1 case. One or two other therapeutic measures might be brieff y mentioned. B. W. WiIIiams and Zachary Cope in EngIand, and Bower and CIark in America, have reported striking resuIts in a Iimited number of cases by the use of anti-gas serum. WiIIiams first caIIed attention to the striking Iikeness between gas gangrene and the termina1 toxemia of intestina1 obstruction and suggested that this simiIarity might be due to the actua1 presence of the toxins of B. WeIchii in the fecal contents above the obstructed bowe1. Wagner in 1922 first pointed out the appIication of the effect of spina anaIgesia in increasing intestina1 peristaIsis, and since that time this measure has been employed sporadicaIIy to overcome the paraIysis of intestina1 obstruction. The resuIts have been very uneven and the issue has been clouded by the bad effects inherent in this specia1 agent. Working from these premises, Ochsner and Gage, of the Department of Surgery of Tulane have recentIy suggested the University, substitution of spIanchnic analgesia for spinaI, on the ground that it is free from the disadvantages of the Iatter type, and

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that, if the method of Kappis be empIoyed, it is not necessary to open the abdomen to administer it. Their cIaim is that in those cases in which paraIysis continues after rehef of the obstruction, with or without drainage of the bowe1, the mechanism being the inhibition of intestina1 motiIity resuIting from impuIses passing by way of the sympathetics, this type of anaIgesia wiI1 overcome the paraIysis by bIocking the reffex and thus abolishing the inhibition. It must, of course, be empIoyed onIy after mechanica reIief of the obstruction. Prior to that time there is present a hyperperistaIsis, and there is no advantage to increasing it. If the clinica1 appIication proves as satisfactory as the experimental work has been, we have reason to hope that we shaI1 have in our possession a most vaIuabIe weapon with which to combat the hitherto invincibIe paralysis of intestina1 obstruction. The concIusion of the whoIe matter is that the prognosis of intestina1 obstruction, as we11 as the rationaIe of its treatment, is absoIuteIy dependent upon the time eIement invoIved. The mortaIity

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rises approximateIy I per cent with each hour of procrastination, and any mortaIity over IO or 12 per cent can be charged onIy to deIay. The death rate, which is popularIy quoted as 30 or 40 per cent, actuaIIy IS 55 or 65 per cent, and we are onIy stuItifying ourseIves when we refuse to face the true figures. In fact, it is very IittIe Iower today than it was forty years ago, when Fitz and Senn did the pioneer work in its study, and when medica treatment for forty-eight hours was the accepted ruIe. MedicaI treatment is not the ruIe today. Surgery is universaIIy admitted to be the onIy rationa and possibIe treatment. The troubIe is, however, that in a Iamentable number of cases our practice does not accord with our theory. And it is this sorry state of affairs, with its resuIting aImost crimina1 mortaIity, which must be my excuse, if excuse be needed, for having presented to you in this paper a subject to which, I am quite aware, I have added nothing new, but which, I am Iikewise certain, can be cIarified and eIucidated onIy by ceaseIess iteration of the tragic facts of the case.