Treves, the greatest authority on intestinal obstruction, says: "There is one measure for the treatment of acute intestinal obstruction, and that is by means of laparotomy. The operation should be performed at the earliest possible moment, as soon indeed as the diagnosis is reasonably clear. In case of acute abdominal trouble in which the diagnosis is not clear, the better and safer course is to operate." This view is now generally accepted by physicians as well as surgeons.

As mentioned above, obturation, ileus, and volvulus of the sigmoid flexure are the only groups of intestinal obstruction in which medical treatment plays a prominent part. The importance of an early operation has been shown by Naunyn, who found that among two hundred and eighty-eight cases of ileus operated upon, the results were the more favorable the earlier recourse was had to surgical intervention. In those cases in which the operation was performed during the first two days of sickness recovery took place in seventy-five per cent. During the third day and still later there were only thirty-five to forty per cent of recoveries.

A similar view is expressed by Gibson,1 who dealt particularly with acute intussusception. Among one hundred and forty-nine cases of this affection he found an average mortality of fifty-three per cent. The first and second days showed mortality inferior to the general mortality, while the four succeeding days showed a steadily increasing mortality, in each instance greater than the average. With regard to treatment by inflation of the bowels by enemata of fluids (or air) Gibson says: "It is probably not an exaggeration to say that if all cases of intussusception were treated on the onset, or say within forty-eight hours, by abdominal section, without any previous attempt at reduction, the mortality, while still considerable, would in all probability be very much less than the present figures." Gibson believes that injections should" be tried only on the first or at the latest on the second day.

1 C. L. Gibson; "Mortality and Treatment of Acute Intussusception, with Table of 239 Cases. Medical Record. July 17th, 1897.

In the discussion on intestinal obstruction which took place at the New York State Medical Association,' all the speakers (Parker Syms, E. D. Ferguson, George D. Stewart, J. W. Gouley, J. D. Rushmore, LeRoy J. Brooks, John F. Erdmann, Fred. H. Wiggin, and H. O. Marcy) were in favor of surgical treatment and for early intervention. J. D. Rushmore says:2 "I have no hesitation in affirming that in competent hands operation for intestinal obstruction would not have a mortality above twenty per cent. In my personal experience, including over one hundred and ten operations, the mortality has been nearly forty per cent. In the last thirty cases there have been six deaths." Wiggin3 considers that operations performed within the first forty-eight hours will give a mortality of 22.2 per cent.

Inasmuch as the question of operation has to be dealt with in each case of intestinal obstruction, it is advisable to have the opinion and advice of an expert surgeon right at the start of the disease. The physician and surgeon should act together, the first watching the symptoms carefully and making the diagnosis, the second prepared to resort to surgical intervention as soon as it is demanded.

1 Transactions of the New York State Medical Association, 1898.

2 J. D. Rushmore: Ibidem.

3 F H. Wiggin: Da Costa's "Modern Surgery." p. 644.

In this way the number of recoveries will be greater in the future than it has been in the past.

The operation consists in making an abdominal incision, finding the seat of the lesion, and removing the obstacle if possible. If not, an enterostomy is performed in the most distended coil of intestine which is then attached to the abdominal wall. The fecal matter and the gases thus find an outlet through this opening. Enterostomy is also required in all cases in which the portions of the intestine are already found gangrenous. Treves says that this operation (enterostomy) could be avoided in acute intestinal obstruction if the abdomen were opened at the very earliest possible moment. Every hour delayed adds to the gravity of the case. "The earlier the operation the less the need for enterostomy. Laparotomy should be performed at an early enough period to render an opening into the bowel unnecessary."