SUBACUTE OBSTRUCTION OF THE PELVIC FLEXURE 133 



diagnosis is complete. Is there or is there not displace- 

 ment of the bowel to the extent of actual twist ? Although 

 for some years I have been looking for it, I cannot yet 

 say definitely that I have been able to detect any pecu- 

 liarity, either in the shape or in the distribution of the 

 bowel that I can put down as diagnostic. So far, how- 

 ever, as my knowledge of these cases at present goes, I 

 am of the opinion that in nearly every instance where 

 this knee-shaped and ingesta-packed piece of bowel is 

 present in the pelvis it may be taken as certain that twist 

 has not occurred. My reason for advancing this opinion 

 is that in nearly every case of volvulus of the large colon, 

 the diagnosis of which I have afterwards verified at post- 

 mortem, the pelvic flexure is displaced to the extent of 

 removing it from reach by way of the rectum. 



Prognosis. — In face of the opinion I have offered, 

 that once this condition is diagnosed volvulus is unlikely 

 to be in existence, I still advise that only a guarded 

 prognosis should be given. It may be that further inves- 

 tigation still will reveal the fact that such a condition as 

 this may occur concomitantly with twist. This advice, 

 however, applies only to that occasion on which during 

 his visits the surgeon is first aware of the exact nature of 

 his case. He should then explain to the owner exactly 

 what he is dealing with,^ tell him that relief will certainly 

 not be obtained for several hours, and, finally, if only 

 to protect himself against contingencies, suggest the 

 possibility of twist. 



After this, should his next visits find the pulse still 

 near the normal, and his patient still exhibiting long 



1 I have found that a very convenient method of doing this is to 

 lay out on the floor an ordinary roller-towel, doubled in such a way 

 as to represent nearly the course of the double colon in the abdomen. 

 — H. C. R. 



