forms of ileus-including the paresis of general peritonitis—at this stage of the disease.

I have omitted to differentiate between dynamic ileus and the various types of mechanical ileus. Dynamic ileus belongs clinically to the mechanical variety, from which it cannot be distinguished if the obstruction occurs in the same portion of the intestine. A discussion of the accessory symptoms which are observable in cases of mechanical ileus, and which differ according to the location and character of the obstruction, is deemed to be beyond the scope of this article.

Dynamic ileus following operations must be regarded as a surgical disease, and surgical treatment, in order to be successful, must be instituted before the vital forces of the patient are exhausted. This statement may at first sight seem to be too radical. The lessons, however, which the cases on record teach us, in my opinion, warrant this assertion, notwithstanding the fact that all the patients died, two with and two without operative interference.

The ordinary means-cathartics, enemata, and stomach-washing -have been faithfully tried and have utterly failed to give relief. The nature of the obstruction has led to the suggestion of antispasmodics. I do not think they can influence a contraction which persists under anesthesia, nor do I understand how we are to find the indication for their use, as post-operative dynamic ileus cannot be diagnosticated.

It is of the greatest importance not to lose time with a method of treatment which, though giving temporary relief, is not curative. I refer to stomach-washing, and I fully agree with those who see in such temporary improvement a danger to the patient, as it is apt to deceive the surgeon. From my own experience, I must warn against lavage in the later course of the disease, as it decidedly hastens collapse.

The two patients treated surgically died; they were operated on too late. As we know nothing about the condition of the contracted portion of the bowel after operation, it is questionable whether a simple incision of the intestine will save the patient. As an emergency operation, a portion of the distended bowel should be sutured to the abdominal wound, incised and the intestinal contents removed. If necessary, a secondary operation may be done later.

DISCUSSION ON THE PAPERS OF DRS. WERDER AND BLUME.

DR. E. W. CUSHING, of Boston.-Mr. President: These papers have opened up a subject of the greatest interest, and it is as important as any topic which has come before the Association at this meeting, for the reason that it is so comparatively new, so obscure, and it forms really the principal danger to which our patients are now subjected. In our operative work, even after getting rid of sepsis, there still remains this difficulty of the bowel. I recognize the clinical picture in these cases. We know the exact conditions, as the last writer has stated. Some of the cases are septic. It is only within the last few years that I have learned to differentiate obstruction from sepsis, as the writer suggests, and prompt operation has saved a number of cases. I have seen this tonic contraction of the intestines during operation and did not know how to account for it. I think it is a condition akin to, only more aggravated than, ordinary colic. Where there is a tonic contraction of the intestines the patients have suffered from colic.

do

In regard to the use of injections, I think they are given in a way to very little good. To simply direct a nurse to give turpentine, etc., in these cases does no good. The method which I have found the most effectual is to put the patient in the obstetric position, but on the right side, with the hips elevated high, so that there shall be as much chance for the abdomen to sag forward, and the fluid to run down hill, as possible. The fluid is allowed to run into the bowel in a continuous stream, and in a little while the rectum will expel some of it. Presently the first portion of the rectum is distended, and the fluid is running out and in. Soon the rectum yields a little more, and then becomes tolerant and distended; you get to the colon, and that is filled with water, and by washing it thus for a while the water will work its way even past the ileo-cecal valve. If lucky, you will notice a fecal odor or matter. If you can once get that you will save the patient. Several patients have been saved by the persistent use of water in this way. Two or three bucketfuls of water may be needed before the desired effect is reached. The water should have soap in it. You do not want to irritate the bowel, but simply to distend it, and gradually the spasm yields.

DR. M. ROSENWASSER, of Cleveland.-As Dr. Cushing has said, these two papers are of great interest and importance; they have given us

additional light as to the manner of procedure in cases of apparent intestinal obstruction from sepsis or otherwise; the more cases the more light. I desire to place on record a case bearing on this subject, which I had last spring. It was one that I had operated on for double pus-tubes in which there were universal adhesions. In breaking up the adhesions I had to do considerable violence to the pelvic floor. The patient did well for the first twenty-four hours. During the second twenty-four hours she manifested symptoms of partial obstruction. She had vomiting, yet slight passage of gas. She also had colicky pains. I had her bed elevated, and copious injections administered, which produced no satisfactory improvement. On the third day there were again occasional evacuations of gas. The size of the abdomen did not increase, so that I felt sure she did not have complete intestinal obstruction, but that it was only partial; for this reason I continued to hope that the patient would get better and would not require a second operation. At the end of five days she died. To relieve the sharp colicky pains I was obliged to use morphine, which, as a rule, I do not use after abdominal operations. The absence of distention of the abdomen coincides with the report of Dr. Werder. It was not at all like the distention we observe in ordinary septic cases. I cannot say whether my patient had previously been neurotic or not. A thorough autopsy was made, including a bacteriological examination. There was a slight amount of fluid in the peritoneum; a little lymph, but certainly no gross evidence of bowel infection; yet the bacteriological examination showed streptococci in three separate cultures. In addition to this we found that the large intestine was distended to the descending colon, which was constricted as far as the rectum to the size of a contracted ileum. The tetanic contraction of the bowel in this case was probably due to septic infection.

DR. WERDER (closing the discussion on his part).-I am very glad to have heard an expression of opinion from other Fellows of the Association who have had a similar experience. Since reading my paper two or three gentlemen have reported cases to me that have come under their observation. I am sorry that the discussion was not more general, for I had hoped to get a little more light on the subject, especially in regard to the relation of the spasmodic and the tonic contractions. The point I wished to emphasize in my paper was that the two conditions were identical, and that they differed only in the severity of the contractions; in other words, the spasmodic contractions found accidentally in the two cases reported were of the same nature as the tonic contractions found in connection with the ileus. That the cases of ileus reported were not due to post-mortem changes, I think was made

plain enough in my paper, but I will state again that in both cases there was a sacculated condition of the intestine above the point of constriction, showing that there had been quite a marked effort on the part of nature to expel flatus.

There is one point that I would like to bring out in the differential diagnosis between the paralytic ileus of septic peritonitis, the so-called adynamic ileus, and the cases of dynamic ileus or tonic enterospasm observed by me, and that is this: In neither of my cases was there any distention of the abdomen-in fact, the abdomen remained flat. Another marked contrast between septic ileus and this form consisted in the marked peristaltic movements persisting for several days; they were so marked that they could be seen through the abdominal walls. The pains were unusually severe, like cramps, showing, in my opinion, conclusively that the intestine was trying to overcome some obstruction.

DR. BLUME (closing the discussion).—It was my intention to bring out in my paper the differential diagnosis between adynamic ileus, on the one hand, and dynamic and mechanical ileus, on the other hand, and I wished to call attention to that form of adynamic ileus which either is not dependent upon sepsis, or is the result of a mild localized peritonitis, conditions not necessarily fatal. The most important symptom which distinguishes adynamic ileus from dynamic and mechanical ileus is the absence of peristalsis. Peristalsis is also absent or decidedly diminished in cases of obstinate constipation, in which we have so much difficulty in moving the bowels and which give us a great deal of trouble.

When a patient who has been doing well the first few days after operation presents the symptoms of intestinal obstruction, sepsis can fairly be excluded. After the usual methods to produce a movement of the bowels have failed, surgical interference is not only justifiable, but is the only means to save the patient. An early operation is of the greatest importance. No time should be lost, for with the appearance of collapse the condition of the patient becomes practically hopeless. Our experience in interfering with this class of cases has, so far, not been very encouraging. Most patients died, not because they could not be relieved by surgical interference, but because interference came too late.

THE ADMINISTRATION OF PHOSPHATE OF

STRYCHNINE DURING GESTATION.

BY WALTER BLACKBURN DORSETT, M.D.,

ST. LOUIS.

STRYCHNINE alone, as the alkaloid, or most frequently the sulphate in combination with iron, quinine, etc., has been used with great success for many years by the profession as a tonic in the treatment of anemic conditions, particularly the class of anemic cases associated with neurotic conditions. Its administration has been generally confined to cases unassociated with the pregnant state, and little attention has been paid to it as a tonic in anemia associated with pregnancy.

That the several pathologic conditions incident to and frequently influencing gestation have not received the proper consideration at the hands of the profession, must be admitted. To Edward P. Davis is due the credit of having done more toward directing the attention to this matter than any other American. One of our own Fellows, Dr. W. B. Dewees, in a paper read before this Association at our Toronto meeting, drew attention to this matter in the presentation of his subject entitled "The Care of Pregnant Women." Still, the literature on this question is meagre, and until the laity understand that the obstetrician's attendance should commence as soon as conception has taken place, and should not cease until at least ten days after delivery, little will be done toward the accumulation of literature on this subject.

Having treated a few cases of pernicious anemia associated with pregnancy, and pernicious anemia associated with malarial toxemia and neurasthenia, both simple and complicated, with poor success with the use of the ordinary remedies in vogue, I began to look around for some remedy that might promise better results.

Constipation and its consequent ptomaïn poisoning, as is evidenced by languor, dizziness, and general malaise, is probably (aside from kidney lesions) one of the most serious conditions with