INTESTINAL OBSTRUCTION FROM PARALYSIS OF THE BOWELS TREATED BY LAPA RATOMY, WITH RECOVERY. ROBERT R. LAWRENCE, M. D., Hartford. The following history of an exceedingly interesting case illustrates the benefit to be derived from operative interference though performed under adverse circumstances, and while advocating conservatism in using the knife, there are times when all other methods having failed it is the only alternative. There is everything to gain and nothing to lose. My chief object in presenting this article for your consideration is to bring the subject before the profession, each individual to judge as to its merits and the feasibility of the operation as a dernier resort. On Sunday, May 10, 1896, Mrs. S., aged sixty-three years, called at my office seeking relief from what had been termed by her family physician indigestion. Patient had been ailing for two years, marked with frequent exacerbations, and as each succeeding attack increased in severity, her family becoming alarmed sought further advice. She was greatly emaciated, in connection with loss of appetite, bowels constipated and tympanitic, tongue furred, etc., suggesting that a proper diagnosis had been made. My time being limited, I did not give the case closer attention but prescribed for the torpid condition of the secretions (that apparently being the chief feature of her distress) and the lady returned to her home. The following Tuesday I was called to visit her, and upon my arrival found her in bed. At this time the bowels were obstinately constipated, not having moved for several days, as the prescription previously given had not produced the desired effect. Temperature was normal, pulse accelerated, tympanitis had increased, pain referred to the left hypochondriac region, nausea with frequent attacks of vomiting, semi-stercoraceous in character, extreme thirst, etc., clearly indicating, when considered as a whole, obstruction of the bowels. After pursuing the usual routine practice, including copious enemas of various combinations, oft-repeated, massage thoroughly and persistently applied, all with negative results, and as the patient was becoming preceptibly weaker, I decided after consulting and obtaining permission of the lady and her family, to open the abdomen and ascertain the nature of the obstruction and if possible relieve it. Accordingly on the 21st (eleven days having now elapsed since I first saw her) I did, with the assistance of Drs. J. Bell and Winans of Benton Harbor and W. L. Garratt of Watervliet, proceed to operate. I will not enter into the details of the technique of the operation but briefly state that with as nearly aseptic surroundings as was possible, which included not only the operating room but the assistants, dressings, instruments, etc. as well, the abdomen was opened through the median line and the intestines exposed. Visual inspection revealed an appalling condition. The intestinal circulation was practically nil, being retarded apparently by the over-distension, which reacting upon the mesentery produced a congestion of this structure, thus rendering the case much graver and the probabilities of relief more uncertain, as the vitality of the tissues involved was at a very low ebb, in fact approaching dissolution. The gaseous accumulation was removed by puncturing the intestinal walls at several points by means of a medium size hypodermic needle and the flatus entirely overcome. There was found a paralysis of a large portion of the intestinal tract. As to the etiology I shall not theorize. Sufficient to say there was not found any localized obstruction, no portion being even attenuated. As the circulation did not return on relieving the distension, I resorted to direct massage. The bowels being protected with towels wrung from a warm saline solution, every portion of them was subjected to pressure. By means of the thumb and fingers they were compressed and relaxed alternately and repeatedly with the effect of restoring the circulation and thus relieving the turgidity of the mesentery. This was followed by douching the abdominal cavity thoroughly with a warm Thierch's solution, a portion of which was retained and the intestines returned to their home. The peritoneum was approximated and retained in apposition by an interrupted suture of sterilized catgut (cut short), the remaining coverings being stitched as one, and the toilet completed. No drainage. Dry dressing applied. Patient rallied from the operation with no alarming symptoms and at the expiration of forty-eight hours her temperature fell to normal, and at no time was it above 100° F. The wound healed by first intention, not a drop of pus was visible at any time. The external sutures were removed on the eighth day. The twelfth day after operation patient expressed herself as having a more natural feeling in the prima. viæ, a pressure in the lower bowel, a call from nature, but alas, the desire could not be gratified. Inserting my finger in the rectum I found an impacted mass of fecal matter of about the appearance and consistence of blue clay, which upon removal was followed by repeated and copious evacuations, in the aggregate enormous. From this time patient made an uninterrupted recovery. Her appetite returned and digestion and assimilation were good, the bowels recovered their normal tone (in a measure) and moved regularly. She is now gaining in flesh, oversees her household affairs and feels that life is again worth living, a comfort to her friends and a living witness to the science of modern surgery. Possibly sooner or later the trouble may return but there has been a respite of life and I shall endeavor to obviate a recurrent attack by stimulating intestinal peristalsis and preserving the tonicity of their muscular structure. ELECTROLYTIC TREATMENT OF ABNORMAL GROWTHS, BOTH MALIGNANT AND BENIGN, WITH AN IL LUSTRATION. WILLIAM J. HERDMAN, M. D., Notwithstanding the charges that are not infrequently heard, both from without as well as within the medical profession, that the surgeon is prone to the knife where less destructive measures would be to the best interests of the patient, it cannot be denied by the well informed that the great advances of modern surgery have all been along the line of conservatism. Scientific surgery aims to ever maintain the attitude of a friend and helper of nature's normal efforts, and not that of a hindrance or an enemy. In confirmation of this it is only necessary to compare the results of the treatment of necrosis of bone, diseases of the cranial, abdominal and pelvic viscera of to-day with what it was twenty or thirty years ago. The beneficence of surgery's aid in saving limbs and life is recorded on the bodies of too many grateful patients to be unacknowledged or denied. It is surgery's purpose to combat the hostile forces of disease with such means as will successfully check or destroy them with as little harm to normal action as is possible. But there have been times when the methods adopted by surgeons while employed with the best intent have gone beyond the mark and resulted in making the cure almost as hurtful as the disease itself. All will admit that surgery has fulfiled its mission most completely when, after having performed its part, it has left the field of its operation as nearly free from abnormality as possible, and there should be no question that, other things being equal, the method of operation that will best accomplish this should be the one adopted by the surgeon, and there is little doubt but that it always will be by the progressive and broadminded man, for with him the chief aim is the best result, and not the maintenance of a special method no matter how skillful he has become in practicing it. It has been my privilege on one or two previous occasions to direct the attention of the members of this section to what appear to me to be superior advantages possessed by the electrolytic methods over others in conserving normal tissue when the surgical removal of certain forms of abnormal growth becomes necessary. And while this method is less destructive to normal tissue than the knife, it is in suitable cases no less efficient in removing the disease. It is not claimed that the electrolytic method of removal is suited to every form of abnormal growth, for there are certain ones, such as lipoma in various localities, carcinoma of the breast, leimyoma of the uterus and osteosarcoma of the long bones, especially when they have reached any considerable size, where there is no substitute for the scalpel; and there are others, such as polypi of the nasal mucous membrane, or of the uterus, with very slender attachments to the surface, that may be as successfully and much more promptly removed by the scissors, the scalpel, the ecraseur or the snare. But between growths of this size and shape there remains another class composed of both benign and malignant growths, which, by reason of their location mainly, but partly because of their nature, in the treatment of which the electrolytic method should be preferred. I include in this class all growths of moderate size, whether malignant or benign, which are so situated that the extensive removal of tissue that would be required to thoroughly extirpate them by a cutting operation would seriously damage the integrity of the part from which they grew so that its function would be impaired, or its appearance marred to a much greater degree than would result if the electrolytic |