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work with the surgeons, and that it would be a great advantage to them to have an institution where children with tuberculosis can have the fresh-air cure. We have our annual reception on Decoration Day, and shall be glad to show you through if you have not a previous golf date.

DR. EVERETT J. MCKNIGHT (Hartford): I should like to ask Dr. Lampson whether he is going to mention his case of appendicitis in the presence of extensive tuberculosis of the lung.

DR. EDWARD RUTLEDGE LAMPSON (Hartford): That case was my brother-in-law, who had tuberculosis for fifteen years. One lung was absolutely solid, and there was very extensive involvement of the other. He had three attacks of appendicitis, beginning a year ago last March; and these attacks came on once in two months. From his appendiceal trouble, and not from a fresh lighting up of his tuberculosis, he lost twenty-five pounds. It was very evident that unless something was done, he would soon get a fresh focus of tuberculosis and would not live long, and the question was how to give an anæsthetic. Ether was absolutely contraindicated. He was operated on in the Presbyterian Hospital by Dr. Blake, under stovaine. The operation was successful. He has regained his lost weight, and is now pretty well.

Dr. Lyman's point is well taken, that ether is the worst anesthetic for cases of tuberculosis. Provided the involvement is not great, chloroform should be the anesthetic of choice, or gas; but where any general anæsthetic is contraindicated, as in this case, stovaine is the anesthetic of last resort.

DR. JAMES JOSEPH BOUCHER (Hartford): I am particularly interested in this subject, as I have seen a large series of cases of tuberculous peritonitis of the ascitic variety. The early treatment of these cases is of importance, their recovery depending upon the early stage at which they can be gotten under treatment. Opening and draining the abdomen and flushing it out means one thing: every surgeon knows why they get well. The fact is that the abdominal cavity is more or less filled with fluid, the hydrostatic pressure of which keeps the Fallopian tubes open and allows the entrance of the tuberculous deposit. By withdrawing this fluid the condition becomes a localized salpingitis; and the peritoneum is then able to overwhelm the bacilli remaining in it.

I am surprised that Ochsner approves of drainage in these cases, because Western men have made a strong point against drainage on account of the danger of mixed infection. In tuberculous peritonitis without involvement of the lungs, ether is safe; but in tuberculous peritonitis with involvement of the lungs, it is dangerous. There is no

contraindication to its use when the lungs are not involved. I believe that it is the safest anesthetic in all cases of peritonitis, whether tuberculous or otherwise. At the Roosevelt Hospital, in New York City, they have several thousands of cases; and they have shown that in those cases in which chloroform was used there was more or less destruction of all the internal organs, while with ether there was practically no change. While we admit that the complications of pregnacy are different from a tuberculous infection, they are all infections. If chloroform will produce these results, it is safe to assume for the present that it is dangerous to use it. Dr. Sullivan speaks of two cases operated on. I have had seven. One of these patients was operated on a week ago, in an absolutely dying condition. It was questionable whether to operate. I found the abdomen filled with fluid. It simply poured out. All the internal organs were a solid mass. I removed the tubes, and the patient is making a splendid recovery. Judging from my experience and that of other men, the peritoneum in this case will clear up, and within about a year, no one will be able to tell that she had a tuberculous peritonitis. This shows that sometimes the cases that we think are far advanced are not. Tuberculous peritonitis is a local disease, unless the involvement has come from some other source; and the best observers to-day support that very view.

DR. DANIEL SULLIVAN (New London), closing the discussion on his paper: That the tonsils and the ears are very often the source of entrance of the tubercle bacilli into the system, is, I think, generally believed by most men. It is a common experience to have specialists in otology examine the discharge from a chronic suppurating ear and demonstrate the presence of tubercle bacilli, and then send the patient to the family physician for an examination of the lungs. It such cases, the lungs are frequently found infected; and this holds the otologist off from going further with his treatment. There have been a good many cases reported, I find, in which the tonsils removed from children have shown tubercle bacilli. Of course, the observation is as old as the hills that there is a change in the lymphatic glands when the lung is involved. These glands are enlarged, and are what used to be called scrofulous, but is now termed tuberculous. These avenues have been the original source of infection in a great many cases. Though they may have healed, the lungs may have taken the infection from them; and even though the lungs also have healed, the bacteria may have gained entrance to the system. These may lie dormant for a long time; but when an opportunity presents itself, they may wake up and take hold of the peritoneum. This is the explanation of most of the writers for the so-called primary cases of tuberculous peritonitis.

A good deal of experimentation along this line has been done on animals, by feeding them the bacteria, putting the sputum obtained from

human cases and from bovine cases into capsules and mixing them with the food. There has been but one case of such an experiment reported, so far as I could find, in which a primary tuberculous peritonitis was produced in the animal. A good many of these experiments produced ulcers in the intestine or tuberculosis of the retroperitoneal glands, which afterwards spread to the peritoneum, however.

In regard to jumping at conclusions and not operating because of the belief that the peritonitis is tuberculous, I wish to emphasize the fact that a good many cases are sent to the surgeon to be operated upon in the belief that they will be surely relieved. I think that the surgeon should protect himself by making a thorough examination and seeing that the lungs are not involved. A good many times, we shall find the focus in the lung quieting down; and only by very careful search will it be revealed. In cases of tuberculous peritonitis operated upon, the prognosis is always the prognosis that we should give in the case of a primary lesion. Ether given to these patients, especially when the lungs are involved, very often sets up a pneumonia that will kill the patient rapidly. This disappoints the medical man, and he that has depended upon the surgeon for advice has some cause to complain. The surgeon should guard himself against such an occurrence.

The Two-Stage Operation for Acute Intestinal

Obstruction.

E. REED WHITTEMORE, M.D., NEW HAVEN.

When we consider the simplicity of the mechanical problem presented for surgical solution in most cases of intestinal obstruction, the mortality does not compare favorably with that of other surgical procedures. A surgeon operating on a case of inflammatory abdominal disease expects to be successful; in the presence of intestinal obstruction he can only hope to be successful. To improve our results we must have earlier operations or better operative methods or both. The difficulty in getting at these cases earlier is due, first, to difficulty of diagnosis, for the disease makes steady and rapid progress, while the condition of the patient may often seem deceptively good; secondly, the patient or family often refuse operation until they have tried medical measures which are useless. With these aspects of this subject I will not attempt to deal, but will simply consider improvement in the technique of the operation itself.

The fundamental weakness of these cases is that they are toxic. The intestine above the point of stoppage is not only distended by gas but its musculature is paralyzed by toxins from putrefying intestinal contents. The heart is not only embarrassed by meteorism, but the cardiac muscle is weakened by intoxication from the same source. Off hand, it seems like a truism to say that the prime object of an operation for intestinal obstruction is the removal of the obstruction, but such is certainly not the case. The real object is to provide drainage for the toxic material in the intestine. The removal of the obstruction is entirely a secondary matter and is a separate procedure.

Nowadays several operations are often done at a sitting and drainage of the bowel and removal of the obstruction are too

often attempted at the same time, with very disastrous results, for under no other circumstances will it more frequently be said that the operation was successful but the patient died.

It is a fallacy to urge that the removal of the obstruction will drain the intestine in the natural way, for such drainage may be as inferior to the drainage afforded by an enterostomy, as the drainage of an empyema through a bronchus after rupture into the lung is inferior to that of a suitable thoracotomy. For, while the toxic intestinal contents above the obstruction is but slowly absorbed by the damaged and distended bowel in which it lies, when the obstruction is removed it passes immediately into comparatively healthy gut and may be quickly taken up and the added intoxication resulting may be more that the patient can stand. This probably explains many of the not infrequent cases where death occurs a few hours after a "successful"

operation.

Where the obstruction is low in the large intestine, this factor may not be important on account of the proximity of the anus, but the higher the stoppage the more imperative becomes the indication for drainage by enterostomy rather than through the remaining gut. I think study of cases bears out this hypothesis. For example, ordinarily obstruction occurs most often in the lower part of the bowel, but obstruction by impaction of a large gallstone is more apt to happen in the upper part of the gut, and under ordinary operative measures these cases seem to do exceptionally badly in spite of the simplicity of the operation. I know personally of one case of this sort and have heard of two others, and in all three the removal of the stone was easily and successfully accomplished, and in all the patient died a few hours later. In another of these gallstone obstruction cases of which I recently read, the removal of the stone was followed in a few hours by severe collapse and the patient had a hard time to pull through.

The following case is a still more striking illustration of this danger. A couple of years ago I did a laparotomy for intestinal obstruction and found that the cause was a strangulation

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