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of intestinal obstruction, and without operation or autopsy the cause of the obstruction is undetermined; and while there is no doubt that an ileus may be produced by local or remote irritation of the nerve supply of the intestine, its persistence sufficiently long to cause complete obstruction and death must, I think, happen with extreme rarity.

The tendency on the part of the physician in cases of intestinal obstruction, from whatever cause, is to err on the side of conservatism; it is especially so in post-operative obstruction due to paralytic or mechanical ileus caused by adhesions or kinks. The dread of, and opposition to, a second operation leads us to persist with medical measures.

It is certainly very difficult to determine the definite cause of postoperative distension, obstruction and vomiting, and I know of no condition that causes more anxiety and calls for more careful judgment. If after a fair trial of rectal enemata and gastric lavage the condition persists, it is wiser to explore, radically relieving the obstruction if we can, or by doing a temporary enterostomy, preferably a colostomy, than to wait indefinitely hoping against hope that the condition will be relieved by medical measures.

In my own experience I am conscious of having postponed colostomy too long, and finding not infrequently a constricting band, a volvulus, or adhesion not a pseudo-ileus but a pronounced and definite ileus, which only surgical intervention can relieve.

THE PRESIDENT: Is there any further discussion?

DR. JOHN W. CHURCHMAN (New Haven): I want to refer briefly to two cases that illustrate points that have merely been touched upon by Dr. Cassidy. The first case was in a patient in whom we had an opportunity not only to see the condition that Dr. Cassidy has described but also to see the actual lesion. The patient had symptoms of obstruction-pain predominating, and nausea without vomiting. It was diagnosed as a case of chronic obstruction, and it was decided to operate. During the operation, the small intestine became completely obstructed by a sharp and definitely localized spasm in the ileum. This caused a tumor mass, which could be picked up and handled, and which had been palpated before the operation. It made the diagnosis absolutely positive, because the enterospasm was seen in the intestine at operation. In this patient, a practical cure was brought about by the administration of large doses of belladonna.

The other case illustrates the risk that one runs in assuming that in any given case the disease is due to an enterospasm. The patient had a definite attack of angio-neurotic edema, with the typical picture of intestinal obstruction, including pain due to enterospasm. The diagnosis was made; but, as a matter of safety, an exploratory operation was

done and the diagnosis confirmed. Two years later, the patient had a similar attack; but in this, the skin lesions were not present. The same man who had operated previously had the patient in charge again this time, and assumed that the condition was angio-neurotic edema this time also. He was observed for a number of days. Finally, we operated again, and found general peritonitis from the appendix; and the patient died. Therefore, I think that this case emphasizes strongly the point that it is far safer to explore in a doubtful case than to assume that the condition of enterospasm is present.

DR. WILLIAM H. CARMALT (New Haven): I remember a case I saw in consultation with Dr. L. W. Bacon of New Haven, some years ago. This case presented some features that were different from those described, being simply those of intestinal obstruction persisting for several days. An operation was finally performed by Dr. Bacon, who told me that he had found the ileum for two feet contracted down to the size of a leadpencil. There was no opportunity for the intestinal contents to get through. It was absolutely tight. He relieved the condition by a gentle stroking manipulation over the surface of the intestine. This relieved the condition of spasm, and the intestinal flow went on again. I saw the patient subsequently, in a second attack. I should say that the patient was a lager-beer saloon-keeper, and that just previous to his first attack he had indulged in sauerkraut and various other substances, which did not have a good effect on his digestive apparatus. He was warned about his diet. Several months afterward, having in the meantime observed good habits regarding his eating, he indulged for a second time in a sauerkraut feast; I saw him in this second attack, in consultation with Dr. Bacon. It was a question whether he should be operated on again. Knowing what the condition had been in the first attack, we decided not to operate, but treated him medically. An anesthetic was first given him, then somewhat large doses of atropin; and the attack passed off, but that was a case in which the condition was different from what had been prescribed heretofore, where the spasm was simply persistent. That was all that there was to it, and this simple treatment did away with the intestinal obstruction.

DR. ERNEST H. ARNOLD (New Haven): Dr. Carmalt's reference to sauerkraut points out possible mechanical factors which may cause spasms. Dr. Flint's remark of tumors pressing forward on the mesenteric plexus might explain the spasm of the intestinal tract that we meet with in deformities of the spine. In tubercular lesions of the dorsal region of the spine, spasms, signalized by pain in the region of the stomach, are frequently observed. That these spasms include spasms of the vaso-motor system, the relatively frequent occurrence of ulcer of

the stomach in cases of this type would suggest. They are most frequent and most violent in cases where the gibbus formation is most pronounced. Pressure on the spinal nerves is a nearly constant symptom of all deformities of the spine, whether these deformities be of destructive or degenerative nature.

I am not well enough posted on the anatomy of the plexus in question to say whether they are connected with the spinal nerves directly or indirectly. If they are, the pressure on the nerves must undoubtedly have an influence on them.

The other mechanical factor may produce direct pressure upon these plexus. In tubercular lesions of the spine, the abscess formation oftentimes gets to be very large, large enough, at any rate, to make it more than probable that it exerts pressure upon the structures in question. For both reasons, I should suggest that an examination of the spine is always important in cases of this type.

DR. JOHN E. LOVELAND (Middletown): May I ask a question? I wonder whether, in looking up the subject, Dr. Cassidy noted whether the paralysis always takes place at the same point. That would have an important bearing on the treatment. If that were so, anastomosis or excision might cure the patient.

THE PRESIDENT: Is there any further discussion of Dr. Cassidy's paper? If not, I will call on the author to close the discussion.

DR. PATRICK J. CASSIDY (Norwich): In answer to the last speaker (Dr. Loveland), I would say that the resection was done by Dean, of England, in his case. There were four attacks, and four operations were performed on the same woman; and in the three operations before the resection was done, the attacks were all in the same portion of the gut. He did the resection to relieve the condition, but it was not relieved. The point that I wanted to bring out in the paper is the necessity for early operative interference in all cases presenting the symptoms of intestinal obstruction, without paying too much attention to the fact of the existence of such a condition as pseudo-ileus of this type.

Dr. Smith spoke of my first case as perhaps not being a true enterospasm. I have been doubtful myself, because the man had a lesion in the left apex; but he died during an attack of the disease, a recurrence of the spasm. I do not know why the death certificate was made out as of death from indigestion. I did not see him in the final attack. The treatment that has been advised, the medical treatment, has been the treatment with belladonna and opium. These cases of enterospasm are not to be confused with cases of pseudo-ileus due to irritative

causes, either in the gall-bladder, or due to round-worms, or due to adhesions, in the gut somewhere else. We know that often, in operating on cases of mechanical obstruction or pseudo-ileus due to an adhesion, we find intensely contracted portions of the gut below the point of adhesion or constriction.

The one point that I wanted to bring out, and rather insist upon, is the fact that although these cases are rare, they seem to be increasing in number or are being reported more frequently. The first case was reported by Hawkins, in 1906. They are apparently increasing in number; yet we should not allow any doubt to enter our mind about the justice in the position of early opening of the abdomen even though there is the chance of the condition being one of enterospasm.

The Aniline Dyes in Surgery.

DR. JOHN W. CHURCHMAN, NEW HAVEN.

I wish to speak of the new principle of selective affinity which drugs have for the cells of the body. Of course, this principle is really an old one; because a number of the drugs that we have long had depend, for their action, on selective affinity of a most striking type. The recognition of what this principle really signifies is, however, new, because it is now being investigated by scientific work all over the world.

This work has had two general effects. One is in increasing our ability to recognize cases, and the other is in increasing our ability to treat them-diagnostic and therapeutic results. The first is an old one, and is illustrated by some of the most familiar drugs-the cycloplegiacs and the drugs used to dilate and contract the pupil; it is hard to imagine a selective principle more keen in the way that these drugs pick out certain cells and spare others. Some of the poisons, and particularly lead, exhibit an affinity of this sort in a remarkable degree. Lead paralyzes some motor nerves alone, leaving the remainder untouched, thus producing the wristdrop or palsy, a selective action of the most precise kind. Another selective action of this kind, exhibited by a virus, is shown in infantile paralysis, where not simply are some of the motor-nerve elements paralyzed, but those that lie next to each other will not be affected alike. The rectus, for instance, will be paralyzed, and the sartorius absolutely spared.

Two drugs that exhibit this selective action are quinine and mercury; and these drugs, though used in medicine for a great number of years, were introduced on purely empirical grounds. Nevertheless, they represent, as well as the newer synthetic drugs, such as salvarsan, the same principle. Quinine was introduced from Peru on empirical grounds, and it has stood the test of trial. Mercury was introduced for the most absurd of reasons-because it was cold, and was supposed to combat the heat on which so many diseases depended. It was

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