After the tenesmus has ceased, proceed as before until the intussusception gives way or the limit of safety is reached. The siphons I have been using contain thirty-seven and a half ounces of water charged with carbonic-acid gas at a pressure of 150 pounds to the square inch. The carbonic-acid gas and water have a soothing effect also on the heated and inflamed bowel, and aid in the induction of retro-peristalsis. The first practical test I had with Dr. Forest's device was in 1886, with my then business associate, Dr. E. B. Bayliss, who reported it, and case 2, in the American Journal of Obstetrics in the November number of the same year. Cases 5 and 6 are introduced with this as completing the report of cases. CASE 4. Carrie S., female, aged three years, July 14, 1886. Was called late in the evening to the patient. She had been suffering with diarrhea for ten days, but for the last three had voided nothing except bloody mucus. There was tenesmus and protrusion of the mucous membrane of the rectum on attempts at stool. Abdomen was tympanitic and tender, and the legs were drawn up against it. There was slight vomiting. Paregoric was given until morning, by which time the necessaries for constructing the apparatus could be procured. A July 15. Condition much the same. tumor about three inches in length was located in the transverse colon, and appeared to be an intussusception of ileum into colon. About one fourth of a siphon was used slowly and carefully, causing the tumor to gradually disappear. The child became calm and quiet and rested comfortably. July 16, the child had had two stools since the injection; the first, fecal, with some blood and mucus; the second was entirely fecal, and was saved for inspection. There was no pain nor tenesmus, and the tenderness had almost disappeared from the abdomen. The same afternoon another small injection was given, as the symptoms indicated a slight return of the trouble. There was no further difficulty, and, save a paregoric mixture, no medicine was given. A careful diet was enjoined, and that the child be kept in bed for a few days and pass her stools while lying down. CASE 5. Lucy K., female, aged eight years, August 14, 1887. Child had been suddenly attacked with diarrhea on August 11th. When seen, she was in great misery. There was vomiting, and the abdomen was slightly swollen and painful at a point near the ileo-cecal valve, where a small tumor was felt. No stools had been passed for eighteen hours, though many attempts, resulting in the discharge of mucus and blood, had been made. An injection of one third of a siphon was given, which caused the tumor to disappear and allayed the vomiting and colic. A prescription of paregoric and cardamon was occasionally given. No food except milk was allowed, and she was also ordered to remain in bed and pass the stools while lying down. Found the patient all right in the morning, she having had one large fecal passage without pain or distress. There was no further trouble. CASE 6. Chris. R., male, aged four years and six months, June 29, 1889. This patient. had been under treatment for entero-colitis two weeks previous to the accident, but had been in ordinary health for a week at the time it happened. happened. He was seized with the usual signs of an intussusception, the tumor being located in the descending colon at the sigmoid flexure. Its presence was demonstrated by carrying the finger well into the rectum and making counter pressure on the abdomen. A small injection from the siphon promptly restored the bowel to a normal condition. There was no relapse. These three cases, with those reported by Drs. Foster and Bayliss, together with the successes of Dr. Senn in this line, encourage the thought that there is no method so successful, nor is there one so safe when the intussusception lies in the colon. If the ilium alone is concerned, laparotomy or opium will probably have to be relied on. The only contraindications to the use of injections of whatever nature are: 1. When the intussusception lies in the ilium. 2. When extensive peritonitis is present. 3. When firm adhesions exist between the opposed surfaces of the gut. 4. When collapse has taken place. 5. (Ziemssen). When in intestinal affections in which there is diminished resisting power of the intestinal walls. Practically this only refers to such conditions as typhoid fever and intestinal tuberculosis. It is estimated that from 30 to 40 per cent of children recover by the use of injections, while only about 14 per cent survive the operation of laparotomy. Of this, Atfield says: "If the case be one of intussusception, the surgeon will in my judgment consult the best interests of his patient by declining operative inteference, because "1. The tender age of many of the subjects of invagination renders them peculiarly illadapted to support so grave an operation. "2. The operation, which is always one of a very serious nature, is particularly so in these cases on account of the frequent existence of peritonitis as a complication. 38 were children, with a mortality of 87 per cent, and 25 were adults, with a death-rate of 68 per cent. In all, 13 recovered and 50 died; mortality 74 per cent. Section was performed in 34 cases, and the bowel released (including Barker's case), with a mortality of 65 per cent. In 29 of these cases the intussusception was irreducible. In 5 of the 29 cases the incisions were exploratory, as there was no attempt at reduction. In 14 the bowel was resected, and in the remaining 10 artificial ani were formed. But a single one of these 29 cases recoveredthat of an adult whose intussusception was resected." In those cases where inflation or abdominal section are contra-indicated or refused, opium must be relied upon to give relief. Here, as in peritonitis, large and oft repeated doses, but "3. The attempt to dislodge the invaginated little short of complete narcosis, are of the bowel is very apt to fail. "4. There is very fair probability of spontaneous recovery after sloughing of the invaginated gut." In view of these expressions it would seem best to reserve the operation for those older than ten years, as each year past that age adds to the chances of the operation being successful. Mr. Barker, of London, England, however, takes a different and more advanced position in the matter than most surgeons, believing that in suitable cases section when done early enough offers a very fair chance of recovery. The Medical News of September 15, 1888, gives an abstract of Mr. Barker's paper as reported by him in the Lancet of August 11, 1888, substantially as follows: greatest value. Enough should be given to completely stop all peristalsis and pain, for by so doing the patient is rendered comfortable, and the intestine is left in a condition favorable to the reduction of the intussusception by nature or manipulation, or to a sloughing of the invaginated portion, as has happened in a number of reported instances. Belladonna has been advised, but its use is attended with very little good effect, and mercury is not to be thought of. When the opiate treatment is adopted in anticipation of a cure by sloughing, the latter may be expected to take place somewhere between the seventeenth and twenty-fifth days; 15 per cent (Treves says 42 per cent) of all cases recover by this means. Lichtenstern's well-known statistics give 557 cases in which the termination was known, and of these sloughing occurred in 149 (26 per cent); 88 of the 149, or 59 per cent, ended in recovery, and 61, or 41 per cent, in death. Of the 408 in which sloughing did not take place, only 63 (about 14 per cent) terminated favorably; 345, or 85 per cent, ended in death. "A child four years old, with positive symptoms of intussusception, came under the care of Mr. Barker. A median incision was made and the hand carried into the abdomen, and the tumor reduced according to Hutchinson's method. This consists in pushing the tumor upward from below, and at the same time retracting the ensheathing bowel with one hand, while with the other gentle traction is made upon that portion of the intestine which enters the upper portion of the invagination. The recovery was complete. Statistics are given of 63 cases of intussusception of all varieties which were treated by abdominal section. Of this number discharged. Another such interesting result Dr. Rinteln (Berliner Klin. Wochenschrift) reports a case May 24, 1875, where sloughing took place in a woman of sixty years on the twentyfifth day. She made a complete recovery, and was in good health ten years afterward. In this case about four inches of the small intestine was occurred in the practice of Dr. John Ferguson, of Toronto, Canada, in which an adult male. discharged four and one half inches of the jejunum on the seventeenth day and recovered. (Medical News, December 15, 1885). A number of instances of repair by sloughing are also recorded in the text books on surgery, and by Treves in Intestinal Obstruction." Some observers are of the opinion that repair by sloughing is not desirable because the adhesion of the surfaces is of a mechanical nature and is apt to give way before permanent healing is complete, or that a stricture may be formed that will seriously impair the normal usefulness of the intestine or even reproduce the intussusception at a later period. These anticipated disasters are almost too remote to have much weight in the treatment; they certainly give the surgeon no uneasiness when he finds it necessary to make a resection of the gut in this or other conditions. Careful attention to diet, habits, and occupation for a considerable time after an intestinal disorder of of this nature will amazingly lessen the dangers which might otherwise happen. For some time following an intussusception, whether the reduction has been accomplished by injection, sloughing, or section, the diet should be most carefully regulated, and only those foods permitted that leave a minimum quantity of bulky refuse to pass through the digestive tract. Neither should the digestion be overtaxed and the risk of diarrhea or constipation incurred. During the presence of the acute symptoms no food should be allowed per os, rectal nutrient enemas being much superior in the management of the case. In these, as in other intestinal disorders, it is well to first rid the rectum and lower colon of fecal material by means of an injection of warm water, and after a few minutes to carefully and slowly introduce from four to six ounces of the selected nutrient. I have been in the habit of using the following emulsion, which, if given every four to six hours, appears to support the patient very fairly. It is as follows: One patient, in whom rupture of a gangrenous bowel took place after operation for femoral hernia, became heavier and more fleshy while fed on this per rectum than previous to the operation. The emulsion is never rejected unless too large a quantity is given. A question which the physician and surgeon will have to decide is, when shall operative procedures be taken? Or how far may other measures be permitted? The exigencies of each individual case will have to be determined upon its own merits, and the good judgment of the physician give the decision. Some cases may present no urgent demand for section for a week or more, while in others it may be imperatively demanded as early as the first or second day, or almost immediately after a positive diagnosis is made. Delay in these latter means inevitable death, for peritonitis will occur and develop so extensively and rapidly that section would only hasten a fatal result. cases Dr. Richardson (Asclepiad, May, 1889) says: "So soon as this symptom (fecal vomiting) is established there should be no hesitation in opening the abdomen for the exploration of the obstruction and the attempt at removing it. Obscurity of diagnosis in regard to the seat and nature of the obstruction ought not, in the presence of this special symptom, to prevent the resort to surgical interference, because sometimes what is inferred to be a complicated obstruction turns out to be an extremely simple one; and again, if the obstruction be complicate, it may admit of being relieved without any further serious danger to the patient than would arise from omitting the operation." It is well to err on the safer side, and attempt to rescue the patient by means of an operation than to passively permit him to die unrelieved. In looking over the history of the accident of the numerous cases reported, and the possibilities of treatment, the following conclusions drawn from the subject are suggested for your consideration: 1. That intussusception in the small intestine is best treated by laparotomy or by opium. 2. That when the intussusception is in the colon it is good practice to make use of liquid or gaseous injections before resorting to the knife. 3. That the earlier abdominal section is made after being decided on, the better are the chances of recovery. COVINGTON, KY. PLEURITIC EFFUSIONS.* BY CHARLES W. AITKIN, M. D. In asking the attention of this Society to the subject of Pleuritic Effusions, I do so, not from the fact that I expect to advance any new treatment; for Dieulafoy's aspirator, with the many modifications it has received, gives us perfected means of treatment so far as serous effusions are concerned. I hope, however, to call the attention of the profession to the fact that pleurisy with effusion-since it is not accompanied by the marked symptoms found in an acute attack-is oftentimes overlooked, and the patient is treated for various affections unless a careful physical examination is made. I have endeavored to select three cases of effusions into the pleura to represent this class that is not often recognized except by physical examinations. In my short experience in the practice a number of such cases have presented themselves for treatment. All have been relieved except four; three of these would not submit to a thoracentesis; one who did, died after several months of pulmonary tuberculosis. only seen one case where there was any effusion of consequence that was absorbed. In the three cases who would not have thoracentesis made, two died in paroxysms of orthopnea, the other passed into a purulent pleurisy, the lung tissue became involved, and the patient died from phthisis. The importance of detecting these cases early can hardly be overestimated. I have We let an effusion alone a few weeks or months and it may become purulent: the patient is subject to septic poison, the pus may pass into the lung, and soon the patient dies with symptoms akin to pulmonary tuberculosis. The general symptoms of effusions of the chest are often wanting; the patient may complain of a slight dyspnea, sometimes a hacking cough; frequently they say, "I am simply fatigued,' without describing any special symptoms; how*Read at the May meeting of the Kentucky State Medical Society, 1890. ever, if we make a careful physical examination we will elicit dullness on percussion, no breathing is detected where the dullness is prominent, and there is absence of vocal resonance. In females the menstrual function is usually arrested. In very many cases we will not see the bulging of intercostal spaces, nor may we notice the absence of intercostal movements, especially if the effusion be recent and the quantity small; however, if we have dullness, no breathing, and no vocal resonance, we are justified in using a hypodermic needle, and this will clear up the diagnosis. The use of the hypodermic as an exploring needle in these cases can do no harm if used in careful hands, provided the needles are kept thoroughly disinfected. Permit me to give brief reports of three cases: 1. Miss A., aged eighteen years, came to my office complaining of a slight cough, without expectoration, amenorrhea, anorexia, constipation, some dyspnea, pulse 96, temperature 99.8°, respiration 24. She being a young lady and I a young physician, a physical examination was embarrassing, so I prescribed a ferruginous tonic, with some palliative for the cough. After a week I was called to see the patient at her home; she said she was "no better, but rather weaker," general symptoms about the same as ten days previous. I percussed the chest, or rather a dress with a full supply of underwear, and then applied a stethoscope to try to listen through this clothing; of course, every physician who has tried these experi ments knows what the result was. I knew no more after such percussion and auscultation. than I did before. I prescribed a tonic with a laxative and left, "hoping the patient would be well in a few days." The "few days" came around as usual, but the patient was not well, and in two weeks I saw her again. At this visit the patient was in bed and was only dressed with a gown and light under garment. In percussing over the light vest I thought I detected dullness on the right side from fifth intercostal space down; then, after some apologizing without any common sense explanation on my part, I got all the clothing covering the chest out. of the way and made my first satisfactory phys ical examination of the case. I gave opinion of effusion, and after considerable persuasion the patient consented for me to use a hypodermic needle, which procedure confirmed my diagnosis. After several days more of lost time trying to aid in the absorption of the fluid, she consented to aspiration, and about one pint of serum was removed. The patient was put on tonics, and in about one month she was enjoying excellent health. She gave no history of an acute pleuritis at the beginning of her illness, and after the fluid was removed there was never any indication of a return of the effusion. Had a physical examination been made earlier the patient might have been saved many days of uneasiness, not to say any thing of the danger to her general health. This case taught me the best lesson on physical diagnosis I have ever learned. 2. In August, 1889, M. T., aged twenty years, called at my office; said he had suffered from neuralgia or rheumatism of the right side for the past month; he complained of a slight dyspnea, no cough, had a fair appetite, claimed to have suffered no severe pain, but said there was constantly an uneasy feeling in the side. Pulse 98, temperature 100°, respiration 26. When his clothing was removed from his chest I found a porous plaster applied to his “neuralgiac or rheumatic side," whereupon he told me that a doctor had applied it in order to relieve the neuralgia. Physical examination revealed that the right chest was the receptacle of a quantity of fluid; the patient at once agreed to a thoracentesis, and in two days afterward I removed by aspiration two and one half pints of serous fluid; the young man was kept quiet for forty-eight hours; he took tonies for about three weeks, and has since been actively engaged at work, there being no recurrence of the effusion. 3. In October, 1887, I saw M. M., aged twenty-four years; he had been treated two weeks prior to my visit for a pneumonia, and was dismissed as well by his family physician. The patient thought he was more poorly when dismissed than when he first called his physician; however, there were no symptoms present indicating any acute sickness; he complained of uneasiness in left chest, an oppressed feeling, had some coughing on least exertion, but no expectoration, bowels constipated, not much appetite. Physical examination showed that, the left chest was too full, intercostal spaces did not respond to respiration, dullness complete on left side, no breathing could be heard over normal space for left lung, the heart was so displaced as to put the apex at the right nipple; an exploratory puncture through the chest walls showed a straw-colored fluid; on aspiration three pints of serum were drawn off; a week afterward one and one half pint were removed; this gave relief for about five weeks, when I was again called to aspirate, and found a sero-purulent fluid, removed three and one half pints and washed out cavity with a bichloride solution; a week afterward three pints more were withdrawn and the cavity was washed out with a solution of iodine; the patient then felt much better for ten days; at that time he complained of pain in left side, and his temperature went up to 103.6°. Thirty-two ounces of an offensive purulent fluid were removed, and the cavity was again washed with a bichloride solution, the patient was advised to have a free opening made into the chest and a drainage-tube inserted, but he hoped for the better without this operation. He improved apparently for a week, when the temperature went rapidly up to 104° and pulse to 140; stimulated him with whisky, and after giving a hypodermic injection of morphia I again aspirated, this time drawing off eighty-two ounces of very offensive pus. He now agreed for the chest to be opened, whereupon Dr. Ransohoff made the opening, washed the cavity thoroughly, and put in a large drainage-tube; from that time the patient improved gradually, gaining thirty pounds in three months, at which time the lung was still expanding, the heart had assumed its natural position, and the patient was in a fair way to make a complete recovery. These cases present briefly various phases of these effusions and show the necessity of careful physical examination; one further shows the hopelessness of aspiration when empyema is established. After making the operation over twenty-five times I have never had any trouble except with the case that became purulent. We should aspirate early and remove |