With the Compliments of the Author. 
THE SURGICAL TREATMENT 
OF 
Intestinal Obstruction; 
A Paper read before the Tri-States Medical Society, during its 
Annual Session, in Evansville, Indiana, 
November, 1879, 
BY 
W. T- BRIGGS. m. d., 
PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF NASHVILLE 
AND OF VANDERBILT UNIVERSITY, NASHVILLE, TENN. 
REPRINT FROM THE “NASHVILLE JOURNAL OF MEDICINE AND SURGERY”*^. 
NASHVILLE, TENN.: 
PRINTED AT “THE AMERICAN” STEAM BOOK AND JOB OFFICE. 
1880. THE SURGICAL IREAMENT 
OF 
INTESTINAL OBSTRUCTION. 
From the earliest period of history, the profession has been 
divided in opinion as to the propriety of resorting to surgical 
means in the treatment of internal intestinal obstruction. Some 
authorities oppose them under any circumstances; some resort to 
them only in exceptional cases, while still others favor their use 
after the failure of the ordinary therapeutic means. Praxagoras, 
350 B. C., according to Aurelianus, (Ziemssen’s Encyclope- 
dia) recommended opening the abdomen in the iliac passion. 
Barbette, in the middle of the Seventeenth Century, proposed it 
in intussusception, in preference to committing the patient to cer- 
tain death. Hevin advocated a resort to laparotomy for internal 
strangulation of the bowels, before the Royal Academy of Sur- 
gery of Paris. After a long debate, the members came to the 
conclusion “ that it was better to leave the patient affected with 
ileus to Providence, even if the case was hopeless, than to en- 
danger the profession and authority of physicians by performing 
laparotomy.” Van Sweiten condemned all operative measures. 
Cheselden, the father of lateral lithotomy, advised and practiced 
gastrotomy in hernia, introducing the hand into the abdomen and 
drawing the incarcerated bowel back into the cavity. In 1852, 
I saw a case of strangulated hernia, in consultation with an old 
physician of Kentucky, who strenuously urged a similar opera- 
tion for its relief, and appeared somewhat disgusted when I de- 
cided to do the ordinary operation. Morand, Blanchard, Breschet 
and others approved of gastrotomy under certain circumstances. 
Boyer, Dupuytren, Masson, and Testu opposed the operation. 
The great Velpeau thought it might be undertaken when we had 
a complete certainty of the existence of a recent strangulation, 
and when the situation of the disease was well ascertained. Nelaton 2 
says “the most serious objections have been made to this operation. 
It is, indeed, very difficult to determine the point or seat of the 
strangulation, and one can only remove it at the expense of 
manoeuvres which singularly predispose to peritonitis. We think 
that in cases of this kind it is better to have recourse to the es- 
tablishment of artificial anus—to enterotomy.” Trousseau writes : 
“ It appears to me, therefore, that the undeniable success which 
has attended ovariotomy would justify for the cure of internal 
strangulation recourse being had to an operation, which, though 
perhaps more calculated to excite alarm, is sure, more rational 
and less dangerous than ovariotomy.” Watson, in his great 
work on practice, in discussing the operation in obstructed bowels, 
says : “And if the peril were my own, and all the other pros- 
pects of relief had failed me, I would subject myself to this for- 
lorn hope of rescue.” Rokitansky (Path. Anat.) : “This affec- 
tion, when diagnosed, most imperatively requires an operative 
proceeding for the purpose of disentangling and arranging the 
intestines, and for the division of the strangulating structures.” 
Aitken (Practice of Medicine): “ When all remedies fail, gas- 
trotomy may be thought of and its chances of success considered.” 
Tanner thinks, “ If by a careful and searching examination, we 
come to the conclusion that the obstruction is in the small intes- 
tine and is caused by a diverticulum or by a constricting band of 
lymph around the bowel, it is the duty of the practitioner to per- 
form gastrotomy. On the contrary, in cases of intramural ob- 
struction, of intussusception, of stricture from contraction of cica- 
trices, etc., in neither of these instances has an operationally 
chances of success.” George Pollock (Holmes’System of Surg.) 
advises the operation for the relief of internal strangulation, or 
stricture of the small intestines, or foreign bodies or calculi, but 
opposes it in intussusception. C. Hilton Faggsays (Guy’s Hosp. 
Reports) : “ I entertain a strong hope that the exploratory oper- 
ation will hereafter be admitted as a legitimate procedure, anti 
will be successfully practiced in carefully selected, but no doubt 
exceptional cases o! internal strangulation of the intestines.” 
Mr. Benj. Philips (Medico-Chirurgical Trans.) concludes “that 
interference by surgical operation is justifiable when three or five 
days have passed without any relief from ordinary means, (pro- 
vided the constipation be complete and the vomiting continues), 3 
because it affords a greater chance for the preservation of life than 
ordinary means.” Erichsen (Science and Art of Surgery, Vol. II.) 
says: “If, however, it can be satisfactorily made out that there is an 
intestinal strangulation, and more especially if the intumescence oc- 
casioned by it can be felt, it will evidently be the duty of the 
surgeon to give the patient the only chance by the division of 
the stricture.” Bryant (Pract. Surgery) writes as follows: “At 
any rate, as matters now stand, a recovery from an internal 
strangulation is a matter of wonder, and it would be well, as all 
collateral experience indicates, that a bolder practice should be em- 
ployed.” Austin Flint, Sr., (Prac. Med.) says: “In short, at the time 
■when the operation, if employed at all, would be advisable the 
chances of recovery would be less than if reliance were placed in 
spontaneous cure. Even with a view to artificial anus, the oper- 
ation would be likely to lessen the chances of spontaneous cure. 
The propriety of surgical interference has, therefore, not many 
advocates.” Ashurst (Principles and Practice of Surg. ,2nd 
Ed.) thinks the operation of laparotomy justifiable under 
certain circumstances. “If, however,” he says, “the case 
be one of intussusception (and this is, as has been seen, 
the cause of obstruction in the majority of acute cases),, 
the surgeon will, in mv judgment, usually consult the best 
interests of the patient by declining operative interference. In 
cases of acute obstruction due to other causes than intussuscep- 
tion, there can be no doubt, I think, that laparotomy is justifia- 
ble should other means fail to give relief in the course of three, 
or, at most, four days.” Agnew writes (Surgery Vol. I.) : 
“ When the usual measures for the reduction of intussusception 
have failed and there is reason to believe that the vitality of the 
part is not lost, it will be proper to open the abdomen and disen- 
gage the invaginated portion of the bowel. When the obstruc- 
tion is due to strangulation, all remedies except opium are use- 
less ; and, when the impediment to the passage of feces is com- 
plete,with stercoraceous vomiting, there remains, as the only ave- 
nue of escape from death, the operation of laparotomy or enterot- 
omy, though this measure offers but a gloomy prospect of relief. 
The difficulties which confront the surgeon in these cases are of 
such a nature that he does not feel at liberty to urge the knife.” 
Gross says (System of Surgery, Vol. II.): “I have myself no fancy 4 
for this kind of interference In internal strangulation depending 
upon intussusception, a twist or the interception of bowel in an 
aperture of the omentum, the diagnosis is so uncertain that the 
proper time for relief is usually allowed to pass before an opera- 
tion is agreed upon ; and, when at length it is performed, the case 
must almost of necessity terminate fatally.” 
One of the chief objections urged against the operation of la- 
parotomy in internal strangulation, is that the peritoneal sac is so 
delicately organized, that the slightest injury is almost certain to 
be followed by intense and probably fatal peritonitis. Such was 
the generally adopted opinion when ovariotomy was in its in- 
fancy, and it was this bug-bear that for awhile retarded its more 
rapid progress. Dr. Peaslee, in his classical work on ovariotomy, 
says “ that even in 1864, there was not another surgeon in the 
city of New York to defend the operation/'’ This opinion was 
maintained, notwithstanding the fact that the peritoneal sac had 
in numerous instances been injured by accident, lacerated, torn, 
bruised, and yet patients so injured recovered without any 
bad symptoms. Mr. George Pollock (Holmes’ System of Surg.) re- 
lates the following case occurring in the practice of Mr. James, of 
Exeter: A lacerated wound nine inches long was made through the 
abdominal walls by a bull. He found the man with a large quan- 
tity of small intestines and omentum protruding and covered with 
dirt, particles of straw, etc. He cleaned and returned t.:em, 
dressed the wound and sent the patient to St. George’s Hospital, 
fifteen miles distant, in a cart. Notan unpleasant symptom fol- 
lowed ; he recovered completely. Dr. Brigham relates a case in 
the American Journal of Medical Sciences, quoted in Eve’s col- 
lection of surgical cases, which is even more remarkable, show- 
ing the tolerance of the peritoneal sac. The patient was a man- 
iacal female, who, in an attempt at suicide with a pair of scis- 
sors, made two wounds in her abdomen, one about an inch and a 
half above the umbilicus, the other half an inch below it. From 
the upper opening she took out part of the small intestines, from 
which she cut off a portion seventeen inches in length, when she 
was discovered by another patient, and the alarm being given, 
she Was forced, not without some resistance on her part, to cease 
from further injuring herself. This case proceeded to complete 
recovery, notwithstanding a portion seventeen inches long had 5 
been removed, and the physician in charge simply returned tie 
divided ends into the abdomen. Mr. Durham (Holmes’ Surg.) 
relates seven cases in which the stomach was opened for the re- 
moval of foreign bodies. All of these cases recovered. 
Statistics show that nearly one-half of the cases of Caesa- 
rian section have been successful, despite the well-known 
fact that in the majority of eases this operation is only performed 
as a dernier resort, when the patients are already in the very 
threshold of death. 
The latest report of Spencer Wells gives eighty per cent, of 
recoveries in his operations for the removal of ovarian tumors. 
In a recent number of the Detroit Lancet we find the report of a 
ease in which a woman had been subjected to the operation of 
gastrot_>my three times. In fact the most extensive wounds and 
injuries of the abdominal cavity are often followed by perfect re- 
covery, unless the intestines be perforated and their contends dis- 
charged into the peritoneal cavity. Is it not reasonable to sup- 
pose that peritonitis would be more likely to supervene upon an 
intestine incarcerated or strangulated internally for several 
days, its circulation interfered with and effusions taking place 
into the peritoneal cavity, than from a smooth, clean incision into 
the cavity ? Haven’s investigations of a large number of cases of 
obs -meted bowels show that in such cases peritonitis is not of 
frequent occurrence. Peaslee, Sims, and in fact, almost all writers 
upon ovariotomy concur in the opinion, that in a majority of cases 
of death following that operation, septicaemia from the retention 
of septic fluids in the abdominal cavity, and not peritonitis, is the 
cause. The pathological changes produced by inflammation of the 
peritoneal membrane, are not of themselves sufficient to produce 
death, but the effusions which are the result of the inflammatory 
action, are likely to become decomposed and septic, thereby en- 
gendering that most fatal disease, septicaemia. The most rational 
treatment of peritonitis, in my opinion, would be .to make an 
incision into the peritoneal cavity, remove the effusions which 
would probably become septic, wash it out thoroughly with an 
antiseptic fluid, and provide some means by which the cavity 
could be drained of its noxious contents. 
Another objection urged against laparotomy is that the diag- 
nosis is necessarily difficult and uncertain, more especially in re- 6 
ference to the nature and seat of the obstructing cause. That the 
importance of diagnosis is great, all will admit; that it is difficult, 
no one will deny ; and that the success of all operative measures 
depends upon it to a great degree, all will acknowledge. Gene- 
rally there are salient points manifest by which the existence of an 
obstruction maybe determined upon beyond peradventnre. The 
symptoms presented mark out clearly two classes of cases, the acute 
and chronic,each characterized by peculiar phenomenaand produced 
by special causes. The one brought about by the sudden block- 
ing up of the lumen of the intestine, the other by the gra- 
dual diminution of the calibre of the canal by causes 
which act slowly. The acute variety is characterized by 
sudden pain paroxysmal in nature, soon followed by vom- 
iting of the contents of the stomach, then of bilious fluids, 
and finally of fecal matter. Constipation, a prominent symp- 
tom, is generally complete from the beginning of the occlu- 
sion. In some cases, the contents of the intestine below the ob- 
struction are evacuated spontaneously or by the aid of enemata, 
after which nothing passes. The sudden vomiting and con- 
stipation, are accompanied by great prostration of the vital 
powers, frequent pulse, hiccough, colliquative sweats, hippocratie 
face, etc. These symptoms indicate without doubt constric- 
tion of the bowels, either situated within or without the ab- 
dominal cavity, and admonishes the surgeon to examine carefully 
the legions of the abdomen at which the bowel may protrude, 
for the presence of external hernia. 
In chronic obstruction, it will be found that for a greater or 
less time abdominal pain or distress has existed with more or less 
difficulty in obtaining actions from the bowels ; that the, gradu- 
ally increasing constipation is followed by obstruction, evidenced 
by pain, nausea, vomiting, borborygmus, abdominal swelling, 
well marked outlines of the bowels seen through the abdominal 
walls, etc. The acute may, it is true, become chronic, and vice 
versa, but the symptoms and history of the case will be generally 
sufficient to enable the surgeon to satisfy himself of the existence 
of an internal strangulation. 
He should, however, attempt more than the mere diag- 
nosis of the existence of an obstruction. He should endea- 
vor to locate the exact seat of the occlusion. Sometime* 7 
an examination of the rectum by the finger, or by instru- 
ments, will decide the position of the obstruction. The 
introduction of the entire hand into the lower bowel, as 
advised by Simon, of Heidelburg, will reveal the trou- 
ble high up in the rectum or in the lower part of the sigmoid 
flexure of the colon. Amussat’s plan of injecting the bowel 
with water and comparing the amount of fluid with the known 
capacity of the bowel may prove of service. A careful explora- 
tory examination by palpation of the abdomen may detect a tumor 
which, by its growth, presses upon some portion of the intestines 
and produces obstruction. By the same means, the enlarge- 
ment caused by an invagination may be recognized. As a gene- 
ral rule, the acute symptoms indicate that the occlusion is in the 
small intestines, and the chronic in the large ; but, if the cause 
producing the impediment in the small intestines is slow and 
gradual in its action, the symptoms will indicate the chronic 
variety; and, if any cause suddenly produces constriction of the 
large bowel, the symptoms arising therefrom will be acute in 
character. Most usually, however, the causes which act suddenly 
are found located in the small intestines, and those which act 
more slowly and gradually in the large. 
If the obstruction is seated in the upper part of the 
small intestines, vomiting and collapse come on early, to- 
gether with a diminution of the urinary secretion. The 
course of the disease is rapid. There is little or no swelling; 
should there be any, it is confined to the epigastrium, and becomes 
diminished after vomiting. The vomited matter is bilious, never 
stercoraeeous. When the seat of the occlusion is in the lower 
part of the ileum, the swelling is very great, and is confined to 
the central part of the abdomen, while the regions corresponding 
to the colon are empty. The course of the disease is here also 
rapid; vomiting, swelling and prostration come on early. The 
vomiting soon becomes stercoraeeous. When the eonstriction is 
located in the lower part of the colon, the course of the disease is 
less rapid. Vomiting and collapse come on later, and the matter 
ejected from the stomach is stercoraeeous. The distention is con- 
siderable and at first is confined to the regions of the colon and 
coecurn. By close attention to these points, the surgeon may 
form a very correct opinion of the seat of the obstruction. 8 
Now, to discover the anatomical causes of the obstruction is a 
still more difficult problem for the surgeon to solve. The causes 
which may occasion an attack of acute strangulation are internal 
hernia, volvulus, intussusception, diverticula, bands, knots, open- 
ings natural or acquired, gall-stones, intestinal stones, foreign 
bodies, etc. They produce symptoms so nearly similar that it is 
often impossible for the surgeon to do more than to form a suppo- 
sition as to their probable nature. It may be revealed in some 
cases by characteristic signs, as in intussusception, when there are 
almost always discharges of bloody mucus, or by the history of a 
foreign body, previous peritonitis, of hepatic colic with passage 
of gall-stones, or the discharge from the bowels of intestinal 
stones. Fortunately, a knowledge of the anatomical eauses of ob- 
struction of the intestine is not essential to the surgeon in the 
treatment of the acute variety of obstruction, but in the chronic 
form it is highly important. Chronic occlusions are most gene- 
rally dependent upon impaction of fecal matter in the rectum or 
colon, or on the mechanical pressure of tumors, intussus- 
ception, the matting together of coils of intestines from in- 
flammation of the peritoneum or mesentery producing contrac- 
tion of the bowel, and stricture of the rectum or colon. Of 
seventy-six fatal cases of obstruction reported by Bryant 
(Practice of Surgery), three were due to impaction of feces, 
three to the pressure of tumors, twenty-three to contraction 
caused by matting together of the intestines, and forty- 
seven to stricture of the bowel. The nature of the obstruction 
when caused by fecal impaction is readily discovered by a digital 
or manual examination of the rectum or colon; when caused by 
a tumor, it is recognized by palpation and percussion, assisted by 
vaginal or rectal examinations. If dependent upon stricture of 
the rectum or colon (benign or malign), it is detected by exami- 
nation of the rectum or colon, as well as by the difficulty in defe- 
cation, the absence of vomiting till near the close of the disease, 
the great distension of the abdomen, particularly in the lum- 
bar regions. When caused by contraction consequent upon 
chronic inflammation, the symptoms are dependent on the 
difficulty of the passage of the contents of the bowel. The 
nausea is paroxysmal, depending upon the attack of col- 
icky pains, which are of frequent occurrence. The ab- 9 
domen is not usually much distended; when it is, the swell- 
ing occupies the central or hypogastric region. The peris- 
taltic movements are plainly visible, accompanied with borbo- 
rygmus. The seat of the contraction is most usually in the ileum 
or ccecum. 
From close attention to these points, the surgeon can most 
usually arrive at a proper conclusion in regard to the nature of 
the obstructing cause in the chronic variety. 
Another objection preferred against laparotomy for the relief 
of internal occlusion of the intestines, is the high rate of mortal- 
ity following the operation. There have been comparatively so 
few operations for the relief of these obstructions that our statis- 
tics are very meagre; but we do not think the death rate is higher 
than that of other capital operations, as hernia, amputation of the 
thigh in its upper part, ligature of large arteries, etc. It 
must be recollected that the disease for the relief of which the 
operation is performed, has a high rate of mortality without the 
operation. Lichtenstein (Ziemssen’s Encyc.) says, that in the 
Vienna General Hospital, out of sixty cases, only six or ten per 
cent, recovered. In a statistical table, prepared by Whitall, of 
New York, (V. Y. Med. Jour.), laparotomy had been performed 
in thirty cases of intestinal strangulation from all causes. In 
three of the thirty cases, the operation was abandoned before com- 
pletion. Of the remaining twenty-seven, twelve recovered and 
fifteen died. Of this number, nine are reported as having been 
in favorable condition and nine recovered. Of the eighteen re- 
ported as having been in an unfavorable condition, three recov- 
ered. Thus in the favorable cases, there was one hundred per cent, 
of recovery after the operation, and in the very unfavorable (al- 
most moribund) about twenty per cent, of recoveries. 
Prof. John Ashurst has collected ninety-three cases in which 
the operation was performed, and the number added to that al- 
ready quoted, makes 123 cases. Of these operations, thirty-one 
were lor the relief of intussusception and ninety-two for other 
causes. Of this number, thirty-seven recovered and eighty- 
six died. 
It must be remembered that many of the cases included in this 
table were collected from the remotest period, two having been 
operated on in the last century. The advance of surgery has 10 
improved our methods of operating and after treat- 
ment, so that it is reasonable to suppose that now the rate of mor- 
tality would be greatly lessened. When we reflect that the opera- 
tion has always been and is still performed only as a last resort, 
after all other remedies have been exhausted, and when the pa- 
tient is almost moribund from the pathological changes neces- 
sarily consequent upon long continued incarceration or strangu- 
lation—it is wonderful that the rate of mortality is not higher. 
Indeed, it is surprising that any case should recover alter the 
operation. The death rate is but little higher than that following 
the operation for strangulated hernia, and if it were resorted to 
only under the same circumstances in strangulated hernia as it is 
in obstruction of the bowel within the abdomen, the rate of mor- 
tality would be as high in external hernia as in internal obstruction. 
Mr. John Birkett (Holmes’ System of Surg.) says: “Mr. Hey states 
that when he entered upon the profession of surgery, now one 
hundred years since, the operation for strangulated hernia had not 
been performed by any surgeon of Leeds; and adds that he (Hey) 
lost three out of five patients upon whom the operation was per- 
formed.” Mr. Birkett asks : “Are the results of the treatment 
for strangulated hernia more successful at the present day?” and 
answers, “'We fear not.” Bryant (Pract. Surgery) states that in 
fifty-nine cases of femoral hernia operated on in Guy’s Plospital 
in eight years, the mortality was fifty per cent, in femoral, and 
sixty percent, in inguinal hernia; and yet all surgeons agree that 
the operation for strangulated hernia is a necessity. The intes- 
tine obstructed, incarcerated, or strangulated in the cavity of the 
abdomen differs in no particular from the intestine obstructed, 
incarcerated, or strangulated in the walls or outside the abdomen. 
The symptoms, the pathological changes and the consequences are 
precisely similar. The treatment which would be rational for the 
one, would be rational for the other. The great object in each is 
to remove the cause of the obstruction, incarceration or strangu- 
lation at the earliest possible moment, since every hour’s delay 
increases the danger to the patient. In the acute variety of intes- 
tinal obstruction, whether dependent upon internal hernia, bands, 
diverticula, volvulus, or intussusception, the physician’s art is fu- 
tile. No benefit can be derived from the administration of med- 
icine. On the contrary’, much injury may result therefrom. The 11 
older physicians resorted to balls of lead or antimony, or pounds 
of shot, or crude mercury, then rolled or shook the poor patient 
until he was breathless, or made him walk up and down the room 
for hours. The practice of administering drastic purgatives, 
adopted by some at the present day, in the hope of breaking through 
the obstruction, is equally absurd and dangerous. In some rare 
cases, such treatment might succeed ; but oftener it will increase 
the strangulation by forcing larger portions of the bowels through 
the constriction ; and, by increasing the dragging at the point of 
obstruction, the inflammatory infiltration is augmented and a 
greater pressure exerted thereby upon the incarcerated bowel, thus 
oftentimes increasing the tendency to mortification. The treat- 
ment by opium, urged by some surgeons, is of no value, for while 
it may mitigate the pain and hold the peristaltic action of the 
bowels in check, it masks the symptoms and leads the surgeon to 
a false security; fatal changes are going on despite it. Opium, 
concentrated diet, and large enemata, are the most reasonable 
means that can be resorted to, because they are less likely to do 
harm than any other means; and yet we can not see how either 
one or all of them combined can remove a compressing band, a 
twist, or an intussusception. Occasionally, it is true, a patient 
recovers from an internal obstruction of the bowels under the 
most adverse circumstances, without any operative procedure. 
The same may be said of external hernia. Occasionally a stran- 
gulated hernia is reduced spontaneously after efforts of the sur- 
geon by taxis, etc., have failed ; but no prudent surgeon would 
willingly leave such a case to the chances of a self-reduction. It 
is unquestionably true that in some cases of intussusception, the 
bowel does, in some unknown way, right itself, and in o hers the 
invaginated portion may slough, pass off, become agglutinated, 
and a cure result; but such relief is not to be depended upon. 
Statistics show that not more than one in five recover in this way. 
Nor is it always desirable that sloughing should take place. It 
may happen before adhesion of the surfaces of the intestine has 
been effected ; or the bowel, at the point of sloughing, may af- 
terward contract to such an extent as to form a permanent 
stricture. There is no hope of relief, then, from the actions of 
medicines, very little, if any, from the efforts of nature. The 
only relief to be expected is from the surgeon. The means 12 
which he has at his command are abdominal taxis, injection of 
air or water, puncture of the bowel, laparotomy, laparo-enter- 
otomy, laparo-colotomy. 
The abdominal taxis, first recommended by Segar, was prac- 
ticed as follows: The patient was put in a warm bath and 
etherized, the limbs drawn up and the shoulders raised 
to relax the abdominal muscles; then the whole abdomen 
was rubbed and kneaded from one part to the other. But this 
method of taxis is too uncertain and empirical to be advised or 
practiced. And it must be borne in mind that serious consequences 
might follow from rupture of the bowel at the point of constric- 
tion, or in cases of intussusception irom the disengagement of the 
invaginated portion which had become gangrenous, before ag- 
glutination had taken place. 
Since the days of Hippocrates the inflation of the bowels by 
the injection of air has been recommended for the relief of inter- 
nal obstruction, especially when caused by intussusception. The 
idea was, that by distending the bowel, the invagination is un- 
folded, and thus the cause of obstruction removed; or the bowel 
is drawn out of the embrace of a band, or from a knot or loop. 
In cases of intussusception loc ited in the large intestines, and in 
the early stages of the disease, before adhesion has taken place, it 
is reasonable to expect that the invagination might be unfolded, 
especially it the patient is placed in the knee-elbow position. But 
if the invagination has lasted for some time, if it has become 
fixed, or if the symptoms indicate gangrene, or if general peri- 
tonitis is present, a resort to inflation is contra-indicated. Indeed, 
in any case, unless done very gently and with great caution, 
serious injury may be inflicted upon the parts involved. The 
same may be said of the forcible injection of large quantities of 
water. 
Another measure which has at times been resorted to by 
surgeons with reported success, is the puncture of the in- 
testine with a tine trochar for the purpose of removing 
the gas. With this object in view, it is proposed that 
the trocar be thrust into different parts of the abdomen, when 
there is great tympanitis, and the gas allowed to escape. Tem- 
porary relief may be given by this operation ; but, in mv opin- 
ion, there is very little chance of any permanent benefit, except 13 
in one particular condition, viz.: in twist of the bowel involving 
especially the sigmoid flexure, which is kept up by the large ac- 
cumulation of gas. The effect of the escape of the gas will be to 
allow the intestine to untwist itself. But this little operation is 
not entirely devoid of danger, for if the contents of the perfo- 
rated intestine be fluid, a small quantity may follow the with- 
drawal of the instrument and get into the peritoneal sac, setting 
up a general peritonitis. 
We have very little confidence in the efficacy of any of 
these methods. Nothing short of a cutting operation, the 
opening of the abdominal cavity by incision, discovering 
and freeing the bowels from constriction, offers any hope 
of permanent relief. It alone offers the only prospect for the 
salvation of life. So long as the obstruction remains, the patient 
is doomed; every hour, every minute, that passes, lessens the 
chances of recovery. Too often the cutting operation is regarded 
in the light of a forlorn hope, not to be resorted to until the 
life of the patient is seriously threatened. In my opinion, death 
from internal strangulation would be a much less frequent occur- 
rence if the knife were employed earlier in the disease. Death 
is not caused by the operation; it is due to the pathological 
changes consequent upon delay in its performance. We would 
unhesitatingly urge laparotomy early in the course of acute in- 
testinal obstructions, at least as soon as the existence and nature 
of the obstruction is ascertained, whether dependent upon in- 
ternal hernia, inflammatory bands, volvulus, knots, diverticula, 
intussusception, etc. MoreoVer, if the exact nature of the 
trouble cannot be satisfactorily determined, the symptoms being 
urgent and characteristic, we would insist upon an exploratory 
incision and a search for the cause of the difficulty. Even should 
we fail to find and remove the cause giving rise to the symptoms, 
no great harm would be done. 
Laparotomy is not a difficult operation, but there are some points 
connected with it that demand the special attention of the sur- 
geon ; for, upon his careful observance of these, the success of 
the operation often depends. The antiseptic plan of Lister should 
be scrupulously practiced from the beginning to the end of the 
operation. The incision in the linea alba should be ample for the 
easy exploration of the cavity. The distended bowels which 14 
rush out as soon as the incision is completed, should be covered by 
a soft flannel wrung out of warm water, and not handled until the 
gas is removed by punctures made at several points with a finetro- 
char. The examination should be conducted with the greatest gen- 
tleness, the hand following the distended bowel downwards or 
the empty bowel upwards until the point of obstruction is reached. 
Most generally the distension, as well as the congestion, cease ab- 
ruptly at the seat of the constriction. The point having been 
discovered, the bowel should be disentangled in the gentlest 
manner. If, after a careful search the obstructing cause can- 
not be discovered, or the bowel be so entangled as to be inextri- 
cable, or is found gangrenous, the formation of an artificial anus 
is the only measure to be adopted. Should a considerable portion 
of the bowel be gangrenous, it has been recommended to excise 
it, and unite the two ends by suture. This operation has been 
performed three times, and one resulted successfully. 
The patient should then be turned on his side so that the fluids 
in the abdominal cavity may escape, and, if necessary, a fine 
sponge, held in a sponge-holder, should be passed into the cavity 
sufficiently often to remove any remaining fluids. The incision 
should be closed with silver sutures including the peritoneum, 
and the antiseptic dressing applied, supported by a well adjusted 
flannel bandage. Opium should be administered at regular inter- 
vals. 
Bland and nutritious diet should be given at stated intervals. 
The bowels mav be opened by an injection of warm water or by 
some mild laxative after six or eight days. 
While the symptoms of the acute variety of obstruction are ur- 
gent and rapidly tend to collapse and death, the fatal issue 
often hanging upon the discretion and firmness of the surgeon in 
seizing upon the proper moment for action—the chronic is dis- 
tinguished by symptoms which come on by degrees, and may con- 
tinue for days or weeks. In most cases the symptoms are so much 
less urgent than those of the former that it allows time for more 
thorough consultation, and if surgical treatment becomes neces- 
sary, many favorable features towards the prolongation of life, 
are offered. The surgical means necessary are less dangerous, 
and the rate of mortality much diminished. 
When it is discovered that the obstruction is dependent upon 15 
fecal accumulation in the bowels, the treatment will consist in 
the removal of the feces by the fingers or scoop, aided by the 
free use of oleaginous enemata. It due to the pressure of a 
tumor, either pelvic or abdominal, the tumor should, if possible 
be removed; or should its nature be such as to forbid its removal, 
then an opening in the bowel should be made for the escape of 
the fecal matter. Should the trouble arise from a chronic intus- 
susception, a resort to laparotomy will be necessary—nor should 
the operation be postponed long, for the reason that adhesion of 
the invaginated bowel will probably take place, and thus often 
prevent the good effect of the operation. When the history of 
the case leads us to believe that the obstruction is caused by con- 
traction resulting from chronic inflammation, etc., more espec- 
ially if the absence ot swelling, the doughy feel of the intestines 
at a certain point, and the arrest of peristalsis at that particular 
part be observed—enterotomy is applicable. Manoury was the 
first to call attention to the establishment of an artificial anus in 
the ileum in cases of internal strangulation when the obstruct- 
ion could not be found or removed. Nekton proposed to abandon 
the search for the seat and nature of the obstruction with the 
intention of removing it and to establish an artificial anus in the 
ileum above the obstruction in order to permit the escape of 
the accumulated feces, leaving the strangulation to take care of 
itself. The advantages claimed for this operation are that the 
peritoneum is injured to only a slight extent, and as the fold of 
the bowel which first presents itself is the one used for the arti- 
ficial anus, the entrance of the elements capable of setting up 
sepsis in the abdominal cavity is prevented and that the operation 
is less dangerous and much easier of execution than laparotomy. 
The serious objections to its performance are that the strangulation 
is not reduced, and that peritonitis may ensue and terminate in 
gangrene and perforation. 
The disadvantages of an artificial anus, which may last through- 
out life, are very great. While this objection is trifling compared 
with the, preservation of life, yet it will cause the surgeon to 
pause and consider well every other plan before he determines to 
resort to its formation. Notwithstanding the recommendation of 
many distinguished surgeons and their efforts to establish its 
■luperiority over laparotomy, we think that the operation of enter- 16 
otomy should be resorted to only in cases of chronic contractions 
situated in the lower part of the ileum, or in the coecum, to cases 
in which the cause of the obstruction cannot be found or re- 
moved, and to others in which the condition of the bowel is such 
as to prevent its return into the cavity of the abdomen after 
laparotomy. Nekton’s operation is performed in the right iliac 
region by making an incision commencing an inch above and 
about an inch and a half to the inner side of the ant. sup. spine 
of the ilium running parallel to Poupart’s ligament to the extent 
of two inches and a half or three inches. Dividing the tissues, 
layer by layer, until the deep fascia is reached, tying vessels as 
may be required, sponging the wound carefully the fascia is cut 
through when the peritoneum is exposed. It is seized by forceps 
and incised. Afterwards a silver suture having a curved needle at 
each end is carried through the intestine in its length, to the ex- 
tent of an inch; each needle is then carried through the skin at 
each side of the wound, making a stitch on each side of the in- 
cision, after which two others are made, at right-angles to the first, 
one at the superior and one at the inferior angle of the wound. In 
this way the intestine is fixed everywhere, laterally and from above 
downwards, to the walls of the abdomen—by this proceeding no 
exudation can take place into the peritoneal cavity. It only re- 
mains to make a small incision, less than one-third of an inch, 
into the intestines by means of a sharp-pointed bistoury. 
When the history of the case, the symptoms present and a 
careiul examination of the rectum and colon, together with an ex- 
ploration through tne walls of the abdomen leads us to the conclu- 
sion that the obstruction is in the large bowel, a recourse should 
be had to colotomy. For it is certain that obstinate constipation 
caused by mechanical obstruction in the large bowel is not bene- 
fited by the persistent use of purgatives or enemata. On the 
contrary, injury often results from their use, while opium only 
conceals the symptoms and deceives the surgeon. When the seat 
of the disease is in the rectum or sigmoid flexure of the colon, 
the opening should be made in the left loin, but when the 
exact location cannot be determined it should be made in the 
right. 
The operation of colotomy was first suggested by Callisen in 
1796. Amussat revived the operation and extended it to the 17 
right loin in 1830. Since that period the operation has been per- 
formed a great number of times with success. 
The rate of mortality has been exceptionally low. It is now 
recognized as one of the most useful operations and is practiced by 
almost all surgeons, in obstruction of the large bowel, even when 
it is known that the obstruction is produced by cancerous deposits 
and that the relief promised can be of but short duration. 
In searching our American medical journals and authorities we 
find very few cases of internal intestinal obstructions reported in 
which laparotomy or laparo-enterotomy have been resorted to. 
The first operation of laparotomy performed in the United States 
was by Dr. John R. Wilson in 1835, (Transylvania Med. Journal) 
for intussusception, on a negro man living in Rutherford county, 
Tennessee. The patient had been suffering from colic, stercora- 
ceous vomiting and other distressing symptoms for seventeen 
days—had taken all the active purgatives, and as a dernier resort 
several ounces of crude mercury had been administered the 
evening before the operation. An incision having been made 
through the linea alba into the cavity, the bowel protruded 
and the portion involved came into view. After some force 
the adhesion between the invaginated parts gave way. It 
was feared that the force necessary to sever the adhesion 
might lacerate the intestine, but no such result followed. 
The bowel seemed to be on the verge of mortification. 
It was returned into the abdomen and the incision closed. In a 
short time the bowels acted. The patient recovered rapidly and 
completely. 
Laparo-enterotomy for obstruction of the intestine was again 
performed by Dr. Joseph Manlove, of Davidson county, Tennessee, 
(Boston Medical Journal) in July, 1844. The patient, a 
colored boy 19 years of age, had had no action from the bowels 
for fifteen days. Had been treated by frequent bleeding, 
purgatives and repeated enemata. Gastrotomy was determined 
on. An incision through the walls of the abdomen was made 
in the middle line. Intricate adhesions had formed between the 
peritoneum and bowel, and in cutting through the walls of the 
abdomen an opening was made into the bowel. Large quantities of 
flatus and feces passed out at once. The wound was closed by sutures 
and adhesive plaster, except a small portion corresponding with 18 
the opening in the intestine. The amendment in all the 
symptoms, in an hour, was amazing. The extremities had 
become warm, pulse full and strong, appetite returned, and 
he was able to fan himself. The discharge continued 
from the wound seventeen days, when the bowel acted 
naturally, the wound healed and the patient recovered 
perfectly. 
Dr. Thomas Wood* of Cincinnati, (Eve’s Surgical Cases) 
reports another case in a man 45 years of age, who had had an 
external hernia and had pushed it back into the abdomen. No 
action of the bowel hadoceured since the accident. He was found 
with feeble pulse, sunken countenance, cold perspiration, and at in- 
tervals of half an hour, vomiting stercoraceous matter. A thor- 
ough examination discovered no hernial tumor at the external or 
internal rings, or in the canal. It was the opinion that either an 
invagination, or the portion of the bowel returned, which had per- 
haps become twisted upon itself and strangulated by adhesive bands, 
was the cause of the obstruction. The operation of gastrotomy was 
performed. When the peritoneal cavity had been opened and the 
omentum raised, the difficulty was discovered to be a part of the 
sigmoid flexure of the colon strangulated in the sac which had 
been returned with the bowel. The stricture was divided and 
the bowel replaced. The patient recovered rapidly. 
Prof. H. B. Sands, of New York City, (New York Med. Jour. 
Vol. 1, 51.) reports still another case in which the operation of 
laparotomy was performed on a child six months old, eighteen 
hours after the appearance of the symptoms. The obstruction was 
caused by intussusception. The result of the operation was good 
and the patient completely recovered. 
In the June number of the American Practitioner, Dr. J. M. 
McCormack details a case in which the obstruction was caused by 
a band extending across the ileum and colon, produced by an old 
gun-shot wound, in which laparo-enterotomy was successfully re- 
sorted to. 
To these we are enabled to add three cases of intestinal ob- 
struction occurring in our own practice during the last eighteen 
months in which laparotomy was performed. 19 
CASE FIRST—EAFAROTOMY FOR INTUSSUSCEPTION. RECOVERY. 
In July 1878, I.was summoned to meet in consultation Drs< 
Pyle and Huff near Tullahoma, Tennessee. The patient, Mrj 
W. T. Bixby, aged 28, a stout athletic farmer, whilst engaged in 
lifting heavy crossties, had been seized with a most excruciating 
pain in the right iliac region accompanied with nausea and great 
prostration. He was carried to his residence about a mile distant 
and Dr. Pyle called to his assistance. The doctor found him 
nauseated and occasionally vomiting, with feeble pulse, skin cold, 
clammy and bedewed with perspiration, anxious expression of 
countenance, and suffering great agony from a constant pain in 
the lower part of the abdomen. After mitigating the pain with 
a full opiate, Dr. Pyle gave him a purgative without any result. 
On the following day he found the patient no better. The pains 
located in the right iliac region were in no wise relieved. The 
bowels had not been moved. The abdomen was somewhat distended, 
but no particular tenderness was detected. The pulse was feeble and 
quick; the skin was wet with perspiration, cold and clammy. A 
more active purgative was given, but except to create great com- 
motion in the bowels, aggravate the pain and increase the vomit- 
ing, it had no effect. The doctor becoming satisfied that some 
existed, put the patient upon opiates and 
nourishment in small quantities, together with large enemata, at 
the same time asking that Dr. Huff, of Manchester, be called in 
consultation. At the suggestion of Dr. H. three drops of croton 
oil were administered with the effect of greatly aggravating the ab- 
dominal pain an l increasing the vomiting. It was then agreed 
that there was an obstruction of the bowels, prob tbly an intus- 
susception, and that nothing but opium should be given, together 
with concentrated diet. 
Three days afterwards the symptoms still persisting, though 
mitigated in severity, it was thought best to call a surgeon to 
consult with them in regard to the propriety of an operation for 
the relief of the obstruction. 
Accordingly I visited him on the tenth day of his sickness, 
k found him in a semi-recumbent position with an immensely 
distended abdomen, countenance expressing great suffering, skin 
bathed in cold perspiration, pulse small and quick, constant hie- 20 
cough, vomiting every five or ten minutes a small quantity of 
fecal matter, pain still intense in the right iliac region. The 
bowels had not moved since the first attack. After full consul- 
tation it was decided that laparotomy was the only hope of relief 
left the patient. When the operation was proposed the patient 
eagerly consented, and even begged that it might be performed 
without delay. The patient was at once placed on the table and 
etherized. An incision was made through the walls of the abdo- 
men in the linea, alba from the umbilicus to the pubis. As soon 
as the peritoneal cavity was opened a mass of small intestines, 
of a very dark color, immensely distended with gas, and with 
the peritoneal coat ruptured at the convexity of every flexure, 
protruded. They were in such a condition that it was quickly 
decided that no examination for the seat of the obstruction should 
be made until the great distension was relieved. This was ac- 
complished by puncturing the bowel with a small hollow needle 
which I fortunately had brought with me. 
After half a dozen punctures had been made, and a large vol- 
ume of gas had escaped, the bowel collapsed, and an exploration 
was commenced for the obstruction by following the coils of the 
bowel downwards. After three or four feet of intestine had been 
examined, a portion was reached which had not been distended, 
and appeared of natural color. At the abrupt termination of the 
dark and distended bowel aif intussusception of six or eight 
inches* was found, the invaginated portion drawn out without 
difficulty, and the bowel returned to the cavity. A quart or more 
of dark, fetid sanguineous fluid was mopped out of the abdomen, 
the sponge being frequently pressed down deeply among the coils 
of the intestine, after which the cavity was washed out with 
a solution of carbolic acid. The incision was then closed with 
silver sutures, a compress and bandage applied, the patient car- 
ried to bed, and an opiate enema administered. 
Six hours afterwards I left the patient doing well. He was 
enabled to assume the recumbent posture, the pain which had 
been persistent was relieved, the pulse less frequent and more 
fnll, and the skin less inclined to perspire. He still had hiccough 
and occasional vomiting. Letters from his physician in- 
formed me that after a pretty sharp attack of peritonitis, he 
recovered completely. The bowels were evacuated on the fifth 21 
day after the operation, and in two weeks he was up. He has 
continued well since. 
CASE SECOND—ENTEROTOMY FOR OBSTRUCTION CAUSED BY 
CHRONIC INFLAMMATION. RECOVERY. 
Robert Ellis, a thin, emaciated young man, aged 26, printer by 
trade, of tuberculous tendency, had always been subject to con- 
stipation, seldom having more than two evacuations during the 
week, and he often congratulated himself that he was not 
troubled in that way like others. For several weeks he had 
more than usual trouble with his bowels, very seldom having an 
evacuation and then with difficulty and slight in character. He 
suffered greatly with borborygmus and occasional nausea. For 
more than a week previous to my first visit he had had no movement 
from his bowels. He frequently had a desire to have an action, 
but when he attempted to defecate, failed. After these attempts' 
he frequently became very sick at the stomach and vomited, and 
was often faint and covered with cold perspiration. He had 
taken several active purgatives without any other effect than to 
increase the nausea and vomiting. My first visit to him was on 
April 2, 1879. He was in bed with a full pulse, furred tongue, 
moist skin and an expression of anxiety on his countenance. 
He had vomited freely a short time previously, and was still nau- 
seated. There was no distension of the abdomen, but the form 
of the intestines could be plainly seen through the thin abdom- 
inal walls, more plainly as the peristaltic action propelled the gas 
from one point to another. In the right iliac region a 
firm, hard swelling as large as an orange was discovered, 
at which point all movement seemed to cease. The swelling was 
not tender upon pressure, and appeared to be slightly movable. 
Thinking that the trouble was occasioned by an impaction of 
feces at that point, I ordered a saline purgative, to be assisted 
by injections of warm water. Several thin, watery discharges 
were produced by their combined action and the patient seemed 
to be much benefitted. The saline was repeated several times 
afterward, together with enemata, but with no effect. 
His nausea, vomiting and prostration continued. On the third 
day after my first visit, Prof. Roberts, of Hendersonville, a rela- 22 
tive of the patient, saw him with mej and suggested small doses 
of calomel with extract of belladonna, to be followed by castor 
oil. No evacuation was induced. For the next ten days, the 
patient, notwithstanding the administration of various remedial 
agents, grew gradually worse. He suffered great pain in the ab- 
domen, became very restless, suffered much with nausea and 
vomited frequently, after which he usually felt easier for some 
hours, and would take some refreshments, and get a little sleep. 
The ejections from the stomach were now evidently mixed with 
stercoraceous matter. The intervals between the vomiting spells 
became shorter and shorter, and he was rapidly becoming ex- 
hausted, when I called a consultation of Prof. Menees and my 
son, Prof. 0. S. Briggs, to consider the propriety of enterotomy 
for preserving his life. They fully agreed with me that the op- 
eration was the onlj resource left us for preserving the life of 
the young man. After a full and frank exposition of the case, 
not omitting to mention the unpleasantness and annoyance of the 
artificial opening which would be left, he begged to have the 
operation performed. Accordingly, assisted by Profs. Menees, 
C. S. Briggs and Drs. M. Baxter and O. H. Menees, I proceeded 
to perform the operation as follow's: An incision commencing an 
inch above and about an inch and a half to the inner side of the 
ant. sup. spine, of the ilium wras made to the extent of two inches 
and a half parallel to PouparPs ligament, and carried through the 
several layers of the abdominal wall until the peritoneum was 
reached. This was opened on a director, and the finger passed 
into the cavity to the swelling visible through the walls of the 
abdomen. It proved to be situated in the lower part of the ileum, 
just above the ileo-csecal valve, and was caused by thickening of 
the intestinal coats and adhesions to all the parts around. In fact 
the parts were so matted together that it was impossible to 
define clearly the true character of the obstruction. I re- 
garded it as dependent on a tuburculous deposit, with sub- 
sequent adhesion, etc. A portion of the small intestine just 
above the obstruction was seized and brought out of the in- 
cision, and silver sutures having curved needle at each end was 
carried through the intestine in its length on each side of 
the wound to the extent of an inch, and each needle then carried 
through the skin at both extremities of the incision. A silver 23 
suture was then passed through the skin at the upper angle, through 
the bowel and the opposite edge of the incision. Another suture 
was similarly placed at the lower angle. These sutures having been 
drawn tight and fastened, the intestine was opened to a small extent. 
In fifteen or twenty minutes the pent-up contents of the bowel 
poured through the opening in large quantities, and continued to 
escape at short intervals. Reaction soon came on, and the patient 
was much more comfortable during the evening and night. The 
pain had disappeared entirely. He had no nausea nor vomiting; 
took some mild nourishment and slept well. He continued to 
improve rapidly, sitting up in a few days, and expressing himself 
as feeling very well. 
On the sixth day after the operation, the sutures were removed 
and adhesion between the bowel and the skin found to be perfect. 
With the exception of the annoyance caused by the excessive 
flow of the contents of the intestine through the artificial anus, 
he was in good condition. Inflammation and excoriation were 
produced by the constant flow of fluids over the skin, and the 
parts were so tender that no instrument could be adjusted to re- 
strain them. He, however, improved so as to be enabled to dress 
himself and sit up all day and to frequently go out. Five months 
after the operation, following an illness of three or four weeks, 
he died of a tuberculous affection of the lungs. 
CASE THIRD—OBSTRUCTION PRODUCED BY AN OVARIAN 
TUMOR REMOVED BY OPERATION. 
In 1873, I performed the operation of ovariotomy upon Miss 
Mary Hearn, of Wilson County, Tenn. The tumor originated from 
the right ovary, and was extensively attached to all the parts around. 
She recovered promptly and returned to her home a month 
afterward. She continued in fine health until eighteen months 
since, when she noticed a swelling in her left side, which gradu- 
ally grew until it attained considerable size. For more than a 
year past, she has been subject to attacks of constipation, accom- 
panied with nausea, vomiting and great prostration. After a few 
days of suffering, she would be relieved by mild purgatives, as- 24 
sisted by enemata. The attacks becoming more frequent and ob- 
stinate, I was called to see her. Upon inquiry, I learned that 
the attacks came on without any known cause at intervals of two 
or three weeks, and were ushered in by nausea, vomiting of ster- 
coraceous matter, with distension of the abdomen and utter pros- 
tration of the system. The tumor was about the size of the 
adult head, firm, circumscribed and elastic. I was satisfied that 
it was an ovarian cyst, and that the attacks she suffered were 
caused by pressure on an imprisoned bowel by the tumor, causing 
an obstruction. I at once tapped the cyst, drawing off nearly a 
gallon of dark, thick fluid resembling molasses. The sac was 
evidently multilocular as the trocar had to be introduced several 
times before the fluid was entirely removed. She was greatly re- 
lieved by the tapping, and had no attack for a month, when, the 
sac becoming again filled, she had the same trouble as before. 
Her physician tapped her again, giving relief, and he continued 
to repeat the tapping at intervals of three weeks. But as the 
frequent tapping and occasional attacks of obstruction were im- 
pairing the patients health, I was requested to visit her, with a 
view to performing some operation for her relief. 
Her physician, as well as one or two other physicians who had 
seen her in consultation, were fully persuaded that the attacks of 
constipation were due to intestinal obstruction from the pressure 
of the tumor. I fully coincided with them in this opinion. I 
proposed to attempt the removal of the tumor, and, if, as I sus- 
pected, the adhesions were too extensive to permit its safe re- 
moval, to incise its walls, and attach the sac to the walls of the 
abdomen, leaving an opening for permanent drainage and a con- 
traction of the cyst. Accordingly on the 6th of June last, as- 
sisted by her physician, Dr. Hanna, and Drs. Anderson and Fite, 
of Lebanon, I made an incision five inches in length in the linea 
semi-lunaris of the left side, and divided the layers seriatim until 
the sac was reached. It was found closely adherent to the walls of 
the abdomen and to every other part with which it came in contact. 
In a cautious attempt to separate the sac from the surrounding 
part, a coil of intestines was found imbedded in the adhesions 
between the tumor and the abdominal wall, liberated and as every 
separation was attended with profuse hemorrhage, I. desisted from 
the attempt, and satisfied myself with an incision into the sac, 25 
afterwards placing a drainage tube through the opening. When 
the larger sac had been incised and emptied, one or two smaller 
cysts were discovered, and a trochar passed through the partition, 
the cyst emptied, and the septum then broken down with the fin- 
ger. The patient bore the operation remarkably well and reacted 
kindly. She slept well the night following, and expressed her- 
self as feeling better than she had for months. I received letters 
from her physician from time to time, all of an encouraging tone. 
She had no unpleasant symptoms after the operation. The dis- 
charge from the cyst passed off freely through the drainage tube 
and by its sides. The tube was removed on the sixth day. The 
sac was thoroughly wished out twice a day with a weak solution 
of carbolic acid. I saw her physician about the 11th of July 
last, and he reported that the sac was entirely obliterated, and 
there was very little, if any, discharge passing from the wound ; 
that her general health had been entirely restored, and that she 
had had no more return of her bowel trouble. OLDEST IN THE SOUTH. 
ESTABLISHED 1851. 
THE 
Jiiirol if jjjeJirittt anJ 
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