Patients suffering from small bowel obstruction of some days' duration, can and do recover after the band or other obstructing agent is removed, but in quite a large proportion of cases, such an operation, though apparently relieving the patient for a time, fails to drain efficiently the distended bowel, and death results from an increasing toxæmia or further signs. of obstruction supervene some days later, necessitating a second operation which the patient may be unable to stand.

This point is illustrated by the two following cases, which have been under my care:

CASE I.-Girl, aged 10, was admitted with the history that for the previous twelve hours she had experienced severe abdominal pain. Vomiting only commenced shortly before admission. Operation was performed immediately and revealed a distended and deeply congested loop of ileum, which had become strangulated by a band stretching from the cæcal region to the posterior abdominal wall. The band was divided, and in a few moments bowel contents were seen to be passing into the contracted ileum. The obstructed loop appeared to be perfectly viable and was returned to the abdomen. The bowels moved on the second, third, and fourth days, but a few hours later vomiting recommenced. During this time the profound toxæmia had persisted, and she now became so collapsed that further operation was deemed inadvisable, and death occurred shortly afterwards.

This patient was operated upon at an early stage, the obstruction was easily found and relieved with a minimum of handling. The bowels moved freely after operation, yet the toxin continued to be absorbed from the jejeunal coils with resulting persistence of the toxæmia, and death.

CASE II. The second case is that of a boy, aged 15, upon whom I operated for gangrenous appendicitis. Drainage was not employed, and he left hospital on the fourteenth day. A month later he was readmitted, suffering from severe abdominal pain, obstinate constipation, and vomiting of three days' duration. Operation was performed at once and a band found, which stretched from the posterior abdominal wall to a loop of ileum, causing it to be kinked and obstructed. The band was divided and its area of attachment to the ileum peritonised, though there was no sign of gangrene. The bowels moved on the following day and continued to be satisfactory until the eighth day, when vomiting recommenced, the abdomen became distended, and the patient's condition was very critical. The abdomen was opened and the ileum found to be involved in further adhesions. Owing to the patient's condition, no attempt was made to deal with these adhesions. Through a separate incision a rubber tube was fixed into a distended

upper loop of jejeunum, the technique employed being similar to that for a Witzel's gastrostomy. The result was excellent; the jejeunostomy drained freely, vomiting ceased, the toxæmia rapidly passed off, and two days later the bowels moved normally. The tube was removed on the seventh day and no leakage occurred. Since then, a period of six months, the patient has been perfectly well.

In addition to its use in the above type of case, enterostomy is of very definite value where bowel resection has been. required, as for example in a strangulated hernia. Such a case is the following, operated upon by Mr Hartley, to whom I am indebted for permission to record these notes.

CASE III.-Female, aged 57, admitted with a strangulated femoral hernia of forty-eight hours' duration. A loop of ileum was found to be gangrenous and was resected, an end-to-end anastomosis completing the operation. Following this the patient's condition remained critical, the bowels did not move and the toxæmia was still profound. On the fourth day the abdomen was reopened, a distended loop of bowel secured and a small tube inserted. Thereafter the patient's condition improved steadily. A further operation was required later to close the enterostomy and she was discharged, having made an excellent recovery.

If jejeunostomy be performed as a routine measure in all cases of acute obstruction, many cases will be so drained, unnecessarily. Unfortunately it is not possible to foresee which patient will and which will not suffer from secondary obstructive symptoms requiring further operative interference. I feel sure that, while a secondary jejeunostomy will prove a life-saving measure in many of these cases, a primary jejeunostomy would have prevented some, at least, of these same cases from being exposed to the risk of a recurrent acute obstruction.

Jejeunostomy is not performed in order to prevent the retained contents from reaching the normal bowel below and being there absorbed, for it has been shown that the mucous membrane of the healthy bowel forms an effective barrier to the toxin. The object is rather to drain the toxic content from an intestinal canal which has become over-distended and partially or completely paralysed by the toxæmia, and is unable itself to drive on the contents to the collapsed bowel beyond.

Remembering the importance of dehydration in acute obstruction, it is essential that subcutaneous salines be given repeatedly after operation. Pituitrin is also of the utmost value. Acute obstruction of the large bowel, though not, as a rule,

so serious as that which occurs in the small intestine, is nevertheless extremely dangerous to life. In a large proportion of cases, the patient is beyond middle age and has suffered for several years from a gradually increasing obstruction which suddenly becomes acute. Some surgeons have stated that jejeunostomy is of value in this type of case, but it must be but seldom that operation is delayed until distension has reached so high a level in the intestine. Proximal drainage is, however, of the utmost value. Sir Harold Stiles has long advocated the value of cæcostomy in the treatment of large bowel obstruction following on malignant disease of the colon. He has shown that cæcostomy not only relieves the patient's acute symptoms, but that when the time comes to remove the obstruction by enterectomy, it acts as a very efficient safety valve, thereby preventing pain and discomfort from flatulent distension, and what is of more importance, it takes the strain off the intestinal sutures.

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The following history of a patient recently treated by me illustrates these points.

CASE IV. Female, aged 54, with a long-standing history of constipation, was admitted to hospital suffering from acute obstruction. The bowels had not moved for three days, and during this time she had vomited repeatedly. Her abdomen was markedly distended and her general condition poor. The abdomen was opened on the right side, a distended cæcum presented and a Paul's tube was inserted into it. No attempt was made to localise the obstructing lesion. The patient rapidly improved and a week later a bismuth enema revealed an obstruction in the pelvic colon. A fortnight after the original operation the abdomen was reopened, a ring carcinoma of the pelvic colon resected and an end-to-end anastomosis performed. An uneventful convalescence followed, the cæcostomy closing without further interference.

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REFERENCES.1 Sweet, Peet, and Hendrix, "High Intestinal Stasis," Annals Surg., Philadelphia, 1916, lxiii., 720. 2 Wilkie, D. P. D., "Acute Intestinal Obstruction," Lancet, London, 1922, i., 1135. 3 Bacon, Anslow and Eppler, "Intestinal Obstruction," Archiv. Surg., 1921, iii., 641. Costain, "Lymphaticostomy in Intestinal Obstruction," Surg. Gyne. Obst., Chicago, 1924, xxxviii., 252. Bonney, "Fæcal and Intestinal Vomiting and Jejeunostomy," Brit. Med. Journ., 1916, i., 583. Summers, "Acute Intestinal Obstruction," Trans. Amer. Surg. Assoc., Philadelphia, 1920, xxxviii., 377. * Lee, Downs and M'Kean, "The Treatment of Acute Mechanical Intestinal Obstruction by High Temporary Jejeunostomy,” Annals Surg., Philadelphia, 1924, lxxx, 45.8 Stiles, Sir Harold, "The Value of Cæcostomy in the Treatment of Malignant Disease of the Colon," Brit. Journ. Surg., Bristol, 1921, ix., I.

ELINICAL RECORD

TWO CASES OF BILATERAL CONGENITAL
CYSTIC DISEASE OF THE KIDNEYS.

By R. LESLIE STEWART, M.B., F.R.C.S.E., Clinical Assistant, X-Ray Diagnostic Theatre, Royal Infirmary.

THE publication of the following two cases was prompted by the very definite and characteristic pyelographic abnormalities found in each of them. For permission to publish the first case I am indebted to Professor D. P. D. Wilkie, who had her under his care. The second case was admitted to the Royal Infirmary with gastro-intestinal symptoms. On examination, renal enlargement was found, and he was kindly referred to me by Mr J. M. Graham for investigation in the X-ray Diagnostic

Theatre.

CASE I.-Mrs B., aged 55, consulted Professor Wilkie, March 1924.

History. Twenty-three years ago, in the Chelsea Hospital for Women, she underwent an operation in which a large ovarian cyst was removed. Even before this date a condition of prolapse of the uterus was present. She did not enjoy very good health afterwards, until fourteen years later, when she was operated on for hæmorrhoids and fissure; thereafter she improved considerably.

While recovering from her first operation, she experienced some slight discomfort in the right side, which, however, disappeared. Of recent years she has been troubled with some frequency of micturition, and occasional dull, aching pain in the right loin. There has never been any pain on the left side.

About Christmas 1923 these symptoms became more marked, there being considerable vesical irritability, with frequency of micturition, and later, slight loss of weight. She eventually consulted her doctor, who, on examination of the abdomen, found a large, firm swelling in the right flank, and sent her for surgical opinion.

There has never been any hæmaturia or pyuria, nor bleeding from other sources. The frequency of micturition was not associated with any appreciable degree of polyuria.

Her

Throughout her life she never enjoyed robust health. appetite and digestion have always been fairly good, but constipa