regenerates the whole, supplying its waste by the absorption of new

matter.

Cellular assimilation consists in properly locating the recently acquired groups within the molecule.

Certain cell molecules, under proper stimuli, rearrange their atomic grouping, polymerise, and thus multiply. This multiplication may be physiological or pathological. Rapid proliferation may tend to inability to function or to react with the food supply, and consequently destroy the molecule or lead to the death of the cell.

With this conception of a living cell, its secretions consist of the atomic groups cast out as a result of its reactions with external matter, and as the cells of different organs are unlike in their chemical composition, it follows that the secretions are specific. Outside the body hemoglobin breaks up, or may be broken up, chemically, into hematin and globulin. In this case the colored split product contains the iron. But the liver cells produce from hemoglobin bilirubin and an iron containing proteid. In this reaction the line of cleavage is quite different from that followed in the ordinary decomposition of hemoglobin. The secretions of some cells enter into a more or less energetic reaction with certain extra-cellular compounds with which they come in con

This is true of the digestive enzymes. Other secretions apparently are made for the purpose of reacting with or at least affecting the reactions of the molecules of other cells. This seems to be true of some at least of the so-called internal secretions, such as those of the thyroid and adrenals.

A most important group of cellular secretions is made up of the ferments of enzymes. Without going into the history of the theories that have been advanced concerning the nature of these bodies, it seems to me that we are no longer justified in speaking of "organized and unorganized" ferments. All the ferments are cellular products. The work of Buchner on the ferment of the yeast plant seems to be positively convincing on this point. Oppenheimer has defined a ferment in a manner that seems to me to be quite in accord with the latest and best experimental investigation. His definition is as follows: "A ferment is a catalytically-acting substance which is produced by living cells, to which it is more or less firmly bound, whilst its action is not associated with the vital processes of the cells (which produce it); ferments are capable of inaugurating chemical processes which take place spontaneously (without the presence of the ferments), but proceed much more slowly. In this process the ferment, itself, remains unchanged. Ferment action is specific, that is, each ferment manifests its activity only on substances of certain structural and stereochemical arrangement."

I am conscious that my translation of this definition is not altogether satisfactory, and in order to give a more exact interpretation of it, as I understand it, I offer the following explanatory statements:

(1) Every ferment is a cellular product; it is a cellular secretion;

a substance of definite chemical composition formed by the rearrangement of the atomic groups within the cellular molecule.

(2) The action of the ferment, while it is determined by the cell which produces it, is not concerned in the "energy traffic" constantly going on between the molecules of the cell which produced it and other molecules external to this cell. With our present limited knowledge of the chemistry of the cell molecule it is impossible, in many cases at least, to distinguish between the chemical reactions resulting from cell metabolism and those due to ferments. I am inclined to the opinion that more exact knowledge will show that the autolytic changes that take place in many cells after death, and which have furnished the theme of so many papers recently, will be found not to be due to ferments at all, but to the cessation of metabolic reaction.

(3) The function of a ferment is to hasten chemical reactions which take place, but much more slowly, without the presence of the ferment. It seems to me that a clear conception of this point gives one a key to the action of ferments in general. I have, in the first part of this paper, called attention to the fact that inertia is a universal property of matter; that the direction and rate of movement in matter can not be altered spontaneously. A ferment is a substance which by its presence changes the tempo of chemical reaction. I am fully aware that this does not explain why the ferment acts by its presence, but it is worth much to have a conception of how it acts, provided, of course, that this conception be correct. Furthermore, it must be admitted that the modus operandi of ferments is still beyond our ken. Some think that certain atoms or atomic groups are detached from one of the substances, combine with the ferment, and then are passed on to the other substance. On this supposition the ferment does enter into the reaction, but is constantly regenerated. Others hold that the ferment combines with the fermentable substance, making its molecule so labile that it falls to pieces, and that in the dissociation the ferment is again set free. There are weighty objections to either of these theories, but time will not permit me to state them in this paper, which is intended to be suggestive rather than exhaustive.

ON THE DIAGNOSIS OF ACUTE OBSTRUCTION OF THE BOWEL.*

BY THEODORE A. MCGRAW, A. B., M. D., LL. D., DETROIT, MICHIGAN.

PROFESSOR of surgeRY AND CLINICAL SURGERY IN The detroit College OF MEDICINE.

DISORDERS, which increase rapidly in virulence and if unrelieved cause speedy death, demand early and correct diagnosis and positive treatment. Of such, there are none which are more urgent than acute intestinal obstructions, and none in which hesitation and delay are more disastrous. The physician who ponders too long in these cases over the diagnosis, comes to a decision too late for his patient's salvation. *Read at the Ann Arbor meeting of the FIRST CONCILOR DISTRICT MEDICAL SOCIETY, December, 22, 1905.

Schlange divides intestinal obstructions into two classes, the dynamic. and the mechanical. The dynamic are paralytic conditions which are usually secondary to other troubles. They may be caused by nervous. shock. I met with this form once in a case of acute pancreatitis, which I operated on in Monroe with Doctor Southworth. A man of fortyfive years was seized with a violent pain in the epigastrium and fell at once into a collapse. I saw him twenty-four hours later. He had then rallied somewhat but was suffering great pain in the abdomen. There was great distension and the abdomen was very sore. I diagnosticated the trouble as perforation by a gastric ulcer and expected to find the intestines highly inflamed. On opening the abdomen, however, I found them of normal color and appearance but highly distended with gas. On lifting up the stomach an abscess was discovered in the tail of the pancreas.

These cases are uncommon. The usual cause of dynamic obstruction is inflammation of the peritoneum of which the type is a suppurative appendicitis. The treatment of these cases is that proper for the inflammation which causes them. Their symptoms, pathology and treatment have been the subject of innumerable treatises and discussions and are familiar to all intelligent practitioners. I shall not, therefore, discuss them in this paper but confine my remarks to obstructions caused by mechanical forces. These include all cases of hernia, volvulus and intussusception, and of obstructions caused by inflammatory bands, by adherent diverticulums, by tumors and cancers, by faults in development and by fecal impactions and foreign bodies.

Mechanical obstructions may be divided into two classes: those which suddenly and completely occlude a gut and those which cause only a partial stenosis of slow development. This is a highly practical division, inasmuch as the two classes differ much in symptoms and demand different treatment.

It is the obstructions due to the various forms of strangulation and to intussusception which are most speedily fatal and which, nevertheless, if operated on early, offer the best results. In many cases an operation in the first twelve hours after the seizure would have little more danger than an exploratory incision, while operations after the lapse of forty-eight hours are almost always followed by death. The symptoms caused by all these various forms of acute mechanical obstruction are uniformly the same, modified only by the seat of the obstruction, as it occurs in the large or small intestine, and by the idiosyncracies of the patient. There is first a sudden and violent pain. in the abdomen, followed by nervous shock and vomiting. There is in the first twelve hours, as a rule, but little abdominal tenderness and the patient rarely objects to the manipulation of the abdomen by the surgeon. Almost immediately, however, there begins a perceptible distension of the abdomen which, in the very beginning, is localized and confined to the affected coil but soon involves the intestines above it. In persons with thin abdominal walls, the coil which is the seat

of the injury may be discovered as a projecting spot on the abdomen. It is distended and paralyzed and will not contract under any stimulus. Vomiting does not relieve the nausea, and continues without cessation. The bowels are obstinately constipated and do not respond to purgatives but may discharge such of their contents as are contained in the part below the constriction. When, as sometimes happens, the affected coil is in the pelvis, there may be no distension of the abdomen but the swollen intestine may be felt by rectal or vaginal examination. This was the case in a boy upon whom I operated on the seventh of this month. He had been ill over three days when he was brought to the hospital enormously distended. His physician told me that the abdomen during the first two days was flat and unsensative. I found a black and gangrenous volvulus of large size, which I fished out of the pelvis. In these cases a careful examination of the pelvic cavity through the vagina or rectum should never be omitted.

The course of the distension in obstruction has an important bearing on the diagnosis. The abdomen is not suddenly inflated as in severe acute enteritis or peritonitis; affecting at first only one coil, the swelling is for some hours localized and moderate, and only gradually extends to the gut which lies above the constriction. In the last stages, however, the whole abdomen may become swollen to its utmost capacity. In fat people it is much more difficult to map out the affected coils.

It is characteristic of obstruction in the early stages that the resulting swelling is comparatively free from soreness. I have, indeed, seen several patients in whom this freedom from tenderness on pressure continued into the second and third day, even though they were suffering extreme pain. In fact, I have come to look upon the disproportion between the pain of obstruction and the soreness of the abdomen as pathognomonic of the disorder. A patient will from the very beginning complain bitterly of pain but will, without flinching, allow the surgeon to thoroughly manipulate and examine the abdomen. There may be some tenderness in spots but it is comparatively slight and unimportant. There are very few morbid conditions in which this contrast between agonizing abdominal pain and nearly complete freedom from abdominal soreness are found in the same degree. Corresponding with this freedom from soreness, the abdominal walls, in most cases, are relaxed and devoid of tension until, at the end of thirtysix or forty-eight hours, all symptoms become aggravated by septic absorption. The increase of indican in the urine is of no avail for early diagnosis, as it does not become apparent before the lapse of twenty-four hours. In obstruction the temperature remains nearly normal until the conditions become septic, when it will rise rapidly. and continuously until death. It is on the combination of symptoms and on the order of the sequence that the physician must base his diagnosis. There is not a symptom of obstruction which may not be present in other maladies but there are few diseases in which they will occur in the same order and in the same connection.

If we pass in review the other troubles which may perplex the practitioner in his diagnosis we may gain a clearer picture of that first stage in which alone operations can be done with nearly certain success.

Obstruction may, first of all, be mistaken for indigestion with autointoxication. The severer forms of this kind of trouble are sometimes ushered in by severe abdominal pain, vomiting and collapse, followed by some tenderness and distension. It is rarely, however, that the nervous shock is as severe as in obstruction. The pain is more colicky in character, the bloating, when it occurs, is less localized and of more rapid development, and there is more fever. The one deciding symptom is the occurrence of diarrhea, which is the usual result of the condition. Should the bowels not move spontaneously, purgatives or enemas will almost invariably produce the desired effect. This is the rule, too, with all forms of enteritis. Osler, indeed, mentions a case which was mistaken for obstruction but does not say anything as to the condition of the bowels. The coexistence of constipation with severe enteritis is so rare that it may be left out of our calculations in forming our opinion.

Bilious colic produced by the passage of gall-stones may cause great agony, feeble pulse, vomiting and temporary collapse. It is, however, usually of short duration and causes neither bloating nor constipation. If the trouble is prolonged, there will be tenderness in the region of the gall-ducts, and if the common duct is the seat of the disorder, there will be jaundice. It rarely causes the permanent prostration of obstruction, unless associated with severe suppurative cholecystitis, in which case there will be chills and high fever as well as great local soreness.

The colic of lead poisoning could hardly be mistaken for intestinal obstruction, notwithstanding the occurrence of constipation. The history of the patient, his occupation, his continued ill health, the blue line of the gums are all distinguishing features. The symptoms are relieved by opium and the constipation is apt to alternate with diarrhea. The patient has a history of multiple attacks, which gradually increase in severity. There is not much distension and, if any exists, it will disappear under opiates, in this respect differing sharply from the distension of obstruction.

In renal colic the patient often suffers severe shock and great pain. There is sometimes, but not always, nausea and vomiting. The pain affects the back, the kidneys, the ureters and the bladder. Micturition is often painful and the urine contains albumin and blood. There is tenderness along the course of the affected ureter. The bowels may or may not be constipated, but are rarely bloated.

Acute pancreatitis, more than any other malady, may simulate intestinal obstruction. Beginning with an agonizing pain in the abdomen, with great shock and vomiting, there is a rapid distension of the abdomen and a tendency to collapse. The very rapidity with which the symptoms develop distinguishes the disorder from obstruction, in