In the first, mercurials profited, followed by a course of non-purgative neutral salts; in the second, mercurials combined with a sedative; in the third, a sedative alone, or partially aided by alkaline doses. Abstinence from, or a sparing use of beef and mutton, were equally useful in both the two last cases.

Of the remaining members of the family to which the two latter patients belong, one brother died between his 50th and 60th year, from well-marked disease of the cardiac orifice of the stomach, precluding at last all introduction of food. The other brother enjoyed a long immunity from affections of the digestive organs, which he severely tried by habitual full diet and stimulants, at the price of being crippled by gout, which finally terminated his life by acute affection of the stomach.

CHAPTER IV.

ILEUS.-POST-MORTEM APPEARANCES.-RECOVERY BY

PASSAGE OF A CALCULUS.

CASES of ileus attended by stercoraceous vomiting, yet terminating favourably, are uncommon. On this account, as well as for its other merits, the paper by Sir George Lefevre, read at the Medico-Chirurgical Society on the 26th of March, was valuable. Regarding the

case there given therapeutically, we may observe that leeches, the internal use of hydrocyanic acid, and doses of croton oil, were efficacious in it; that opiates were administered without advantage.

The following unsuccessful case of similar obstruction, which occurred at the Marylebone Infirmary in 1841, may, in some points of treatment, be contrasted with this; at any rate the juxtaposition of unusual cases is advantageous. Besides, the case which I shall now record, if it cannot suggest effective treatment during its course, is instructive in its autopsy.

H. Dunn, ætat. 29, thin, muscular, reported of intemperate habits, was admitted May 10, as labouring under obstinate constipation and pain of the abdomen. He stated that on three former occasions he has suffered similarly. He was seen by me at eight P. M.; described as having had no motion for four days, but as having passed a little fæcal matter that morning with an enema terebinthina. He had severe griping

pains, but the abdomen was not tender; his pulse was quick, sharp, and rather hard; his breathing excited in the lower lobe of the left lung anteriorly, where he complained of pain from deep inspiration. Hyd. Chlorid. gr. iij., had been given him, and Mist. Magnes. c. Magnes. Sulphat., 3iss., had been prescribed 6tis. I ordered that he should be cupped ad 3xij., at the painful point of the thorax.

11th, 2 P.M.-The small watery evacuations, breathing, and pain, relieved. Pulse softened; tongue dry, brown, coated.

Ol. Croton. mj.; Ext. Colocynth. Co. gr. x.; in pil. ij. divis. statim. Enema Terebinth. vespere. Perstet. in Mist.

12th, 1 P.M.-Severe griping pains had ensued during the night, which were appeased by a grain of opium, and then croton oil mij. Ext. Colocynth. Comp. gr. x., had been repeated. Some sleep had occurred, and the griping was then less severe, but no evacuation. The urine, however, was plentiful, the tongue less dry, though not less coated and brown, the pulse soft. Nausea was now first complained of; the abdomen swelled and flatulent, but with little tenderness. He lies on his back, his knees raised. I directed Elaterii, gr. iij., as a suppository, to be followed by a warm bath; and, at 5 P.M., I found that one small hard motion had resulted. I then directed Hydrarg. Chlorid., gr. x., 3tâ quâque horâ ad 4tem vicem; of which, it may be observed, three doses were taken. Good beef tea, and brandy and water, were allowed.

13th, 8 A.M.-During the night, I found stercora

ceous vomiting had occurred, to the extent of three potfuls! of loose, lumpy, dark fæcal matter, of an olive colour, with great relief of pain and tympanitic distension, but extreme prostration of strength. Pulse very feeble; skin cold and clammy; no nausea at present; but he had passed a restless night.

Sumat Hyd. Chlorid. gr. iv., Opii, gr. ij., 4tis. with careful surveillance, cum sit opus: the object being to obtain rest without reproducing constipation. Strong beef-tea by the mouth, or by enema.

1 P.M.-I found him less restless; no vomiting. His pulse, after the dose of calomel and opium, had become stronger and more distinct; 84. He had turned on his side, and hiccup, which had existed in the morning, had ceased. He took brandy and water. Occasional griping; generally little suffering; tongue moist, abdomen less tumid; urine plentiful; mind collected.

7 P.M.-He has taken three doses of the pills, and his bowels have acted loosely, from a broth enema; no sickness. He is anxious to obtain sleep.

Sumat h. s. Hydrarg. Chlorid. gr. iij.; Mist. Camphora, 3j.; Tincturæ Opii, mxl.

He slept well through the night, and died suddenly the next morning, at seven o'clock, choked apparently by excessive fæcal vomiting, which occurred during sleep.

With great difficulty we obtained leave to make a hasty examination of the abdomen, but neither of the thorax nor of the brain. The rugæ of the stomach and

duodenum were very large, and highly injected with blood, as also in a lesser degree were the intestines generally. The cœcum very large, containing some fæcal matter similar to that rejected by vomiting, of which there was a large quantity in the colon; this intestine was large; the ileo-colic valve normal; no ulceration, and no stricture, until we arrived at the rectum, of which about ten (the lower) inches were so constricted as scarcely to admit a quill. Its coats otherwise normal, and of a very white colour. The above were the only morbid appearances in the viscera of the abdomen.

Now, in reviewing the treatment of this case, I may observe―1st, that the quantity of blood obtained from cupping on the thorax would have probably been more beneficial if taken by leeches spread over the abdomen, as was the case with Sir George Lefevre's patient. For the mucous membrane of the intestines was highly injected with blood; and our exploration of the thorax gave us no reason to presume inflammation in that quarter. It is likely that the patient's pain in inspiration was connected with the descent of the diaphragm, or an inflamed intestinal canal. Large depletion would have been ill borne, as there was much depression of power; indeed, the constipation itself had, we found, lasted a much longer time than that mentioned by the patient.

2dly. We may observe, that the introduction of bougies into the rectum was indicated in this case by the seat of the stricture, and might have relieved it, to the extent of affording a downward passage to the