The patient described himself as leaving home quite well on the morning of the attack, and walking down to Westminster Hall, where he continued discharging his official duties until the moment when his suffering commenced. Now did the severe pain mark the moment of the intestine passing through the mesentery, or did it mark the passage of a gall-stone? and was the intestine forced through the mesentery during the writhing and agony consequent upon the passage of a biliary calculus? No gall-stone was found, and therefore the question remains open. It is true that there are many cases of external hernia where the stricture was very tight, and where agonizing pain was quickly developed; it is true that in some of the cases on record of internal strangulation, violent suffering has occurred suddenly, and therefore the urgency of the first symptoms do not constitute a sufficient reason for believing that, strange though it be, the intestine may not have been protruded through the opening at the moment the pain came on, and the patient at rest; but the opening was so small that it seems scarcely possible to have happened in this case. In La Fayes' case there was no sensible inconvenience until the excessive pain occurred, and yet the patient was dead within thirty-six hours. The case in many respects resembles our own, and there are on record others not unlike it.

Whatever explanation may be adopted, I apprehend the question of gastrotomy could hardly have been entertained in that case.

The impression which must be produced by reading the preceding cases is this, that, no matter what may be the cause of the obstruction, no certain remarkable difference is observed in the more prominent symptoms by which it is accompanied. There are in all abdominal pain, abdominal tension, obstinate constipation, and sickness; but in the mode of their occurrence it would be difficult to point out any distinct difference. Thus constipation, abdominal pain or uneasiness, with tension, and sickness of the stomach, are present, in greater or less intensity, in most cases, but there

is no certain and definite line to be drawn, either as to the time at which they occur, or the severity with which they are ushered in, whether the obstacle be a biliary calculus or a band of false membrane.

The constipation may have the same general characters, whether the obstruction be caused by hardened fæces, by a contraction depending upon ulceration or other disease, by bands or by tumours: this is certain. It is true that some cases of invagination are accompanied by diarrhoea or by dysentery, but in the great majority of cases the constipation is complete.

The same may be said of sickness; it is usually a very distressing symptom, and ends in fæcal vomiting: but it may be as obstinate in a case of invagination, as in a case of tight strangulation of the ilium by bands. It may be as urgent, and the vomited matter may as soon assume a fæcal character, in a case of invagination, as in a case of the passage of the intestine through an abnormal opening. The abdominal tension is often excessive, but there are on record many fatal cases, where it was not so great as to occasion the patient much distress; and in some instances the abdomen has been quite flat, and, no matter what the obstructing cause may be, the gaseous distention of the intestine may equally take place, and with equal intensity.

Taking the symptoms altogether, it is true that when the obstruction is complete and suddenly developed, they are usually more urgent than when it is slowly produced; but there are cases in which the obstruction has terminated life, within forty-eight hours, without much sickness or severe pain. In cases of invagination, or where a tumour gradually encroaches upon the calibre of the tube, where the canal becomes contracted by change of structure, the pain does not commonly, even up to a late period, exhibit so much intensity as in the former case. But I say again, that we cannot with confidence rely upon these distinctions, the exceptions are so

many.

For some time I had hoped that by arranging the cases in

small groups the symptoms might be made to assume a more characteristic form; but I found that distressing sickness, severe pain and abdominal tension might be present or absent in any case, no matter what may have been the cause of obstruction that life might be extended as long in a case where the intestine passed through an unnatural opening, as in a case of gradual malignant contraction.

It is of course desirable to know the seat of the obstruction; but we shall be unable to obtain that knowledge in many cases. There are, however, certain means which we must not lose sight of, which will materially assist us in coming to a conclusion: there are others, upon which some persons rely, which will prove only broken reeds. Thus it is said that the vomiting and pains are more severe when the obstruction occurs in the small than in the large intestines, and I think there is some truth in the remark; but, after an anxious consideration of the cases before me, I find the exceptions to the rule so many, that I do not think we can safely rely on it. It has also been said that much assistance may be derived from observing the condition of the urinary secretion; that if it be copious, the obstacle must be far removed from the stomach, and vice versá; but the exceptions to this rule are also many.

Laugier thought that by a careful examination of the distended convolutions of intestine, much assistance might be derived in determining the seat of the obstruction; and to a certain extent he is right: but in some cases the distention is trifling, and in all cases the examination must be made before the general abdominal tension is considerable, or it may be difficult to profit by it. There are many cases in which a careful examination of the distended intestines will afford most important assistance, in determining the seat of the obstruction. It is true that in a case where the ilium is obstructed near its termination, the jejunum and the ilium may be so much distended, that it may seem difficult to determine whether the distention affects them or the descending colon; but the absence of distention of the ascend

ing and transverse colon will go far to remove the obscurity, especially when assisted by an exploration, by means of a long tube, per rectum. There are, certainly, cases in which we may satisfactorily follow a distended intestine up to the point of obstruction, but there are many more in which this sign will fail us. However, it has been found useful in diagnosis, and we must take it for what it is worth. In Mr. Luke's case, described hereafter, he found the colon distended down to the sigmoid flexure, and that fact, added to the impossibility of passing a tube far up the rectum, or throwing up much fluid, left little doubt on his mind that the lower part of the colon was the seat of the obstruction; and he was right.

It must, however, be borne in mind, with reference to the tube, that it may produce an error in diagnosis: it may reach the obstruction and then be bent back upon itself; this has happened in my own experience and also in that of Mr. Luke.

Still the history of the case, the particular seat of pain, the occasional existence of a tumour, which is now and then detected in cases of invagination, and indeed in some other cases, before there is much abdominal tension, the distended convolutions, the long tube and the injection, will usually afford us most important assistance in coming to a conclusion, as to the seat of the obstruction. At the same time, it is certain that in the experience of the ablest men they have failed.

The diagnosis being at best but uncertain,-though it may be sufficiently conclusive to justify us in acting upon it,-it is proper to inquire into the results of the treatment usually employed, because, if those results be not very unfavourable, the doubtful diagnosis, and the gravity of operations performed upon the abdominal cavity, might stand in the way of our having recourse to them.

Certainly in a large number of these cases the symptoms are aggravated by the drastic treatment employed for the purpose of overcoming the obstruction; and although I admit that Croton oil and such irritants have occasionally succeeded

in relieving the obstruction, in most cases I am confident they have left matters worse than they found them. Opium and blood-letting have in many cases allayed irritation and spasm, and Calomel given, at the same time, in large doses, has sometimes seemed to exercise a happy influence over the obstruction, and not least in those cases where its appropriate action has been excited in the system. Associated with such means, enemata, of various kinds and quantities, frequently repeated, are most valuable.

Of the cases to which I have referred, 169 in number, and subjected to various modes of treatment, certainly 133 terminated fatally. If they constitute a fair average of the results of such cases, I apprehend there can be no doubt that where a disease terminates fatally under ordinary treatment, in seven cases out of nine, it will be granted that it is proper to entertain the question, whether a better chance of life be afforded by surgical operation. It must be understood, however, that I do not insist upon that average of results as being absolutely correct; but it was the only means I possessed for obtaining data on a large scale in severe cases, and it is at all events an approximation to the truth, for I apprehend that most of the severe cases which have been successfully treated have found a record. There is no doubt that a large number of cases of obstinate constipation do yield to ordinary treatment, but it is probable that in many of those cases the obstruction did not depend on mechanical causes at all.

Before I express my own opinion, or the data on which it is formed, as to the expediency of having recourse to surgical operations for the relief of intestinal obstructions, I will shortly refer to those of several men who have carefully considered the subject.

Hevin concludes his Memoir* by saying-" How are we to remedy those cases in which the symptoms may be so similar, the causes so different, and which, though so formidable,

* Mem. de l'Academie de Chirurg., tome iv. p. 201.