contraction of its area. The ileum beyond this part to the extent of from 20 to 24 inches, was highly inflamed and gangrenous, with extensive recent adhesions.

CASE XXXI.-A gentleman, aged 24, had been for several years liable to attacks of pain in the abdomen, affecting chiefly the right side. They usually continued for several hours; sometimes they recurred every evening for weeks together; and sometimes he was for weeks or months perfectly free from them. One of his longest intervals was ascribed to taking daily a small dose of Epsom salt. On the 11th of June 1818, he was seized with violent pain across the lower part of the abdomen, which was drawn into balls,-pulse 60; no vomiting. He was seen by Mr. White, who gave him an opiate and a purgative, with relief, and his bowels were freely moved. On the 12th, he was free from complaint; and on the 13th, he walked out, but, at night, the pain returned with violence; pulse 60. At four in the morning of the 14th, the pain continuing unabated, and his pulse having risen, he was bled, and his bowels were moved by injections; at mine, he was found pale, cold, and exhausted; belly tympanitic, and the pain continuing severe. He died at two in the afternoon. I saw him only two hours before death.

Inspection.The small intestine was greatly distended, and, on many places, especially on the ileum, there were inflamed portions with exudation of false membrane, and other parts of a dark colour, approaching to gangrene. The right side of the colon was singularly turned upwards upon itself, so that the surface of the caput cœcum was in contact with the surface of the ascending colon immediately above it, and was attached to it, for about two inches, by a very firm adhesion of old standing. The parts concerned in it did not appear to be thickened, and

the colon and caput coecum were in other respects quite healthy.

§ II.-OLD ADHESION OF THE PARTS CONCERNED IN A

HERNIA.

CASE XXXII.—A man, aged 63, had been for 40 years affected with double inguinal hernia, easily reducible; and he was liable to violent paroxysms of pain in the abdomen, during which he said the hernia were generally forced out. In November 1812, he suffered one of these attacks, more severe and longer continued than usual. During this attack, the herniæ had protruded frequently, but he always reduced them with ease, till the morning of the 29th, when he failed. They were easily reduced by a gentleman who then saw him, but, at night, when I saw him, they had again protruded; they were then also easily reduced, but protruded again almost immediately, though he was lying on his back; he had some vomiting and violent pain in the abdomen, which was hard and tender; pulse 120, feeble, and irregular; features collapsed. The bowels had been moved by injections. He died at night.

Inspection. Both hernia were completely reduced, and without any adhesion to the sacs, the mouths of which were large and free. The sacs were thickened, and the inner surface of that on the left side was inflamed and sloughy. The small intestine, down to the middle of the ileum, was greatly distended, and in many places inflamed and gangrenous. The disease stopped at the part of the ileum, which had formed the hernia of the right side; the surfaces of this portion, where they had been in contact in the hernia, were firmly attached to each other, by an old adhesion about three inches in extent. The coats of the

intestine at this place appeared slightly thickened, but scarcely produced any sensible diminution of its area.

III. A SLENDER BAND OF ADHESION BETWIXT TWO

CONTIGUOUS PORTIONS OF INTESTINE.

CASE XXXIII-A boy, aged 8, had frequent vomiting and obstinate costiveness; belly swelled and tympanitic; countenance exhausted; pulse frequent and feeble. He had been ill 10 or 12 days, during which the complaint had resisted every remedy; and he died in two days more.

Inspection. The small intestine was distended to the greatest degree, down to a point on the ileum, where the following cause of the disease was discovered. Betwixt two turns of intestine, there was a narrow band of adhesion, rather more than an inch in length. It was evidently of long standing, and, while the parts had remained contiguous, had produced no effect; but, by some relative change of situation of the parts, another turn of intestine had insinuated itself betwixt the two adhering portions. This portion, however, was healthy. The origin of the disease seemed to be, the band of adhesion being thus put upon the stretch, so that the peristaltic motion had been interrupted; for at the lower attachment of the band, the intestine was drawn aside into puckers, and, precisely at this point, the distention ceased, and the canal became white, collapsed and empty. At this part, however, there was no actual obstruction, and the coats of the intestine were perfectly healthy, except a circumscribed redness on its inner surface, at the point corresponding to the attachment of the band of adhesion. On the distended portion of intestine, there was a slight appearance of superficial in

flammation, but it was of small extent and appeared to be quite recent.

§ IV. SINGULAR TWISTING OF THE SIGMOID flexure

UPON ITSELF.

CASE XXXIV.-A man, aged 60, (23d April 1815) had been ill for a week, with the usual symptoms of ileus, which had resisted all the ordinary remedies; he was now much exhausted; and his belly was enlarged and tympanitic, with frequent vomiting. He lived in great distress till the 28th, and the swelling of the abdomen progressively increased, until it resembled the abdomen of a woman at the most advanced period of pregnancy; yet to the last he could bear pressure upon every part of it; his pulse varied from 108 to 116.

Inspection.-On opening the abdomen, a viscus came into view, which at first appeared to be the stomach enlarged to three or four times its natural size. On more accurate examination, however, this turned out to be the sigmoid flexure of the colon, in such a state of distention that it rose up into the region of the stomach, and filled half the abdomen. The stomach was contracted and healthy. The small intestine was healthy at the upper part; lower down, it became distended and of a dark colour; and, at the lowest part, it was much distended, with some spots of gangrene. The colon was greatly distended, being in some places not less than five or six inches in diameter; and the sigmoid flexure was also enormously enlarged in the manner already mentioned, and of a dark livid colour; it contained only air and thin feces. The rectum was collapsed and healthy. The following appeared to be the cause of this remarkable state of disease.

The sigmoid flexure was found to have taken a singular turn upon itself, so that the rectum lay to the left, in contact with the descending colon; and the ascending portion of the sigmoid flexure passed in front of this portion, and lay on the right. In consequence of this transposition, the rectum, as it descended passed behind the lower curve of the sigmoid flexure, where it takes the first turn from the descending colon; and the rectum itself at this part received a twist, as if half round. Exactly at the point where this twist had taken place, the distention and dark colour of the diseased intestine terminated abruptly, and the remainder of the gut became white and collapsed. At this point, however, there was no mechanical obstruction, for the part was quite pervious, and, excepting the slight twist, perfectly healthy.

In this singular case also, I had an opportunity of ascertaining the state of the part during life. For on the 25th, three days before the man's death, having exhausted all the usual means, I was induced to examine the rectum with a large ivory-headed probang; when I found, at a certain depth, which was afterwards seen to correspond with the point where the rectum was twisted, a very slight obstruction to the passage of the instrument, which however passed with very little difficulty, and was withdrawn without any. A piece of the intestine of an animal, tied at the end, was now carried up beyond this point, and filled, by forcibly injecting water into it. This was retained for some time in the distended state, and then slowly withdrawn; but no discharge followed, though, as I have already stated, the distended intestine contained only air and fluid feces.