the first instance the disease seems to the Dr. to be little more than paralysis of the muscular coat; in the second, paralysis is complicated with inflammation and to the third and fourth are superadded inflammation and its effects. But all are merely grades of one and the same disease, and, however their remote causes may differ, the effects produced by these are very much the same. In reviewing the cases above detailed, it will be seen that distentions is the only uniform appearance which they present; but, whether this distention is to be considered as an effect or a cause, is, perhaps, a difficult but important question. The author's reasoning upon it is ingenious, and the evidence which he brings in favour of his views must be admitted to be strong where it fails to produce conviction. According to him the distended part is the seat of the disease, and the part which appears contracted is collapsed because empty; spasm is, therefore, wholly excluded, and his theory resolves itself into a mere loss of muscular action, or paralysis. But, lest we should misinterpret, or be misunderstood, we shall bring forward the language of the original on this point,

"It is probable, therefore, that there occurs in the state of ileus a certain loss of the muscular power in a portion of the canal, in consequence of which it does not act in concert with the other parts, but becomes distended by the impulse from the parts above, which in the healthy state would have excited it to contraction.

"In a fatal case of ileus, however, we generally find one part of the intestine in the state of distention here referred to, and another part empty and collapsed, presenting nearly the form of a cord; and there has been supposed to be a difficulty in determining which of these is the primary seat of disease,—some having contended that the collapsed part is contracted by spasm, and thus proves a source of obstruction, which leads to the distention of the parts above. The doctrine of spasm, as applied to this subject, must be admitted to be entirely gratuitous; and we must proceed upon facts, not upon hypothesis, if we would endeavour to throw any light upon this important pathological question. The following considerations seem to bear upon the inquiry :

"I. The collapsed state of intestine, in which it assumes the form a cord, appears to be the natural state of healthy intestine when it is empty. We often see nearly the whole tract of the canal in this state in the bodies of infants, who have died of diseases not connected with the abdomen; but in whom the bowels have been kept in a very open state up to the period of death. We cannot doubt that a similar state of uniform contraction is the healthy condition of other muscular organs when they are empty, such as the bladder. We have then no sufficient ground for assuming that the state of uniform contraction of intestine is a state of disease; on the contrary, the facts favour the supposition of this being its healthy condition when it is entirely empty.

"2. On the other hand, we learn from various cases, particularly from the remarkable case, (Case L.) that a state of uniform distention, with lividity, may occur as a primary disease of the intestinal canal, without any appearance of obstruction, and without any part of it being in a contracted state.

"3. In a case of ileus, the collapsed parts are almost invariably found in a healthy condition at all periods of the disease; the morbid appearances, whether inflammation, lividity, exudation, or gangrene, being almost entirely confined to the distended parts.

“4. In Case XXXV. every obstruction below was entirely removed, while the parts above were, to external appearance, in a healthy state, and yet the action was entirely suspended.

"5. In Case LI. the cause, which uniformly acted in so singular a manner, must be supposed to have acted upon a part only whose action was impaired, not upon one which was spasmodically contracted.

"6. In cases XXIX, XXX. and XXXI., we see the state of distention arising from causes entirely of a different nature, without the peculiar contraction here referred to; and on the other hand, in Cases XXXII, XXXIII, and XLIV. in which the disease was distinctly traced to a mechanical cause, this peculiar contraction, existed below the seat of the obstruction but could not be considered as having had any influence in producing the disease. In Case XXXIII, also it is to be remarked, that the contracted part was repeatedly and freely dilated during the course of the disease, without any effect in relieving the parts above.

"On these grounds, I submit the probability of the opinion, that, in a case of ileus, the distended part is the real seat of the disease; and that the contracted part is not contracted by spasm, but is merely collapsed, because it is empty, its muscular action being unimpaired." 136.

Now, although not disposed to travel to the same extent with the Dr. in his theory of ileus, nor prepared to criticise, seriatim, the arguments by which it is supported, we are ready to contribute our meed of approbation to its ingenuity, and unwilling to let it pass without some further notice.

That the distended intestine is generally in a diseased state is probable, and that this disease arises from want, or deficiency of muscular power, we believe; that the contracted intestine may present no appreciable derangement is admitted, and that its diminished area may result from its being empty may occasionally be true: and, finally, that a distended condition of the fæcal tube may exist as a primary affection we consider proved by several of the facts and cases above recorded. But it must be equally certain, that ileus does arise from obstruction, and that distention may be the first effect of this obstruction. The cases of the impacted gall-stone and strictured colon will be regarded, we presume, sufficient vouchers for this point. Now, if obstruction to the passage of the fæces can and does occasion ileus, we would ask our author what evidence exists against the doctrine, that irregular muscular action, or, in other words, spasm, is never the cause of this obstruction ? We are not aware that any of his cases or facts furnish such evidence, and we are certain that many of the causes and symptoms, and much of the treatment of this disease, are in favour of this view.

In the first place, attend to the nature of the causes;-they are generally such as are calculated to excite spasm, as cold applied to the surface of the body, acrid and poisonous matter received into the stomach and applied to the surface of the intestines, disordered bile, and unhealthy fæces. Secondly, examine the character of the symptoms; they are generally such as betoken the presence of spasm, as excruciating pain relieved by pressure, violent vomiting, tenesmus, and retraction of the muscles of the abdomen. The last symptom we should wish the Dr. to explain upon any other principle than spasm, and the first can be regarded as attending any disease rather than palsy. Thirdly, observe the remedies most effectual in relieving or removing the disease;-carminatives, opiates, tobacco enemata, cold affusion, and depletion. These are not such as would be first selected or most depended on in the cure of palsy, yet they constitute the sum and substance of our hope in ileus. In the fourth place, if a piece of distended intestine be the seat of ileus, and loss of muscular power be the cause of this distention, on what physiological or pathological principle will the Dr. account for this partial paralysis, and are the causes, symptoms, and progress of the disease, in appropriate keeping with its supposed nature? Is a sudden VOL. XI. No. 21.

3

exposure to cold, or an unexpected suppression of the menstrual discharge, or the presence of acrid matter in the alimentary canal, among the most active causes of paralysis? Or is violent pain, or incessant vomiting, or tenesmus, or spasm of the abdominal muscles, or relief from pressure over the abdomen, among the most pathognomonic signs of palsy? Or is death in the course of a few hours or days, while nothing can be seen upon dissection, but a few alternate patches of contracted and distended gut, without vascularity, inflammation, effusion, or gangrene, the ordinary, result after such a period in palsy? In the fifth place, what symptomatic or pathological difference appears between those cases which did arise, according to the Dr.'s own showing, from mechanical obstruction, and those which are supposed by him to have originated in partial palsy? Let cases 36 and 37, which were occasioned by strangulation of a part of the focal tube, be compared with cases 27 and 28, which are considered by the author as pure specimens of ileus from loss of muscular power; let their symptoms during life, and their appearances after death, be viewed in connexion, and then let the reader draw his own conclusion as to the modus formandi of the last two. During life we find violent pain of abdomen, urgent vomiting, and obstinate costiveness, the first, the last, and the leading symptoms of each; the treatment in all is alike, their duration very much the same, and the appearances of all upon inspection are inflammation and gangrene of the distended parts. And lastly, we are not disposed to admit that a healthy intestine in an adult, when empty, and simply because it is empty will always contract itself into an apparently solid cord; nor that a distended portion of intestine, and simply because it is distended, is always in a state of disease. Mere distention of the coats of an organ is insufficient to establish the presence of disease in these coats, in the absence of other less equivocal symptoms. Distention under such circumstances may be no more than excessive relaxation, and excessive relaxation is frequently an effort of nature to relieve disease, and not disease itself. Thus, spasm, or stricture of the urethra, may prevent the bladder from discharging its contents, and great distention of the organ is the consequence; but who will maintain that the bladder thus distended is in a diseased state? 'Tis true that this distention may occasion gangrene! but then the gangrene is a mere accident which depends upon the degree of this distention. So is it frequently, we imagine, in the case before us;-a portion of the intestinal tube becomes obstructed, an impediment is thus presented to the progress of the fæces beyond the point of obstruction; but the peristaltic action from behind must occasion one of two results, either relaxation of the spasm, when the fæces shall be allowed to pass on, or distention of the tube adjoining the spasm, to give room to the fæces urged forward by the vis a tergo. The first result, we consider produced in those transient cases of colic which arise from sudden exposure to cold, are attended with severe pain, and last but a short time, the second result we regard as a secondary remedial effort following failure of the first, and except, perhaps, in a very few cases, not entitled to be called disease until overdistention destroy the organization of the parts, when inflammation, or other palpable consequences, will soon appear. Why is it that the distended part is always contiguous to the contracted portion? Is it not a too steady combination of circumstances to be explained by coincidence, that the distended and contracted parts should, in

every instance, be placed in juxta position? Since the distention is a primary affection depending on paralysis, and liable to occur in any portion of the tube, and since the contraction is a natural condition, depending merely on the absence of fæces, which may be present or absent in any portion of the tube at the period of attack, these two states are merely accidents, which bear to each other no etiological relation, and have for their origin no common cause; yet, wherever there is contraction there is dilatation, and the dilatation immediately adjoins the contraction!

Did space permit, this theory ought to be more extensively discussed, but the few strictures now made will, perhaps, be sufficient to encumber it with as much dead weight, as shall prevent it from floating free and unexamined along the current of public opinion; and as we wish, in every point of novelty and importance, to interest our readers as much as we feel ourselves interested, we shall not pursue this question further, but request them to take it up for themselves, convinced that whether they support or oppose the preceding train of argument, facts will be the only authority admitted in the investigation.

Before entering on the treatment of ileus our author very properly advises an examination of the abdomen, lest hernia be the source of disturbance; and, since a very small portion of strangulated intestine may give rise to a fatal attack of ileus, and this hernial state may escape even the suspicions of the patient, too minute attention cannot be paid to this point.

"In the medical management of cases which are referable to the general head of ileus, there are important distinctions to be kept in mind as to the state of the symptoms, which seem to require important diversities in the treatment. It is impossible to delineate minutely all these distinctions, but there are certain leading varieties, which, in a practical point of view, may be briefly referred to. These are chiefly the following.

"1. Obstinate costiveness with distention of the abdomen, and considerable general uneasiness, but without tenderness, and without much acute suffering.

"2. The same symptoms, combined with fixed pain and tenderness, referred to a defined space on some part of the abdomen, frequently about the head of the colon.

"3. Violent attacks of tormina, occuring in paroxysms, like the strong impulse downwards from the action of a drastic purgative,-the action proceeding to a certain point, there stopping and becoming inverted,-followed by vomiting, the vomiting often feculent.

"These forms of disease will be recognized by the practical physician, as constituting affections distinct from each other. In a practical view, the importance of the distinction consists in pointing at two modifications of the disease which seem to lead to differences in treatment; namely, a state in which there is a deficient action of the canal, and one in which there is a violent action limited to a certain part of it, though ineffectual for overcoming a derangement which exists below. The practical application of the distinction refers chiefly to the use of purgatives in ileus; and to the question, whether, in every case of ileus, the action of the canal requires to be excited by purgatives or whether there are not modifications of the disease in which its action rather requires to be moderated. The adaptation of the remedies to the individual cases in fact demands the utmost discretion; and it is impossible to lay down any general rules for it. There are some cases which yield at first to a powerful purgative, and there are others in which any thing like an active purgative is highly and decidedly injurious. A large dose of calomel will frequently settle the stomach, and move the bowels; but, upon the whole, I think the best practice in general is the repetition, at short intervals, of moderate doses of mild medicine, such as aloes combined with byosciamus. The peculiar and intricate character of the disease appears very remarka

bly from the fact, familiar to every practical man, that there are cases which yield to a full dose of opium, after the most active purgatives have been tried in vain. In regard to the use of purgatives, indeed, it may perhaps be said, that they form but a part of the treatment of ileus, and a part, too, which in some forms of the disease, requires to be used with the utmost discretion." 143.

The cautious phraseology of this extract encourages the hope, that the Dr.'s paralytic theory of ileus has not yet been enrolled among the sealed and settled articles of his creed. If this disease be so often paralytic in its nature, why should not purgatives be administered in the first stage before inflammation have come on ?-They are stimulating, the disease requires stimuli, their stimulus is applied to the very part requiring it, and, in place of suspecting their adaptation, or questioning their efficacy, they should be faithfully and freely given. The truth is, that spasm, or inordinate action is in many instances the morbid cause; to administer severe purgatives would increase this action, and to increase this action would aggravate the symptoms; therefore, as the Dr., not very consistently, yet judiciously observes, "The best practice in general is the repetition, at short intervals, of moderate doses of mild medicine, such as aloes combined with hyosciamus. This is the very language of Hoffman and Cullen, and when the advocates of schools, so differently organized, agree in their practical directions; the theories advanced by either are of less importance. Speranza, who thought ileus depended on inflammation, recommends the lancet as the leading remedy; and, although proselytes to another faith, we attach much importance to judicious depletion. Violent and neglected spasm will soon pass into inflammation, and it is a fact of great practical value, that when inflammation supervenes on spasm, it is more inveterate in its ravages and more rapid in its course than perhaps under any other circumstances, and that if its approach be not prevented, it will often, after it has commenced, outrun the most vigorous remedies in its progres to gangrene. The tobacco injection is considered by the author the remedy of most general utility in all forms and stages of ileus. It is, certainly, a powerful medicine, and, if cautiously employed, may do much good. The quantity at first used should be small, increasing it according to the nature and degree of its effects. The application of cold to the lower extremities has been an old and favourite treatment, and its efficacy is attested by many cases. The patient is raised into the erect posture and cold water is dashed forcibly about his legs; some are satisfied with applying to the abdomen cloths wet with vinegar and water, and cold injections have been preferred by others. Cases do occur in which all these remedies may prove ineffectual; and recourse may then be had to opium; should abdominal tenderness, however, or an excited pulse betray the presence of phlogistic action, the lancet may be an appropriate preliminary. Lastly, stimulants will sometimes be found useful. When the constitution has been worn down by excessive pain, or the strength exhausted by active treatment, mild stimuli may and must be given. Aloetic wine, and tincture of aloes are highly spoken of, and a case is given which seemed to have been cured by galvanism. As this is a case of very considerable interest, and is referred to in corroboration of the Dr's. views of ileus, it will be proper to detail it; and the history, which succeeds, we adduce as a specimen of the extent to which this disease may proceed, while still within the influence of art and reach of recovery.