the absence of vomiting; and somewhat later in this attack, when vomiting began to occur, the urine diminished in quantity and the sp. gr. rose throughout the case albumen was invariably absent.

The administration of belladonna in this attack was pushed more freely, about as much as grain of the extract being given every three or four hours sometimes, but the intervals were often a little longer at times the effect on the throat was pronounced, and the medicine was stopped or diminished; and during the alarming attack on Dec. 22nd (to be noticed presently) the belladonna was stopped, in case it might be responsible for any part of the disturbance. On Dec. 21st, and for two or three days previously, a curious urinary symptom was observed, viz., a hesitation, as it were, in the contraction of the bladder, and the stream of urine sometimes stopped; along with this difficulty there was a little pain in micturition: the quantity of urine at this time was abundant. There was some suspicion that this symptom might be due to the belladonna. This free use of

belladonna seemed, however, to fail in relieving the pain of the spasms in the bowels, and morphia suppositories, or other preparations of opium, were had recourse to when the pain was severe. Sometimes the opiate was administered in the form of twenty-minim doses of Battley's solution, given with the beefjuice injections, to favour their retention as well as to subdue the pain: the aim was to give belladonna steadily, and only as much opium or morphia as seemed absolutely necessary to overcome the violent pain.

The tension of the belly varied a little from time to time, but always remained considerable; the swelling, however, was by no means excessive, and seemed to be much the same as during the former attack. The swollen coils of bowel felt during a paroxysm of pain seemed to indicate that the mischief was situated in the right iliac region.

On December 22nd a serious change for the worse occurred. An injection given the previous night had failed to bring away anything more than one or two small pieces of fæcal matter; during the night violent spasmodic pains came on; the patient vomited, and early in the morning vomiting of green biliouslooking matter supervened. At the visit-hour in the forenoon

he was found to be looking desperately ill, pulse over 100, but scarcely perceptible, surface cold and appearance collapsed. He was ordered at once a morphia suppository; the belladonna was stopped, a fomentation applied to the abdomen, and only a little ice allowed by the mouth, but nutrient enemata as before. Under this treatment he rallied, and by the next day had regained his usual appearance. The belladonna was resumed on the 24th December, and enemata tried again and again with but little result; indeed, the vomiting became more troublesome; the vomited matters were usually bilious in appearance, never fæcal, but sometimes seemed to consist of altered blood. This unsatisfactory state continued till December 28th, on which day he seemed worse than ever (except during the time of collapse already mentioned); but on that night some improvement set in -probably the obstruction had been then overcome, as early next morning he passed a small motion and the tension of the abdomen had disappeared: two or three motions occurred during the course of the next twenty-four hours, and this second attack of obstruction, after lasting from Dec. 9th to Dec. 28th, was obviously at an end.

Warned by the experience of the relapse, great care was taken to prevent, if possible, a third attack; the diet was carefully regulated, and the patient was kept in bed long after he might otherwise have been allowed to get up; attention was also directed to the least symptom of abdominal pain, and the patient seemed in a fair way to recover; but on January 8th the bowels ceased to act, and a third attack, lasting from Jan. 8th to Jan. 19th, was endured. The symptoms and the treatment were essentially the same as before: on January 17th a paroxysm of pain of greater severity than any previously witnessed supervened; the patient sat up in bed and felt as if he would choke, the pulse became uncountable, the aspect pinched, and the perspiration appeared in great abundance. Under free use of opium or morphia the pain subsided again. The resolution of this attack differed from the previous ones in concurring with the use of an injection. A large quantity of tepid water was introduced by means of the long tube, the patient lying on his right side, and when it acted immediately afterwards a little fæcal matter came away; but when it acted a second time, for all

the water did not seem to have come away at once, a very distinct fæcal motion was obtained, with great relief. Several motions subsequently occurred, and the recovery was complete and lasting. He was dismissed in the course of two or three weeks, and he was searched out and found to be all right four or five months later.

CASE III-William Wilson, æt. 22, a sailor by occupation, and a native of Hamburg, was admitted to the Western Infirmary on the afternoon of October 7th, suffering from severe pain in the abdomen and with a history of constipation. The bowels had acted slightly on Oct. 1st, but they had not been properly relieved for at least a fortnight before that time. He had been taking various forms of purgatives during that interval, most of which he had vomited. The paroxysmal pains from which he suffered began on Sept. 29th. There had been no severe vomiting, except in connection with the taking of physic : he had, however, been taking very little food for the last four days, as his stomach could not retain it. For three nights he had slept little, on account of the severity of the pain. About four days before admission he seems to have become much worse, as up to that time he had been able to walk about to some extent.

When seen by me on the night of Oct. 7th, he was suffering from severe paroxysmal pains, occurring every ten minutes or oftener; during these paroxysms tense portions of intestine could be felt in the lower part of the abdomen, particularly on the right side. There was no very great distension of the abdomen: the percussion-note was tympanitic: there was slight tenderness on pressure and some sensation of gurgling in the right iliac region above Poupart's ligament. No hernia could be detected, and on examination per rectum nothing was felt except general bulging from the distended bowels. The case had a very protracted course, with several periods of partial improvement leading to hopes of a complete recovery; but after more than two months' residence, and many periods of excruciating agony, the patient at length succumbed, in the midst of the most extreme weekness and emaciation, during an attack of looseness of the bowels when all abdominal pain and distension had quite subsided.

The source of the mischief proved to be an epithelioma involving the caput cæcum coli, and extending to the ileo-cæcal

valve: the growth presented very marked softening in certain parts, due to colloid degeneration, and the completeness of the obstruction might no doubt be lessened by the breaking down of certain parts of the tumour. As a lesion of this kind in this situation is somewhat rare, the following notes, extracted from the report by Dr. Joseph Coats, are added :—“ In the right lumbar region a tumour is observed connected with the ascending colon, and in fact forming a part of its wall. At the seat of the tumour the colon is puckered, and the serous membrane has a deadwhite, half-cicatricial appearance. There is comparatively slight adhesion to surrounding parts. By cutting up the intestine the tumour is found to have its seat in the caput cæcum, just within the valve, which it partly involves. It is circular in shape, measuring about an inch and a quarter in diameter, and with markedly prominent margins which partially overhang. Its surface towards the cavity of the bowel is somewhat rough, and in the central parts it is somewhat deeply ulcerated. It is to be observed that the caput cæcum is almost entirely involved in the tumour, which has formed a ring around it, the ring-shaped tumour gradually contracting till the calibre of the caput is nearly obliterated. A probe can still be passed through the centre of the tumour into a small pouch from which the normal vermiform appendage passes off. The ring-shaped tumour is just at a level with the valve, partially involving it, but not at present producing any great obstruction to the passage from the ileum into the colon, the constriction described above being virtually beneath the valve, and only shutting off the remains of the caput cæcum and the vermiform appendage. The mucous membrane of the lower part of the ileum is very much thickened and deeply pigmented, and the calibre of the gut is greatly increased. Above, there is little if any thickening, but a frequent pigmentation of Peyer's patches. In the ascending colon there is great thickening and pigmentation of the mucous membrane. This is less marked in the transverse colon, but is again very pronounced in the lower part of the descending colon and rectum. On microscopic examination of the tumour there. are found glandular-looking masses of cells, with a remarkable tendency to colloid degeneration. In some places there are vacuolated cells filling the spaces, and in others the regular

appearance of colloid cancer. It can be seen that the cancer extends between the muscular trabeculæ, these extensions being often colloid, in which case the infiltration presents very prominent appearances. The lymphatic glands of the mesentery are very slightly enlarged, and are not the seat of any secondary tumours."

In view of the pathological details given above, the course of the case became intelligible enough; but during its progress the nature of the obstruction was very obscure, and indeed it was only a few days before death, when the abdomen had collapsed, that a tumour could be felt in the region of the cæcum; the repeated relapses and the extreme degree of emaciation had led before that time to a suspicion of some malignant growth.

The obstruction was not quite complete, at least for very long periods; but from October 1st till October 18th no motion was passed, and the enema given failed to bring away even small quantities of fæces; on the 18th and 19th, however, some fæcal discharge occurred, on the second occasion the motion coming away with the injection fluid which had been retained from the previous day. On the 18th the tension of the belly was less, and the hope was entertained of relief having occurred; but on the following day, although a further discharge took place, the tension had returned and the symptoms continued.

The next time of apparent improvement was on October 27th. From the 18th to the 27th repeated discharges of fæcal matter came away in small quantity, usually after enemata had been used, and these motions, obtained in this way, seemed to afford a slight amount of temporary relief; but this was both very slight and very temporary, for the paroxysmal pains in this period attained an extreme intensity, notwithstanding the enormous doses of morphia administered. Sometimes the large injections given in this period returned without the colour or the odour of fæces. The explanation no doubt was that small quantities of fæces succeeded at times in passing the stricture, and remaining for a short time in the large bowel they had time to assume the form of small fæcal masses, and these were expelled with the large enemata; but after their removal the descending colon remained empty for a time, so that succeeding injections were scarcely ever coloured. On the 27th October