diverticula, or adhesions. (3) Invagination. (4) Volvulus, or twist. (5) Compression by growths within or without the bowels. (6) Obstruction by fæcal accumulations. (7) Obstruction by foreign bodies. (8) Obstruction due to acute peritonitis, resulting in paralysis of peristaltic action.

Or they are classified in regard to the time and character of the development of the symptoms, into acute and chronic obstructions.

From a purely clinical standpoint, I would prefer to divide them into classes of cases-the one embracing those dependent on change of structure or structural relations, the other including those dependent on change or cessation of function.

The first class would take in internal hernias, constrictions, compressions, invaginations, and volvulus, and should also include true hernias. The second would embrace cases of obstructive fæcal accumulation, of obstruction by foreign bodies, the prohibition of intestinal movement due to acute peritonitis, and also obstruction due to spasmodic contraction caused by irritation. Speaking generally, and subject to exceptions, the cases of the first class are acute, and those of the second class are chronic in character. Those in the first class require prompt, active surgical interference; those in the second class may, generally speaking, tarry a while for deliberation, although it is not to be forgotten that they may change their characters.

I have found this broad division of service in assisting me to promptly decide at the bedside whether the case might be treated tentatively, somewhat temporizingly, as it were, or whether it must be the object of ceaseless solicitude until terminated by the death or recovery of the patient. Even to determine such limitations is sometimes difficult, while to differentiate the particular species of each class is often impossible.

What data, then, will we have to study in seeking a conclusion? Every complete obstruction to the bowel hangs out four signal lights of danger, varying in intensity-they are pain, shock or collapse, vomiting, and constipation, and in the study of every doubtful case the character, relation, and degree of these symptoms will greatly govern the conclusions reached.

In examining a case of supposed obstruction the first duty, I take it, is to exclude beyond a doubt every form of hernia. The

openings must be carefully examined for any swelling, whether pain is complained of or not. I recall distinctly two cases of strangulated inguinal hernia in which there was no local pain, no marked tenderness, and in both of which the patient stated that he felt no difference in the condition of his rupture.

The presence of a tumor, probably hernial, the absence of impulse in it, with the general symptoms of obstruction, should sufficiently determine the case. It must be remembered, too, that a knuckle of gut may be caught and constricted at the inner ring, yet be so small as not to be seen, or perhaps felt; but as it generally occurs in those who had worn a truss and neglected its use, the abdominal symptoms, with the history of a rupture, would justify an exploratory operation. The late Prof. Agnew states that he knew of a number of deaths that resulted from this form of hernia that had been treated for colic.

Being satisfied from the general condition and local examination that there is no rupture, the probability of functional obstructions may be considered. Obstruction by spasmodic contraction, colic, or as an element of hysteria, is generally so com paratively mild affection that its character is not difficult to recognise. The colicky pains are violent, and may be continuous when not wisely treated, but the absence of shock, the history of recent irritating ingesta or a neurasthenic condition, and the rapid yielding to anodyne and antispasmodic remedies, administered either by the mouth or by the rectum, determine the nature of the case.

The prohibition of movement by peristaltic paralysis in local peritonitis: this condition will be diagnosed by the determination of the governing disease, which will have preceded it some time. It lacks suddenness of onset, and the local tenderness and the early local rigidity of the abdominal wall mark the primary vice as one of the three choice situations of peritonitis, the pelvis, the appendicular region, or the neighborhood of the gallbladder, and not in or of the intestinal tube; yet if not seen early, or if the history is obscure, the diagnosis is not without doubt.

The obstruction of the bowel by foreign bodies-such as cherry-stones, seeds, gall-stones-by fæcal accumulations, concretions of magnesia, and other insoluble ingesta, may be brought to the observer's attention as an acute case, but the

obstruction is rarely without indicative preceding symptoms-milder attacks have preceded the one in question, and symptoms are less pronounced. The symptoms, except in rare cases where peritonitis has developed, are not nearly so marked in degree as in the typical strangulation of the gut. Fæcal accumulations are most common in the old and feeble, and at times acquire considerable size; and in patients with thin abdominal walls, a soft, doughy, somewhat movable tumor may be felt. As they are in the large intestine, examination by rectum will, in some cases, determine their presence. The absence of tenderness, of abdominal distension, the colicky, intermittent pain, the history of continuous constipation, and the age and condition of the patient will assist in the diagnosis.

The different varieties of obstruction caused by change in structure or structural relation are clinically always difficult and sometimes impossible to differentiate; they also present only modifications of a terrible type, which once seen, as in strangulated hernia, will never be forgotten. As stated before, the symptoms of pain, vomiting, shock or collapse, and constipation are present in every case of complete structural obstruction. The pain in all of them is sudden, acute, violent; at first periodic and afterward continuous. It is referred not to the spot of localized injury, but to the region of the umbilicus. The patient is restless, the face anxious, features pinched, the limbs at times drawn up. The vomiting varies as to the time of its onset, but is rarely absent; peculiar as to its thorougness; contents of stomach, bilious material and fæcal matter. Constipation is always present save that in invagination there is frequently a discharge of blood or blood-stained mucus from the bowel. Of course the contents of the bowel below the point involved may be washed out, but the profound shock to the nervous vitality of the whole canal prohibits spontaneous movement, even when the lower bowel has fæcal contents. While the symptoms clearly indicate the nature of the case and the required relief, it is only by their relative degrees and the application of the doctrine of probabilities as deduced from statistics that a diagnosis could be made, sight unseen, with a closed abdomen.

The relative frequency is perhaps about that stated as the result of the collection of 305 cases from English, German, and

French literature, which I found in the Annual of Medical Sci

McDonald, as quoted from the Omaha Clinic, has arranged a table of comparisons to assist in arriving at an accurate diagnosis of these cases:

PAIN.

INTUSSUSCEPTION.

Young children.

Above umbilicus, severe In hygogastrium or Prominent, comes in from beginning.

back; comes on at waves.

once; not so severe;

intermits.

Tu

CONSTIPATION. Complete from first.

ABDOMINAL
DISTENSION.

Not marked. No tumor. Rapid accumulation of Usually absent.

DURATION. Die fifth day.

gas. No tumor.

Average six days.

mor felt in parietes or rectum.

Twenty-four hours to several days.

In volvulus a lack of equality in the size of the two sides of the abdomen has been pointed out as a special condition. I have seen a number of cases myself, and in the course of the last twenty years have read an immense amount of literature on the subject, and have had the candid experience of good surgeons, and I am constrained to believe that early positive differential diagnosis is the exception rather than the rule. About two years ago I saw a case in which I supposed a positive diagnosis was made, with a tumor in the abdomen to the left side, in a child ten years old, with the history of a blood-stained, mucous stool and the symptoms of strangulation and invagination sure. It was seen in the afternoon, and, with the assistance of Drs. Hulshizer and McFetridge, I opened the abdomen the next morning, and found that the constriction was produced by a dermoid cyst. Again, I saw, with others, a case of sup. apenditus.

As to treatment: In the functional cases, where fæcal accu

mulations can be detected by rectal examination, the mass may be broken up by the fingers and then copious injections of warm water and oil, used by a fountain syringe, will wash out the tube. When in the colon, the long rectal tube will carry the injection up safely, but in these cases the early use of ether anesthesia facilitates the successful treatment. When, for any reason, an anæsthetic cannot be employed, I have produced local relaxation by a large tobacco poultice to the abdomen, and I have at various times employed medicated enema-turpentine, glycerine, valerian-but I do not know that they did better than hot water, except that I have found an injection of a solution of epsom salts serve me well. In a recent case I tried a recommendation seen in one of the journals: a pint of a decoction of tobacco; dr. 1 to the pint was employed with success.

Massage has been very highly lauded, and while there are no acute symptoms may be of great service, as it certainly would be as a prophylactic if sufficiently employed. The very thorough massage recommended by Hutchison, involving after thorough kneading, the lifting the patient up, shaking him backward and forward and up and down, and when in the inverted position the introduction of a copious enema. I have never tried, and except in a very mild and protracted case, would, in my opinion, be dangerous. I have tried, with very doubtful results, hypodermic injections of a solution of sulphate of magnesia, and had a very sore arm. In cases where the stomach will retain medicine, calomel and belladonna are favorite agents.

In those cases where mild measures do not succeed soon there is reason to open the abdomen, even where the diagnosis is undoubted. A case is reported by Worrall in the Med. Record, of a girl of 13 with large accumulation; purgatives proving unavailing and the symptoms growing urgent, the abdomen was opened and nothing more was necessary. Apparently the stimulation of contact had stimulated peristaltic action, and the bowel moved freely. In cases of local peritonitis not requiring immediate operation the high stimulating injections will be of service, but the treatment depends essentially on the treatment of the peritonitis.

In the structural forms of obstruction comparatively early operation is the treatment. Volvulus when diagnosed may be