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2d, That it is set down as rare, because the altered sounds and perverted periods of the rhythm of the heart causes a confusion of its diastole with its systole.

3d, That this confusion can only be avoided by feeling the heart's apex beat, while listening to its sounds.

ARTICLE VI.-Observations on the use of Opium as a substitute for Purgatives in severe cases of Obstruction of the Bowels. By GusTAVUS EVANS, M.D., Carlisle.

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NOTWITHSTANDING the frequency, alarming character, and fatal termination of those cases which belong to that class of diseases of which colic is the type, and where there are symptoms clearly indicating a serious obstruction to the natural passage of the contents of the bowel, there is not to be found in works on the practice of medicine a system of treatment specifically based upon physiological indications. If we except the treatment of idiopathic enteritis, we find that authors sanction the purgative plan of treatment, including the exhibition of croton oil and other powerful cathartics. They, however, admit that it is absolutely impossible to determine with any degree of certainty the existence or non-existence of a mechanical body; its precise character, and whether removeable or not. Dr Watson and Dr Copland wisely denounce in strong terms the exhibition of purgatives in obstructed bowel connected with idiopathic enteritis; they, however, admit that in colic, inflammation may be present without any indication of its existence. Dr Copland says that "the pulse is often a most fallacious guide in every form of colic and ileus; and that the diagnosis between colic and inflammation cannot be stated with precision, for there is no symptom which can be relied upon, for inflammation with its consequences, may exist, and yet the abdomen may not be painful on pressure;" he even enumerates among the aids to a correct diagnosis, the operation of the remedies administered. Dr Watson would discontinue the exhibition of purgatives in colic after a fair trial, from the conviction that the mechanical obstacle is such that it cannot be overcome. Alluding to the purgative plan of treatment, he says:-"Common sense and common humanity answer, you must stop it the instant you are convinced that there is a mechanical obstacle which cannot be overcome; to persist in the use of drastic purgatives after that conviction is to inflict wanton and needless torture upon the patient." The reader who may be inclined to peruse what has been written by the following authors on colic and ileus will not be surprised 1 Mackintosh's Practice of Physic, chap. v., p. 247; Abercrombie's Researches on the Bowels, p. 134; Copland's Medical Dictionary, vol. i., p. 360; Watson's Lectures on the Practice of Medicine, vol. ii., p. 433; Tweedie's Library of Practical Medicine, vol. iv., p. 125; Eliotson's Lectures, p. 648.

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when I state that the pathology and treatment is most indefinite, unsatisfactory, and uncertain. It would seem from the purgative treatment sanctioned that the pathological phenomenon of spasmodic intestinal stricture has been entirely overlooked, and that the primary indication of treatment is the removal of constipation, and that evidently without any special reference either to the causes giving rise to it or to the altered physiological conditions leading to spasmodic constriction of the intestine.

However, I maintain that the primary and most important indication to be pursued is the alleviation of spasmodic constriction, and that this is scientific, and in accordance with physiological indications, and in no case, however ambiguous, productive of mischief, nor even distress, to the patient. For supposing a removeable mechanical body existed which produced local irritation of the nervous fibres of a given portion of the intestine, and consequently spasmodic contraction of its muscular coat, it is manifestly clear that it can only be removed by the equable and consentaneous action of the intestine, and that, after the alleviation of spasmodic constriction.

The secondary and comparatively least important indication of treatment is the removal of constipation; and this it appears scientific to accomplish by the repeated injection of copious lavements, instead of the exhibition of purgatives by the mouth. For should the obstruction arise from causes which can only be discovered by a post-mortem examination, such as intussusseptio, internal hernia, or a tumour within the peritoneal cavity, after the partial or complete alleviation of general and local nervous irritation, the forcible injection of copious lavements is the only rational means of relief which the physician can with safety adopt.

I will now briefly detail two cases, the former of which came under my observation prior to having thoroughly and inwardly digested the principles upon which its treatment was based; however, the following apt observation of my esteemed and talented friend, Dr Henry Lonsdale, who saw the case in conjunction with me, will show the indications of treatment pursued, and in reference to which we were both perfectly agreed:-" Let us tranquillize the nervous system, and trust to opening the bowels from below." I consider this brief remark full of the most comprehensive and valuable import, and applicable in its practical bearing, to all these ambiguous

cases:

CASE I.-Aug. 21, 1853, 9 A.M.—I was requested to visit Mr P., aged 42, of good muscular development, possessed of a strong vigorous constitution, and ordinary good health. Tascertained that he had been to Shap Wells, and had drank moderately of the water; had suffered from a slight attack of diarrhoea, which entirely subsided about two days before his return. He now had all the symptoms of a severe colic; the abdomen slightly more distended than usual; severe twisting pain over the left iliac and umbilical regions, not aggravated on pressure, but rather relieved; constant nausea, with occasional vomiting; constipation, accompanied with a great sense of bearing down, and frequent inclination

1854.]

IN INTESTINAL OBSTRUCTION.

to go to stool. The paroxysms of pain, which were frequently attended with vomiting, were of a very severe description, and returned about every 15 or 20 minutes with a hard and contracted state of some of the abdominal muscles. The pulse was full, soft, and only quicker than ordinary during the paroxysm; the tongue perfectly moist, and presented a healthy appearance; the skin rather hot and dry. Administered Tr. Opii 3iss. Ol. Ricini 3ss., hot applications to the abdomen. At 10 A.M. the pain had considerably abated in severity, and he was Ordered a pill, containing Pulv. Opii gr. i., Hydr. Chlocomparatively easy. rid, gr. iss., every two or three hours; or at shorter intervals, should the pain in the least assume its former features. 8 P.M.-Had taken three doses during the day; pain entirely abated; bowels moved; motion rather watery; pulse He had slept about four hours, quiet. Ordered to be taken, at bed-time, Ol. Ricini 3vi., Tr. Opii m xv. Aug. 22.-Was called to visit him at 6 P.M. but awoke with a similar paroxysm to the first, and his attendants immediately gave him a dose of castor oil. He had all the previous symptoms, but the paroxysms were decidedly much more severe, and regular in their occurrence at shorter intervals, with but slight intermission of pain. His countenance was anxious, and indicative of excruciating suffering; vomiting for the first time was distinctly stercoraceous; his pulse was upwards of 100, but full and soft; tongue quite moist. Gave him 3iss. Tr. Opii in water, and very shortly after a copious injection, containing about 3i. Ol. Ricini, Ol. Terebinthinæ 3i. Tr. Opii The pain continued 3iv. This was soon returned with a quantity of dark flocculent focal matter. In about forty minutes he took, in water, Tr. Opii 5ss. somewhat abated for about an hour, after which it returned in all its severity. He was then bled, and fully 28 ounces of blood were removed before any impression was produced upon the pulse, or syncope supervened. He then took Tr. Opii Div.; the pain soon after considerably abated, both in severity and frequency, and the vomiting had almost subsided.

At 9 A.M. he was seized with another severe paroxysm of pain: Pulv. Opii gr. iss. Hydr. Chlorid gr. ii. was administered to him; hot fomentations to abdomen, to which had previously been applied a mustard plaster, a copious warm injection containing a 3iss. of chloroform, which was shortly followed by the same effects usually produced by its inhalation, and with marked relief, although after its influence had subsided, the pain was more or less felt, but 10.30 A.M. Dr H. Lonsdale saw him in conjunction with not nearly so severe. me: he was then considerably easier than he had previously been. There was but slight tenderness over the abdomen; pulse full and inclined to hardness. It was agreed to persevere with the use of injections; hot turpentine applications to abdomen; occasionally sponging with vinegar and water; and to administer a pill containing Pulv. Opii. gr. iss. Hydr. Chlorid gr. iij. every two hours, the opium to be increased according to circumstances, and to repeat the bleeding, if the pulse indicated.-3 P.M. During the previous hours the paroxysms had materially abated in severity and frequency, and the vomiting had almost entirely subsided. The iliac and umbilical regions were very sensitive and painful on pressure; pulse one hundred and twenty, small and hard; a copious warm injection was administered, from which the patient experienced great ease; the greater portion was retained, the other voided with a quantity of similar feculent matter, to that passed before, also a little of a more natural quality. About fifteen ounces of blood were removed, this was followed by the most perfect syncope, from which he very slowly rallied. In about thirty minutes he took a pill containing Morphia Hydrochl. gri, Ext. Hyoscyam gr. iv..after which he slept about five hours, his skin warm and Covered with a copious perspiration.-11 P.M. Still continued inclined to sleep, but expressed himself free from all pain; the pulse soft and quiet.

Aug. 23.-Had slept soundly during the night; continues free from pain; pu ulse quiet and soft. Ordered beef tea, which he took with evident relish ; bowels moved during the day; a tolerable healthy motion.

NEW SERIES.-NO. XLIX. JANUARY 1854.

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Aug. 24-Doing well. Suffering slightly from the effects of the mercury. Took the following aperient draught, to be repeated occasionally when necessary-Tr. Rhei. C. 3iiss., Tr. Card. 3i., Mannæ 3ii., Pulv. Rhei. gr. vij., Tr. Zingib m x. Aquæ Mentha Pip. ad. 3i., Mt. Haustus.

Aug. 25.-Continues well; bowels moved; motions natural.
Aug. 30. He is perfectly well, and tolerably strong.

CASE II.-Sept. 8, 1853.-9 P.M. I was requested to visit Mrs S., aged 28, a very delicate and slender woman, of only moderate muscular development; general health not very good; her appearance upon the whole indicative of deficient constitutional vigour and energy. I ascertained that during the previous fortnight she had suffered from the effects of cold, pain in her back and limbs, accompanied with slight bronchial irritation, and on the 6th was seized with pain over the left iliac, extending over the lower portion of the umbilical region; she also had paroxysms of more severe pain, which varied in frequency from fifteen to twenty minutes. She distinctly recognised these attacks, and states that occasionally she was free from them for two or three hours, although she constantly felt a certain amount of tenderness over the part. She had constant nausea, with occasional vomiting; occasional watery stools, accompanied with pain, and a frequent inclination to go to stool. She states that the only motion passed that day was watery, and contained a little blood; and had scarcely slept any for the last three nights.

Symptoms.-Anxious expression of countenance; abdomen natural size; no tympanitis; acute sensitiveness and extreme pain on pressure over the left iliac and lower portion of the umbilical regions. During the only paroxysm that occurred since my visit, there was extreme hardness and contraction of some of the abdominal muscles, and below the umbilicus there was distinctly felt by the hand a hard, narrow, contracted substance, about three or four inches long. Tongue moist, and natural in appearance; skin dry, and of moderate temperature; slight thirst; constant nausea, and occasional severe vomiting; pulse upwards of 100, small, hard, and wiry. Took about twenty ounces of blood from the arm before the slightest syncope occurred; hot turpentine applied to the abdomen, Gum Opii, gr. iij., Hydr. Chlorid, gr. iij., in a pill immediately given, and a pill containing half these quantities to be given every hour. 12 P.M.-Pain almost entirely abated, with little or no increase on pressure; pulse about 90, and soft. Administered an injection containing about five pints of warm water, Ol. Olivæ, 3iij., Tr. Opii., 3ss. This was returned with a quantity of slimy, unhealthy matter, and about an ounce of small, soft portions of focal matter. Took Gum Opii, gr. iij., Hydr. Chlorid, gr. iss., and the former pill to be repeated every two hours.

Sept. 9th, 8 A.M.-Pain entirely removed, with not the slightest uneasiness on pressure; had slept about two hours, and had no vomiting; pulse about 100, soft and feeble. Administered a copious injection, containing Ol. Ricini, 3ij., Ol. Terebinthinæ, 3iss., Tr. Opii, 3ij. The greater part was retained, the other rejected, containing a large quantity of white flakes of slimy matter, a few streaks of blood, together with nearly an ounce of similar focal matter to that previously passed. Beef-tea to be taken frequently at short intervals, and a small quantity of brandy and water every half hour or hour, according to circumstances. Took Gum Opii, gr. iij., Hydr. Chlorid, gr. iss. The only manifest indication to be followed at this stage was the judicious support of the system, and its tranquillity. 10 P.M.-Strength not diminished, although not increased; indications of a return of vomiting; still perfectly free from pain. Administered a copious injection, with Tr. Opii, 3iij., and ordered Gum Opii, gr. ij.

Sept. 10th.-Pulse soft and very feeble; had slept a few hours; evidence of serious prostration; stomach very irritable; beef-tea, brandy, and water administered during the day; a starch enema, about a pint, with Tr. Opii, 3iij. During the day, the stomach more frequently rejected than it retained what

was taken. 11 P.M.-Slight pain on pressure over the stomach. With a view of allaying irritability of the stomach, as well as producing sleep, administered Etheris Sulph. C. 9ij., Tr. Opii, 3i., and ordered a mustard plaster over the stomach.

Sept. 11th.-Vomiting and nausea had entirely subsided after the draught; slept soundly fully five hours; prostration considerably less; strength returning; pulse quiet; to take no medicine or stimulants, but simple nutritious food.

Sept. 12th. Continues to improve; suffering slightly from the effects of the mercury; simple nutritious food as before.

Sept. 13th.-Still improving; pulse quiet; complains of slight headach. To take the following draught, Tr. Rhei. 3iij., Tr. Card. 3i., Mannæ 5iij., Pulv. Rhei., gr. x., Tr. Zingib, mxii., Aquæ Mentha Pip. ad 3iss.

Sept. 14th.-Pulse quiet, and very much stronger; appetite good; bowels thrice moved; motions copious, consisting of healthy focal matter.

Sept. 15th.-Expressed a desire to sit up, and says she feels comparatively strong; appetite still good; bowels naturally moved; motions perfectly healthy.

Sept. 18th. She is quite well, and tolerably strong, and says she never felt better.

The reasons which induced me to refrain from the exhibition of purgatives in the early stage of these cases, were,-Firstly, The inability to determine, with absolute certainty, that inflammation did not exist, either as a cause or as an effect. Secondly, That there was not an irremoveable mechanical obstacle in existence. Thirdly, That whatever the nature of the mechanical obstacle (if any existing), the true pathology of colic and ileus, in its earliest stage, beyond all doubt, must necessarily embrace intestinal spasmodic constriction. Fourthly, A reference to the therapeutic action of purgatives, in some respects, shows an analogy between their physiological mode of operation and that of inflammation or of a meclianical body, which, however, by producing undue irritation only of a limited portion of the bowel, gives rise to inordinate muscular contraction. Fifthly, That if a portion of the bowel be closely constricted, in consequence of either sympathetic action, inflammation, or the presence of a removeable or irremoveable mechanical body, purgatives, if retained by the stomach, must necessarily act upon that portion of the bowel above the seat of stricture, and would be eminently calculated to lead to ileus, by inverting the peristaltic action of the intestines. Sixthly, A reference to the physiological action of purgatives and the pathology of colic show, that purgatives are contraindicated, inasmuch as they are calculated to develop inflammation, and also to aggravate it if present; and by increasing both general and local nervous irritation, conduce to keep up the immediate exciting cause of constriction of the muscular coat of the intestine.

My reasons for perseveringly adopting the opiate plan of treatment were,-First, That general or local nervous irritation, either singly or combined, is the exciting cause of intestinal spasmodic constriction,-its alleviation, a rational and scientific treatment, devoid of speculation, I would consider as the primary indication of pursuit.

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