Absolute rest is of the greatest importance. The patient should be kept in bed and told to avoid any abrupt motions. He should not be allowed to go to the water-closet, but should use a bedpan. With Treves, Graser,1 and others I am for absolute rest of the stomach and intestines, i.e., no food whatever should be given to patients suffering from acute obstruction of the bowels.

1 R. Fitz: " Transactions of the Congress of Physicians and Surgeons," vol. i., 1888.

2 Curschmann: "Die Behandlung des Ileus." Congress fur innere Medicin, Wiesbaden, 1889.

If there is great thirst a teaspoonful of hot water or very weak tea may be given every half-hour or hour or a small piece of ice may be held in the mouth until it melts, but the water should not be swallowed. Neither should any stimulants like wine, champagne, or whiskey be given by the mouth. In obstruction of the small intestine small quantities of a saline solution (about seven to twelve ounces) may be injected into the bowel several times during the day. If the sickness lasts several days, nutritive enemas consisting of milk and egg or of a peptone solution may be given in the same way. If, however, the patient is not able to retain the enema, considerable quantities of saline solution must be injected either subcutaneously or intravenously.

All writers agree that no cathartic remedies whatever should be used, as they increase the peristalsis and thereby may cause great harm. A cathartic should be permitted only in cases in which the obstruction is positively due either to gall stones or hardened fecal masses or in dynamic ileus. It is, however, of benefit to evacuate the lower parts of the bowel by means of an enema. This cleans out the rectum, diminishes the feeling of tension to a slight extent, and prepares the bowel for the nutrient enemas.

The administration of opium plays a principal part. It is indicated not only as a means of allaying pain but for its soothing action upon the intestinal peristalsis. The arrest of the latter may have a direct curative effect, since it may promote a return of the partly incarcerated or in-vaginated or slightly twisted coil to its normal position.

1 Graser: "Behandlung der Darmverengerung und des Darmver-schlusses." Penzoldt-Stintzings "Handbuch der speciellen Therapie innerer Krankheiten, " Jena, 1896.

In order to secure a prompt action of the drug it is best to first give a hypodermic injection of morphine, one-sixth to one-fourth of a grain. A short time afterward a suppository of two-thirds of a grain of opium is administered and repeated every three or four hours until the pains are kept in abeyance. In cases in which the vomiting is not so marked, opium may be given in the form of the tincture fifteen to twenty drops every three to four hours. It is hardly necessary to say that the opiates should not be used too lavishly. Only so much should be administered as is absolutely necessary for relieving the pain and quieting the violent peristalsis of the intestine. Given in this way, opium not only acts as a sedative but also as a stimulant on the heart. Patients in deep collapse very soon after an injection of morphine become warm, show a better pulse and a more normal temperature. The only disadvantage of opium is that it slightly masks the true picture of the disease. It is therefore best whenever possible first to make an exact diagnosis by thorough examination of the abdominal viscera by palpation, auscultation, etc., before administering it.

If the symptoms- of the disease persist after the administration of opium, especially if the tension of the abdomen is not relieved and no flatus is passed, it is well to discontinue the remedy for a certain period of time. This will enable the physician to judge the situation critically.

As a further sedative agent applications of poultices can be considered. A hot-water bag, a hot plate wrapped up in flannel, or a Japanese warm box, wet packs (Priessnitz) are useful. If there are signs of peritoneal inflammation, applications of ice or of very cold poultices are preferable.

Lavage of the stomach was first recommended in this disease by Kussmaul and Calm.1 This procedure is of benefit if the obstruction is situated high up in the small intestine. It empties the stomach, relieves the vomiting, and also decreases the abdominal tension. There is no doubt that this therapeutic measure is sometimes crowned with success in appropriate cases. As a striking instance of the efficacy of this mode of treatment the following case may be reported:

E. K., thirty-five years old, had always been well, when he suddenly became critically ill with violent abdominal pains and constant vomiting. For three days there was no evacuation of the bowels nor was the patient able to pass any flatus. On examination I found his abdomen considerably distended and tense. The stomach could be mapped out and was considerably dilated, the greater curvature extending a hand's width below the navel. On palpation there was considerable tenderness all over the abdomen. The pulse was quite frequent (110) and weak, temperature 96.5° in the mouth, the extremities were cold. The face showed an expression of great suffering. There were almost continuous hiccough and now and then vomiting of a watery, turbid, somewhat brownish-looking liquid with fecal odor. On introducing the tube over a quart of liquid of the same character was obtained. The stomach was then washed out with several quarts of water until the fluid returned quite clear. The patient felt somewhat relieved. The vomiting stopped and on the following day there was a spontaneous evacuation of the bowels. The patient was now able to pass flatus, the distention subsided, and he gradually recuperated.

For the sake of completeness I would add that besides washing out the stomach, the treatment consisted in the administration of opium suppositories.

1 Kussmaul-Cahn: "Heilung von Ileus durch Magenausspulung." Berl. klin. Wocheuschr., 1884, Nos. 42 and 43.