>}<™i IRRARY OF MEDICINE N A T I O N A I I I R R A « Y O F M I D I C I N I N A T I O N A I I I • R A R Y O F M I 0 I C I N I NAT 0 A.V.BI1 TVNOILVN I N I 3 I 0 1 W J O A . V I • II 1 V N 0 I 1 V N i N I 3 I 0 i W J O A a V ■ t II 1 V N O U V N INI LIRRARY OF MEDICINE N A T I ON A I I I RR AR Y OF M E 0 I C I N E N A T I 0 N A I 11 R R A R Y O F M E 0 I C I N E NAT d r 0 AaVRRII IVNOIIVN 1 N I 3 I 03 W J O A a V a R 11 1 V N O 11 V N 1 N I 3 I 0 ] W J O A « V I ■ I 1 1 V N O I 1 V N JNI ',&•■ <\ I a IO AaVRBM IVNOIIVN 3 N I 3 I 0 3 W J O A a V a 9 I 1 1 V N O I 1 V N 3 N I 3 I 0 3 V* J O A » V » B II 1 V N O I 1 V N INI • /W i RY OF MEDICINE NATIONAL LIRRARY OF MIDICINI N lOlimnUNOIITN 9NI3IQIW JO A.V...1 IVNOIiVN INI JIOJV. IO UV1II1 1YNOIITN IN >i «•"> o. „,„,<,„, .,„„.., „„„, OI mioiohi NAI|oN/>i t.....r o> ! \iz;-» z .-......-J ,_ : ^0 i ) A.V.9I1 1YNOI1YN J N I 3 I 0 3 W J O A » V » B I 1 1 V N 0 I 1 V N I N I 3 I 0 3 W JO A I V I B I 1 1 V N O 11 V N INCH ton r* 3 gzr—' p 3 r^- n IBRARY OF MIDICINI NATIONAL LIBRARY OF MIDICINI NATIONAL LIBRARY OF MIOICINI NATIO ABVIBIl IVNOIIVN 3 N I 3 I 0 3 W J O A a V I B IT 1 V N O I 1 V N 3 N I 3 I d 3 W J O A I V R B I 1 1 V N O I 1 V N INI) ■ jC-* ✓ — ;3I^> V^ NX ■ OF MIOICINI NATIONAL LIBRARY OF MIOICINI NATIO* i rS/ A.V.BIT IVNOIiVN I N I 3 I 0 I* J O A . V . . ,1 1 V N O I i V N i N , 3 ! 0 . W J O A . V . . .1 ! Y N O 11 V N ,N,3 /Lai \~ I /W 'i V.XV S # PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, THE INTESTINAL CANAL, THE LIVER, AND OTHER VISCERA OF THE ABDOMEN. BY JOHN ABERCROMBIE, M. D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, &C. AND FIRST FHYSICIAN TO HIS MAJESTY IN SCOTLAND. THIRD AMERICAN FROM THE SECOND LONDON EDITION, ENLARGED. < A CAREY, LEA AND BLANCHARD. 1838. ■ w z1: A M-4-J* MERRliM, WOOD AND CO., FRINTER3, SPRINGFIELD MASS. PREFACE TO THE FIRST EDITION. Nothing appears to have had greater influence in retarding the progress of knowledge, than misconception in regard to the proper objects of scientific inqui- ry. It was in this manner that so much talent was wasted and lost in former times, when learned and able men devoted their attention to searching after the hidden causes of events; and the great purpose of the illustrious fathers of mod- ern science was accomplished, by bringing back the atfcntion of inquirers to ob- jects which are within the reach of the human faculties. We often talk of the philosophy of Bacon, without fully recognizing the important truth, that the philosophy of Bacon and of Newton consists entirely, to use the words of an e*m- inent writer, in ' ascertaining the universality of a fact.' This cannot be better illustrated than by a reference to that department of sci- ence, in which the philosophy of modern times is so distinguished above the con- jectures of former ages. The theory of gravitation, even extended as it has been to the great phenomena of the universe, is nothing more than the universality of a fact. Of the cause of that fact we know nothing, and all the investigations of Newton were carried on independently of any attempt to discover it. ' When Newton (says Mr. Stewart,) showed that the same law of gravity extends to the celestial spaces, and that the power by which the moon and planets are retained in their orbits, is precisely similar in its effects to that which is manifested in the fall of a stone,—he left the efficient cause of gravity as much in the dark as ever, and only generalized still farther the conclusions of his predecessors.' If medicine is ever to attain a place among the inductive sciences, its first great step towards this distinction will be made, when medical inquirers agree to restrict their investigations to ascertaining the universality of a fact. By ad- hering to this rule, we shall avoid two errors, which will probably be admitted to have been frequent in medical reasonings, and to have had no inconsiderable influence in retarding the progress of medical science. The one is the construc- tion of hypothetical theories, or the assumption of principles which are altogether gratuitous and imaginary ; the other is the deduction of general principles or conclusions from a limited number of facts. Doctrines of the former class may be considered as almost independent of observation; and those of the latter kind, though they have an apparent foundation of facts, are framed without due inquiry whether these facts are universal. The confidence is indeed remarkablewith which general statements of this last description are often brought forward, and the facility with which they are received, without due examination, as established principles. We even find some writers expressing such confidence in these de- ductions, as to talk of general rules in medicine, with exceptions to these rules; and in this manner new observations, by which the rules might be corrected, are overlooked or forgotten. Such a phraseology, indeed, must probably be con- sidered as at variance with the principles of sound investigation. We are in the habit of talking of general rules in grammar, and exceptions to these rules, IT PREFACE. because we know the precise extent to which the rules apply, and the exact number of instances which form the exceptions ; but, in physical science, to speak of exceptions to a general rule cannot be regarded in any other light than as an admission that the rule is nut general, and consequently is unworthy of confidence. The best means of avoiding the errors which have now been referred to, will probably be, to keep in mind the important principle, that the object of physical science is ' to ascertain the universality of a fact.' A considerable number of medical doctrines, there is reason to apprehend, will come out of the examination in rather an unsatisfactory manner, if we apply to them the tests which this rule would furnish, namely,—are they facts, and are these facts universal? The object which the author has proposed to himself in all his medical re- searches has been, to furnish facts in a concise and accessible form, and to ad- vance to conclusions by the first step of the most cautious induction. If, in fol- lowing out this course of investigation, he has sometimes had occasion to call in question doctrines which have been generally received, he has only to appeal to the principles which have now been stated. To opinions which have been re- ceived by others, he would never presume to oppose mere opinions of his own ; but he cannot hesitate to submit both to the test of observations, which are cal- culated to ascertain, whether they are facts, and whether the facts are universal. He is deeply sensible of the favorable manner in which the profession have re- ceived his Researches on the Pathology of the Brain. The volume which he now presents to them is intended to answer a similar purpose, namely, to furnish them with a connected series of authentic facts, from which he is anxious that they should draw their own conclusions. Those which he draws from them he will keep entirely distinct from the facts on which they are founded; and, wi«h regard to all his conclusions, his only anxiety is, that they should be'tried in the most rigid manner, both by the facts themselves, and by farther observa- tions on the same subjects. This volume is divided into five parts, in reference to the five organs to which it relates, namely, the Stomach, the Intestinal Canal, the Liver, the Spleen, and the Pancreas. The two former are treated of at some length, with a view both to pathology and practice; and the three latter are considered with a more immediate reference to their pathological changes. Edinburgh, October, 1828. PREFACE TO THE SECOND EDITION. A new edition of this volume has been called for much sooner than the Au- thor expected ; but he has been anxious to make such additions and correc- tions as the shortness of the time admitted. The new matter that is added consists chiefly of the following cases, and the observations connected with them : Cases XVII, LI, LII, LV, CXI1, CXXI, CXXII, CXXVI, CXLII, CL, CLI. There are also some addtional facts and observations on the sub- jects of Dysphagia, Diseases of the Duodenum, Tympanites, and the Theory of Ileus. Edinburgh, November, 1829. CONTENTS. Page VIEW OF THE STRUCTURES CONCERNED IN THIS IN- QUIRY, AND THE PRINCIPAL MORBID CONDITIONS TO WHICH THEY ARE LIABLE..... 23 I. Peritoneum - - - 23 II. Muscular Coat ... 25 III. Mucous Membrane - - - 26 PATHOLOGY OF THE STOMACH 29 SECTION I. INFLAMMATORY AFFECTIONS OF THE STOMACH AND ULCERATION - - - ' - - * - 30 General Observations on Acute Gastritis - - 30 _____________-------on Chronic Gastritis - - 33 Progress and Termination of Chronic Gastritis - 34 § 1. Succession of small Ulcers of the Mucous Membrane of the Stomach,—fatal by gradual exhaustion - 37 vhi COaVTENTS. Page § 2. Circumscribed Ulceration with Thickening,—fatal by gradual exhaustion - - - - 38 § 3. Extensive Ulceration with Thickening, complicated with remarkable disease of the Omentum and Perito- neum,—fatal by gradual exhaustion - - - 41 § 4. Ulcer of the Stomach,—fatal by haemorrhage - 44 § 5. Simple Ulceration of very small extent,—suddenly fatal by Perforation of the Stomach - - - 46 § 6. Old Ulceration with Thickening, the Ulcer Cicatrized on its inner surface, with loss of Substance, leaving a cavity which had been bounded only by the Peritone- al covering of the Stomach,—suddenly fatal by that giving way at the part - - - - 49 § 7. Perforating Ulcer of the Stomach, and communica- ^ tion with the Arch of the Colon - - - 51 § 8. Extensive Ulceration of the Stomach of a Cancerous character - - - - - -52 DIAGNOSIS AND TREATMENT OF THE AFFEC- TIONS OF THE STOMACH REFERRED TO UNDER THE PRECEDING HEADS - - 54 Of some modifications of Inflammatory Affections of the Mucous Membrane of the Stomach - - - 59 Diphtherite - - - - - - 59 Of the Softening of the Coats of the Stomach - - 62 SECTION II. OF ORGANIC DISEASES OF THE STOaMACH - - 63 $ 1. Induration and Thickening of the Coats of the Stom- ach - - - - - - 64 § 2. Chronic Peritonitis of the Stomach, with disease of the Omentum and the Pancreas - - - 65 § 3. Diseases of the Pylorus - - - - 65 § 4. Diseases of the Cardia - - - 69 CONTENTS. ix SECTION III. Pag-e PATHOLOGY OF DYSPEPSIA.....69 Various sources of Deranged Digestion - - - "71 Outline of the Treatment of Dyspepsia - - - 72 Observations on some of the more troublesome Symptoms connected with Derangements of the Stomach - 75 I. Gastrodynia - - - - - ^5 II. Chronic Vomiting - - - - 78 III. Obstinate Pyrosis - - - - 78 IV. Haematemesis - - - - 79 V. Sympathetic Affections of the Heart - 79 APPENDIX TO THE PATHOLOGY OF THE STOMACH......86 SECTION I. DERANGEMENT OF THE FUNCTIONS OF THE STOM- ACH BY TUMORS ATTACHED TO IT EXTERNAL- LY, WITHOUT DISEASE OF ITS COAT - - - 86 SECTION II. DISEASES OF THE (ESOPHAGUS ... - 87 1. Inflammation of the CEsophagus - - - - 87 2. Pathology of Dysphagia..... SECTION III. DISEASES OF THE DUODENUM ... - 93 2 X CONTENTS. Page PATHOLOGY OF THE INTESTINAL CANAL - 97 PART I. OF ILEUS ------ 99 SECTION I. OF SIMPLE ILEUS......- 99 <§> 1. Ileus Fatal in the state of Distention without in- flammation ......-99 § 2. Ileus Fatal with Distention and a dark livid color of the parts without Disorganization - - 101 $ 3. Ileus Fatal by Gangrene without Exudation - 102 § 4. Ileus Fatal by Gangrene combined with Exudation 102 SECTION II. ILEUS FATAL WITH PREVIOUS DISEASE OF SUCH A NA- TURE THAT IT SEEMED TO ACT BY DERANGING THE MUSCULAR POWER OF THE CANAL WITHOUT MECHANICAL OBSTRUCTION.....103 <§> 1. Old adhesion of the Intestine of small extent - 103 <§> 2. Old adhesion of the parts concerned in a Hernia 105 § 3. A slender band of adhesion betwixt two contigu- ous turns of Intestine - - - - - 106 § 4. Singular twisting of the Sigmoid Flexure on itself 106 § 5. Ligamentous band confining a portion of Intestine to the mouth of a Hernial sac - - - 108 CONTENTS. XI SECTION III. Page ILEUS WITH MECHANICAL OBSTRUCTION, OR OTHER ORGANIC CHANGES IN THE STRUCTURE OF THE PARTS ..........109 <§> 1. Old Disease of the Intestine connected with Her- nia and Artificial Anus - - - - - 109 § 2. Internal Hernia - - - - - -110 <§. 3. Intus-susceptio - - - - - -111 4 4. Fatal Ileus from a Gall Stone - - - - 113 <§> 5. Contraction of the Calibre of the Intestine - - 114 § 6. Remarkable Stricture of the Arch of the Colon - 116 § 7. Stricture of the Sigmoid Flexure of the Colon - 117 APPENDIX TO THE PATHOLOGY OF ILEUS - 118 § 1. General Distention and Lividity of the Intestinal Canal rapidly fatal ~.....119 § 2. Effects of Galvanism on Distended Intestine - 119 SECTION IV. PATHOLOGICAL AND PRACTICAL INDUCTIONS FROM THE PRECEDING FACTS......120 SECTION V. TREATMENT OF ILEUS ..--'--- 130 xu CONTENTS. PART II. Page OF THE INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CANAL, INCLUDING PERI- TONITIS AND ENTERITIS - - "- 135 SECTION I. SYMPTOMS OF INTESTINAL INFLAMMATION UNDER THESE FORMS.........137 I. Simple Peritonitis - - - - - 137 II. Enteritis......139 SECTION II. EXAMPLES OF PERITONITIS AND ENTERITIS - - ho § 1. Simple Peritonitis - - - - - -140 «§> 2. Peritonitis confined nearly to the descending Colon and Rectum ---___ ^43 <§> 3. Local Peritonitis of very small extent - - 144 § 4. Peritonitis terminating by extensive Suppuration - 145 <§> 5. Peritonitis passing into Enteritis - I47 § 6. Enteritis - - - _ _ _ -149 Practical Conclusions from the preceding facts - 151 SECTION III. °UT^a^tT£E TREATMENT OF INTESTINAL IN- 152 CONTENTS. Xiil SECTION IV. Page ERYSIPELATOUS PERITONITIS......158 SECTION V. CHRONIC PERITONITIS - -...... 165 <§. 1. Chronic Peritonitis in its more distinct form - 167 <§> 2. Chronic Peritonitis in its more obscure form - 169 <§> 3. Chronic Peritonitis supervening upon Measles - 172 «§> 4. Chronic Peritonitis of the Colon supervening on an injury -------- 172 <§» 5. Chronic Peritonitis complicated with disease of the Omentum ------- 173 § 6. Chronic Peritonitis with extensive Suppuration making its way outwards by the external Oblique 174 PART III. OF THE INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE IN- TESTINAL CANAL.....176 Preliminary Observations on the principal Morbid Appear- ances of the Mucous Membrane, and their influence on the Functions of the Bowels - - - 177 XIV CONTENTS. SECTION I. Page ACTIVE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL.....185 Symptoms, &c.......^jj Terminations - - - - - - -189 1. Fatal in the Inflammatory Stage - - - 189 2. Gangrene ------- I9" 3. Ulceration.......190 4. By passing into Peritonitis or Enteritis - - 190 <§, 1. Inflammation of the Mucous Membrane confined to the Rectum, and part of the Ascending Colon - 199 <§, 2. The disease extending along the whole course of the Colon and Rectum,—Fatal in the Inflammatory Stage........191 <§, 3. The Disease occupying the whole Colon and Rec- tum,—Fatal by Gangrene - - - - 192 <§> 4. The disease occupying the whole Colon and Rec- tum, and part of the Ileum - 194 § 5. The disease in the Colon,—Fatal by Extensive Ul- ceration with Peritonitis - - - - 196 § 6. The Disease confined to the Caput Coli, and part of the Ascending Colon,—the Patient dying of an Affection of the Brain - - - - - 197 § 7. Fungous Ulceration of the Caput Coli, and recent Inflammation of the Ileum, with a Coating of False Membrane.....- - 198 § 8. The Disease in the Ileum, with Deposition of False Membrane ------- 199 «§. 9. The Disease in the Ileum,—Fatal in the state of Red Elevated Portions, with Incipient Ulceration 200 § 10. The disease in the Ileum,—Fatal by Gangrene - 201 §11. The Disease in the Ileum, with Ulceration,—Fatal by a perforating Ulcer and Peritonitis - - 202 <§> 12. The disease occurring in Continued Fever, with Ulceration -......202 Pathological and Practical Conclusions from the Preceding observations - 204 CONTENTS. XV SECTION II. Page OF THE CHRONIC DISEASES OF THE MUCOUS MEM- BRANE. ..........207 General View of the Morbid Appearances in the Chronic Cases ------ 207 General View of the Symptoms - 209 <§> 1. The Disease Fatal, with elevated Red Patches without Ulceration ----- 210 § 2. Numerous small detached Ulcers, the intervening Membrane healthy - - - - -210 <§> 3. Extensive continued Ulceration of the Mucous Membrane of the Colon - - - - 212 § 4. Extensive continued Ulceration in the Small In- testines ------- 214 § 5. Ulceration of the Mucous Membrane, with Thick- ening and Induration of the Coats of the Intestine 216 SECTION III. ULCERS OF THE MUCOUS MEMBRANE WITHOUT PRO- MINENT SYMPTOMS.......220 § 1. An Ulcer of this class Fatal by Haemorrhage with- out previous Symptoms in the Bowels - - 221 § 2. An ulcer of this class suddenly Fatal with Perito- nitis ........221 <§> 3. An ulcer of this class suddenly Fatal by Perfora- tion of the Intestine in continued Fever - - 222 § 4. Ulcers of this class, without any previous illness, suddenly Fatal by Perforation of the Intestine 224 <§> 5. Ulcers of this class found connected with obscure Symptoms of long standing - 225 XVI CONTENTS. SECTION IV. Page OF THE TREATMENT OF THE AFFECTIONS OF THE MUCOUS MEMBRANE.......226 <§. 1. Treatment of the Acute Affections - - 226 <§> 2. ---------of the Chronic Affections - 233 SECTION V. OF THE INFLAMMATION OF THE MUCOUS MEM- BRANE IN INFANTS ------- 237 SECTION VI. CASES SHOWING THE STATE OF THE MUCOUS MEM- BRANE AFTER THE CESSATION OF THE SYMP- TOMS, THE PATIENTS DYING OF OTHER DIS- EASES ...........239 Concluding Observation on the Pathology of the Mucous Membrane, with Reference to the Investigations of Continental Writers on this Subject - - 242 APPENDIX TO THE PATHOLOGY OF THE INTES- TINAL CANAL. SECTION I. DISEASES OF THE MESENTERIC GLANDS ... 247 SECTION II. DISEASE OF THE OMENTUM......249 SECTION III. TYMPANITES..........250 CONTENTS. xvii SECTION IV. ARTERIAL HiEMORRAGE FROM THE RECTUM - - 255 SECTION V. OF A VERY OBSCURE AFFECTION, IN WHICH THE SYMPTOMS ARE CHIEFLY REFERABLE TO THE BOWELS .... ......256 SECTION VI. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI.........257 SECTION VII. EXTENSIVE DISEASE OF THE RECTUM AND PROS- TATE GLAND.—STRICTURE OF THE ARCH OF THE COLON, &c........- - - 258 SECTION VIII. EXTENSIVE DISEASE OF THE BLADDER, AND COMMU- NICATION BETWEEN IT AND THE INTESTINAL CANAL, AT THE EXTREMITY OF THE ILEUM 259 PATHOLOGY OF THE LIVER - 261 SECTION I. OF THE MORBID CONDITIONS OF THE LIVER CON- NECTED WITH ACUTE DISEASE ----- 263 § 1. Inflammation of the Liver - - 263 3 xviii CONTENTS. Page $ 2. The Mass of the Liver more or less Enlarged, espe- cially on the right side; externally of a very dark color, or nearly black ; its substance, when cut into also very dark colored, and giving out much very dark blood. In other cases the black color is only on the surface, the internal structure being tolerably healthy ------- 264 <§» 3. Abscess of the Liver ----- 266 § 4. Simple RamoUissement of the Liver - - 272 <§> 5. The black RamoUissement of the Liver - 272 § 6. The wliite or Encephaloid RamoUissement of the Li\er........274 <§> 7. Copious Deposition of Gelatinous Matter of a soft con- sistence and a reddish color - 275 $ 8. Remarkable distention of the Biliary Vessels - 275 SECTION II. OF THE CHRONIC AFFECTIONS OF THE LIVER - 275 § 1. Chronic Inflammation of the Liver - 276 § 2. Simple Enlargement, without change of Texture 276 § 3. Tubera in the Liver, without other Disease in its Structure -- - _ _ _ _^ 277 § 4. The Pab degeneration, consisting of change of Color without remarkable alteration of Texture - 278 § 5. Pale Color, with Induration - 279 A. Pale Indurated Liver, of the natural size - 280 ~-----------------with Enlargement - 281 C' ~~~------------with Remarkable diminution of Size ---____ ocq § 6. Dark Induratiom of the Liver - 283 § 7. Tuberculated Disease on the surface of the Liver without disease of its Structure - - ' 284 § 8. Tubercular Disease of the Liver, with severe Pectoral Complaints and Ulceration of the Stomach - 285 § 9. Tub2rcles, or Tubera of various characters diffused CONTENTS. XIX Page through the substance of the Liver, with Disease of the intervening Structure - 286 § 10. Hydatids - - 288 $11. Large Cysts, containing a Watery Fluid, contained under the Peritoneal Coat of the Liver - - 288 Outline of the Treatment of Diseases of the Liver 289 APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. HAEMORRHAGE FROM THE LIVER ----- 293 SECTION II. RUPTURE OF THE LIVER BY EXTERNAL VIOLENCE - 293 SECTION III. DISEASES OF THE GALL BLADDER 294 1. Biliary Calculi.......294 2. Perforation or Rupture of the Gall Bladder, or one of its Ducts, and Escape of the Bile into the Perito- neal Cavity.......294 SECTION IV. CHANGES IN THE dUANTITY AND aUALITY OF THE BILE...........295 XX CONTENTS. SECTION V. Page PATHOLOGY OF JAUNDICE - - - - - - " 297 PATHOLOGY OF THE SPLEEN. $ 1. Inflammation ------- 305 <§> 2. Suppuration of the Spleen - 3P6 § 3. RamoUissement or Black Degeneration of the Spleen 308 $4. Simple Enlargement of the Spleen - - - 310 $ 5. Tubercles.......312 $ 6. Pale Induration of the Spleen - - - - 313 § 7. Hydatids.......313 § 8. Haemorrhage from the Spleen, and Laceration by External Violence - - - - - -313 PATHOLOGY OF THE PANCREAS. 1. Inflammation and its consequences - 315 2. Enlargement with a mixed state of Disease, partly con- sisting of Induration, and partly of a softened state, resembling the Medullary Sarcoma - - 316 3. Scirrhus Induration, with little enlargement - - 318 4. Calculus Concretions.....- 320 PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, THE INTESTINAL CANAL, THE LIVER, AND OTHER VISCERA OF THE ABDOMEN. PATHOLOGY OF THE STOMACH AND INTESTINAL CANAL. VIEW OF THE STRUCTURES CONCERNED IN THIS INQUIRY, AND THE PRINCIPAL MORBID CONDITIONS TO WHICH THEY ARE LIABLE. In entering upon the pathology of the stomach and intestinal canal, it will be advisable first to take a general view of the va- rious structures which enter into the formation of these organs, and of the principal morbid conditions to which they are liable. The structures are chiefly three, namely, the peritoneal, the muscular, and the mucous coats of the canal. I. The peritoneum is a serous membrane, which is constant- ly carrying on the function of exhaling and re-absorbing a serous fluid. It is liable to inflammation, both acute and chronic, and to various remarkable changes of structure, some of which are evidently the result of inflammation, while others seem to have a different origin. The first effect of a certain low degree of inflammatory action upon serous membranes, appears to be simply an increased deposition of the serous fluid ; and, in this manner, it is probable, that a certain state of these membranes, which, if not actually inflammatory, closely borders upon it, is sometimes relieved; the increased quantity of fluid being afterwards absorbed, and the parts thus recover- ing their healthy relations. But, in different states of the dis- ease, we find remarkable varieties in the characters of the fluid which is deposited: in one case, it is simply opake and milky, —in another, it contains shreds of flocculent matter,—in a 24 STRUCTURES OF THE STOMACH third, it has all the sensible properties of pus. All these varie- ties of the effused fluid are sometimes found without any re- markable change in the membrane itself; but, in general, it has undergone some considerable deviation from the healthy struc- ture. These deviations are chiefly two. The first is a slightly softened and thickened state of the membrane, giving it some- what the appearance <5f a par't^which Jiasjaeen boiled. This I thwik^fcorhmorrly",tf»nRgcted witfc. the dpalte milky deposition. The second and the more cpmmt>n*appea'fVnces,consists in the surface being covered by a coating of false membrane. This may be connected with the milky flocculent fluid, or with fluid which has all the sensible qualities of pus, or with a fluid which is entirely limpid. In the latter case, the deposition on the sur- face of the membrane will prevent the re-absorption of the fluid, so that the accumulation which might otherwise have dis- appeared will thus become a permanent dropsy of the cavity,— provided the disease has not existed in such a form as to be speedily fatal. This state of parts is often seen most remarka- bly in the cavity of the pleura, the cavity being full of a limpid fluid, while it is lined by a complete and uniform cyst of false membrane. We are entirely unacquainted with the causes which regulate these varieties in the deposition from inflamed serous membranes. Under the influence of inflammation, also, whether acute or chronic, serous membranes are liable to form adhesions betwixt their opposite surfaces, and this may consist of simple adhesion with very little appearance of any interposed substance ; or there may be an interposition of false membrane, which is often of very considerable thickness. In their structure, serous membranes are liable chiefly to three morbid conditions. 1. Simple thickening. This is seen most strikingly in the peritoneum, which is sometimes found thickened in a most re- markable degree; and it appears to be the result of inflamma- tion which has gone on in a chronic form. 2. Tubercular disease—the whole surface of the membrane being found studded with innumerable tubercles, generally of a very small size, and of a firm consistence. They appear to be covered by cysts, and present the same characters with tuber- cles in other parts of the body. 3. There is another affection, often met with in the perito- neum, which appears to be in its nature quite distinct from tu- bercular disease. It consists in the surface of the membrane be- ing covered by nodules of various shapes and sizes,___of a semi- pellucid character and smooth rounded surface. The masses of AND INTESTINAL CANAL. 25 this substance are sometimes of great size, and a large extent of the peritoneum may be found covered by them. This is the disease described by Dr. Baron, and supposed by him to be of the nature of hydatids. On first inspection it has a resemblance to hydatids; but in the specimens which I have had an oppor- tunity of examining, it appeared to be of an entirely different na- ture. The nodules were of a uniform firm gelatinous consistence, or even more dense at the centre than at the circumference. They did not appear to be covered by a cyst, and they were en- tirely soluble in boiling water. II. The second structure is the Muscular Coat. It completely invests the whole extent of the canal; and the healthy function of the parts depends upon this muscular covering performing at all times its healthy and regular action. We know little of the diseases of muscular fibre, except in as far as relates to de- rangement of its functions. In a muscular *covering which invests a cavity, the principal deviations from the healthy state appear to be the following. 1. A morbidly increased but uniform and harmonious action. This appears to arise chiefly from causes of irritation applied to the internal surface of such cavities. In this manner we see vomiting produced by various irritations applied to the stomach, and diarrhoea by similar causes applied to the intestinal surface. A similar effect seems to arise from a morbid irritability of the surface itself, provided it be uniform over a considerable extent of the membrane; the ordinary stimuli producing in this case the same effect that the irritating causes do in the healthy state of the membrane. 2. A morbidly increased but partial and irregular action. This appears to arise chiefly from morbid irritability of small portions of the internal surface; the ordinary stimuli produc- ing, at these parts, a morbidly increased action, with which the other parts do not harmonize. This appears to be the state which is often expressed by the indefinite term spasm. It is seen in the urethra, and the oesophagus, in the affection which is called spasmodic stricture ; and a similar condition appears to occur in the bowels, particularly in certain states of dysentery, in which we find frequent irritation and morbid discharges from ■ the lower part of the canal, with retention of the natural feces in the parts above. 3. Diminution or loss of muscular power. In a muscular covering investing a cavity, this appears to arise from two causes, namely, over distention and inflammation. The former we see distinctly take place in the bladder, and there is reason 4 26 STRUCTURES OF THE STOMACH to believe that something similar occurs in the bowels in certain states of Ileus. Inflammation seems also to destroy the action of muscular fibre. Thus, intestine which has been highly in- flamed is generally found in a state of great distention, showing the complete loss of its healthy museular action; and, if the disease has gone on until the intestine has either become rup- tured, or has given way by ulceration, it is found to have fallen together like an empty bag, without any appearance of muscu- lar contraction; whereas, healthy intestine, when it is empty, contracts uniformly into a round cord. In regard to the imme- diate effects of inflammation upon muscular fibre, there is con- siderable obscurity ; but, one point may be considered as known and established, which is of considerable importance for our fu- ture inquiries, namely, that a result of inflammation in muscular fibre is gangrene. When, therefore, we find gangrene in the intestinal canal, we have reason in general to conclude that in- flammation has Existed in the muscular coat; for we shall after- wards find grounds for believing, that it may exist in each of the coats separately without affecting the others, but giving rise to most important diversities in the symptoms. 4. Thickening of the muscular coat has also been described by some of the French writers, particularly as occurring in the stomach. It constitutes an affection to which they have given the name of Hypertrophia of the stomach ; though some of them appear to apply this term to a general thickening of all the coats. III. The third structure to which our researches will refer, is the Mucous Membrane. This lines the whole course of the intestinal canal from the pharynx to the rectum. In the struc- ture and functions of this membrane, we have to keep in view the following circumstances. 1. The whole surface of the membrane is constantly secreting a mucous fluid, which is transparent, glutinous, and is said to have slightly acid properties. It appears to be formed in large quantity ; according to Haller, to the extent of eight pounds in twenty-four hours. Wiien an animal has fasted for a considera- ble time, this fluid has been supposed to undergo digestion forming^chyme and excrementitious matter; and, in this way' some have explained the appearance of excrementitious matter in tedious fevers, and other protracted diseases, in which the patient has taken little or no nourishment. 2. Besides this general secretion from the whole mucous purface, there is a distinct formation, from numerous follicles or simple glands of a liquid which has been called the follicular fluid. These follicles exist in great numbers along the whole AND INTESTINAL CANAL. 27 course of the intestinal membrane, though they are more numerous at some parts than at others. The peculiar proper- ties of the follicular fluid have not been ascertained ; but, it is considered as certain, that it is distinct from the general mucous secretion,—because, in observations upon living animals, the latter may be seen to be produced from portions of the mem- brane, where no follicles appear to exist. The mucous and follicular fluids of the stomach, mixed with similar fluids from the oesophagus, and with saliva, are considered as forming the gastric juice. 3. There is likewise from the whole mucous surface a serous exhalation, similar in its properties, as far as is known, to the exhalation from serous membranes. 4. The intestinal mucous membrane is also to be considered as an absorbing surface ;—numerous absorbents opening from every part of it, and conveying the absorbed fluids towards the thoracic duct. These are most numerous in the small intestines. We are to attend to various forms of disease in mucous mem- branes connected with these peculiarities of structure. These are chiefly the following. 1. Inflammation and its consequences. This appears to exist in mucous membranes in various forms, or rather various de- grees, but we are ignorant of the causes which regulate these varieties. The effect of the first or lowest degree of inflamma- tion on a mucous membrane, appears to be simply an increase of its proper secretion, more or less changed in its qualities from the healthy condition. This we see most familiarly in the nose and in the bronchial membrane. In another state of inflamma- tion, we find the formation of aphthous crusts, and in a third the deposition of false membrane. This last we see most re- markably in the bronchial membrane; it is also met with, though more rarely, in the mucous membrane of the intestine. In a more advanced stage, inflammation of the mucous intestinal membrane terminates by ramollissement, or an ash-colored pulpy degeneration of portions of the membrane; these fall out and leave spaces, which are apt to pass into ulceration. A conside- rable extent of the membrane is also occasionally found in a state of uniform dark softening, resembling gangrene. Adhe- sion of the opposite surfaces of the mucous membrane of the in- testine is sometimes met with, producing complete obliteration of the canal; but this is very rare. A case has been related to me, in which it was found to have taken place in the. parts included in a hernia. Inflammation of mucous membranes exists in a more chronic form, in which it goes on for a long period, and is chiefly distinguished by increased and morbid secretion from 28 STRUCTURES OF THE STOMACH, &C. the parts. In its progress in these cases, the membrane is apt to become thickened and even indurated, so as considerably to •diminish the capacity of the cavity. In this manner is formed stricture of the urethra, and similar diminution of the area of the intestinal canal. The diseased surface in those cases is fre- quently found covered with fungous elevations: and these fre- quently alternate with portions of the membrane in a state of ulceration. The French writers have started a controversy, whether the change of structure in these cases be in the mucous membrane itself, or in the subjacent cellular texture. It is a point which it must be next to impossible to decide, and of no practical importance. 2. Diseases of the follicles, or simple glands of the membrane. This subject is involved in much obscurity, but seems to pro- mise some interesting results. The follicles appear to be liable to a vesicular or pustular disease, which passes into small de- fined distuct ulcers, quite unconnected with any disease of the mucous surface. 3. Disease of a tubercular character is often met with on the mucous membranes. It is probably seated in the follicular or glandular structure, and is most commonly met with in some particular situations, as the cardia, pylorus, and the extremity of the rectum, in which situations it often assumes a scirrhous character. 4. Diseases of the parts concerned in the absorption of the alimentary matter, so that, though elaborated in the usual manner, it passes off without entering the circulation. The cause of this most familiar to us, is disease of the glands of the mesentry; but the same effect appears to result from cer- tain conditions of the surface of the mucous membrane itself. This slight outline of the various morbid conditions, to be considered in regard to the intestinal canal, will serve to show the importance of the subject; and the extent of it will farther appear, when we recollect, that the various diseases are also greatly modified by their seat,-—as being in the stomach, the small intestine or the colon and rectum. Of a subject so ex- tensive, it is but a very imperfect view that can be given in such an essay as the present; but I am anxious that what is given may be correct and authentic, as far as it goes, and that it may be of some use in directing the researches of those who have opportunities ©f prosecuting the investigation. PATHOLOGY OF THE STOMACH. There are few points in medical science which have under- gone more discussion than affections of the stomach; and yet, it must be confessed, that when we come to investigate the sub- ject, according to the rules of pathological induction, we find little that is satisfactory. This has in part arisen from nume- rous difficulties which attend the investigation. Many of the affections of the stomach, though productive of much and pro- tracted discomfort, are not apt to be fatal; and thus few opportunities occur of investigating their pathology, except when the patient dies of another disease. The great proportion of these seem also to be entirely of a functional nature, leaving no morbid appearance that can be discovered after the death of the patient; and, in others, the appearances are of so doubtful a kind, that they do not afford sufficient ground for any precise principle in pathology. In a practical point of view, also, this is perhaps more encumbered with uncertainty than almost any other department of medical practice ; for the diseases are so much under the influence of moral and other adventitious causes, that the action of remedies is aided, modified, or coun- teracted, in a manner which entirely eludes our observation, and is often altogether beyond our control. From these various causes, diseases-of the stomach have presented a wide field for speculation, conjecture, and empiricism; a vague and indefinite phraseology has often been allowed to take the place of princi- ples ; and the whole subject is removed in some measure out of the usual limits of pathological inquiry. Amid this uncer- tainty we must endeavor to discover what is truth ; and, should this prove to be more limited than a slight view of the subject might lead us to expect, something will at least be done by ascer- taining its extent and tracing the course by which it may be enlarged. 30 INFLAMMATORY AFFECTIONS I shall consider affections of the stomach under three classes : I. Affections of an inflammatory kind, including ulceration and its consequences. II. Affections which more properly come under the class of organic. III. Functional affections, embracing a slight outline of the subject of dyspepsia. In an appendix, I shall briefly allude to the affections of the oesophagus—and the duodenum—and to derangement of the functions of the stomach by tumors attached to it externally. SECTION I. OF THE INFLAMMATORY AFFECTIONS OF THE STOMACH AND ULCERATION. Acute gastritis is a disease described by all systematic writers, But in the records of pathology it is very difficult to find a pure example of it in an idiopathic form. I have been often very much astonished to find, in my own observation, how seldom the stomach shows marks of inflammation, even when the organs most nearly connected with it have been inflamed in the highest degree. In cases of very extensive peritonitis, the peritodeal coat of the stomach is sometimes affected; but even this is rare, and a case of pure inflammation of this membrane I have never seen, and do not find described by any writer. Dr. Armstrong, in the first fasciculus of his work on the morbid- anatomy of the stomach and bowels, gives a plate representing inflammatory deposition on the peritoneal coat of the stomach; but no account is given of the case from which it was taken, so that it does not appear whether it was an example of pure idio- pathic gastritis, or whether the appearance occurred in connec- tion with more general peritonitis. The disease which we call gastritis is to be considered, there- fore, as seated chiefly or entirely in the mucous membrane, and even here it is extremely rare as an acute and idiopathic disease. It is from the action of the acrid poisons that we chiefly find inflammation of the stomach, but we cannot consider these cases as necessarily exhibiting the same symptoms which would accompany the disease in its idiopathic form. The symptoms which are usually described as those of gastritis are pain and tenderness in the region of the stomach, with urgent OF THE STOMACH. 31 vomiting and fever ; but, in as far as we have facts on which we can proceed with confidence, it does not appear that the symptoms are so uniform as systematic writers would lead us to believe. A man mentioned by Haller, having swallowed a large quantity of very cold water when he was much heated, was seized with acute pain in the stomach and fever, and died delirious in fifteen days,—no other symptoms being mentioned. The stomach was found to contain a fetid ichorous matter ; and the fundus of it was inflamed with gangrenous spots and ulce- rations. In another case, by the same writer, which was com- plicated with disease of the lungs, the chief symptoms were, pain and oppression of the breast, with perpetual hiccup and difficult deglutition. The stomach is said to have been every- where inflamed, with effusion of blood into its cellular texture. In a case by Morgagni, the principal symptoms were anxiety and sense of fullness in the stomach, with frequent vomiting of a brown matter, in which were floating shreds of a membranous appearance; and these symptoms were followed by hiccup, delirium, and convulsion. A young man mentioned by Storck complained chiefly of a burning uneasiness in the abdomen, with hiccup and intense thirst; and a man mentioned by Lieutaud had intense fever, and violent pain in the stomach, with urgent vomiting, distention of the epigastrium and difficult breathing. In these and other cases of the same kind, however, it is merely stated in very general terms that the stomach showed marks of inflammation—except in Haller's case, in which ulceration is mentioned; and the cases described by Broussais appear to be equally unsatisfactory. On the other hand, we find De Haen, Stohl and Frank de- scribing cases of what they term inflammation and gangrene of the stomach, in which none of the usual symptoms of gastritis had occurred ; and other cases which had exhibited all the symptoms of gastritis, while no appearance of inflammation could be discovered on dissection. The last mentioned writer farther admits, that symptoms, closely resembling those ascribed to gas- tritis, frequently subside under treatment the very reverse of that which would have been applicable to inflammation. To these circumstances we have to add the important facts ascer- tained by Dr. Yeloly and others. In numerous cases of persons who died of other diseases, without any s} mptoms in the stom- ach, and in the bodies of criminals who had been executed, they have pointed out appearances which might have been con- sidered as distinctly indicating inflammation of the mucus mem- brane of the stomach. The older writers appear to have been very indefinite in re- 32 INFLAMMATORY AFFECTIONS gard to the use of the term inflammation ; and it will now proba- bly be admitted, that it ought not to be applied to any appear- ances consisting of mere change of color or increased vascularity, without some decided change in the structure of the part, or some of the actual results of inflammation ; and, upon the whole view of the subject, the conclusion seems to be, that we are still very much in the dark in regard to idiopathic acute gastritis. For my own part, I have never seen a case which I could con- sider as being of this nature ; and I am disposed to regard as points not yet ascertained, what are the characters exhibited by the mucous membrane of the stomach in the earlier periods of acute gastritis, and in what they differ from appearances which may exist without any symptoms of gastric disease,- or take place after death. If we might proceed in any degree upon the analogy of the corresponding affection in the mucous membrane of the bowels, I should be inclined to suppose that the disease exists under two forms;—that in the one, it is seated chiefly in ' the follicles or simple glands, in the other, in the mucous mem- brane itself;—that, in the former case, it would consist, in its early stage, of detached and minute pustules or vesicles, and would terminate at an early period in minute and detached ulcers ; —and that, in the other, it would exhibit in its first stage, the appearance of defined portions of the mucous membrane of a red or livid-brown color, and sensibly elevated above the level of the surrounding parts—these portions afterwards terminating ' by softening or ulceration, or passing into a chronic state of disease with ulceration, thickening, or fungoid elevations upon the diseased parts. This is in some measure conjectural, but I think we may safely assert, that, in this investigation, nothing can be founded upon a mere general or extensive redness of the membrane, discoloration, or increased vascularity,—whether more or less extensive,—venous turgescence, extravasation of blood into the cellular texture, or upon any appearance which consists of mere change of color, without any decided change in the structure of the part. In a case mentioned by Mr. Annes- ley, in his late work on the diseases of India, which was fatal in seven days, the mucous membrane of the stomach was found covered with small defined ulcers, discharging a thin sanious fluid. The symptoms were incessant vomiting and hiccup, with fever of a tertian type, without any complaint of pain'. In another case, by the same writer, there was at first acute pain in the stomach, increased by pressure, with very slight fever and no vomiting. On the fourth day vomiting began, and he died on the seventh. The coats of the stomach in this case OF THE STOMACH. 33 appeared to be thickened, but its internal surface was only deep- ly injected. I leave this part of the subject, merely pointing it out for far- ther investigation, and proceed to another of much practical importance, in regard to which we have numerous interesting facts on which we can proceed with confidence. We have every reason to believe, that the mucous membrane of the stom- ach is liable to inflammation in a chronic form, which often ad- vances so slowly and insidiously, that the dangerous nature of it may be overlooked, until it has passed into ulceration, or has even assumed the characters of organic and hopeless disease. Farther, we shall find, that even ulceration may exist in the stomach without producing any symptoms of an alarming nature, until it gives rise to an attack which is very speedily fatal. In the early stages of this affection, the prominent symptoms are often such as merely indicate derangement of the functions of the stomach, and are apt to be included under the general term dyspepsia. The patient perhaps complains of extreme acidity, eructations, flatulence, and oppression of the stomach after eat- ing. There is generally some degree of pain in the region of the stomach, but it varies very much both in its degree and its duration. In many cases, it is complained of only after eating, continues in considerable severity while the process of digestion is going on, and subsides when that process is completed. The appetite is often unimpaired, but the patient is afraid of taking food on account of the uneasiness which is produced by it, and he is entirely free from complaint when the stomach is empty. A frequent expression of such patients is, ' I should be quite well, if I could do without eating.' In other cases, there is more permanent uneasiness, which is aggravated by taking food ; and sometimes there is pain in the back at the part correspond- ing to the seat of .the stomach. In other cases, again, there is no actual pain, but the uneasiness is described as a feeling of heat, or a great degree of pyrosis. The tongue is, in some cases, little altered from the healthy appearance; but in others, it shows a peculiar rawness and tenderness, and occasionally minute ulcers may be observed on its edges. Vomiting is apt to occur, but in the early stages is only occasional, and is as- cribed to some error in diet, or other accidental cause. After- wards it becomes more frequent, but still without that regularity which would seem to indicate serious disease ; by attention to diet it may be, in a great measure, prevented, and in this man- ner the disease may go on for months without exciting alarm. The vomiting then, perhaps, becomes more frequent, and the uneasiness in the stomach more permanent, until the patient 5 34 INFLAMMATORY AFFECTIONS either sinks by gradual wasting, or is suddenly cut off by one of those rapid attacks to be afterwards particularly described. In all the forms of this insidious disease there is great diversity in the symptoms. In some cases, there is little or no vomiting, the prominent symptoms being pain excited by taking food, with gradual wasting, and, as the disease advances, a feeling as if the stomach were incapable of holding any thing beyond the small- est possible quantity. In other cases, there is chiefly a con- stant and most painful feeling of pyrosis, with gradual emacia- tion ; but, in many, it will be found that little or no uneasiness had ever been complained of, until the attack takes place which is fatal in a few hours. An important circumstance, therefore, in the history of this affection, is, that it may run its course al- most to the last period without vomiting, and with scarcely any symptom except the uneasiness which is produced by eating, and which subsides entirely in a few hours after a meal. This most interesting modification of the disease will be strikingly il- lustrated by Case IV. In some cases, again, the prominent symptom is a very copi- ous discharge from the stomach of a clear glairy fluid like the white of eggs. In a woman, mentioned by Andral, this dis- charge amounted to about four pints in twenty-four hours ; and she never vomited either food or drink. Sometimes this dis- charge is streaked with a black matter, or is entirely of the color of chocolate, and not unfrequently is mixed with grumous blood. The disease which is going on during the course of symptoms now described, consists of chronic inflammation of the mucous membrane of the stomach, which in many cases appears tc commence in a very small and circumscribed portion. Its pro- gress seems to be very slow, and, it is probable that it may con- tinue for a considerable time and then subside, and occur again after various intervals, until at last it produces more permanent and extensive disease, by thickening of the parietes of the stom- ach, adhesion to the neighboring parts and ulceration. The result which we have occasion to attend to most frequently as the immediate cause of urgent symptoms, is ulceration of the inner surface of the stomach ; and we shall find that it exists in various forms, the most important of which, in a practical point of view, are the following:— 1. A small defined ulcer of limited extent, with evident los° ot substance, and rounded and elevated edges, varying in extent from the size of a split pea to that of a shilling. We may find only one such ulcer, every other part of the stomach being ir the most healthy state; or we may find that there has been a OF THE STOMACH. 35 succession of them, some of them cicatrizing, and others appear- ing, while the health of the patient gradually sunk under the disease, which after all may be found to have been of no great extent. In the cases of this first class, there is no general dis- ease of the coats of the stomach, the ulcer being confined en- tirely to the mucous membrane, or perhaps to the follicles. 2. Ulcers like the former, of small extent, perhaps the size of a shilling, but complicated with thickening and induration of the parietes of the stomach, perhaps to the extent of a crown piece or more around the ulcer, all the rest of the stomach be- ing perfectly healthy. 3. Extensive irregular ulceration of the inner surface of the stomach, generally complicated with thickening and induration of the coats, and fungoid elevations. In some cases there is no actual ulceration,—the prominent morbid appearance being a thickened state of the mucous mem- brane to a greater or less extent. The thickened portion in this case may be of a pale ash color, or of a brown color, or of a dark color with the characters of melanosis; and these ap- pearances may be farther complicated with thickening and in- duration of all the coats of the stomach at the part affected, and perhaps adhesion to some of the neighboring organs. In other cases again portions of the mucous membrane have been found softened or entirely destroyed. In the progress and termination of this disease, there is con- siderable variety.; the most important modifications in a practi- cal point of view may be thus stated. 1. The disease may be fatal by gradual exhaustion after pro- tracted suffering. In these cases we find either a succession of small ulceis which have been spreading from one place to an- other, or more extensive irregular ulceration with thickening of the coats, and probably adhesion to some of the neighboring parts; and this is frequently complicated with disease of other organs, as the liver, the pancreas, or the omentum. In some cases of this class we find the thickened and fungoid disease of the mucous membrane, or thickening and induration of a de- fined portion of the parietes of the stomach without actual ul- ceration. 2. It may be fatal by haemorrhage from the ulcer, assuming at first the characters of the simple haematemesis, but resisting every attempt to check it,, or to prevent its recurrence, until the patient sinks under it within various periods—from a f£w hours 'to several days. 3. It may be fatal by perforating the stomach,—the contents 36 INFLAMMATORY AFFECTIONS thus escaping into the peritoneal cavity, and giving rise to ex- tensive peritonitis, which is fatal in a period of from eighteen to thirty-six hours. In cases of this class we find on inspection two important modifications of the morbid appearances. In the one, the simple ulceration seems to have advanced gradually through the coats, without any other disease, until the complete perforation took place. In the other, there is much thickening at the part; the ulcer seems to have perforated the thickened substance, and to have cicatrized at the edges, leaving a round defined cavity with smooth sides and edges, and the bottom of it formed merely by the peritoneal covering of the part. From the smooth appearance of the edges of the cavity which is form- ed in these cases, it is evident that the disease must have been of long standing ; and the fatal event seems to take place by the slender peritoneal covering of the part suddenly giving away. This remarkable modification of the disease will be il- lustrated by Cases IX. and X. The same symptoms arise from a similar affection occuiring in the duodenum. A singular variety in the appearances is to be referred to be- fore leaving this part of the subject. Though a complete per- foration of the stomach by ulceration may have taken place, it is frequently found that an adhesion had been formed to some of the neighboring parts most commonly the liver, in such a manner that a portion of the surface of the liver supplies the place of the portion of the stomach that has been destroyed, and thus no escape of the contents takes place. This remark- able circumstance will be found exemplified in Case VIII. which was afterwards fatal by a small perforation immediately adjoin- ing the portion where this adhesion had been formed. Another important modification arises from adhesion of the stomach to the arch of the colon, and a communication being formed be- tween them by the ulceration. This will be found illustrated, with very remarkable symptoms in Case XI. In some examples of adhesion of the stomach to the neighboring parts, it will be found that it has taken place to various organs, and perhaps also to the parietes of the abdomen,—showing that inflammatory ac- tion had existed in the coats of the stomach at various places and probably at different times, until one of the attacks had terminated in the fatal ulceration. This had probably occurred in Cases III. and VI. In other cases, again, we find a dense and thick mass of a tubercular character deposited betwixt the adhering surfaces, as was very remarkable in Case XL The principal modification of this important class of diseases will be illustrated by the following selection of Cases. In the FATAL BY GRADUAL EXHAUSTION. 37 arrangement of them I shall not study minute pathological accuracy, which is in fact unattainable ; but shall describe them in the manner which seems best calculated for practical utility. § /.—Succession of small ulcers of the mucous membrane of the stomach, fatal by gradual exhaustion. Case I.—A gentleman, aged 50, had been many years in the West Indies, where he had enjoyed good health; but, after his return to Scotland, he began to have various dyspeptic complaints, which were supposed to be connected with an af- fection of his liver. These complaints began about two years before his death, but never assumed any serious aspect till the winter 1823—4, when he was confined to the house, and his general health became considerably impaired. He now corn- plained of pain in the region of the stomach, which was not constant, but occurred at irregular intervals, and was sometimes dull and sometimes acute. He had vomiting, which generally occurred every day, and frequently several tines in a day. Ar- ticles of food or drink which he took were sometimes vomited almost immediately, and sometimes retained for several hours. His appetite was greatly impaired, and his strength was much reduced, but without emaciation. The pulse and other func- tions were natural. In the beginning of winter he suffered se- verely from the violence of the pain ; towards the spring it be- came much less acute, and the vomiting was less frequent; but he continued without appetite, and progressively losing strength. I saw him along with Mr. Joseph Bell in the beginning of June, 1824. He then complained chiefly of total want of ap- petite, and dull uneasiness across the region of the stomach; but there was much less acute pain than he had formerly suffer- ed ; the vomiting had also much subsided. His look was dull and languid; his countenance extremely pale, but not ema- ciated ; strength very much reduced ; pulse a little frequent and weak ; bowels natural. No other symptom could be discovered, and no organic disease could be detected on the most careful examination. He died about a week after this, without any change in the symptoms, except that for a day or two before death he was a little incoherent and slightly lethargic. Inspection.—The stomach was laige and distended with air, but externally healthy. On laying it open, there were ob- served about the middle of the small curvature two or three 38 ULCERATION OF THE STOMACH small round ulcers, not more than an eighth of an inch in di- ameter, with inflamed margins, but without any appearance of thickening of the parts. Higher up towards the cardia, there were numerous white or ash-colored spots, of various sizes, like the marks of small-pox. They were much smoother than the surrounding membrane, and of a much lighter color; and there was every reason for considering them as the cica- trices of small ulcers. They were numerous along the car- diac portion of the stomach, were all smooth and cicatrized, except the two or three spots with inflamed edges already men- tioned, which were in a state of actual ulceration. The disease seemed to be entirely seated in the inner membrane, without any thickening of the coats, and there was no other appear- ance of disease in any part of the stomach. The liver seemed smaller than natural, but was quite healthy. The pancreas ap- peared firmer than usual, but not remarkably so, and was not enlarged. The spleen and all the other viscera were perfectly healthy. The apex of the heart adhered to the pericardium at a space about an inch in length, and a quarter of an inch in breadth. The adhesion seemed of very old standing, and there was no other appearance of disease in the thorax. The brain was entirely healthy. In this very remarkable case, the disease appeared to be seated entirely in the mucous follicles. Among the various in- teresting facts which it presents, we may particularly remark, the activity of the symptoms in the early stages, probably while the follicles were in a state of inflammation,—and the obscurity of them when the disease was more advanced; likewise the proofs that many of the follicles had been in a state of ulceration, and had cicatrized ; while, at the time of the patient's death, not above two or three of them were in a state of ulceration. § 17.—Circumscribed ulceration with thickening, fatal by gradual exhaustion. Case II.—A woman, aged 45, had long complained of her stomach, but without any uniformity in the symptoms. She had occasional pain, with sense of oppression at the stomach; her appetite was variable, and she sometimes vomited, but at long and irregular intervals. For some months she had been sensibly falling off in flesh, but the affection did not assume any more decided character, till about two months before her death, when she began to have more frequent vomiting, with diarrhoea, FATAL BY GRADUAL EXHAUSTION. 39 and constant uneasiness in the abdomen. She was first seen by Dr. Begbie, about a fortnight after the commencement of these symptoms, when she complained of a fixed pain across the region of the stomach, where a considerable hardness was felt. She was much wasted,—had a small, quick pulse, and frequent vomiting; and, without any other change in the symp- toms, she died exhausted in about six weeks. Inspection.—In the small curvature of the stomach, the coats were thickened and indurated, so as to form a hard mass about three inches long and two broad, and about three fourths of an inch in thickness at the thickest part. When cut through, this portion presented a uniform white struct- ure of almost cartilaginous hardness, except the internal surface of it, which was in a state of white, soft, fungous ulceration. The stomach was in other respects entirely healthy. The mu- cous membrane of the intestines presented many spots, which were of a dark red color and highly vascular, but without any change of structure. Case III.—A lady, aged 50, had been for many years affect- ed with dyspeptic complaints, and about eight years before her death, was first attacked with copious discharge of dark gru- mous blood both from the stomach and bowels. She soon re- covered from this, and enjoyed tolerable health, though with constant dyspeptic symptoms, until 1826: she then had much pain in the stomach, constant feeling of acidity, and frequent vomiting of tough ropy mucus of a brown color. She recovered from this attack after three or four months, but the stomach continued to be easily disordered; she was liable to vomiting of sour matter, and there was occasional discharge of grumous blood both by vomiting and by stool. Soon after this, she be- gan to have pain on pressure in the region of the stomach, and a broad flat tumor was felt in the left side of the epigastric re- gion. Repeated topical bleeding was now employed, and the tumor subsided in a most remarkable degree; but from this time, she continued liable to pain and distention of the stomach and bowels, and vomiting of acid matter ; and occasionally she vomited considerable quantities of the tough brown mucus ; she was now much reduced in flesh and strength, but for the last six or eight weeks of her life a remarkable change took place in the symptoms. There was little or no uneasiness in the epi- gastric region, even on very firm pressure, and scarcely any re- mains of the tumor could be perceived. Her food was relished and retained, and the bowels were natural; but she be- 40 ULCERATION OF THE STOMACH came progressively more and more emaciated, without suffering, and died in April, 1828. Inspection.—The stomach was drawn up into the left hypo- chondriac region, and adhered in several places by loose mem- braneous bands to the parietes of the abdomen, to the spleen, and to the left lobe of the liver. The spleen was not above one- sixth of its usual size. The stomach when laid open presented a circular ulcer more than two inches in diameter, on the part which was coniiguous to the pancreas. The surface of the ul- cer was rough, with several indurations like small glands. The pancreas was enlarged, and felt throughout of schirrous hard- ness. Opposite to, and connected with, the ulcerated part of the stomach, the blood vessels of the omentum were very numerous, turgid, and more matted together than usual; and this appearance occupied the space where the tumor had been felt in the course of the disease. The coats of the stomach were considerably thickened at the place of the ulceration, and for a small space around it; the other parts of it were healthy. These cases will serve to illustrate some of the varieties and the changes of symptoms which occur in this formidable disease, and the insidious manner in which it is apt to advance with symptoms which are liable to be considered as merely dyspep- tic. Other remarkable varieties occur both in the symptoms and in the morbid appearances of which it is impossible to give any general statement. A woman mentioned by Chardel had dyspeptic complaints, with pain in the stomach and back, and occasional vomiting. Solids only were vomited, and by great attention to diet, she suffered little inconvenience for several months. The vomiting then became more frequent; at length it occurred daily, and several times in the day. She then wasted, and died gradually exhausted about eight months from the commencement of the disease, and between two or three months from the time when the daily vomiting began. The stomach was found adhering to the liver, the spleen and the pancreas; along the great arch it was considerably thickened, and internally ulcerated and beset with granulations ; there was ulceration also about the cardia. A man mentioned by the same writer had for five months vomiting after meals, and died by gradual wasting, without any other symptom : nothing could be felt in the region of the stomach on the most careful exami- nation. After death, the stomach was found adhering inti- mately to the concave surface of the liver ; and an ulcer at this place had perforated the stomach, and penetrated a considera- ble way into the substance of the liver; there was also ulcera- FATAL BY GRADUAL EXHAUSTION. 41 tion in the neighborhood of the cardia. A man mentioned by Pinel had great acidity of the stomach, and other dyspeptic symptoms, with occasional attacks of acute pain;—afterwards vomiting and gradual wasting; and a tumor was felt in the epi- gastric region. The pain became more acute, the smallest quantity of food producing great uneasiness, and he died ex- hausted after six months. The omentum was found hard, red and fleshy, and gathered up into a mass under the great arch of the stomach. The mucous membrane of the stomach was much destroyed, and there was an ulcer three inches in length near the pylorus. A different course of symptoms occurs in a case related by Frank. A man, aged 50, was seized, after violent exertion, with copious vomiting of blood, followed by discharge of blood by stool: these symptoms continued several weeks, and then ceased. He then had dyspeptic symptoms, with debility and emaciation ; his appetite was good ; but he had great uneasi- ness after eating; and some tenderness was felt in the right hypochondrium, with difficulty of lying on the right side. He became gradually more and more emaciated, and had some vomiting and dropsical symptoms before death,—h% illness having continued seven or eight months. On inspection the liver was found pale, hard, and much diminished in size, and the small curvature of the stomach was adhering to it. At the place of the adhesion, there was a very large ulcer which per- forated the stomach, and penetrated into the substance of the liver. <§> III.—Extensive ulceration, with thickening, complicated with remarkable diseases of the omentum and peritoneum; —fatal by gradual exhaustion. Case IV.—A gentleman, aged 53, consulted me in autumn, 1825, on account of pain in the region of the stomach, which attacked him only after dinner. It usually continued an hour or two, and frequently extended considerably upwards along the thorax on both sides. He was cupped in the epigastric re- gion, was put upon a carefully regulated diet, with the use of the oxide of bismuth; and, after a short time, he got into very good health, and so continued through the following winter. In summer 1826, he frequently complained of his stomach, without any regularity in the symptoms: but in the following winter, the affection returned with the same violence as before. 6 42 ULCERATION OF THE STOMACH He was quite well during the earlier part of the day, no un- easiness taking place after breakfast; but immediately after dinner the pain began, and continued in great severity for about two hours; it then remitted, and in the evening he was again free from complaint, and had good nights. Sometimes the pain came on during dinner in such violence as obliged him to leave the table suddenly; and at last he was obliged to give up tak- ing a regular dinner, and confine himself to small quantities oi arrow root. • After a variety of treatment in the country, he came to Edin- burgh, in the beginning of June, 1827. He had then his usual look of good health, but the pain continued undiminished, so that he could only take the mildest kinds of food, and in very small quantity, without severe suffering for some time after. No organic disease could be discovered, and no particular ten- derness in the epigastric region. He had never had any vomit- ing ; his pulse was natural; and his bowels, though rather slow, were easily regulated. After the usual treatment for a day or two, he left town on particular business, with the promise of returning in a very few days ; but he did not return for a fort- night, when it was found that ascites had taken place to a con- siderable extent, with same anasarca of the limbs. He now be- gan to decline rapidly in flesh and strength, and refused almost every kind of nourishment. He did not complain so much as formerly of acute pain, but had a feeling of intolerable disten- tion after taking even the smallest quantity of food. He said that he felt as if there was no room for any thing in his stomach, and that the smallest quantity distended it in an intolerable manner. A variety of treatment was now employed without relief, and he died about the 25th of July. For some weeks before his death, a small tubercular mass was felt in the abdo- men a little way to the right of the umbilicus. There was no other appearance of organic disease. His pulse had continued calm and regular to the last. He vomited a few times, but to no extent, and his bowels were easily regulated through the whole course of the disease. Inspection.—There was a considerable quantity of fluid in the abdomen. The peritoneum lining the cavity was through its whole extent remarkably thickened, very firm, and uniformly covered with small miliary tubercles ; and the same appearance extended along the lower surface of the diaphragm. The stom- ach was remarkably contracted, and its coats were much thick- ened and indurated, and on its internal surface there was an ulcer the size of a half crown. On its external surface, but not corresponding with the seat of the ulcer, there was a mass of FATAL BY GRADUAL EXHAUSTION. 43 irregular fungous disease of a tubercular character. The omen- tum presented a large mass of tubercular structure, of nearly cartilaginous hardness, about four inches in extent, and in some places about an inch in thickness. The right extremity of this mass had formed an adhesion to the parietes of the abdomen, and it was at this spot that the hardness had been felt for a few weeks before death. The diseased omentum also adhered so intimately to the contracted and thickened stomach, that they seemed to be blended into one mass. It likewise adhered to the arch of the colon, but this was not otherwise diseased. The duodenum from its very commencement was entirely healthy; but among the other small intestines there were some slight adhesions. The liver was rather pale, and seemed diminished in size, but upon the whole was very slightly diseased. I have been particular in the description of this case, because it would be difficult to find one calculated to show in a more striking manner the insidious nature of this affection, and the extent of disease which may be going on with such symptoms only as, up to a very advanced period, might have been con- sidered merely indicating a high degree of dyspepsia. The important characters of the case in this respect are, the inter- mitting nature of the pain,—the absence of vomiting,—and the general appearance of health continuing unimpaired until a very few weeks before death. This very interesting variety of the disease is farther illus- trated by many cases which are on record. A man mentioned by Chardel had dyspepsia and acute pain after eating, which subsided after the process of digestion was completed. By restricting himself to very mild food in small quantities he felt little uneasiness; but after some time, without any change in the symptoms, he lost strength so much that he was confined to bed. His appetite continued, but he was afraid to satisfy it; he had very little nausea, and did not vomit above two or three times during his illness which continued many months. On inspection there was found thickening of the coats of the stom- ach at the upper part, without ulceration, and enlargement of the lymphatic glands in the neighborhood of the stomach. A man mentioned by the same writer had pain in the right hypo- chondrium and loss of appetite, with great acidity and gradual wasting. He had no vomiting, but a good deal of diarrhoea, the stools at last having become black and bloody, and he died gradually exhausted after a year. The stomach was found adhering both to the diaphragm and the colon. At the place of adhesion to the diaphragm, a portion of the stomach was 44 ULCERATION OF THE STOMACH entirely destroyed by ulceration, and, by means of the adhesion, a portion of the diaphragm supplied the place of the part that was destroyed. A woman mentioned by Pinel had laborious digestion, pain in the stomach after eating, and gradual wasting. • She had nausea, but seldom vomited, and died after several months; for a short time before death the vomiting had become rather more frequent. The stomach adhered to the liver and the pancreas; the mucous membrane was irregularly destroyed and ulcerated; and at the place of adhesion to the liver the parietes were perforated by the ulceration. .The pylo- ric extremity was considerably thickened, and the omentum was thickened and indurated. § IV.—Ulcer of the stomach fatal by haemorrhage. Case V.—A gentleman, aged about 40, had been long dys- peptic, and liable to pain in his stomach, which had not assumed any fixed or regular character; but he required great care in re- spect of his diet, and many articles were apt to disagree with him. He was otherwise in good health, and applying himself actively to business till Saturday, 5th November 1825, when he was sud- denly seized in his counting-house with a feeling of extreme faintness. He was'assisted with difficulty to his dwelling-house, which was in the neighborhood, and soon after vomited a large quantity of black fluid resembling ink. On Sunday he con- tinued very sick and faint, and vomited occasionally the same kind of fluid, and he had discharges of similar matter from the bowels. On Monday he was better and walked out, but had some vomiting in the afternoon. On Tuesday he still felt very unwell, but without any marked symptom. On Wednesday he was seized with pain in the stomach, followed by vomiting of pure blood to the amount of several pounds. This was fol- lowed by extreme faintness and coldness, and the vomiting of blood returned in the afternoon. I now saw him for the first time along with Dr. Robert Hamilton, and found him extremely pale and exhausted, his skin cold, and his pulse very feeble. He complained of nothing but great faintness: but every attempt to rally him proved ineffectual, and he died in the night, having been again seized, sometime before his death, with vio- lent pain in the stomach. Inspection.—The stomach.was of immense size, but showed no appearance of disease in its structure, except at a part in the small arch about half way between the cardia and pylorus. FATAL BY HEMORRHAGE. 45 Here a round defined portion about the size of a half-crown piece was much indurated and about half an inch in thickness. On the inner surface of this portion, there was a small defined ulcer about half an inch in diameter, and more than a quarter of .an inch in depth, and the bottom of it was occupied by a firm fungous mass of a dark brown color. No other disease could be detected in any organ. Case VI.—A woman, aged 45, had been for several years lia- ble to attacks of pain in the stomach, which at first passed off in a short time ; but they gradually became more severe, and of longer continuance, until at length they continued for several weeks at a time, and were little affected by any remedies. I saw her in several of these attacks during the last eighteen months of her life. While affected by them, she complained of acute pain in the epigastric region, chiefly referred to a par- ticular spot of very small extent; it was much increased by eat- ing, so that her only relief was when the stomach was empty ; and it was accompanied by frequent vomiting, which however did not occur at any regular periods. These attacks usually continued for several weeks, and then left her for weeks or months in very good health. Three weeks before her death, after having been for several months free from any uneasiness, she was exposed to cold by getting her feet wet, and almost immediately complained of uneasiness at the stomach. At first it was slight, with loss of appetite, but after several days it became more severe with some vomiting; there was no fever, and nothing could be discovered by examination. The pain was chiefly referred to a small spot in the epigastric region, rather to the left side ; and no symptom occurred different from those in her former attacks, until, after eight or ten days, she was suddenly seized with copious vomiting of blood. This oc- curred repeatedly ; and she died rather suddenly about a week from the first occurrence of it, and about three weeks from the commencement of the attack. Inspection.—The stomach had contracted an adhesion, of small extent to the left lobe of the liver, and another of greater extent, and very firm, to the pancreas. At both these places, the coats of the stomach were diseased, but in the greatest de- gree at the adhesion to the pancreas. Here they were much thickened and indurated, for a space about three inches long, and two inches broad; and the internal surface of this portion was entirely in a state of ulceration. There were also on this ulcerated surface several points which penetrated more deeply, and some of these contained coagulated blood, giving every 46 SIMPLE ULCERATION OF THE STOMACH reason to believe that they had been the source of the hae- morrhage. The other parts of the stomach were in a natural state, and all the other viscera were healthy. I considered this case as one of very great interest, on ac- count of the periodical nature of the pain, and the long inter- vals of perfect health. There seems everyreason to believe that the paroxysms had been connected with inflammatory action, confined to a circumscribed portion of the mucous membrane of the stomach, subsiding from time to time, and leaving the part in a comparatively healthy state; but that, under these successive attacks, the parietes had become gradually thickened at the part, until the last attack terminated by ulceration, and this by the fatal haemorrhage. § V.—Simple ulceration of very small extent, suddenly fatal by perforation of the stomach. Case VII.—A young woman, aged 18, had been affected, for about six months, with variable appetite, and occasional pain in the stomach, which made her frequently sit with her body bent forward, and her hand pressed upon the epigastric region. Little notice was taken of the attacks, as she was going about, and otherwise in good health, and for some weeks previous to the attack now to be described, her appetite had greatly im- proved. On the 26th November, 1824, while Jn a room by herself late in the evening, she was heard to scream violently ; and when a person went into the room, she was found unable to express her feelings, except by violently pressing her hand against the pit of the stomach. When she was soon after seen by Mr. M'Culloch, she was moaning as if in extreme agony, but was unable to speak; the pulse was 86 and very weak; she could scarcely swallow; but soon after vomited the contents of the stomach, which seemed to be merely food which she had recently taken. Various remedies were employed without re- lief. She continued with every appearance of extreme suffer- ing, and unable to speak, trll seven o'clock in the morning of the 27th, when she said the pain was considerably easier, but was still very severe in the pit of the stomach, and was extend- ing downwards over the abdomen. The abdomen was now becoming distended, and when I saw her about three o'clock in the afternoon, it was distended to the greatest degree and very tense. The pulse was extremely feeble; she was scarcely able to speak, but her countenance was expressive of extreme FATAL BY PERFORATION. 47 suffering. Nothing afforded the smallest relief, and she died about two in the morning, 29 hours from the attack. Inspection.—The cavity of the peritoneum was distended with air, and likewise contained upwards of eight pounds of fluid of a whitish color, and fetid smell. There was slight but extensive inflammatory deposition on the surface of the intes- tines, producing adhesions to each other, and to the parietes of the abdomen. In the upper part of the small curvature of the stomach near the cardia, there was a small perforation of a size which admitted the point of the little finger. Internally this opening communicated with an ulcerated space on the mucous membrane, about the size of a shilling, with slightly thickened and hardened edges, and a considerable perpendicular loss of substance. The stomach in all other respects was entirely healthy. Case VIII.—A gentleman, aged about 60,—in the year 1825, had for a considerable time suffered from complaints in his stomach. He had occasional pain, but it was not severe ; his more prominent symptoms were an intense feeling of Pyrosis, and occasional vomiting. He was often obliged to leave the table suddenly during meals from attacks of this kind, in which he chiefly brought up small quantities of an extremely acrid fluid. He became much emaciated, and had every appearance of extensive organic disease, though none could be discovered on examination. He required to be kept upon the most cautiously regulated diet; and after continuing for some months in a state from which he was not expected to recover, he gradually got into his former good health, and his stomach entirely recovered its healthy functions. He had at various times, however, slight threatenings of his former symptoms, and required to live with great caution ; but he was full in flesh, and his general hearth was excellent. About a fortnight before his death, he had one of those slighter attacks, which affected him chiefly with a dis- tressing feeling of Pyrosis, impaired appetite, and occasional vomiting. On account of these symptoms he was keeping the house, though able to attend to the affairs of an extensive busi- ness, until Saturday evening, 3d February 1827, when he was suddenly seized with excruciating pain in the pit of the stom- ach, accompanied by some vomiting, coldness of the body, and a small frequent pulse. From the moment of this attack, no- thing that was done afforded the least relief. He continued in the most violent and unceasing pain through the night and through the following day ; the whole abdomen became dis- 48 SIMPLE ULCERATION OF THE STOMACH tended and tender, with sinking of the vital powers, and he died on Sunday night, about 30 hours after the attack. Inspection.—On the posterior surface of the stomach near the Pyloric extremity, there was a space rather larger than a shilling, where the substance of the stomach was entirely de- stroyed ; but the margin of the opening adhered all around very closely to the surface of the liver, which thus preserved the continuity of the part. Below this portion, and very near the Pylorus, there was an ulcer on the mucous membrane, smaller than a sixpence, and through this a perforation of the coats had taken place of such an extent as would have transmitted a full- sized quill. Through this opening the contents of the stomach had escaped into the cavity of the peritoneum, where there were exhibited the usual marks of extensive but recent peritoni- tis. Except the two spots now referred to, the stomach was perfectly healthy. These examples will be sufficient to illustrate this most formi- dable modification of the disease. Many others are on record, in some of which the previous symptoms were very slight and ob- scure. A young lady, aged 15, mentioned by Dr. Carmichael Smith, had for many months complained occasionally of pain in the stomach: but it was so slight, that no attention was paid to it, until one evening she was seized with violent pain and vomiting, and died in 24 hours, with symptoms of peritoneal in- flammation. In the anterior part of the stomach there was a round ulcer no larger than a sixpence, with hard callous edges, and some thickening of the c©ats at the part on which it was situated. On farther examination it was found that the ulcer had entirely penetrated the coats of the stomach by an opening sufficient to transmit a quill. The other parts of the stomach were entirely healthy. M. Gerard has collected about seven- teen examples of this affection, in a memoir, ' Des Perforations Spontanees de l'Estomac' In some of these there had been previously chronic vomiting, and other symptoms indicating dis- ease in the stomach ; but in others the previous symptoms were slight and obscure ; and some had enjoyed tolerably good health. The fatal attack and the morbid appearances corres- ponded with the cases now described ; and death took place in periods of from 12 to 24 hours. Several cases of the same kind are described by Dr. Crampton and Mr. Traverse, in the Medico-Chirugical Transactions. In a lady mentioned in the Journ. Gen. de Medicine for August, 1821, the attack com- menced with severe pain in the epigastric region, extending to- wards the left kidney, and accompanied by cold shivering, dys- FATAL BY PERFORATION. 49 pncea, and prostration of strength. These symptoms subsided, but returned in the same manner every day, after taking food, for four days, leaving her in the intervals free from complaint. On the fifth day it returned, but did not subside, and was fatal in 20 hours. In the anterior part of the stomach there was a perforating ulcer nine lines in diameter, and surrounded by a mar- gin of slight inflammation. There was peritoneal inflammation, with effusion of a brown fluid, mixed with portions of food. The kidneys were healthy. To these observations, may be added, the remarkable case of Admiral Wassenaer, mentioned by Boerhaave, who died sud- denly in the act of vomiting, or rather of attempting to vomit, soon after he had dined. The lower part of the oesophagus had given way at the seat of an ulcer, and the food and drink which he had taken at dinner were found in the cavity of the thorax. A similar case is related in the first volume of the Arch. Gen. de Medicine. A man who had for six months suffered severe- ly from his stomach, especially after eating, was seized with vio- lent vomiting, which continued three days. He was then seized with palsy, and in four days,more died comatose. Effusion was found in the brain. The oesophagus had given way a little above the cardia, by a rent an inch and a half long, and much fluid had been discharged into the right cavity of the pleura. § VI-—Old ulceration with thickening—the ulcer cicatrized on its inner surface, with loss of substance, leaving a cav- ity which had been bounded only by the peritoneal covering of the stomach—suddenly fatal by this covering giving way at the part. Case IX.—A woman, aged 50, had been for several years in bad state of health ; her principal complaints were referred to the region of the uterus, and the os uteri was felt to be harden- ed. She was also liable to pain in the stomach, capricious ap- petite, and occasional vomiting; but these complaints had not been so severe or regular as to attract much attention, until she was suddenly seized with most violent pain, referred to a small spot in the epigastric region, accompanied by vomiting, and fol- lowed by pain and tension of the whole abdomen: and she died in eighteen hours. Inspection.—The stomach was healthy on its whole anterior aspect. On the posterior part, there was a portion about three inches in extent, which was much indurated, and about half an 7 50 SIMPLE ULCERATION OF THE STOMACH, &C inch in thickness at the centre. In the middle of this portion, there was a round excavation about one-third of an inch in di- ameter, and entirely penetrating the part. Internally this open- ing was smooth on its sides, and the smoothness extended to the bottom of the cavity, where a thin membrane seemed to have recently given way so as to make the opening ragged. The stomach in other respects was healthy. The neck of the uterus was scirrhous. In all the examples now described, there had been some symptoms indicating more or less disease in the stomach ; but in the following remarkable case, for which I am indebted to the late Dr. Kellie, there had been no complaint of any kind previously to the attack, which was fatal in eighteen hours. Case X.—A strong and healthy looking servant girl, aged about 21, while engaged at her work between seven and eight o'clock in the morning, of one of the last days of September, 1827,- was suddenly seized with excruciating pain in the abdo- men, sickness, and vomiting. About ten, she was bled ad deli- quium, and twice afterwards in the course of the day. The bowels were freely moved by an enema, and she took purgative medicine, which did not operate ; but there was no alleviation of the symptoms. The belly became tense, tender, and tym- panitic, the pulse feeble and rapid; everything she took was vomited, and she died in eighteen hours from the attack. Inspection.—The peritoneal cavity was distended with air, and also contained a considerable quantity, of fluid, which had the appearance of the liquids she had swallowed. There was extensive peritoneal inflammation, with a coating on the bowels of puriform matter. In the middle of the smaller curvature of the stomach, there was a round opening about one-third of an inch in diameter. At the part where it was situated, the coats of the stomach were in some places nearly half an inch in thick- ness, and the thickening extended in a greater or less degree over a portion five or six inches in extent. The pinner surface, at the place of the rupture, presented a deep excavation with rounded and smooth edges, like a deep eroding ulcer which had cicatrized. It was fully half an inch in diameter, and a third of an inch or more in depth, having penetrated the thickened sub- stance until it was bounded merely by the peritoneal covering; and it was this which had given way in the fatal attack. This patient had been residing in the house in which she died 'for four months, and was never known to complain of her stom- ach, or to show the smallest deviation from most robust health ; PERFORATING ULCER OF THE STOMACH, &C. 51 and the only farther information that Dr. Kellie could obtain in regard to her was, that she had had fever in the spring. § VII.—Perforating ulcer of the stomach, and communication with the arch of the colon. Case XI.—A gentleman, aged 56, who had previously en- joyed good health, except occasional dyspeptic complaints, be- gan to feel languid, with impaired appetite, some loss of flesh, and occasional pain in the abdomen; but he was able to go about and attend to all his engagements, which were extensive and fatiguing. These symptoms had continued two or three weeks, when one day, while walking in the street, he was seized with vomiting, and the matter vomited had the odor and appearance of feces. He felt no farther inconvenience till about a week after, when he was again seized in the same man- ner. After this attack, he was seen by Dr. Combe of Leith, who found him with a look of impaired health, but with a natu- ral pulse and a good appetite. His bowels were easily re- gulated, and no appearance of organic disease could be de- tected. Dr. Combe Mas disposed to doubt his account of the feculent vomiting, until it occurred a few days after, while he was at home, and Dr. Combe had an opportunity of seeing it. It consisted of thin healthy feces, which could not be distin- guished from that which he had passed from his bowels the same day. After this, the vomiting returned at various inter- vals, sometimes three or four times a day; and sometimes he was free from it a week at a time. The matter vomited al- ways consisted of pure feces, sometimes so consistent that it was brought up with difficulty, until he diluted it by swallowing hot water. During the whole course of the affection, the bow- els continued regular or easily regulated ; the feces varied con- siderably in their appearance; but that which was vomited al- ways resembled what was passed from the bowels so closely, that it was impossible to distinguish them. He never was ob- ■ served to vomit food, or other matters which had been taken in- to the stomach. His appetite continued good, and no disease could be detected by examination. He lived in this state three months, and died gradually exhausted, without any particular change in the symptoms, except that a week before his death he vomited a considerable quantity of blood. There was occa- sional pain in the abdomen, but not distinctly referred to any particular part. Inspection*—-The stomach was found contracted and adher- 52 EXTENSIVE ULCERATION OF THE STOMACH ing to the parietes of the abdomen on the left side, and to the arch of the colon. At the place of kthe adhesion, a soft tuber- cular mass was formed, which seemed in general to be about two inches in thickness. The stomach appeared externally healthy ; internally it showed a mass of ulceration which occu- pied the whole of its great curvature, and covered about one half of the inner surface of the stomach. The pylorus and whole pyloric extremity were healthy. In the centre of the ul- cerated part there was a ragged, irregular opening fully two inches in diameter, which made a free communication with the arch of the colon ; and, around the opening, there was also some ulceration of the mucous membrane of the colon. The intestines in all other respects were healthy. The small intes- tines were empty ; the caput coli was distended with feculent matter, and the colon throughout contained healthy well formed feces. $ VIII.—Extensive ulceration of the stomach of a cancerous character. I conclude this part of the subject with the following re- markable case, which I do not attempt to refer to any class. It is perhaps one of the most extraordinary examples on record of destruction of the stomach by ulceration, and the disease had more of a cancerous character than in the cases formerly de- scribed. Case XII.—A lady, aged 49, had been in bad health through the winter 1811—12, complaining chiefly of weakness and a constant uneasiness across the region of the stomach, with oc- casional attacks of acute pain towards the left side. In May 1812, she began to have vomiting, which continued from that time, and became more and more urgent. 1 saw her in July, and found her much emaciated; she complained of a dull pain in the epigastric region, where considerable hardness was felt; and she vomited a portion of every thing she took, sometimes immediately after taking it, and sometimes a considerable time after. She continued with little change till the beginning of September, when the vomiting subsided, and she was free from **. for more than a fortnight. But during this time she was af- fected with diarrhoea; her strength sunk, and she died on the 23d,—the vomiting having returned, though with less severity, three or four days before death. During the period when she OF A CANCEROUS CHARACTER. 53 was free from vomiting, she took food and drink of various kinds, and in very considerable quantity, and continued to do so till a few hours before death. Inspection.—On opening the abdomen and looking for the stomach, a large irregular opening presented itself, which was found to lead into the cavity of the stomach, in consequence of a large extent of its great arch being entirely destroyed. In the left side, there was a large irregular mass, which appeared to consist of an enlarged and diseased spleen and the remains of the great arch of the stomach, so blended into one mass, that it was impossible to distinguish one part from another ; in the substance of it there was a cyst full of very fetid matter. This mass was attached to the cardia by a narrow portion, which re- mained of the coats of the stomach at that place ; and when the parts were taken out and displayed, by suspending the stomach by the cardia and the pylorus, the appearances were very re- markable. When stretched out in this manner, about one half of the stomach at the pyloric extremity was sound and healthy. This part was attached to the cardia by a narrow portion of the small curvature which remained ; and by another small portion of the greater curvature, the large irregular mass now referred to hung down on the left side. The left side and the lower part of the great arch of the stomach were entirely wanting to such an extent, that, when the parts were extended in the man- ner now mentioned, it seemed as if nearly one half of the stomach had been entirely destroyed. There was reason to be- lieve that the part which seemed to be wanting was involved in the diseased mass on the left side. The sound parts were separated from this portion by a line of ulceration of such extent, that the pyloric extremity remained attached to the cardia only by a portion about two inches in breadth which remained of the small arch. The ulcerated edge, where the separation had ta- ken place, was studded with numerous hard tubercles like the edges of a cancerous ulcer. The pancreas was hard ; the liver was pale and soft; the other viscera were healthy. Various instances are on record of the true melanosis of the stomach, but I have not thought it necessary to detail examples of it, as they do not present phenomena remarkably different from the affections which have been described. The affected portion of the stomach is generally much thickened, and, on its internal surface, ulcerated. In its structure it presents va- rious degrees of consistency, but the whole is more or less deeply tinged with that peculiar black matter from which it has derived its name. The symptoms do not differ from those of 54 DIAGNOSIS AND TREATMENT the other cases of organic disease of the stomach with ulcera- tion, except that the matters vomited are often deeply tinged with the dark melanotic discharge from the ulcerated surface. DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE STOM- ACH REFERRED TO UNDER THE PRECEDING HEADS. From the facts which have been related, we have every rea- son to conclude, that the dangerous affection referred to in the preceding observations exists in two conditions; namely, chronic inflammation of a defined portion of the mucous mem- brane of the stomach, or the mucous follicles,—and the termi- nation of this by ulceration. In both these conditions, it may probably be the subject of medical treatment; for we have rea- son to believe, that the inflammation may be arrested and pre- vented from passing into ulceration, and that the ulceration may heal before it has become connected with any permanent change in the organization of the part. Hence appears the importance of minutely watching the progress of the disease in its early stages, in which only it is likely to be treated with success. The difficulty here is in the diagnosis,—the disease often assuming the character of a mere dyspeptic affection through a great part of its progress; while, in fact, a morbid condition of a very serious nature is going on, which would require treatment in many respects very different from that adapted to dyspepsia. ■ The disease may be suspected, when there is pain in the stomach occurring with considerable regularity immediately af- ter meals, and continuing for a certain time during the process of digestion,—especially if the pain be distinctly referred to a particular spot, and if there be at that spot tenderness on pres- sure. It may be farther suspected, if the pain continues severe until the patient is relieved by vomiting; but we have seen that the disease may go on to a very advanced period without vom- iting, and, on the other hand, that it is sometimes indicated by vomiting occurring occasionally, without any regular periods, and with very little pain. In the cases will be seen other im- portant varieties in the symptoms, which are of great interest in a practical point of view, particularly the intense and pe- culiar feeling of pyrosis mentioned in Case VIII. When this feeling occurs with great intensity after food of all sorts, taken even in the most moderate quantities, we have reason to sus- pect disease of the mucous membrane of the stomach. The OF CHRONIC GASTRITIS. 55 feeling appears to be in some cases connected with the forma- tion of an acrid fluid, which we often see brought up in con- siderable quantities; and in others, seems to depend merely upon the morbid condition of the mucous membrane itself, in consequence of which, ordinary articles produce that peculiar feeling of irritation, which in the sound state of the parts is produced by matters of an acrid quality. It is common to hear such patients say, that attention to diet makes little difference in their feelings, but that every thing turns immediately to in- tense acidity, even a bit of meat or a glass of cold water. The disease may be also suspected, when, along with any of the above mentioned symptoms, though in a mild and obscure form, the patient is becoming weakened and emaciated in a manner which a mere dyspeptic affection could not account for. The affection, again, is sometimes accompanied and cha- racterized by a raw and tender state of the tongue and throat; and in some cases, with minute ulcers; and in others, with the formation of slight aphthous crusts. One gentleman lately stated to me that his complaint began with minute ulcers and a burning sensation on the tongue, and that he afterwards dis- tinctly felt the same state of disease extending gradually along the oesophagus, and at last into the stomach. Amid such a diversity of symptoms as occur in connection with this disease, our chief reliance in the diagnosis must proba- bly be on a careful examination of the region of the stomach itself, with the view of discovering the existence of tenderness referred to a particular part. This examination should be made with the most minute attention, at various times, both when the stomach is full and when it is empty. If induration be dis- covered, the character of the case will be obvious ; but we have seen, that most extensive ulceration may exist without any in- duration ; and likewise, that extensive induration may exist without being discovered by external examination. Other important cautions in regard to the diagnosis will be learned from the cases which have been described. In particu- lar, we should not be deceived, either by the pain having re- markable remissions and the patient enjoying long intervals of perfect health, or by remarkable alleviation of the symptoms taking place under a careful regulation of diet; for these cir- cumstances we have found occurring in a very striking manner, while the disease was making progress to its fatal termination. When the disease is detected at an early period, the treat- ment must consist chiefly of free and repeated topical bleeding, followed by blistering, issues, or the tartar emetic ointment. The food must be in very small quantity, and of the mildest 56 DIAGNOSIS AND TREATMENT quality, consisting chiefly or entirely of farinaceous articles and milk, with total abstinence from all stimulating liquors; and it would appear to be of much consequence to guard against any degree of distention of the stomach, that can possibly be avoided even by the mildest articles. The patient should ab- stain in a great measure from bodily exertions, and hence the importance of endeavoring to distinguish the disease from mere dyspepsia, as the regimen and exercise which are proper and necessary in a dyspeptic case, would in this case be highly in- jurious. In the early stages, little probably is gained by medicine given internally, beyond what is required for the regulation of the bowels. In the more advanced stages, or when there is reason to suspect that the disease has passed into ulceration, the same observations will apply in regard to external applications and regimen ; and benefit may now be obtained by some inter- nal remedies, such as the oxide of bismuth, lime water, and nitric acid ; and, in some cases, small quantities of mercury appear to be useful. Small opiates, combined with articles of a mucila- ginous nature, appear frequently to be beneficial,—likewise articles of an astringent nature, such as kino, alum, and the Rhatany root. The arsenical solution has also been recom- mended, and small doses of the nitrate of silver ; and in several instances in which I suspected this disease to be going on, I have found remarkable benefit from the sulphate of iron. Dr. Maiden recommends borax, in doses of from ten grains to half a dram, taken in solution three or four times a day, as of great efficacy in cases of this class : he sometimes combines with each dose, one or two drops of laudanum.* Whether the dis- ease can be cured, after it has advanced to ulceration, must indeed remain in some degree a matter of doubt; because, in a case which has terminated favorably, we have no means of ascertaining with certainty that ulceration had existed. In some of the cases, however, which have been described, we have seen every reason to believe that some of the ulcers had cicatrized, "though the disease had afterwards gone on to a fatal termination ; and from what we observe in the intestinal canal, we can have little doubt that simple ulceration of the mucous membrane may cicatrize. I am satisfied that I have seen the cicatrices of such ulcers when the patient has died of another disease, after liaving been for a considerable time free from any symptom in the bowels. * Midland Medical and Surgical Reporter, May, 1829. • OF CHRONIC GASTRITIS. 57 1 insert here the following case, without deciding whether it is referable to the affection which has been the subject of the preceding observations. In a practical point of view it is of some importance. Case XIII.—A lady, aged about 30, came to Edinburgh from a distant part of the kingdom, in summer, 1818. She was af- fected with violent pain in the stomach, which seized her every day immediately after dinner, continued with great violence through the whole evening, and gradually subsided about mid- night ; it sometimes occurred after breakfast, but more rarely. The complaint was of two year's standing, during which time a great variety of practice and every variety of diet had been tried, but with very slight and transient benefit. The paroxysms oc- curred with perfect regularity ; she was considerably reduced in flesh and strength, and had a sallow unhealthy look; and her whole appearance gave strong grounds for suspecting organic disease. In the epigastric region no hardness could be discov- ered, but there was considerable tenderness on pressure at a particular spot. Various remedies were employed during the summer with little advantage; at last, however, she appeared to derive some benefit from lime water, and returned home in the autumn rather better. But the affection soon recurred, and she returned to Edinburgh in 1819 as bad as ever. After an- other trial of various remedies, this severe and intractable affec- tion subsided entirely under the use of the very simple remedy to which I have above referred. She took two grains of the sulphate of iron three times a day, combined with five grains of the aromatic powder and one grain of aloes, which was found sufficient to regulate the bowels. Under the use of this remedy she was soon free from complaint, and has continued to enjoy good health. In every form and every stage of the affection, the utmost attention to diet, both as to quality and quantity, is of essential and indispensable importance. The farinaceous articles and milk are those which seem in general to agree best; and some cases have been found to make most satisfactory recoveries un- der the use of a diet restricted entirely to small quantities of milk or soft fresh-made curd, after they had exhibited for a length of time every character of most formidable or nearly hopeless disease. The following interesting case of this kind has been communicated to me by Dr. Barlow of Bath. Case XIV.—A female, whose age is not mentioned, had for 8 9 58 DIAGNOSIS AND TREATMENT, &C. a considerable time labored under symptoms which were sup- posed to indicate scirrhus of the pylorus, and her case had been regarded as entirely hppeless. She suffered severe pain in the stomach when the smallest quantity of food was taken in, with great tenderness upon pressure, and constant vomiting, which occurred regularly about the same period after eating, at which it usually takes place in affections of the pylorus. A variety of treatment had been employed without benefit, when Dr. Barlow determined upon trusting entirely to regimen, by restricting her to a diet consisting wholly of fresh-made uncompressed curd, of which she was to take but a table-spoonful at a time, and to repeat it as often as she found it advisable. On this article she subsisted for several months, and recovered perfect health. An inflammatory affection of the mucous membrane of the stomach of a peculiar kind, is frequently met with in practice, in conjunction with a general inflammatory condition of the whole course of the mucous membrane from the pharynx downwards. I think it sometimes occurs as an idiopathic disease, but I have generally observed it taking place at an advanced period of other diseases,—as simple fever, or any of the inflammatory af- fections, as pneumonia. There is a peculiar rawness and ten- derness of the whole mouth and throat; often with a dry and glazed appearance of the tongue, a deep redness of the pharynx, interspersed with aphthous crusts ; and, in some cases, the whole pharynx presents one continued dense crust of an aphthous character. There is generally tenderness on pressure in the epigastric region, with uneasiness in swallowing along the whole course of the oesophagus, and great uneasiness in the stomach, excited by the mildest articles of food or drink. In some cases this is immediately communicated to the bowels, and the articles speedily pass off by a rapid diarrhoea. In other cases, vomiting takes place, and in others, both vomiting and diarrhoea. I have not seen the affection fatal, when the original disease had been removed; but I have seen it assume a very alarming character, with a very rapid pulse, and extreme exhaustion. The remedy which I have generally found most useful is lime water, or equal parts of it and a strong decoction of quassia. Small opiates are required, with very mild articles of food; and, when there is much sinking, wine or brandy, mixed with arrow root. The following case will illustrate the affection. Case XV.—A woman, aged 30, and previously healthy, after some continuance of a febrile disorder, with very mild symptoms, became affected with pain and tenderness in the epigastric re- DIPIITHERITE. 59 gion, extending over the abdomen. The mildest articles of food produced great pain; there was diarrhoea, with much griping, and frequent vomiting. The affection was accompanied by a feeble rapid pulse, great debility, and collapse of the fea- tures ; and there was a peculiar rawness and tenderness of the mouth, tongue and throat. After various remedies had been employed without benefit, the symptoms subsided speedily un- der the use of lime water. The aphthous affection of the mouth and throat, which is sometimes fatal to infants, seems to be allied to this diseased condition of the mucous membranes; and it is often found to be connected with minute ulcers of the mucous membrane of the intestine. A similar Condition occurs in advanced stages of phthisis, and is often the prelude to the colliquative diarrhoea. It is likewise found affecting the mouth and throat, accompanied by tenderness along the oesophagus and in the stomach, where there is no affection in the bowels. Another modification of disease in the mucous membrane of these parts, is that to which the French have given the name of Diphtherite. It does not appear to be a common affection in this country; but I have had opportunities of seeing it at various times, particularly in summer 1826, when it was frequent and fatal in Edinburgh. It is an epidemic chiefly affecting children. The first symptom is a deep redness of the tonsils or velum, without swelling or ulceration ; but with the formation of aph- thous crusts, which are generally of a pure white color. When these crusts either are removed, or drop off spontaneously, the membrane beneath is seen to be deeply red without breach of surface, and the crust is reproduced in a few hours. We find usually excoriation, or very minute ulcers along the inner mem- brane of the cheeks and lips, and a painful excoriation of the membrane of the nose,—often sponginess and bleeding of the gums; and, in some cases, the whole mouth becomes inflamed in a manner resembling the effects of mercury. There is in general but little fever, but great prostration of strength, and often a diseased state of the whole system, in which blistered parts run to gangrene, and even the slightest scratch is apt to assume an ulcerative action, with some vesication, and inflam- mation of the neighboring lymphatics. The disease is in some cases a slight affection, confined to the fauces ; but in others, it evidently extends along the oesophagus and to the stomach, pro- ducing tenderness of the epigastrium and vomiting; and in a few cases there was diarrhoea, with excoriation about the anus. 60 DIPHTIIERITE. The most formidable termination of it was that in which the affection extended to the larynx, when it was rapidly fatal, with all the symptoms of croup in its most untractable form. In the epidemic of 1826, I saw no case fatal except where the disease extended to the larynx; but of those patients in whom the larynx was distinctly affected, very few recovered. The dis- ease was often protracted for several weeks : and in some cases, which had previously been going on in a mild form, the fatal affection of the larynx took place so late as the 14th day. When this termination did not occur, the affection seemed to run through a certain course, over which medical treatment had little control. It was in general necessary to support the strength, frequently by wine in considerable quantities; and benefit seemed to be obtained from the free use of tn*e vegetable and mineral acids; careful regulation of the bowels, without strong purging; very free ventilation, and frequent sponging of the body with tepid vinegar and water. When there was much affection of the stomach, the bismuth appeared to be useful, or lime water, with small opiates. Gently stimulating or acid gar- gles were in some cases beneficial. Dr. Hamilton recommends the acetate of lead, both internally and in gargles. M. Breton- neau trusts chiefly to the free use of calomel; and he touches the fauces, by means of a sponge, with a mixture of equal parts of honey and hydro-chloric acid. When the larynx is affected, the danger is extreme, for the disease does not in general bear bleeclrhg, and blisters are apt to run to gangrene. The free use of calomel seems to be the only practice that is capable of arresting it. One -of the most satisfactory recoveries that oc- curred to me under these circumstances, was in the case of a child of fourteen months. He took in the first 24 hours 24 grains of calomel, combined with occasional opiates, and a di- minished quantity for a day or two after. The disease has been described by Dr. Hamilton, jun. in the Edinburgh Journal of Medical Science for October 1826 ; and at great length by M. Bretonneau, in a work, ' Des Inflamma- tions Speciales du Tissu Muqueux.' The error of the French writers consists in having, from their zeal for generalizing, con- sidered the affection as synonymous with croup. There is every reason to consider it as being primarily an affection of the mucous membrane of the fauces and oesophagus, which may go no farther, or may extend, in one case to the stomach, in another to the larynx. It is distinguished from the cynanche maligna, and the sore throat of scarlatina, by the absence of ulceration ; and it is evidently an affection quite distinct from the idiopathic inflammation of the membrane of the larynx and RAMOLLISSEMENT OF THE STOMACH. 61 trachea, to which we commonly apply the name of croup. The distinction is of much practical importance ; for when, either in this disease or in the cynanche maligna, the inflammation extends to the larynx, the cases do not bear any active treatment, and a very large proportion of them are hopeless. But the idiopa- thic croup is a pure active inflammation, in which, by early and decided treatment, we have the fairest prospect of being able to arrest its progress. Dr. Cheyne has described a remarkable affection, in some respects very similar to that now mentioned, which was fatal to four individuals in one family, all adults. The symptoms were aphthae covering the pharynx, tenderness of the epigastrium, and untractable vomiting of a fluid the color of verdigris. The body was examined in one of the cases only. The veins on the internal surface of the stomach were remarkably turgid: the mucous membrane, particularly at the great extremity, was of a dark mahogany color, which appeared to be owing to vascular distention and general extravasation into the submucous tissue. The mucous membrane of the oesophagus was of a deep red color, and highly vascular.* A singular affection has been described by various writers, in which the stomach has been found, after death, perforated by large irregular openings, while no symptom had previously ex- isted, indicating extensive disease of that organ ; or even when the patient had died of another disease, without any symptoms referable to the stomach. This appearance has been ascribed by Hunter and others to solution of the substance of the stom- ach by the gastric juice ; but it must be confessed that this doc- trine seems extremely questionable ; for, were the gastric juice capable of producing such an effect, the appearance ought to be of much more frequent occurrence. This curious subject has been carefully and ably investigated by Dr. Gairdner, in the first, volume of the Med. Chirurgical Transactions of Edinburgh. In his cases, the appearance occurred in children, and was pre- ceded by obscure symptoms, indicating general febrile disturb- ance, usually accompanied by some symptoms referable to the stomach and bowels, as vomiting or diarrhoea. On the other hand, the appearance has been observed in the bodies of per- sons who died* by violence: and there are some observations which tend to show that it may take place even after death. In a case by Mr. Burns, the parts were sound on the first ex- amination of a body at the usual period after death ; but, upon a second inspection, two days after, this peculiar destruction of * Dublin Hospital Pepnrts, Vol. IV. 62 RAM0LL1SSEMENT OF THE STOMACH. parts was found to a considerable extent; and, in the experi- ments of Dr. Wilson Philip, upon, rabbits, he found in many instances the great arch of the stomach dissolved-to a great ex- tent and perforated, especially when the animal had been killed very soon after eating fully, and when the body had been left for some time after death before it was examined. The affection differs entirely from the diseases which have been the subject of the preceding observations, exhibiting no character of ulceration, or, in general, of inflammation. It is a soft gelatinous or pulpy regeneration of the substance of the stomach. Part of the softened portion commonly has fallen out, leaving an opening which is surrounded by the parts in a thin state, and partially softened, but in general without any appearance of increased vascularity. The perforation is in some cases very large ; in others, there are four or five perfo- rations, separated by narrow portions in a partially softened state ; and, frequently, there is no actual perforation, but merely a considerable extent of the stomach much softened, which tears upon the slightest touch. For various interesting details in regard to it, I refer to Dr. Gairdner's Essay. Upon the whole, the conclusion, in regard to this singular af- fection, seems to be, that it takes place after death ; that it has been in some cases preceded by disease of the stomach ; but that, in others there has been no ground for believing the ex- istence of any such disease. It is certainly not an appearance on which any pathological principle can be founded, in regard to previous disease; and this is*a point of the utmost conse- quence, especially in reference to the judicial examination of bodies in cases of suspected poisoning. For a variety of most important matter on fthis subject, I refer to the valuable work on Poisons, lately published by Dr. Christison. Some experiments of Professor Autenrieth and Dr. Camerer, seem to render it probable, that in the affections of children, in which this softening of the stomach is chiefly observed, the gas- tric juice acquires a peculiar acrimony, which enables it to dis- solve the parts after death, though it is incapable of acting upon the living stomach. Dr. Fels, again, and other German writers, consider the affection as a peculiar disease of infancy, which they describe at great length under the name of Gastromalaxia. From a full view of the subject, however, the -truth seems to be, that it is not to be considered as a peculiar and distinct dis- ease, but as a peculiar state of the parts, which may occur in various diseases, and, as was already stated, may take place without any previous disease. The affections of children, in connection with which it had been chiefly observed, are prin- ORGANIC DISEASES OF THE STOMACH. 63 cipally febrile diseases, accompanied with diarrhoea and vomit- ing. Nearly the same observations seem to apply to the ramollis- sement of the mucous membrane of the stomach, on which much attention has been bestowed by some of the French wri- ters, particularly in a very interesting memoir by M. Louis.* This appearance consists in portions of the mucous membrane being found in a soft state like semi-transparent mucus, in gene- ral without any other disease of the parts. In nearly all his cases, it occurred in persons who had also been affected with other diseases, chiefly phthisis: and they had complained some- time before death of pain and heat in the epigastric region, with loss of appetite, nausea, and occasional vomiting. It is, how- ever, to be observed, that, in a large proportion of the cases described by M. Louis, there existed some other disease capable of accounting for derangement of the functions of the stomach and uneasiness in the epigastric region, such as disease of the liver and spleen, and ulceration of the mucous membrane of the bowels: and farther, that M. Louis himself shows this ramollissement of the mucous membrane existing wfeere there had been no symptom referred to the stomach. Upon the whole, there seems reason to doubt whether this is to be con- sidered as an appearance on which can be founded any princi- ple in pathology. SECTION II. OF ORGANIC DISEASES OF THE STOMACH. Many of the cases referred to under the former section, might properly have come under the head of organic disease, from the thickening of the coats of the stomach, and other per- manent changes in the structure of the parts ; but, in most or all of them, the ulceration of the mucous coat appeared to have been the primary disease. In this section I shall refer to some affections more purely organic; and, as they are seldom the objects of medical treatment, I shall mention them very briefly under the following heads : I. Induration and thickening of the Coats of the Stomach. II. Chronic Peritonitis of the Stomach, with disease of the Omentum and the Pancreas. III. Diseases of the Pylorus. IV. Disease of the Cardia. * Louis' Memoircs et Recherches Anatomico-palhologiques. 64 ORGANIC DISEASES OF THE STOMACH. § I.__Induration and thickening of the coats of the stomach. Case XVI.—A woman, aged 56, (August, 1816,) had been liable, for about a year, to disorders of the stomach, consisting chiefly of distention, acidity, and occasional attacks of acute pain". After several months from the commencement of these symptoms, she began to be affected with vomiting; and, for* three or four last months, had vomited daily, generally in the afternoon or evening, at irregular periods after dinner. Some- times she escaped it till she went to bed ; but then it always came on early in the night. A hard tumor of considerable ex- tent could be felt in the epigastrium. She^died iii September, in a state of extreme emaciation, having* before death, dis- charged much blood, both by vomiting and by stool. Inspection.—The stomach adhered to all the neighboring parts, so that it was with difficulty separated from them. The cardia and pylorus were healthy, and also a small portion of the stomach adjoining to each of these openings. The whole of the smaller curvature, except these two portions, presented one continued mass of scirrhus hardness, in general, about an inch in thickness ; and, when cut into, white and very firm. On the inner surface of this portion, about its centre, there were two tumors, the one the size of a pigeon's egg, and the other of a hazel nut. Externally they were of a dark purple color, in- ternally white. The large curvature and the anterior part of the stomach were extensively ulcerated, dark colored, and of very irregular thickness; and at one place, there was a perfora- tion the size of a shilling. The pancreas was hard, and the liver tubercular. The other viscera were healthy. It is unnecessary to multiply cases of this kind, which present little variety in their characters, and admit of no treatment. The disease consists, in some cases, of an uniform hard mass, with the character of scirrhus, or almost of cartilage ; in others, it has more the appearance of tubercular disease: frequently, a considerable part is of a soft texture resembling the substance of the brain, and this sometimes forms a mass of tumors pro- jecting internally. In a case by Pinel, a large abcess had formed in the substance of the diseased mass, and had burst into the cavity of the stomach. A large tumor in this case had been felt in the epigastric region, had been gradually increasing, and suddenly disappeared during a fit of coughing, a considerable time before the death of the patient. , DISEASES OF THE PYLORUS. 65 $ II—Chronic peritonitis of the stomach, with disease of the omentum and the pancreas. Case XVII.—A gentleman, aged about 60, a year before his death, began to complain of pain, which was referred chiefly to the right side of the abdomen, with some tenderness on pressure and a confined state of the bowels. There were also frequent griping pains referred to various parts of the abdomen ; and extending with much severity to the back,—the pulse was natural. He derived temporary benefit from the usual means ; but the complaints were not removed. After several months, he began to lose flesh and strength ; and a hard defined tumoi was discovered between the umbilicus and the region of the stomach, which was somewhat painful on pressure. His appe- tite became much impaired, but he never had any vomiting; his bowels became irregular, being sometimes confined and sometimes loose. Dropsical swellings at length took place, and he died in March 1825, after a violent attack of pain in the ab- domen, accompanied with yellowness of the skin, which con- tinued two days. Inspection.—The stomach adhered extensively and closely to the liver, the colon, the pancreas, and all the other adjoining parts. The pancreas was much enlarged and hard, and when cut into, discharged a milky fluid. The omentum was drawn up, and formed a firm fleshy mass attached to the stomach. There were slight adhesions of the intestines to each other. The substance of the liver was healthy. <§, III.—Diseases of the Pylorus. In a pathological point of view, there are some facts relating to the disease of the pylorus, which are worthy of being recor- ded, though they can seldom become the objects of medical treatment. Disease of the pylorus may begin in a slight and insidious manner, like a mere dyspeptic affection, and gradually exhibit its more confirmed characters ; or, it may come on in a more rapid manner, with acute symptoms resembling an inflammatory attack. In its advanced state, it is generally distinguished by periodical vomiting, occurring at certain regular intervals after meals, generally with fixed uneasiness in the region of the stomach ; and we can commonly discover, on examination, more or less induration in the region of the pylorus. But we find 9 66 DISEASES OF THE PYLORUS. remarkable deviations from these, which we are apt to consider as the established characters of the disease. The cases which I shall here introduce are intended to illustrate some of those de- viations, by showing extensive disease of the pylorus, existing with remarkable remissions In the symptoms, and considerable intervals of good health,—without any vomiting,—and without any induration that could be discovered on examination. Case XVIII.—A gentleman, aged 30, had been for several years liable to paroxysms of pain in the stomach, which usually continued for several hours, and went off with vomiting. They returned at uncertain intervals, frequently of many weeks ; and, upon several occasions, he seemed to have got entirely free from the disorder. He was in other respects in tolerable health, un- til about a year before his death, when he was suddenly seized with copious vomiting of blood. From this time, his attacks of pain in the stomach became more frequent, and he had repeat- ed attacks of the vomiting of blood ; but still he had considera- ble intervals of health ; no hardness could be discovered by ex- amination ; and that uniformity of symptoms wras entirely want- ing which usually accompanies organic disease. After having complained for two days of pain in the stomach in the usual form, he was found in the morning of the third day exhausted and without pulse, and died in a few hours: but he was not emaciated ; and, three days before his death, he had been able to walk out a good deal, and made no particular complaint. - Dissection.—The pylorus was surrounded by a mass of scirr- hus, the size of an orange, very firm, or nearly cartilaginous. The stomach in other respects wras entirely healthy, as were also the liver, the spleen, and the pancreas. There were con- siderable adhesions among the intestines ; and there was slight ossification of the valves on the right side of the heart. Case XIX.—A man, aged 40, came under my care in De- cember, 1817. He was weakened and emaciated to the last degree, with a weak pulse at 120, but without any other com- plaint ; he had no pain, and no cough, his appetite was good, his bowels were natural, and the functions of the stomach were entirely healthy. About half way between the ensiform carti- lage and the umbilicus, a . hardness was felt which could be traced for several inches, and was painful upon pressure. He had been ill eighteen months, and the affection had commenced with vomiting, which occurred generally five or six times a day. This continued for five or six months, when the vomiting ceas- ed entirely ; and for the last twelve months, he had no com- DISEASES OF THE PYLORUS. 67 plaint, except progressive debility and emaciation. He died completely exhausted in the beginning of February, having con- tinued without any other symptom than repeated attacks of vi- olent pain in the abdomen. Inspection.—A mass of scirrhus, four or five inches in diame- ter, surrounded the pylorus ; and the pyloric orifice was so nar- rowed, as scarcely to admit the point of a very small finger. The inner part of the mass opened upon the internal surface of the stomach, by an ulcerated space covered with large cancer- ous looking tubercles. The other parts of the stomach were tolerably sound, and the other viscera were healthy. Case XX.—A gentleman, aged 66, came under my care on- ly a few weeks before his death. He was then emaciated in an extreme degree, with an exhausted, withered look. He had been long in bad health, but particularly for the last four months, during which period he had been affected with frequent vomit- ing which however did not occur at any regular periods. When questioned about it, he said, that he seemed to vomit by a vol- untary effort to relieve an extreme uneasiness which took place in his stomach ; and, accordingly, by putting him upon a regu- lated diet, it appeared that he could in a great measure prevent it. His debility and emaciation, however, continued to in- crease, and he died in a state of extreme exhaustion in June, 1817. No organic disease could be discovered on the most careful examination, and for some weeks before his death the vomiting had in a great measure subsided. Inspection.—The pylorus was surrounded by a mass of scirr- hus, the size of a small apple; and the internal part of it pro- jected into the cavity of the stomach, in the form of numerous hard papillae. The principal projection of the mass was back- wards, where it had formed adhesions, by means of which the pylorus was firmly bound down to the pancreas. The pyloric orifice was not much contracted, as it admitted the point of the thumb. The stomach was in other respects sound, and the other viscera were healthy. These cases show disease of the pylorus existing with remark- able deviations from the more common characters of the affec- tion ; but they are not in these respects singular exceptions to the general history of the disease. A man mentioned by Char- % del was affected with a strong pulsation in the epigastric region, in which a pulsating tumor was felt corresponding with the pulsation of the heart. It was most troublesome when his stomach was full, but his appetite was good, and the functions of his stomach were unimpaired. He became gradually ex- 68 DISEASES OK THE PYLORUS. hausted, and died without any other symptom, except diarrhea and oedema of the legs. The tumor was found to be an enor- mous mass of scirrhus, occupying the posterior part of the py- lorus, and extending along the small curvature of the stomach. The pancreas also was hard, and the liver tubercular. A woman mentioned by the same writer had pain in the epigastric region, followed by very deep jaundice, and died, gradually exhausted with diarrhoea and ascites. On dissection, there was found scirrhus of the pylorus and of the pancreas; and the latter compressed the ductus communis. In another case, compli- cated with enlargement of the liver, the patient died, gradually exhausted by violent pain in the epigastrium, without vomiting. A mass of scirrhus three inches in length occupied the pylorus, and extended along the small curvature of the stomach. It does not appear that these varieties in the symptoms de- pend upon the degree of contraction of the pyloric orifice; for, in Case XX. there was little contraction; and in a case by Chardel, there did not appear any contraction at all, though a large mass of schirrus surrounded the pylorus. In this case, there had been frequent vomiting, with violent attacks of pain. In Case XIX. on the other hand, there was great contraction of the orifice; and in a case mentioned in the ' Journal de Medicine,' for October, 1815, the pyloric orifice was nearly closed, though the patient had died of gradual emaciation, and there had been no vomiting until three days before death. We have seen that there may be extensive disease of the pylorus which cannot be discovered during the life of the pa- tient. This may result from the mass being bound down by adhesion to the parts behind, as in Case XX. But besides this, the disease may be of so small extent as not possibly to be de- tected in this manner, while it is capable of producing the usu- al symptoms in their most violent form. In a case by Dr. Morrison,* the pylorus was almost totally obstructed by small tubercles arising from its internal surface, without any external disease. The patient died, after several years' illness, with pain of the stomach and vomiting; and in a case by Charpel with the same symptoms, the pyloric orifice was reduced to a very small chink, but with very little external enlargement ■ consequently nothing had been discovered during life, though the patient was very much emaciated. * Med. Ob. and Enq. vol. vi. DISEASE OF THE CARDIA. 69 § IV.—Disease of the Cardia. Case XXI.—A man aged 38, consulted me in summer, 1815, on account of difficulty in swallowing. The articles swallowed seemed to lodge at a spot to which he pointed, (cor- responding to the seat of the cardia,) and were almost imme- diately brought up again. He had been for many years liable to this affection in a greater or less degree, but at first it at- tacked him only occasionally, and he was sometimes for several months together entirely free from it. For some time back it had become more permanent. He had pain on pressure behind the ensiform cartilage, and a slight hardness could be felt there. At this time he could swallow liquids, but in the course of the summer the complaint increased, until he could scarcely swal- low a drop of any thing; articles of all kinds lodged for a few seconds in the lower part of the oesophagus, and were rejected. He died gradually exhausted in November. Inspection.—A mass of schirrus about three inches in length extended from the cardia along the course of the oesophagus, and nearly obliterated the passage; at the cardia it projected into the stomach by several round protuberances. The stom- ach was healthy. Case XXII.—A man, aged 60, had been liable for many months to difficulty in swallowing, which had at various times been better or worse, and sometimes entirely removed for a week at a time: but he was now emaciated to a great degree. By the probang an obstruction was felt about the middle of the oesophagus; and under treatment directed to this in the usual manner, he seemed to improve considerably in swallowing. But his strength continued to sink, and he died after a few weeks. Inspection.—There was a slight contraction about the middle of the oesophagus, two inches in extent, without any thickening of its coats. The cardiac orifice was compressed by a tumor the size of a walnut, situated on the outside of the oesophagus, or rather confined under its external membranous covering, without any other disease of the parts. SECTION III. PATHOLOGY OF DYSPEPSIA. When the digestive organs are in a healthy state, it appears that a mass of food, composed of a variety of articles, is 70 DYSPEPSIAi changed, in the course of from three to five hours, into a ho- mogeneous pultaceous matter called the chime. The observa- tions of Majendie have rendered it probable, that, sometime after the process of digestion has commenced, a motion begins to take place in the stomach, by which the contents are slowly moved backwards and forwards betwixt its splenic and pyloric portions. This motion is said to be more active, and to extend over a greater portion of the stomach, when it contains but a small quantity of food; and to be more limited when the quan- tity is large, being then in a great measure confined to a portion near the pylorus. After this alternate motion has continued for a certain time, the chime is at last gradually propelled into the duodenum, and thence very gradually through the intestinal canal, by a certain consecutive muscular action, which is called its vermicular or peristaltic motion. In this course, the alimen- tary matter is mixed with the bile, pancreatic juice, and the fluids of the intestinal canal; and it undergoes farther impor- tant changes, by which it is converted into chyle fit for absorp- tion, and the excrementitious matters are separated and ex- pelled. The fluid called the gastric juice appears to be merely a mixture of the mucous and follicular fluids of the stomach. It is evident that it bears an important part in digestion, but not as a mere chemical solvent, for it is not found to dissolve articles of food out of the stomach. All that we know there- fore of digestion is, that it is the result of the combined action of this fluid, and of the peculiar muscular motion of the stomach now referred to. In healthy digestion, it appears that no gas is generated in the stomach, but that a certain quantity is evolved in the farther progress of the alimentary matters through the intestines, especially in the colon ; and it is said to be composed of carbonic acid, hydrogen, and azot, in various proportions. When these actions are in any respect deranged or deficient, the alimentary matters are not converted in the regular man- ner into healthy chyme ; but, remaining perhaps longer in the stomach than, in the healthy state of the process, they would do, they undergo in a greater or less degree those chemical changes, which would happen to them in other circumstances. Hence the generation of acidity, the evolution of gases of vari- ous kinds, and the lodgment in the stomach of matters imper- fectly digested, partly fermented, perhaps- partly putrid ; hence, also, irregular muscular contractions, arising from the morbid stimuli thus produced, giving rise to regurgitations of matter into the oesophagus, eructations, and perhaps vomiting; or, the muscular coat yielding to the 'distending force of the evolved DYSPEPSIA--CAUSES. 71 gaseous fluids, there are produced painful distention, oppres- sion, and anxiety, or in other words, a paroxysm of dyspepsia. For the healthy condition of the process of digestion, in all its stages, the following circumstances appear to be necessary: 1. A healthy state of the muscular action of the stomach. 2. A healthy, consecutive, and harmonious action of the muscular coat of the intestinal canal." 3. A healthy state of the fluids of the stomach, both as to quality and quantity. " 4. A healthy state as to quality and quantity of the other fluids, derived from the liver, pancreas, and intestinal mem- brane. 5. A healthy state of the mucous membrane itself, both in the stomach and intestines. The dependence of the function of digestion upon the influ- ence of the eighth pair of nerves, is among the most beautiful discoveries of modern physiology; but nothing of a practical nature has hitherto been deduced from it. In the preceding part of this treatise, we have seen these functions deranged by various diseases of the coats of the stomach ; but our attention, under the present section, is chiefly directed to those cases in which the derangement is of a func- tional nature, or not connected with any change of structure either of the stomach itself or of any of the neighboring parts. Upon the strict principles of pathology, it is extremely difficult to ascertain the exact nature of these functional derangements, as they are merely impaired actions of living parts ; but I think there are a few points which we may consider as not entirely conjectural. 1. We have much reason to believe, that the muscular ac- tion of the st#>niach may be deficient, so that the alimentary mat- ters remain in it too long, are imperfectly changed, and pass into chemical decompositions. We know the state of the uri- nary bladder, in which its muscular action is lost or very much impaired, and in consequence of which it is gradually distended, so as to hold an enormous quantity of fluid ; and when emptied by the catheter, it does not contract equally, as in the healthy state, but falls flat like an empty bag. A state analogous to this we not unfrequently see in the stomach on dissection, a state in which it appears much enlarged, and collapsed by flattening, without healtl y contraction. 2. There n.ay be a deficiency of the corresponding and har- monious ar d intestinal action, interfering with the second stage of digestion, and giving rise to imperfect chylification and vari- ous morbid actions in the upper intestines. 72 DYSPEPSIA--TREATMENT. 3. The various fluids may be deficient in quantity, or morbid in quality, so as to derange the process in various ways. We have grounds for assuming that the fluids of the stomach may be in a morbid condition, without actual disease of its coats. We see in certain cases a fluid brought up by eructation in large quantities, in a morbidly tenacious state, quite different from the healthy appearance of the fluids of the stomach ; and we have reason to believe, that similar changes may take place in the other fluids concerned in digestion, particularly the bile. 4. If the mucous membrane be morbidly irritable, the mus- cular coat will probably be too easily excited to action, and a different state of things will arise. If this occur in the stomach, the articles will not be allowed to remain in it a sufficient time for healthy digestion ; but, after producing much uneasiness, they will either be rejected by vomiting, or propelled in a half-digest- ed state into the intestine, there to prove a source of new irri- tation. This is probably the state to be afterwards more par- ticularly referred to, in which animal food produces much uneasiness in the stomach, often followed by vomiting; but in which digestion goes on in a healthy manner on a regimen restricted to farinaceous articles and milk. If the irritability occur in the intestine, the articles may undergo their proper change in the stomach, but will be propelled too rapidly through the intestinal canal, without time being afforded for the com- plete process of healthy chylification ; and, accordingly, in many affections of the stomach and bowels, we see articles, even of the most digestible kind, pass through partially digested, or sometimes entirely unchanged. I have no intention of entering at any length upon the treat- ment of indigestion ; but there are a few obvious and important rules, which, upon the strict grounds of pathology, may be de- duced from the points which have been briefly referred to. I. It appears that the muscular action of the stomach is both more vigorous and more extensive when its contents are in small quantity, than when it is much distended ; and, if we sup- pose the fluids of the stomach to be secreted in nearly a uniform quantity, their action must also be greatly regulated by the quantity of matter which they have to act upon ; hence the in- dispensable importance in dyspeptic cases of restricting the food to such a quantity as the stomach shall be found capable of di- gesting in a healthy manner. This is unquestionably the first and great principle in the treatment of indigestion ; and with- out invariable attention to it, no other means will be of the smallest avail. DYSPEPSIA--TREATMENT. 73 II. It appears that various articles of food are of various de- grees of solubility in the stomach. When, therefore, digestion is apt to be easily impaired, it will be of the greatest impor- tance, not only to avoid articles which are of difficult solution, but also to avoid mixing various articles which are of different degrees of solubility. Attention to this rule will probably favor in a great measure the process of chymification going on in a regular and healthy manner, by avoiding a state in which the so- lution of one article may be more advanced than that of anoth- er. The articles of most easy solution appear to be solid animal food, and white fish, both plainly dressed: vegetables are less soluble ; and, among the articles of more difficult solution, ap- pear to be fatty substances, tendinous and cartilaginous parts, concrete albumen, the epidermis of fruits, and, according to some, mucilaginous and sweet vegetables. From some experi- ments of Sir Astley Cooper, it is supposed, that the solubility of animal food is in the order of pork, mutton, veal, beef. Arti- cles in small pieces are much more speedily dissolved than in larger, the action being found to begin at the circumference of the portion ; and hence the importance of careful mastication. III. If digestion go on more slowly and more imperfectly than in the healthy state, another important rule will be, not to take in additional food until time has been given for the solu- tion of the former. If the healthy period be four or five hours, the dyspeptic should probably allow six or seven. The injuri- ous infringement of this rule by a breakfast, a meat lunch, and a dinner, all within the space of seven or eight hours, is too obvi- ous to require a single observation. The rules now briefly referred to, I conceive to be of more importance in the treatment of dyspepsia than any means what- ever. I believe that every stomach, not actually impaired by organic disease, will perform its functions if it receive reasona- ble attention ; and when we consider the manner in which diet is generally conducted, both in regard to quantity, and to the variety of articles of food and drink which are mixed up into one heterogeneous mass, instead of being astonished at the prevalence of indigestion, our wonder must rather be, that in such circumstances, any stomach is capable of digesting at all. In the regulation of diet, much certainly is to be done in dys- peptic cases, by attention to the quality of the articles that are taken; but I am satisfied that much more depends upon the quantity; and I am even disposed to say, that the dyspeptic might be almost independent of any attention to the quality of his diet, if he rigidly observed the necessary restrictions in re- gard to the quantity. It is often, indeed, remarkable, how ar- 10 DYSPEPSIA--TREATMENT. tides which cannot be borne as a part of mixed diet, agree per- fectly when taken alone ; how a person, for example, who fan- cies that milk disagrees with him, will enjoy sound digestion upon a milk diet; and how another, who cannot taste vegeta- bles without being tormented with acidity, will be entirely free from acidity on a vegetable diet. The following case occurred to me some time ago, in which this experiment was made in the most complete and satisfactory manner. A gentleman, accustomed to moderate but very comfortable living, had been for many years what is called a martyr to stomach complaints, seldom a day passing in which he did not suffer greatly from pain in his stomach, with flatulence, acidity, and the usual train of dyspeptic symptoms; and in particular, he could not taste a bit of vegetable, without suffering from it severely. He had gone on in this manner for years, when he was seized with complaints in his head, threatening apoplexy, which, after being relieved by the usual means, showed such a constant tendency to recur, that it has been necessary ever since, to restrict him to a diet almost entirely of vegetables, and in very moderate quantity. Under this regimen, so different from his former mode of living, he has continued free from any recurrence of the complaints in his head, and has never been known to complain of his stomach. In the regulation of the diet for all affections of the stomach, however, strict attention must always be paid to the nature and source of the disease. Animal food is in general the most di- gestible, but there are many cases which depend upon an irrita- ble state of the mucous membrane, in which the diet found to be beneficial or even necessary, is one restricted to farinaceous articles and milk. The higher degrees of this affection, in which the disease amounts to inflammation of the mucous mem- brane, have already been referred to; but there appear to be modifications of it, which, without assuming this formidable character, have a similar effect on the functions of the stomach, and require a similar treatment, especially in regard to diet. The subject is one of great interest, and opens a most impor- tant field of observation to him who, renouncing a mere empiri- cal treatment of dyspeptic affections, shall direct his attention to the important varieties in the nature and source of the dis- ease. Such a person will be astonished to find the improve- ment which is made in certain cases, under a diet restricted entirely to rice, arrows-root or bread and milk, with total ab- , stinence from all stimulating liquors, after the patient has spent years of wretchedness upon animal diet, with wine or brandy and water, and the usual round of Stomachic remedies. Other cases again agree better with animal diet in very small quantity, DYSPEPSIA--TREATMENT. 75 and the moderate use of stimulating liquors. The diagnosis is often difficult, and must be guided more by the judgment and attention of the practitioner, than by any general rule. This subject has been well illustrated by Dr. James Johnson, in his Treatise on Morbid Irritability of the Stomach. In the medical treatment of dyspeptic complaints, it is im- possible to advance any thing new\ One thing, however, has al- ways appeared to me to be of the utmost importance in regard to the regulation of the bowels, which in general are habitually slow. It consists in regulating them by the daily use of very small doses of laxatives combined with tonics, so as, without ever purging, to imitate at all times that moderate but regular action, which constitutes the most healthy state of the bowels. For this purpose various combinations will be found to answer: such as Columbo powder with carbonate of potass and a-few grains of rhubarb, taken once or twice a day: sulphate of iron with aloes ; sulphate of quinine with aloes or rhubarb, and a few grains of ginger; oxide of bismuth with rhubarb or aloes, &c. Lime water is often useful, and the mineral acids. The nitric acid, in particular, is often fotrnd one of the best tonics, and one of the best correctors of acidity. This kind of mild treatment, with a proper regulation of diet, and regular exercise without fatigue, appears to be the plan best adapted to the ordinary cases of dyspepsia. Injury is done by the free use of stimulants, and by active purging; and I must also express my apprehension that no small injury is done by the indiscriminate use of mercury. There are indeed some affections of the stomach, probably connected with derange- ments of the liver, in which a very cautious use of mercury ap- pears to be beneficial; but in many others, it is decidedly hurt- ful ; and I conceive that in all disorders of the stomach, mercury in any form or in any quantity ought not to be employed, when the desired effect can be accomplished by any other means. When the muscular action of the stomach is much impaired, it is probable that galvanism might be useful; the effect of it on the action of the bowels will be illustrated in a striking manner by cases to be afterwards described. In concluding this slight outline of the pathology-of the stomach, it may be right to add a few observations on some points which frequently become objects of attention in the treat- ment of diseases in this organ. I. Gastrodynia or pain in the stomach. This occurs to us 76 OASTRODYNIA. in practice under four different forms, which seem to imply im- portant differences in the nature of the affection. 1. Pain occurring when the stomach is empty, and rather re- lieved by taking food. This probably depends upon some de- gree of acrimony of the fluids of the stomach itself, and is generally relieved by absorbent and alkaline remedies. 2. Pain occurring immediately after taking food, and contin- uing either during the whole process of digestion, or till the stomach is relieved by vomiting. This is probably connected with chronic inflammation or increasing irritability of the mucous membrane of the stomach. The treatment which it requires has been referred to in the preceding observations. 3. Pain beginning from two to four hours after a meal, and continuing for some hours. This is probably seated in the duo- denum, and connected with inflammatory action or morbid sen- sibility of its mucous membrane. This form of the affection is often accompanied by pain and tenderness on pressure in the right hypochondrium, and, on that account, is apt to be mista- ken for disease of the liver. In the course of the paroxysm, the pain is apt to extend obliquely downwards and backwards in the direction of the right kidney, and thence again inwards towards the umbilicus. The duodenum evidently bears an im- portant part in the function of digestion, and is probably the seat of some affections which are apt to be mistaken for diseases of the stomach and liver. Facts are wanting upon this subject, but the investigation promises important results. All that we can say at present is, that, if the disease be chiefly or entirely seated in the duodenum, the patient will be comparatively well for two or three hours after a meal; and that his uneasy sensa- tions will then commence, and will in the first instance be chiefly seated in the right side. Much confusion has arisen from the prevailing fashion of ascribing all such affections to disease of the liver. It is difficult to say what remedies are best adapted to each of these forms of gastrodynia. I have found nothing of more general utility than the sulphate of iron, in doses of two grains, combined with one grain of aloes and five grains of aromatic powder, taken three times a day. Oxide of bismuth combined with rhubarb in the same manner, is also frequently very useful; likewise lime-water, and small opiates. AVhen the affection proves more obstinate, it must be treated by topical bleedin<* and blistering, with farinaceous diet. 4. Pain in the stomach takes place in a fourth form occurring at uncertain intervals, in most violent paroxysms ; accompanied generally with a feeling of distention, much anxiety, and ex- GASTRODYNIA. 77 treme restlessness; and, in females, it is frequently combined with hysterical symptoms. This form seems to depend upon over distention of the stomach, and is relieved by carminatives ; but it is often very severe and untractable. I think the most effectual relief, in general, is obtained from exciting a brisk action of the bowels, by means of a strong injection. From the facility with which such affections often yield to this reme- dy, it is probable that the uneasiness is sometimes seated in the arch of the colon. External stimulants, such as sinapisms, and friction with strong spirits, often give great relief. There seem to be some other modifications of pain in the region of the stomach, not referable to any of these classes. Among these may be reckoned a pain which affects persons of a gouty habit, and may occur either in the form of severe and sudden paroxysms, or as a more continued pain going on for many days together. It seems in general to be most relieved by stimulants, combined with alkalies and small opiates; but it requires to be carefully attended to, and to be treated by topi- cal bleeding and blistering, if it do not soon give way. There is also a violent affection of the stomach, occurring chiefly in females of an irritable habit, and assuming a spasmodic or neu- ralgic character. It seems in general to be relieved by opiates combined with absorbents or alkalies. All these affections of the stomach, however, should be watched with attention, for seve- ral remarkable examples have been given which show that they are often connected with chronic inflammation or ulceration, and that they may be very rapidly fatal, without having as- sumed any formidable character till the fatal attack. In all these painful affections of the' stomach, attention to regimen is, of course, of the utmost consequence. On this head it is impossible to lay down any general rules, as the diet must be regulated by attention to the nature and character of the case. One rule is applicable to all of them, namely, that the food ought always to be in the smallest quantity. In re- gard to quality, there is great diversity. Some^of the cases agree best with farinaceous diet and milk, while in others, the pain is aggravated by articles of this kind; and the patient goes on most comfortably upon animal food in small quantities, with bread, or a little rice. For a variety of interesting facts on this subject, I refer to a work by M. Barras, ' Sur les Gas- tralgies et les Enteralgies.' It is directed against the prevailing doctrine of the French school, by which all affections of this class are referred to the ' gastro-enterite chronique ;' and shows in a satisfactory manner the evils which arise from the indis- criminate application of this system, and the practice founded upon it. 78 CHRONIC VOMITING AND PYROSIS. II. Chronic vomiting, occurring at various irregular inter- vals, and without suspicion of organic disease. This seems in general to be connected with a morbid irritability of the mu- cous membrane of the stomach, and sometimes proves very untractable. It may occur at a short period after taking food, or at the distance of three or four hours. In the former case, the disease is probably seated in the stomach ; in the latter, in the pylorus or the duodenum. The treatment is very uncer- tain ; the oxide of bismuth is in some cases extremely useful, and in others lime-water. In some forms of the affection, again, articles of a stimulating nature are beneficial; and I have known some very protracted cases yield to the use of a strong tincture of garlic ; and others, to small doses of calomel. Much depends upon regimen, and some of the most severe and i protracted cases have got well under a diet restricted entirely to milk. External applications are also frequently useful as blistering, and tartar emetic ointment. It is to be kept in mind, that habitual vomiting often depends upon diseases of other organs, affecting the stomach sympathetically, such as affections of the kidney, the liver, the spleen, the pancreas, and sometimes the brain. Protracted cases of vomiting which have resisted much treat- ment, sometimes yield to the practice of keeping up a slight but continued actbn on the bowels, by very small doses of lax- atives repeated at short intervals. An interesting example of this is mentioned by Dr. Parry, in which the vomiting was in such a degree, that everything was rejected, even a tea spoon- ful of water. The case had gone on in this manner for seve- ral weeks, and the patient was reduced to the last degree of emaciation, when Dr. Parry ordered half a grain of aloes to be given every four hours, moistened only with a few drops of li- quid. This was retained, and acted gently on the bowels, and in less than two days, the complaint entirely subsided. The bowels had been freely moved from time to time during the previous treatment, and other remedies in great variety had been employed without any benefit.* III. Obstinate and untractable pyrosis often accompanied with discharge of quantities of thin acrid mucus by eructation, or with a feeling of constant and intense acidity, produced by articles which are not likely to become acid. These symp- toms are probably connected with a diseased condition of the mucous membrane of the stomach. In some of the cases for- * Collections from the unpublished writings of Dr. Parry. Vol. 1L HJEMATEMES1S. 79 merly described, we have seen them connected with actual ul- ceration ; in others, the membrane appears thickened, pale, and spongy, with an increased and unhealthy secretion. A woman mentioned by Andral, vomited every day about four pints of white glairy mucus like the white of eggs; and she never vom- ited either food or drink. On dissection, no other morbid ap- pearance could be discovered than a general thickened state of the mucous membrane of the stomach, which was of a brown- ish color, and the follicles were remarkably developed. When the fluid discharged is tinged of a brown or chocolate color, ulceration is to be suspected: in other cases, only a thickened state of the mucous membrane is met with, combined with an appearance of melanosis. The fluid in these cases has been found to contain a large proportion of albumen, and the color appears to arise from the coloring matter of the blood. The affection is very untractable ; it is often benefited by lime water, bismuth, the stimulants, as garlic and benzoin, and fre- quently by the acids, particularly the nitric; likewise by blister- ing and mild farinaceous diet. IV. Hcematemesis.—This, which we have seen as the result of ulceration, also occurs without any such disease ; and I have seen it fatal where no organic disease could be discovered, and even the source of the haemorrhage could not be detected.- In other cases, a varicose state of the veins is observed in the mucous membrane of the stomach. The quantity of blood brought up is often immense, so that" the patient is reduced to the last degree of exhaustion ; and yet the disease is not often fatal. Some persons, especially women, are liable to frequent or almost periodical attacks of it, sometimes in connection with retention of the menses. When the patient is much exhausted, it is necessary to give small quantities of brandy at short inter- vals. For settling the stomach, and restraining the haemorrhage, the acetate of lead is often very useful, and may be given in doses of one or two grains, repeated every three or four hours, for thirty-six or forty-eight hours, if necessary; also the acids, the muriated tincture of iron, bismuth, alum, and kino in pow- der or tincture. The blood is apt to pass into the bowels, from which it must be discharged by the mildest means, as injections repeated two or three times a-day. The patient must be sup- ported by farinaceous nourishment in small quantities, or by milk, or fresh-made, soft curd. V. Sympathetic Affections of the Heart. These are often among the most troublesome symptoms that accompany affec- 80 SYMPATHETIC AFFECTIONS OF THE HEART. tions of the stomach, and are always the most alarming to the patient. They appear under various forms, and frequently assume, in a verv great degree, all the characters of fixed disease of the heart or" large vessels. The slightest and perhaps the most common form consists of a momentary feeling of a rolling or tumbling motion of the heart, like that which is produced by a sudden surprise or fright, and it is accompanied by an inter- mission of the pulse. This feeling may be repeated only once or twice at a time, and occur at long intervals ; or it may return in rapid succession, for half an hour or an hour together; or it may be felt occasionally, at irregular intervals, for several days or weeks, or for a still longer period. It is sometimes accom- panied by a feeling as if the heart were violently grasped. In other cases, the affection assumes the form of continued fits of palpitation, or strong and irregular action of the heart, which continue without any remission for an hour or more at a time, and recur in this manner daily, or several times in a day, for a length of time ; or recur at uncertain intervals. In other cases, again, these fits of palpitation continue for several days together. They are of course accompanied by irregularity of the pulse, when the action of the heart is itself irregular ; but frequently there is no irregularity in the action,—the affection merely con- sisting of a strong pulsation, which the patient feels or hears throbbing in his ear, and can count distinctly by the sound, especially when he lies in bed. In other cases, again, there is only an increased frequency of the action of the heart, showing itself by paroxysms of quick pulse, accompanied with a feeling of anxiety, continuing far an hour or two at a time, without any irregularity. I shall mention in the sequel a remarkable case, in which an affection of this kind continued with little remission for a year. Betwixt the various forms of this affection and disease of the heart, the principal diagnosis consists in the pulse being regular, and the action of the heart natural, during the intervals between the attacks,—in an obvious connection with disorders of the . stomach, and relief by treatment directed to that organ,—and, particularly, by the symptoms being most apt to occur while the patient is at rest, especially after meals, not being increased by bodily exercise, but rather relieved by it,—and not being excited by such bodily exertion as we should naturally e'xpect immedi- ately to influence a disease of the heart. The affection is al- ways very alarming to a patient, and sometimes perplexing to the practitioner; for, from the permanency of the symptoms, they certainly often assume, in a great degree, the character of disease of the heart, and may even exhibit some of the stethos- SYMPATHETIC AFFECTIONS OF THE HEART. 81 copic signs, particularly the bruit de soufflet. There is, also in many cases, a considerable degree of dyspnoea, and sometimes there are paroxysms of it of considerable urgency. Without entering into any discussions in regard to the manner in which these singular affections are produced, the following selection of facts will perhaps be acceptable to practical men. Between four and five years ago, a gentleman, aged 52, con- sulted me on account of paroxysms of violent palpitation of the heart, which occurred at irregular but rather short intervals, and generally continued for several days together. He was otherwise in good health, and accustomed to take a great deal of exercise, and he did not complain of his stomach. His pulse in the intervals was quite natural; his bowels were rather con- fined, but very easily regulated. The affection had been going on for about three years, and a great variety of treatment had been employed without benefit. I confess I did not expect to do any good in this case, and, rather by way of doing something, than from much expectation of benefit, advised him to take every night one grain of the sulphate of iron, with one grain of aloes, which was found sufficient to regulate his bowels. Cau- tions were given him with regard to his regimen ; but I believe they were not attended to, for under the simple remedy now mentioned, this severe affection very soon disappeared. After a short time, he left off the regular use of the medicine; but afterwards recurred to it occasionally for a few days, and in this manner he enjoyed very good health for upwards of two years. He then went to the continent, and I lost sight of him for about a year. I saw him on his return, as he passed through Edin- burgh, on his way to his seat in the north, and found him very unwell. His pulse was frequent and extremely irregular; the action of the heart was diffused, irregular, and tumultuous ; he had attacks of dyspnoea, amounting at times to a feeling of suf- focation ; his appetite was impaired, and his general feelings were in the highest degree uncomfortable. He left Edinburgh next day, and I wrote to his surgeon in the country, expressing great apprehension, and requesting him to watch the case very narrowly. In a short time I received notice, that the patient had been attacked with gout, and that all his other symptoms had disappeared. Since that time he has had repeated attacks of gout, but in other respects has enjoyed tolerably good health. A gentleman, aged 48, in November 1825, began to be af- fected with paroxysms of palpitation of the heart, and intermis- sion of the pulse. They attacked him daily, sometimes twice 11 82 SYMPATHETIC AFFECTIONS OF THE HEART. or three times a day, and generally continued about an hour at each time; and they were occasionally accompanied with a consid- erable degree of dyspnoea. During the intervals, the pulse was calm and regular, and the action of the heart quite natural. The period of the attack was generally soon after meals ; but it likewise oc- curred at various other times; sometimes on first getting up in the morning, and sometimes in the night. During the parox- ysms, he could take walking exercise without increasing the symptoms. His digestion was imperfect, and his stomach easily disordered ; his bowels were rather slow, and the motions were dark and unhealthy. A great variety of treatment, and every possible variety of diet, were employed with very little benefit. He went to London, and then to Chelthenham, where much treatment was again had recourse to with little effect. He sometimes lost greatly in flesh and strength, and sometimes im- proved again; his digestion was sometimes better and some- times worse; but, amid all these changes, the affection of the heart continued in the same form, namely, paroxysms of violent palpitation of about an hour's duration, occurring once or twice every day, and at no stated hours. After the affection had continued in this manner for two years and a half, it at last subsided under the use of the colchicum wine, in very moderate doses. I do not attempt to account for the action of the rem- edy in this singular case ; it acted at first strongly as a purga- tive, so that he was only able to take ten drops of the wine twice a day. The patient's own account of the effect of it is in these words:—' At the time of commencing the use of the col- chicum, I had at once, at least every day a severe fit of palpita- tion of an hour's duration ; often two, and sometimes three fits in a day. So immediate was the effect of the colchicum, that, with the exception of the first and third days after beginning its use, I have not had a single paroxysm of the palpitation.' He adds, that he continued the use of it for a month, and then left it off entirely ; and that the quantity did not, in general, exceed from fifteen to twenty drops in a day. About four years ago, a gentleman, aged 65, began to be af- fected with some uneasy feelings in his chest, accompanied by an occasional sense of dyspnoea. On examination, his pulse was found to be very rapid, seldom under 120, often 130 or more, with some irregularity, and it was uniformly thus fre- quent at all hours, of the day. The action of the heart was frequently irregular; his digestion was impaired; his nights were often very disturbed ; and during the night he had fre- quently a feeling of dyspnoea, which obliged him to sit up in bed. A variety of treatment was employed for months, with SYMPATHETIC AFFECTIONS OF THE HEART. 83 little or no benefit; he fell off greatly in flesh and strength ; some oedema appeared in his legs: and, upon the whole, the case assumed such an aspect, that I watched it with much anxi- ety, and had long ceased to consider it as sympathetic. At length, however, about a year after the commencement of the disorder, it disappeared spontaneously, and rather suddenly. The patient has now enjoyed good health for more than three years, and circumstances have come to my knowledge, which induce me to believe that the source of the affection had been continued anxiety of mind. This gentleman had been liable to gout; but he had some slight attacks of it during the continuance of these symptoms without relieving them; and there was no gout connected with their final disappearance. A gentleman has frequently consulted me, who is affected in the following manner': in an instant, and without any warning, he is seized with a most painful feeling in [the region of the heart, accompanied by great anxiety and oppression across the thorax; and his pulse becomes feeble and very rapid. There is no dyspnoea, but on the contrary he attempts to relieve Tiis uneasiness by frequent and very deep inspirations, which are performed without difficulty. While the lungs are in a state of full inspiration, a sound is heard by himself and by persons sitting near him, exactly resembling the loud tick of a watch ; it corresponds in frequency with the pulse, and is only heard while the lungs are fully inflated ; but it continues to be heard as long as he keeps them inflated, by resting upon a deep in- spiration. The attack generally continues from 15 minutes to half an hour, and then passes off in an instant, with a feeling of some obstruction suddenly giving way ; every uneasy sensa- tion is then instantly removed, and the pulse becomes full, soft. regular, and of the natural frequency. This affection was origi- nally brought on by intense anxiety of mind nearly 30 years ago; it continued to recur since that time, but at very uncer- tain intervals, often of weeks or months, and has never produc- ed any injurious effects upon his general health. It is unnecessary to enter into any general detail of the va- rious sympathetic affections, which, in connection with disor^ ders of the stomach, appear in other organs, particularly in the head, as these are familiar to every practical man ; but I shall conclude this part of the subject with a short account of the following affection, which seems to be one of very rare occur- rence. A gentleman, aged about 50, liable to delicate health and im- e4 PATHOLOGY OF THE STOMACH. paired digestion, about five years ago, began to be affected in the following manner :—At various times of the day, and without any warning, he was suddenly seized with an uneasy feeling in the epigastric region, accompanied by a violent and very loud sound, as from the belching of wind. At the instant when this sound took place, he was seized with a violent pain in some part of the lower extremities, generally on the inside of the thigh, a little above the knee. This was accompanied by a convulsive start of the limb, and the pain for the time was so acute, that he generally at the instant of the seizure, grasped the part with both his hands by a kind of involuntary or convulsive effort. The whole was the work of a moment, and passed off as suddenly, leaving only a kind of soreness about the knee, which was relieved by friction. These paroxysms occurred many times in the day, and, in the night he had frequent start- ing of his limbs. His digestion was bad: the bowels were confined, and the motions were dark and unhealthy. At one time during the continuance of the complaint, his limbs be- came considerably weakened, so as to assume the appearance of a slight degree of paraplegia ; but nothing could be discover- ed about the spine, and the limbs after sometime recovered their strength. The affection has continued to recur from time to time, though it is very much diminished, both in frequency and in violence. The only treatment that appeared to have any influence over it was regular moderate purging, alternated with opiates. The imperfect outline which has now been given of affections of the stomach, will serve to show the extent and importance of the subject, and the necessity which there is for constantly at- tempting a more correct diagnosis of this class of diseases. Some of them appear to be merely functional, or what may properly be called dyspeptic; while others are connected with most important and defined diseases of the mucous membrane, or the other coats of the stomach; and it appears that many of these cases, though of a very formidable nature, may be treated with success, if their characters are ascertained, and the necessary means adopted, at an early period of the disease. Other cases will be afterwards mentioned, which are connected with corresponding diseases of the mucous membrane of the bowels, or with affections of the neighboring organs. It ap- pears to me that some late writers have confounded a variety of these diseases under the vague and undefined use of the term dyspepsia, supposed to exist in different forms and PATHOLOGY OF THE STOMACH. 85 different degrees; and, in this manner, have introduced much ambiguity into the inquiry. Thus, when we find these writers talking of a stage of dyspepsia in which it termi- nates by ulceration, or various organic affections of the parts concerned, I cannot avoid considering them as using a phraseology which is at variance with the principles of sound investigation, and calculated to obscure a subject of the ut- most practical importance. APPENDIX TO THE PATHOLOGY OF THE STOMACH. In this appendix I mean to introduce a few observations on the following subjects, closely allied to the pathology of the stomach, though not connected with disease of that organ itself. 1. Derangement of the functions of the stomach by tumors attached to it externally, without disease of its coats. 2. Outline of the pathology of the oesophagus. 3. Outline of the pathology of the duodenum. SECTION I. DERANGEMENT OF THE FUNCTIONS OF THE STOMACH BY TUMORS ATTACHED TO IT EXTERNALLY, WITHOUT DISEASES OF ITS COATS. Of the singular phenomena connected with some of the af- fections of this class, I shall only give the following example : Case XXIII.—A lady, aged about 70, had been affected for more than thirty years with periodical vomiting, which occurred so regularly a few hours after meals, that during the whole of this period she had vomited a part of almost every meal. It was brought up without nausea, or any unpleasant effort, and the affection had never injured her general health. I was in the habit of seeing her for several years, during which time she continued to enjoy good health, till she began to fall off rather Diseases of the (esophagus. 87 suddenly, and died after a short illness with diarrhoea and rapid failure of strength. Inspection.—The only morbid appearance that could be dis- covered, was a tumor the size of a hazel nut or a very small walnut, and resembling an enlarged gland. It lay in contact with the outside of the stomach, near the pylorus, and slightly attached to its outer coat, but without any appearance of dis- ease in the stomach itself. In a similar case by Morgagni, in which the symptoms had gone on for 24 years, the only morbid appearance was a slight induration of the pancreas. I have seen one case which was fatal in about a year, with constant vomiting, in which the only morbid appearance was a scirrhus hardness of the pancreas, without enlargement; and I have seen several in which the pancreas was enlarged and diseased in various ways. Similar symptoms may also arise from diseases of the other neighboring parts, as the liver, the spleen, and the omentum. Many years ago, I examined the body of a woman who died gradually ex- hausted by daily vomiting, which had continued more than a year, and I could discover no morbid appearance except the gall bladder distended by a large number of biliary calculi, which completely filled it. In the Philadelphia Journal of Medical Science, a case is mentioned in which symptoms re- sembling those of deep-seated disease in the stomach were connected with a tumor attached to the oesophagus at the third, fourth, and fifth dorsal vertebrae. The patient had knawing pain in the stomach, much flatulency, emaciation, and frequent vomiting ; and he died after a protracted illness. The stomach and all the abdominal viscera were sound. SECTION II. DISEASES OF THE CESOPHAGUS. § I.—Inflammation of the cesophagus. Case XXIV.—A gentleman, aged 26, came to town in June, 1826, to consult me about complaints in his head. On his journey he thought he caught cold in crossing the Frith of Forth, and, when I saw him, he complained of his throat, and there was a granular swelling on the right side of his neck. His voice was hoarse, with a peculiar husky sound. The fauces 88 DYSPHAGIA. were of a bright red color without much swelling, but were covered in several places with aphthous crusts. He was at this time not confined, and there was no fever; but, after a few days, he became feverish, the other symptoms continued as before. He was now confined to bed and actively treated, and after eight or nine days he was much better, so as to be able to be out of bed; but there was still some rawness of the throat, with small aphthous crusts, and a husky sound of the voice. After a few days there was a recurrence of fever which now assumed a typhoid type, with considerable appearance of ex- haustion. He had some dyspnoea, with considerable difficulty of swallowing. The attempts to swallow excited sometimes cough, and sometimes vomiting; and by both he brought up considerable quantities of a soft membranous substance. He became more and more exhausted, without any remarkable change in the symptoms, and died at the end of about three weeks from the first appearance of the disease. For twelve hours or more before death he swallowed pretty freely. Inspection.—The whole of the pharynx was covered by a loose soft adventitious membrane, which also extended over the epiglottis, and portions of it were found lying in small irregular masses, within the larynx, at the upper part. A similar mem- brane was traced through the whole extent of the inner surface of the oesophagus, quite to the cardia. Near the cardia, it lay slightly attached, forming a soft continuous mass about a third of an inch in diameter, and with the oesophagus closely con- tracted around it. The other parts were healthy. § II—Pathology of Dysphagia. The subject of dysphagia has been so fully treated by various writers, particularly Dr. Monro, that it is not necessary to intro- duce more than a slight outline of it in connection with these investigations. The causes of dysphagia, in as far as I have had occasion to observe them in practice, are chiefly the following: 1. Enlargement of the epiglottis and disease of the larynx Ihese affections are generally distinguished by cough and diffi- cult breathing, but these are often slight or scarcely observed • and I have seen several cases in which the dysphagia was the prominent symptom, so as to lead to the suppositioTof disease of the oesophagus rather than of the trachea. In one of these cases, the epiglottis was thickened and much ebngtted the DYSPHAGIA. 89 patient had no constant difficulty of swallowing, but was liable to sudden attacks of it during his meals, which threatened in- stant suffocation. In another case, the dysphagia was perma- nent, and was combined with a hoarse husky cough and slight dyspnoea. The whole body of the larynx was much enlarged and thickened ; and it was in some degree ulcerated both in- ternally and towards the oesophagus. In both cases, the oeso- phagus was entirely healthy. 2. Paralysis of the oesophagus, generally connected with dis- ease of the brain or spinal cord. Of this I have given some remarkable examples in a treatise on the Pathology of the Brain, and one in particular, in which the patient was entirely supported by nourishment introduced through an elastic gum tube, for five weeks before his death. Dr. Monro has described several re- markable cases, in which complete loss of the power of the oesophagus seemed to take place without any other disease. The peculiar character of the affection was a sudden and com- plete loss of the power of swallowing, while a full-sized probang could be passed without any difficulty. The cases in general got well in a short time ; and several of them seemed to derive remarkable benefit from electricity. One of the patients could not for some time swallow at all except when he was seated on the electrical stool. 3. The simple structure of the oesophagus, which consists of a contraction of small extent at a particular spot, generally con- nected with thickening of the mucous membrane at the part, without disease of the other coats. 4. Contraction with more extensive disease, as thickening induration of the coats of the oesophagus; often of great extent, and frequently combined with ulceration of its inner surface, which sometimes assumes a cancerous character. Stricture, referable both to this and the preceding heads, may take place gradually without any known cause, or may be distinctly traced to a cause which produced inflammation or other injury of the parts. A case occurred lately to Dr. Renton of Pennycuick, in which nearly total obliteration of a considerable extent of the oesophagus followed an injury produced by swallowing a preparation of potash. Dr. Cumin has described a very inte- resting case of this kind, produced in a girl 7 years of age, by swallowing American potash in a state of deliquesence, which the child mistook for treacle. After the first violence of the symptoms was subdued, sloughs were discharged, and it was hoped that the danger was over. But difficult deglutition then took place, and when Dr. Cumin saw her, nearly four months after the injury, she was emaciated to the last degree and in a 12 90 DYSPHAGIA. state of extreme distress. She had an eager desire for food, and most urgent thirst, which she attempted to relieve by con- stant attempts to swallow, but the liquids were instantly returned. This very unpromising case Dr. Cumin succeeded in treating successfully by elastic gum catheters. By these he at first in- jected nourishment into the stomach, while he acted upon the disease, but such a power of deglutition was soon recovered as to render the former unnecessary. The final cure of the dis- ease was accomplished in eight or nine months.* 5. Tumors external to the oesophagus, formed by enlargement of the thyroid gland, the bronchial glands, or the glands in the posterior mediastinum ; and morbid productions of various kinds formed within the thorax, so as to compress the oesophagus; also certain affections of the vertebras ; and diseases of the dia- phragm. Great distention of the pericardium appeared to be the cause in a case mentioned by Bleuland.f 6. Polypous tumors, growing from the inner surface of the asophagus itself. Some remarkable examples of this are related by Dr. Monro. 7. Collections of matter behind the oesophagus, or betwixt its coats, and forming a tumor projecting into its cavity. These sometimes attain a great size, and continue for a considerable time before the nature of them is ascertained; and even after the matter has been discharged, it is very often collected again. I have seen several examples of this in the upper part of the oesophagus, so situated that they could be reached by the point of the finger and opened by a curved instrument. They all did well, but from the quantity of matter discharged from one of them, the disease must have been of immense extent. The breathing was much affected in this case, and swallowing was almost impossible. A rsmarkable case occurred to Mr. George Bell, in which the dysphagia had existed so long that it was considered as an example of stricture of the oesophagus, and a probang was introduced. When this reached the part, which was very low down, it ruptured the abscess, and an immense discharge of matter took place, with immediate and permanent relief. A fatal case from the same cause is mentioned by Bleu- land: the matter was collected between the vertebrae and the upper part of the oesophagus. In a case by the same writer, a communication was found between the oesophagus, and an ab- scess in the right lan-r. A similar case is mentioned by Kunze, in which there was much disease of the glands in the posterior * Trans, of the Medico-Chirurgicjl Society of Edinburgh. Vol. iii. part ii. f Blculand dc Sana et Morbosa CEsophagi Structura. DYSPHAGIA. 91 mediastinum, and a communication between the oesophagus and an abscess in the left lung.* 8. Aneurism of the aorta. I have seen several examples of this affection, and the symptoms had not been such as to excite any apprehension of the disease, until the fatal event took place by rupture into the oesophagus. I have described one remark- able case in which the fatal attack was complicated with ramol- lissement of the spinal cord. In another, a gentleman, in the vigor of life, there had been for a few weeks, difficulty in swal- lowing, which on some days was considerable, so as to oblige him to stop in the middle of a meal, and on other days was almost gone. There was no other symptom, and in the morn- ing of the day on which he died, he ate his breakfast well and swallowed without difficulty. In less than an hour after, he was seized with copious vomiting of blood, and died in two hours. , Another case has been related to me, in which a probang was passed, under the idea of stricture of the oesophagus ; it occa- sioned rupture of the aneurism, and almost immediate death. 9. Disease of the Cardia. This has been already briefly re- ferred to. 10. Dysphagia appears to exist, assuming all the characters of a fixed disease of the oesophagus but really connected with a morbid irritability, or some degree of inflammatory action, of a part of. its mucous membrane. This is, probably, the affection which has been called spasmodic stricture of the oesophagus; but the indefinite doctrine of spasm will certainly not account for it. My attention was first particularly drawn to the disease by the case of a lady 40 years of age, who had been under treatment more than a year, for what was considered a stricture of the oesophagus, accompanied by all its usual symptoms. Va- rious courses of medicine and the frequent use of bougies had been employed without benefit. I scarcely know what induced me to propose, instead of the bougies, an egg-shaped silver ball, attached to a handle of silver wire, to be passed occasionally through the stricture, which felt to be at the distance of about four inches below the pharnyx. To my astonishment, the af- fection was completely removed, by four or five applications of this instrument. The patient continued well for more than a year, and then had a return of the complaint, which was removed in the same manner; and she had afterwards several slight re- turns of it, which always yielded readily. The attacks of the affection were generally ascribed to cold, and were preceded by some degree of tenderness of the pharynx, and a feeling of * Kunze de Dysphagia. 92 DYSPHAGIA. rawness and tenderness a short way down the oesophagus. I have no doubt that they depended upon a superficial disease of the mucous membrane, at a particular spot; but the precise nature of it I cannot determine; and I confess myself unable to explain the speedy removal of the complaint, by the means which I have mentioned, especially in the first attack, when it had continued for more than a year, with all the characters of a severe and permanent stricture. In an interesting case describ- ed by Dr. Cumin, the affection came on in connection with dyspeptic symptoms, with vomiting and great derangement of the bowels, produced, in a young woman, by want of exercise in attendance upon a sick relative. Pain was felt behind the cricoid cartilage, and articles swallowed were rejected with a sense of choaking and stricture of the gullet. She derived im- mediate relief from passing a large elastic gum catheter through the part, the vomiting and the spasms of the gullet having ceased immediately. After some time the symptoms returned, and were again removed in the same manner. She was then sent into the country.* For numerous interesting facts relating to what has been called the spasmodic stricture of the oesophagus, as well as to the whole subject of dysphagia, I refer to the learned work of Dr. Monro.f 11. Mr. Mayo has described a remarkable case of fatal dys- phagia connected with a dilated state of the oesophagus. The affection had existed in a greater or less degree for about ten years, and was at length fatal by exhaustion. Articles that were swallowed lodged for a few minutes and then were brought up again, very small quantities only appearing to reach the stomach. The oesophagus at the upper part was healthy, but about half an inch below the pharynx it began to enlarge and gradually acquired an extraordinary degree of dilatation. Its greatest en- largement was about four inches above the cardia; it then con- tracted abruptly, and an inch of the lower extremity was healthy. The inner membrane of the dilated part was opake and thick- ened, and was marked by numerous longitudinal furrows, and by numerous depressions of various sizes and figures.J This singular affection must have been connected with a total loss of the muscular action of the dilated part. Dilatations of a more limited kind have been observed, as in a case by Marx, in which a part of the oesophagus was dilated into a cyst five inches long and three broad. 12. Dislocation of the Os Hyoides. An eminent medical * Trsns. of the Med. Chirurgiol Society of Edinburgh, vol. iii. t Vorbid Anaiomv of the Gullet, Stomach, and Intestines. ; Mcdict.1 Gazette, vol. iii. DISEASES OF THE DUODENUM. 93 man, now deceased, was liabje to this accident, and I have seen him seized with it in an instant, while engaged in conversation. It produced slight difficulty of articulation, and total inability to swallow. He easily relieved himself by a particular movement of the parts with his hand, which had become familiar to him from the frequent occurrence of the accident. A man men- tioned by Dr. Mugna,* while swallowing a large morsel of tough beef, suddenly experienced a sensation as if it stuck at the en- trance of the oesophagus, and immediately lost all power of de- glutition. A sound having passed without difficulty, Dr. Mugna suspected dislocation of the os hyoides., He accordingly intro- duced the fore and middle fingers of the right hand beyond the root of the tongue, and, on moving the parts a little by the left hand applied to the front of the neck, the affection was speedily removed. SECTION III. DISEASES OF THE DUODENUM. Facts are wanting on this interesting subject, but it is proba- ble that the duodenum is the seat of several diseases, which are apt to be mistaken for affections of the stomach or the liver. The leading peculiarity of disease of the duodenum, as far as we are at present acquainted with it, seems to be, that the food is taken with relish, and the first stage of digestion is not im- peded ; but that pain begins about the time when the food is passing out of the stomach, or from two to four hours after a meal. The pain then continues, often with great severity, sometimes for several hours, and generally extends obliquely backwards in the direction of the right kidney. In some cases, it gradually subsides after several hours, and, in others, is relieved by vomiting. The peculiar characters of disease of the duodenum are well illustrated by a case related by Dr. Irvine, in the Medical Jour- nal of Philadelphia for August, 1824. The patient was liable to attacks of pain and vomiting, which at first occurred at long intervals, but gradually became more frequent, until they occur- red regularly every day. His appetite was good, and the func- tions of his stomach were unimpaired for two, three, or four hours after a meal. He was then seized with violent pain, fol- * Annali Universali, quoted in the Medical Gazette, vol. iv, 94 DISEASES OF THE DL'ODENl M. lowed by vomiting, and the pain did not cease till the stomach was completely emptied. He died gradually exhausted, in about six months from the time when the attacks began to oc- cur daily. About three weeks before his death, a tumor was felt in the right hypochondrium, which after eight or ten days subsided. On inspection, the stomach was found distended but healthy, and the liver was sound. The duodenum was enlarged and hardened, and internally showed an extensive surface of ragged ulceration. It was also studded with tuber- cles, varying in size from that of a hickory nut to a hazel nut. In the largest there was a soft, white matter, and the cavity of the duodenum contained about four ounces of pus. In a case by Broussais, the symptoms seem to have been very obscure, or rather are slightly detailed.^ A man, 63 years of age had suffered much from dyspeptic symptoms, which were alleviated by a careful diet. He underwent amputation of the arm, after which he had pain in the epigastric region, with a feeling of pulsation. On the tenth day after the operation, he was seized with coldness, paleness, and convulsive movements, and soon died. The intestinal canal was full of blood ; in the first portion of the duodenum, there was an ulcer which had formed a communication with the hepatic -artery.* In a case by Dr. Hastings, the patient, a woman of 30, had vomiting which usually occurred once in twenty-four hours, and a very confined state of the bowels. She complained of severe pain in the epigastric region, in the right hypochondrium below the margin of the ribs, and in the back between the shoulders. In the two former situations there was great tenderness on pres- sure. She had a teasing cough, by which the pain was ago-ra- vated, but her breathing was easy. Pulse 96. She became emaciated, and her countenance was expressive of much suffer- ing. She died in about three months. Ten or twelve days before death her skin became yellow. On inspection, the tho- racic viscera, the stomach, and liver, were found healthy. In the duodenum, beyond the opening of the biliary duct, there was an ulcer, the size of a crown-piece, of a cancerous character with ragged and everted edges, and its surface was irregular from fungous excrescences. The coats of the intestine around the ulcer were much thickened. All the other viscera were healthy.f This case might very readily have been mistaken for disease of the liver. Ulceration of the duodenum may also be fatal by perforation * Broussais sur la Duodenite Chronique. t Midland Medical and Surgical Reporter, May 1829. DISEASES OF THE DUODENUM. 95 and rapid peritonitis, in the same manner as we have seen in regard to the corresponding affection of the stomach. There is a preparation of this kind in the Museum of the Royal College of Surgeons of Edinburgh, but no account is given of the case, except that it was fatal in twenty-four hours, with symptoms of enteritis; these of course occurred after the perforation had taken place. A very interesting case has been described by M. Roberts.* A man, aged 27, had complained for some months of wandering pains in the epigastric region. For the last six weeks there had been diarrhoea, and for six days pre- ceding the following attack f he had complained of nausea and loss of appetite. On the 10th of December, 1827, three hours after dinner, he was suddenly seized with excrutiating pain in the epigastric region, which soon spread over the abdomen, and he died in extreme agony in about twenty hours. There were the usual marks of extensive peritonitis, and the cavity of the peritoneum contained much gas, and a considerable quantity of fluid. The stomach was healthy ; but, in the duodenum, near its origin, there was an oval ulcer three or four lines in diameter, with rounded edges, and so deep that it seemed to have been bounded merely by the peritoneal covering of the part; this had given way by a small opening about a line in diameter. Near this ulcer there was another about the same size, but less deep; affecting only the mucous membrane. In a very singular case described by Dr. Streeten,f a commu-" nication took place between the duodenum and an external opening*on the side of the thorax, between the seventh and eighth ribs, and articles of food or drink were frequently dis- charged by it. The duodenum was found greatly contracted beyond the seat of this communication, which was produced by means of a canal two inches and a half in length, passing from the opening in the duodenum through thickened cellular texture to the external aperture. The affection was complicated with extensive disease of the liver, and of the thoracic viscera. The patient appears to have lived about a month after the commu- nication took place between the duodenum and the external parts. In concluding this imperfect outline of the pathology of the stomach, and the parts immediately connected with it, I add the following observations as possessing considerable interest in a practical point of view. * Nouvclle Bibl. Medicale, Join 1828. f Midland Medical and Surgical Reporter, No\cmba, 1S29- 96 EPIGASTRIC HERNIA. A gentleman from the country consulted Dr. Kellie and my- self, in regard to a tumor in the epigastric region, of about a year's standing; and the commencement of it was dated from a violent exertion in lifting some heavy body. The tumor was large, flat, and firm, and free from pain or tenderness. On first inspection, it had the appearance of a mass of organic disease of great extent; but, when we considered that his health was good, and the functions of the stomach little impaired, we de- parted from this opinion, and were disposed to believe it might be formed in the parietes. After repeated examinations, we were prepared to send him home with general instructions, when, on making a final examination, Dr. Kellie perceived in the tu- mor an obscure feeling of crepitus. Following this indication, persevering pressure was now employed, and the tumor gradu- ally disappeared. It was distinctly a hernia, but what the con- tents of it were we cannot decide. A lady from the country consulted me respecting paroxysms of pain in the epigastric region, accompanied by vomiting, to which she was liable at short but uncertain intervals: and they had very much impaired her general health. After repeated examinations, I could detect no organic disease ; but at last, by mere accident, discovered a minute opening through the abdom- inal, parietes, about half way betwixt the ensiform cartilage and the umbilicus. It felt scarcely larger than the mouth of a large pencil case, and was covered only by a thin integument. There was every ground for considering it as the aperture of a small hernia, though the patient had never observed any protrusion at the part; and, by adapting to it a light and slender truss, the paroxysms were prevented. PATHOLOGY OF THE INTESTINAL CANAL. In attempting to trace the pathology of the intestinal canal, we have to keep in mind the three distinct structures of which it is composed, namely, the peritoneal, the muscular, and the mucous coats. These structures perform separate functions, and are liable to be the distinct seats of disease. One of the most interesting points in this investigation, is to trace the different classes of symptoms which arise from or are connected with these varieties of structure. This I think we are enabled to do with some degree of accuracy, by tracing, in other parts of the body, in which the three structures are more distinct from one another, the leading phenomena connected with the diseases of each. Thus, from ample observation, we have reason to believe, that the most frequent result of inflammation in a serous mem- brane, is deposition of false membrane,—in a mucous membrane, ulceration,—and in a muscular part, gangrene. There are va- rious modifications of these terminations, but those now men- tioned are the most prominent, and the most peculiar to the different structures. When, therefore, in a fatal disease of the intestinal canal we find ulceration of the internal surface, we have reason to conclude that the disease has been seated chiefly in the mucous membrane; when we find only false membrane, that it has been in the peritoneum; when we find gangrene, that the muscular coat had been affected; and when we find both gangrene and false membrane, that both the muscular and peritoneal coats were involved in the disease. In tracing the symptoms connected with inflammatory affec- tions of the abdomen, we find them resolving themselves into three most important modifications. Thus, we meet with in- nflammation existing in the intestinal canal, with a perfect!*- 13 98 PATHOLOGY OF THE INTESTINAL CANAL. natural state of the bowels,—with a loose state of them,—and with a state of insuperable obstruction. In the progress of this investigation, we shall see reason to believe, that these three states of disease, so different from each other, are connected with three distinct varieties in the seat of the inflammation ; that, when it is seated in the mucous membrane, there is an irritable state of the bowels assuming the characters of untractable diar- rhoea or dysentery ; that, when the muscular coat is affected, there is obstruction of the bowels; and that inflammation may exist in the peritoneal coat alone, and go on to a fatal termina- tion, while the functions of the bowels continue in a perfectly natural state, through the whole course of the disease. It is necessary to anticipate these results, in connection with the ar- rangement of this extensive subject. But, besides the various forms of inflammatory affections of the intestinal canal, there is a class of diseases entirely distinct, namely, those which affect it simply as a muscular organ. This includes the various modifi- cations of Ileus, which, though it very often terminates by in- flammation and its consequences, is in its early stages to be con- sidered as a disease of the canal, affecting chiefly its muscular action. The investigation of the pathology of the intestinal canal might, therefore, divide itself into diseases affecting it as a muscular organ, including the varieties of Ileus,—and the in- flammatory diseases under three classes; namely, 1st, Simple Peritonitis, without any derangement of the muscular action of the bowels,—2d, Peritonitis combined with obstruction of the bowels, constituting the disease commonly called Enteritis,—3d, Inflammation of the mucous membrane. This is perhaps the correct pathological division of the sub- ject, but I think it will answer the purposes of practical utility to consider peritonitis and enteritis together, and the diseases of the mucous membrane separately. On this plan, the actual di- vision of the subject will be, I. Ileus. II. The inflammatory affections of the more external parts, including peritonitis and enteritis. III. The diseases of the mucous membrane. The principal organic affections, and the various forms of chronic disease of the intestinal canal, are so connected with one or other of these classes, that the consideration of them must be very much combined. PART I. OF ILEUS. Colic and Ileus are different degrees or different stages of the same affection, and the name, therefore, may apply to both. The symptoms, in the early stages, are pain of the bowels, chiefly twisting with great severity round the umbilicus, obstinate cos- tiveness, and generally vomiting; but without fever, and com- monly at first without tenderness,—the pain, on the contrary, being rather relieved by pressure. As the disease advances, and if no relief be obtained, the abdomen becomes tense, tender, and tympanitic ; the vomiting very often becomes stercoracious, with severe tormina, intense suffering, and rapid failure of strength. In this manner, the disease may be fatal without inflamma- tion, or, at an advanced period, it may pass into inflammation, and be fatal by extensive gangrene. The first part of our inquiry is to investigate the conditions of the affected parts in the various degrees and stages of this dis- ease. In a pathological point of view, it resolves itself into three leading modifications. 1. Simple Ileus without any previous disease. 2. Ileus with previous disease of such a nature that it acts by deranging the muscular power without mechanical obstruction. 3. Ileus with mechanical obstruction. SECTION I. OF SIMPLE ILEUS. § J.—Ileus fatal in the state of distention without inflamma- tion. Case XXV.—A man, aged 40, 20th August, 1814, had vio- lent pain of the abdomen, urgent vomiting, and costiveness. The pain-was at times increased by pressure, but not uniformly so; his pulse was generally about 96, but at last rose to 120. The attack had commenced with symptoms resembling cholera, 100 ILEUS, which had speedily passed into those of ileus. Repeated blood- letting and the other usual means were actively employed, and his bowels were moved on the 29th, but without relief. I saw him on the 30th. His abdomen was then distended, tense, and tympanitic: his strength was rapidly sinking; and he died the same afternoon. For some time before this attack, he had been affected with slight symptoms, which had been referred to the liver. Inspection.—A large portion of the small intestine was in a state of great and uniform distention, without any appearance of inflammation. The lower part of the right lobe of the liver was unusually soft. No other morbid appearance could be discovered on the most careful examination. In the symptoms of this case at its commencement, there was a complication which, perhaps, may remove it in some degree from the correct history of ileus; though the fact of cholera passing into ileus is by no means uncommon, and the fatal symp- toms were simply those of ileus. The following, perhaps, was a more decided example, and showed the affected parts in the state of high distention, with a slight and recent blush of red- ness, not amounting to inflammation, or, at least, not to such a state of it as could be considered the fatal disease. Case XXVI.—A woman, aged 20, (23d June, 1813,) was affected with violent pain at the upper part of the abdomen, extending towards the left side, and at times increased by pres- sure : frequent and violent vomiting, and obstinate costiveness. The belly was distended and tense; the tongue white ; pulse 76, and small. On the 16th, she had got wet during the flow of the catamenia, which ceased, but returned at night; pain about the umbilicus bega i on the 17th, and increased gradually ; vomiting began on the 21st, with hiccup. Blood-letting, with various purgatives, injections, warm bath, &c. were actively employed by a physician of eminence. (24th.) Incessant screaming from the violence of pain ; fre- quent hiccup ; no stool; pulse 88, and small ; frequent vomi- ting ; belly distended and tender ; every medicine was instantly vomited. (25th.) No stool; everything vomited; pain almost gone ; pulse very feeble. (26th.) No stool; free from pain ; vomiting continued with hiccup. Died in the night. Inspection.—The whole of the colon, and about twelve in- ches of the lower extremity of the ileum were empty, contrac- ted, of a white color, and seemed perfectly healthy. The re- FATAL WITHOUT DISORGANIZATION. 101 mainder of the small intestine was distended to the greatest de- gree, so as to appear thin and transparent; its contents were chiefly watery matter and air. On the surface of the distended intestine, there was on several places, especially at the lower part near the contracted portion, a superficial blush of vivid red- ness, but without any appearance of exudation. There was a small abscess in the left ovarium. All the other parts were healthy. A remarkable feature in this case is the mode of its termina- tion, namely, by rapid sinking and cessation of pain, resembling the symptoms of internal gangrene, yet with the inflammatory appearance in its earliest stage. It is also to be observed, that the pain was increased by pressure as early as the 23d, when we can scarcely suppose any inflammation to have existed ; and the same happened in the former case, where there was no appear- ance of inflammation. <§> II.—Ileus fatal with distention, and a dark livid color of the parts uithout disorganization. Case XXVII.—A lady, aged 70, after her bowels had been confined for several days, was seized on the 5th of January, 1820, with violent pain of the abdomen and vomiting ; pulse natural. The usual means were employed by Mr. White with- out relief. On the 6th, the pain was considerably abated, but there was severe sickness, with frequent vomiting and obstinate costiveness ; the pulse from 80 to 90. The belly was natural to the feel, and without any degree of tenderness. On the 7th the same symptoms continued; the pulse 80. Towards the afternoon, sinking began to take place, and she died in the night. Inspection.—The colon contained a great deal of hardened feces, but appeared quite healthy and without any flatulent dis- tention. The lower extremity of the ileum, to the extent of 18 inches, was empty, contracted, and of a white color, like the in- testine of an infant; immediately above this, a portion from 18 to 24 inches in extent, was throughout of a dark livid brown color, or nearly black, but without disorganization or softening, and without any appearance of exudation. This portion was considerably distended, and the whole of the remaining part of the small intestine to the very commencement of the canal was in a state of uniform and great distention, and of a dull leaden color, with here and there portions of a dark livid brown. It contained only thin fluid feces and air. There was considerable 102 ILEUS. disease of the internal surface of the abdominal aorta. The other parts were healthy. * - The part chiefly affected in this case would appear to have been in an intermediate stage of that condition which passes into gangrene ; and it is worthy of observation, that it was with- out any appearance of inflammatory exudation. $ HI.__Ileus fatal by gangrene without exudation. Case XXVIII.—A boy, aged 12, (26th Oct. 1813) was af- fected with violent pain of the belly, chiefly round the umbilicus, urgent vomiting, and costiveness for two days ; abdomen dis- tended, pulse 50. Various remedies were employed without benefit. On the 27th, the pulse rose to 120, with increase of the pain, tension and tenderness of the abdomen. Blood-let- ting was used in the morning, and again at 3, P. M., after which the pulse fell to 112. The other usual means were em- ployed without procuring any evacuation from the bowels ; the pain continued unabated ; sinking took place, with coldness of the body ; and he died between 7 and 8 o'clock in the evening, having continued in violent pain until immediately before death. I did not see this case during the life of the patient, but was present at the examination of the body. Inspection.—The stomach was healthy ; the small intestine was a little distended and slightly inflamed, especially at the lower part where it had contracted some adhesions. The whole right side of the colon was in a state of gangrene, especially the caput coecum, which had burst and discharged into the cavity of the peritoneum a large quantity of fluid feces. The diseased parts appeared to have been much distended, and, after being emptied by the rupture, had not contracted, but had fallen flat, presenting a very broad surface like an empty bag. There was no inflammatory exudation ; and, at the upper part of the as- cending colon, this diseased part terminated at once in healthy intestine, which was white, collapsed and empty. This was the state of the remainder of the colon, except the sigmoid flexure, with the rectum, contained much consistent feces. § IV.—Ileus fatal by gangrene combined with exudation. Case XXIX.—A young^ man, aged 19, (17th Oct. 1813,) ADHESION OF INTESTINE. 103 was affected with violent pain round the umbilicus; incessant vomiting ; abdomen hard, tense, and tumid ; bowels obstinately costive ; pulse 84; countenance depressed and anxious. He had been ill six days, during which a variety of remedies had been employed without relief. He was now treated by repeated general and topical bleeding, blistering, various purgatives, pur- gative and tobacco injections, and all the other usual remedies, but without any permanent relief. On the 18th, the pulse was 120, and the belly tympanitic; the vomiting was urgent, but not feculent, and there was some slight feculent discharge by the injections. On the 19th, the symptoms were somewhat abated; but, on the 20th, they again increased; the pain vio- lent, the vomiting incessant, the belly much distended; the pulse from 92 to 96 ; slight discharge of watery matter by stool. He died on the 21st. Inspection.—The stomach was healthy. Almost immediate- ly below it, the intestine was distended to the greatest degree. It was in some places thin and transparent; in others, highly inflamed and gangrenous, and bursting when handled ; and in others firm, though perfectly black. This state continued to the middle of the small intestine, where a portion twelve inches in length was empty, contracted, and healthy. Below this, the canal was again diseased as in the parts above, distended, in- flamed, gangrenous, and adhering by extensive exudation, until three inches from the extremity of the ileum, where it became again contracted, empty, and of a healthy color. These con- tracted portions were quite pervious, easily dilated, and, in their coats, appeared perfectly healthy. The colon was healthy and collapsed, except at its lower part, where it contained some consistent feces. The distended portions of intestine were chiefly filled by air: there was in some places thin feculent mat- ter, but in small quantity; and no consistent feces could be found in any part of it. SECTION II. ILEUS FATAL WITH PREVIOUS DISEASE OF SUCH A NATURE, THAT IT SEEMED TO ACT BY DERANGING THE MUSCU- LAR POWER WITHOUT MECHANICAL OBSTRUCTION. •§> J.—Old adhesion of the intestine of small extent. Case XXX.—A gentleman, aged 17, had been for a con- 104 ILEUS. siderable time liable to attacks of vomiting, accompanied by a very constipated state of the bowels; but, in the intervals, he enjoyed good health. On the 26th July, 1822, he had vomit- ing, with pain in the left side of the abdomen; pulse 100; bowels open. He was bled by Mr. Newbigging with relief; and on the 27th and 28th, he was free from complaint,—his bowels open, and his pulse natural. On the evening of the 29th, he was seized with vomiting and pain of the abdomen,— pulse natural, bowels confined. (30th.) Vomiting of almost everything that was taken; occasional attacks of pain in the abdomen ; pulse natural; bowels confined. I saw him on the morning of the 31st. His face was then cadaverous, and ex- hausted,—body cold ; pulse extremely feeble; severe pain in the abdomen, increased by pressure ; urgent vomiting; no stool. He died at four in the afternoon. Inspection.—The small intestines were uniformly distended, and had a blush of redness. From the caput coli, the extrem- ity of the ileum took a turn downwards into the pelvis, and ad- hered to the parietes of the pelvis by an attachment of old stand- ing for several inches, without any contraction of its area. The ileum beyond this part to the extent of from 20 to 24 inches, was highly inflamed and gangrenous, with extensive recent ad- hesions. Case XXXI.—A gentleman, aged 24, had been for several years liable to attacks of pain in the abdomen, affecting chiefly the right side. They usually continued for several hours; sometimes they recurred every evening for weeks together; and sometimes he was for weeks or months perfectly free from them. One of his longest intervals was ascribed to taking daily a small dose of Epsom salt. On the 11th of June, 1818, he was seized with violent pain across the lower part of the abdomen, which was drawn into balls,—pulse 60; no vomiting. He was seen by Mr. White, who gave him an opiate and a purgative, with relief, and his bowels were freely moved. On the 12th, he was free from .complaint; and on the 13th, he walked out, but, at night, the pain returned with violence ; pulse 60. At four in the morning of the 14th, the pain continuing unabated, and his pulse having risen, he was bled, and his bowels were moved by injections; at nine, he was found pale, cold, and exhausted; belly tympanitic, and the pain continuing severe. He died at two in the afternoon. I saw him only two hours before death. ADHESION OF PARTS CONCERNED IN HERNIA. 106 Inspection.—The small intestine was greatly distended, and, on many places, especially on the ileum, there were inflamed porhons with exudation of false membrane, and other parts of a dark color, approaching to gangrene. The right side of the colon was singularly turned upwards upon itself, so that the surface of the caput coecum was in contact with the surface of the ascending colon immediately above it, and was attached to it, for about two inches, by a very firm adhesion of old standing. The parts concerned in it, did not appear to be thickened, and the colon and caput coecum were in other respects quite heal- thy. <§> //.—Old adhesion of the parts concerned in a hernia. Case XXXII.—A man, aged 63, had been for 40 years af- fected with double inguinal hernia, easily reducible; and he was liable to violent paroxysms of pain in the abdomen, during which he said the hernias was generally forced out. In Novem- ber, 1812, he suffered one of these attacks, more severe and longer continued than usual. During this attack, the hernias had protruded frequently, but 1 e always reduced them with ease, till the morning of the 29th, when he failed. They were easily reduced by a gentleman who then saw him, but, at night, when I saw him, they had again protruded; they were then also easily reduced, but protruded again almost immediately, though he was lying on his back ; he had some vomiting and violent pain in the abdomen, which was hard and tender; pulse 120, feeble, and irregular; features collapsed. The bowels had been moved by injections. He died at night. Inspection.—Both herniae were completely reduced, and without any adhesion to the sacs, the mouths of which were large and free. The sacs were thickened, and the inner sur- face of that on the left siole was inflamed and sloughy. The small intestine, down to the middle of the ileum, was greatly distended, and in many places inflamed and gangrenous. The disease stopped at the part of the ileum, which had formed the hernia of the right side ; the surfaces of this portion, where they had been in contact in the hernia, were firmly attached to each other, by an old adhesion about three inches in extent. The coats of the intestine at this place appeared slightly thickened, but scarcely produced any sensible diminution of its area. 14 106 ^ ILEU9, ^ Ul_A slender band of adhesion betwixt two contiguous portions of intestine. Case XXXIII.—A boy, aged 8, had frequent vomiting and obstinate costiveness ; belly swelled and tympanitic; counte- nance exhausted, pulse frequent and feeble. He had been ill 10 or 12 days, during which the complaint had resisted every remedy ; and he died in two days more. Inspection.—The small intestine was distended to the great- est degree, down to a point on the ileum, where the following cause of the disease was discovered. Betwixt two turns of in- testine, there was a narrow band of adhesion, rather more than an inch in length. It was evidently of long standing, and, while the parts - had remained contiguous, had produced no effect; but, by some relative change of situation of the parts, another turn of intestine had insinuated itself betwixt the two adhering* portions. This portion, however, was healthy. The origin of the disease seemed to be, the band of adhesion being thus put upon the stretch, so that the peristaltic motion had been inter- rupted : for at the lower attachment of the band, the intestine was drawn aside into puckers, and, precisely at this point, the distention ceased, and the canal became white, collapsed, and empty. At this part, however, there was no actual obstruction, and the coats of the intestine were perfectly healthy, except a circumscribed redness on its inner surface, at the point corres- ponding to the attachment of the band of adhesion. On the distended portion of intestine, there was a slight appearance of superficial inflammation, but.it was of small extent, and appear- ed to be quite recent. $ IV.—Singular twisting of the sigmoid flexure upon itself. Case XXXIV.—A man, aged 60, (23 April, 1815,) had been ill for a week, with the usual symptoms of ileus, which had resisted all the ordinary remedies ; he was now much ex- hausted ; and his belly was enlarged and tympanitic, with fre- quent vomiting. He lived in great distress till the 28th, and the swelling of the abdomen progressively increased, until it resembled the abdomen of a woman at the most advanced pe- riod of pregnancy; yet to the last he could bear pressure upon every part of it; his pulse varied from 108 to 116. Inspection.—On opening the abdomen, a viscus came into view, which at first appeared to be the stomach enlarged to WITH TWISTING OF SIGMOID FLEXURE. 107 three or four times its natural size. On more accurate exam- ination, however, this turned out to be the sigmoid flexure of the colon, in such a state of distention that it rose up into the region of the stomach, and filled half the abdomen. The stomach was contracted and healthy. The small intestine was healthy at the upper part; lower down, it became dis- tended and of a dark color; and, at the lowest part, it was much distended, with some spots of gangrene. The colon was greatly distended, being in some places not less than five or six inches in diameter; and the sigmoid flexure was also enormously enlarged in the manner already mentioned, and of a dark livid color; it contained only air and thin feces. The rectum was collapsed and healthy. The following appeared to be the cause of this remarkable state of disease. The sigmoid flexure was found to have taken a singular turn upon itself, so that the rectum lay to the left, in contact with the descending colon ; and the ascending portion of the sigmoid flexure passed in front of this portion, and lay on the right. In consequence of this transposition, the rectum, as it descended, passed behind the lower curve of the sigmoid flexure, where it takes the first turn from the descending colon ; and the rectum itself at this part received a twist, as if half round. Exactly at the point where this twist had taken place, the distention and dark color of the diseased intestine terminated abruptly, and the remain- der of the gut became white and collapsed. At this point, however, there was no mechanical obstruction, for the part was quite pervious, and, excepting the slight twist, perfectly healthy. In this singular case also, I had an opportunity of ascertain- ing the state of the part during life. For, on the 25th, three days before the man's death, having exhausted all the usual means, I was induced to examine the rectum with a large ivory- headed probang; when I found, at a certain depth, which was afterwards seen to correspond with the point where the rectum was twisted, a very slight obstruction to the passage of the in- strument, which, however, passed with very little difficulty, and was withdrawn without any. A piece of the intestine of an animal, tied at the end, was now carried up beyond this point, and filled, by forcibly injecting water into it. This was re- tained for some time in the distended state, and then slowly withdrawn; but no discharge followed, though, as I have al- ready stated, the distended intestine contained only air and 'fluid feces. 108 9 ILEUS. § V.__Ligamentous band confining a portion of intestine to the mouth of a hernial sac. Case XXXV.—A man, aged 53, May, 1814, was affected with vomiting and uneasiness in the bowels, which seized him in the following manner. The attack commenced with a feel- ing of commotion,, or, as he termed it, ' a working,' which be- gan at the lower part of the belly, towards the left side; it moved gradually upwards, till it reached the stomach, and then he vomited almost everything he had taken since the last at- tack. He was affected in this manner, at uncertain intervals, several times a-day, and the complaint had continued about a fortnight. He had been for fifteen years affected with a small hernia of the left side, which often came down, but was easily reduced. He had never used a truss until a few weeks before I saw him. From that time his hernia had never appeared, but very soon after he applied the truss, the above mentioned complaint began. There was no fixed pain in the belly ; his pulse was natural; his bowels were confined, but motions were procured by medicine. For a month after I saw him first, he continued to attend to his work. He was then confined to his house, and soon after to bed, with increasing debility and emaciation; and he had frequently violent paroxysms of pain in the abdomen. The other symptoms continued as before. His hernia never appeared; the pulse was natural; evacuation from the bowels was procured by medicine. He died of gradu- al exhaustion, about ten weeks from the commencement of the vomiting. Inspection.—The hernia was found to have been femoral; a portion of the sigmoid flexure of the colon adhered to the mouth of the sac, and a fine ligamentous band, connected by both its extremities to the mouth of the sac, surrounded the intestine at this spot, but without producing any diminution of its area ; and the coats of the intestine were healthy. There was intus-sus- ceptio in two places of the small intestine ; and the lower part of the ileum was inflamed. The colon was collapsed ; the py- lorus was hard, and a-little thickened ; and the inner surface of the stomach at the pyloric extremity was considerably eroded. ILEUS. 109 SECTION III. 1LEU* WITH MECHANICAL OBSTRUCTION. OR OTHER OR- GANIC CHANGES IN THE bTKU'J 1MJRE OF THE PARTS. <§> I.—Old disease of the intestine connected with hernia and artificial anus. Case XXXVI.—A lady, aged about 60, had twenty-seven years before her death suffered from strangulated hernia, which terminated in artificial anus in the right groin. This continued open for very considerable time, and then gradually closed. Ten years after this, she had another attack, which was reduc- ed without operation ; but, from this time, she had been liable to attacks of pain in the abdomen, accompanied by obstruction of the bowels. It was in one of these attacks, more violent than usual, and which had not yielded to the usual remedies, that I saw her along with Mr. Young on the 12th March, 1827. There were then severe pain and tension of the abdomen, ur- gent vomiting and obstinate costiveness; the pulse little af- fected. In the right groin the cicatrix left by the artifical anus was very obvious; a small puffy tumor protruded from beneath the crural arch, which could be reduced without any difficulty ; and the aperture felt quite free. This severe case having resisted every remedy for four days, and the patient's stiength beginning to give way, it was deter- mined, in consultation with Dr. BaUingall, to attempt her relief by an incision in the seat of the cicatrix. This was accordingly made by Dr. BaUingall in the evening of the 15th. The inci- sion laid open an old hernial sac, which adhered intimately to the surrounding parts, and a small quantity of serous fluid was discharged from it. Towards the outer side of the sac, there lay a substance scarcely exceeding a third of an inch in diame- ter, descending from beneath the crural arch, and attached closely by its extremity to the bottom of the sac. It was entirely without strangulation—the passage around it beneath the arch being entirely free on all sides. This body, on farther exami- nation, was found to be a small finger-like process of the intes- tine, and had evidently formed the communication betwixt the intestine and the artificial anus,—the extremity of it being closely attached to the cicatrix. It had been accidentally opened in making the first incision, and was afterwards more freely laid open ; and the finger introduced by it, could be freely carried into the intestine, in every direction, without any feeling of ob- 110 ILEUS. struction. No relief followed the operation: the symptoms continued unabated, with stercoraceous vomiting; and the pa- tient died on the sixteenth—eighteen hours after the incision. No discharge had taken place from the opening during all this period. Inspection.—The portion of intestine laid open in the ope- ration was found to be in the lower part of the ileum; and a small process, or appendix, went off from one side of the intes- tine at the part, and descended into the hernial sac. The coats of the intestine were somewhat thickened, both above and be- low this spot, but there was very little sensible diminution of its area. Above the diseased portion, the intestine was greatly distended, without any remarkable change of color, or structure. It contained only air and liquid feces ; and no obstacle ap- peared to the free discharge of these by the orifice in the groin, for the feculent matter began to flow freely during the dissec- tion. § II.—Internal hernia. Case XXXVII.—A gentlemen, aged 25, on 8th August, 1821, was seized with pain in the abdomen, and other symptoms of ileus, for which he was treated by Dr. Macaulay in the most ju- dicious and active manner, but without relief. I saw him on the 10th ; his pulse was then 96, and weak, and his counte- nance exhausted. The pain had subsided ; there was no tume- faction of the abdomen, and he bore pressure over every part of it; but there had been no stool. On the 11th and 12th there was no change, except some very slight evacuations by injections. On the 13th, the pain returned with great violence in the abdomen, with vomiting and rapid failure of strength, and he died in the night. Inspection.—The whole tract of the small intestine was great- ly distended, and there was superficial inflammation in many places. About three inches from the caput coli, a turn of the ileum about three inches in extent was strangulated and gangre- nous ; and the strangulation was produced by a firm ligamen- tous band, which came down from the omentum, and was firm- ly attached to the parts about the brim of the pelvis. t iCa?Si oXX-VLIILrrA gir1' aged 17' was seized> on ^e 5th of July 1818, with violent pain and tenderness of the abdomen, vomiting and obstinate costiveness. Various remedies were em- INTUS-SUSCEPTIO. Ill ployed for four days without relief. I saw her on the 9th ; the abdomen was then enormously enlarged, tense, and tender; there had been no evacuation of the bowels ; the pulse was fee- ble and rapid ; and she died at night. Inspection.—The small intestine was much distended and in- flamed ; and in several places it had burst, and discharged thin feculent matter into the cavity of the peritoneum. At the root of the mesentery, on the right side, and on a line with the head of the colon, there was a mass of diseased glands the size of a large egg. To this mass the appendix vermiformis adhered very firmly by its apex, and, as it stretched across betwixt this tumor and the caput coli, it left beneath it a space which ad- mitted three fingers. In this space, a turn of intestine, six inches in length, was strangulated and gangrenous. Case XXXIX.—A man, aged 28, was seized with the symp- toms of Ileus in the usual form, on the 15th August, 1815, and died on the 18th. Inspection.—There was a hard glandular mass of considera- ble size formed in the mesentery. To this mass several turns of intestine had contracted adhesions of long standing, and the calibre of the intestine, at several of these points, was very much contracted. At one place, a portion of intestine ad- hered to the mass by two contiguous points, leaving betwixt them a space which admitted a finger; and, in this space, a small portion of a contiguous turn of intestine was strangulated. The parts above were distended and gangrenous. About two years before his death, this man had suffered much, for some months, from deep-seated pain in the abdomen; but he had got well, and from that time had enjoyed tolerable liealth, except two attacks of pain in the abdomen and vomiting, which were of short duration; the second was about a fortnight before his death, and was relieved by a dose of castor oil. <§> HI.—Intus-susceptio. Case XL.—A woman, aged 32, (9th November, 1818) while sitting dressing her child, was suddenly seized with vom- iting, and pain at the stomach, which soon after moved down- wards, and fixed with intense severity in the region of the head of the colon ; the whole abdomen then became painful and tender. (10th.) Urgent vomiting, violent pain over the whole abdomen, with frequent paroxysms of aggravation, which pro- 112 ILEUS, duced screaming;—abdomen tender; pulse 120, small and feeble ; countenance exhausted. She lived in extreme distress, without any particular change in the symptoms, for three days more, and died on the 13th. Inspection.—The small intestine was greatly distended. About three inches from the lower extremity of the ileum, there began an inversion of the intestine to such an extent, that more than eighteen inches of the ileum had passed into the cavity of the caput coli. The inverted parts were inflamed, and extensively gangrenous, some portions being reduced to the state of a soft pulp. The colon was healthy. Case XLI.—A young man, aged 19, awoke in the night of 23d October, 1819, complaining of violent pain in the abdo- men, with urgent vomiting. Pulse at first natural, but in the course of the day became frequent—pain little increased by pressure. All the usual remedies were employed without relief. I saw him on the 25th; pulse then 120, and feeble; urgent vomiting; belly not tumid, and little or no pain on pressure ; no stool; features collapsed. He died in the night. Inspection.—The small intestine was considerably distended, with inflamed portions and spots of gangrene. Near the lower end of the ileum, there was an intus-susceptio, in which the included portion, about eight inches in extent, was very soft and gangrenous. Below this, there was in the cavity, of the ileum, a considerable quantity of coagulated blood. Case XLII.—A boy, aged 2 years and 5 months, (7th May, 1812) had vomiting, pain in the lower part of the belly, and tenesmus, by which he passed small quantities of bloody mu- cus, and some pure blood. Pulse very frequent; abdomen to the touch, natural; much restlessness; countenance depressed and anxious. On the 8th, while he was straining at stool, a tumor of a dark bloody color protruded from the anus, to the bulk of an egg. It was easily reduced, but, on examination, was distinctly ascertained to be inverted intestine; and a pro- bang, being introduced, passed to a great depth by its side, without reaching the commencement of the inversion. The child died on the following morning. Inspection.—A most remarkable inversion of the intestine was discovered, which began at the middle of the arch of the colon; and the parts concerned in it, including the remainder of the colon and the corresponding portion of the ileum, mea- sured thirty-eight inches. The part that had protruded at the anus was the inverted caput coli. The inverted portion of the FROM GALL STONE. 113 colon was of a dark livid color, very soft, and, in some places, thickened. The portion of the ileum included within this was tolerably healthy. Besides the mesentery connected with the inverted intestine, a portion of omentum was included. I have seen another case exactly resembling this, except in the extent of the inversion, which began at the lower part of the colon. The patient was a boy of about 4 years of age, and he survived five or six days. Case XLI1L—A child, aged 8 months, (12th June, 1826) lay with an expression of much exhaustion, and occasionally seemed in a state of syncope; frequent vomiting; abdomen soft, free from tension, and without any appearance of tender- ness ; but no stool except small quantities of bloody mucus. Ill three days ; continued through the day without any change in the symptoms, and died in the night. Inspection.—A portion of the ileum, more than twelve inches in extent, was inverted, and firmly impacted within the caput coli; some inflammation had commenced in the parts above. Case XLIV.—A child, aged 6 months, had been ill for some days with diarrhoea, with frequent green stools. 28th July, 1826, was seized with screaming, and screamed violently for several hours ; had also frequent vomiting. (29.) Some vom- iting, but not urgent; febrile oppression and scanty discharges of bloody mucus from the bowels. (30th.) Much oppression; abdomen soft, but a deep-seated, defined fullness was felt in the left side ; no vomiting; a few scanty stools of reddish mucus, without feces. Various purgatives had been given without ef- fect, and injections could not be made to pass up. (31st.) No vomiting; no distention of the abdomen; increasing exhaus- tion ; evacuations from the bowels the same as yesterday; died at night. Inspection.—Extensive intus-susceptio ; the inversion began at the middle of the arch of the colon; and the remainder of the. colon and the corresponding extent of the ileum, were in- cluded in the inversion, and extended as low as the sigmoid flexure of the colon. The included parts were very dark color- ed, turgid, and in some places ulcerated. § IV.—Ileus from a gall stone. Case XLV.—A man, aged 45, had been repeatedly affected with violent paroxysms of pain, followed by jaundice, which had 15 114 ILEUS. been supposed to indicate the passage of gall stones. On 3d June, 1822, he was seized with one of those paroxysms in the usual manner, and the pain continued in great violence through the whole day, accompanied by vomiting. On the 4th, the vio- lent pain in the region of the gall ducts had subsided ; but he now complained of more general pain over the abdomen ; his pulse was becoming frequent, and his bowels had not been moved. On the 5th, the symptoms were those of complete ile- us, and he died in the night. I had seen him only late in the evening. Inspection.—The upper half of the small intestine was dis- tended and inflamed, with considerable exudation. The lower half was collapsed, empty, and of a healthy appearance. At the place where the distention ceased, there was found a large biliary calculus, four inches in its larger circumference, and three and a half in its smaller. The common duct was enlarged, so as easily to admit a finger. The gall bladder was in a state of inflammation, and was softened and partially disorganized. § V.—Contraction of the calibre of the^intestine. Case XLVI.—A man, aged 70, had complained for several weeks of a deep-seated pain referable to a defined spot at the lower part of the abdomen ; but it was not so severe as to pre- vent him from following his usual employments. On the 27th July, 1815, he was seized with symptoms of ileus, and died on the 31st. Inspection.—The whole of the small intestine and the colon were in a state of great and uniform distention, and of a dark color. The distention stopped at the second turn of the sig- moid flexure, before it turns down to terminate in the rectum. Here the intestine was, for about an inch and a half, very much thickened in its coats, and its calibre was so diminished as scarcely to admit the point of the little finger. The inner sur- face of this portion was covered with red fungous excrescences, like grandulations. Much feculent matter was accumulated in the parts above. Case XLVII.—A woman, aged 60, had complained for some time of frequent uneasiness in her bowels, with much flatulent distention. (27th August, 1817.) The uneasiness in the bow- els was increased ; no stool for four days. From this time she resisted every remedy, but the symptoms were not violent; CONTRACTION OF THE INTESTINES. 115 there was occasional griping, but no fixed pain; no fever; no tenderness ; and little vomiting; but the bowels did not yield, and the belly became gradually more and more distended. She died exhausted on the 4th September. Inspection.—The whole tract of the intestinal canal was pro- digiously distended, and there was in several places recent in- flammation, with exudation of false membrane. The disease extended to the rectum, about four inches from the anus, where the canal was so contracted as scarcely to admit the point of a very small finger. Behind this spot, there was a large mass of diseased glands, and the contraction was occasioned by a firm flat substance, which crossed the intestine in front, and was con- nected on both sides with this mass. When this substance was cut through, the intestine was set at liberty, and its coats were healthy. Case XLVIII.—A woman, aged 63, had enjoyed tolerable health till within three months of her death. She then had vomiting and costiveness for a week, and was relieved by pur- gatives. After this, she complained of nausea, without vomit- ing, and without pain; the abdomen was at first tumid, but afterwards subsided. After a month, she was confined to bed, with constant nausea and an obstinate state of the bowels, and she had frequent attacks of vomiting, which sometimes contin- ued for several days; in the intervals, she complained only of nausea and want of appetite ; purgatives were vomited, but the bowels were kept open by injections. She died, gradually ex- hausted, about three months from the commencement of the disease. Inspection.—There was great thickening and induration of the coats of the ileum at its termination in the colon, and the opening was so narrowed that it only admitted the point of the little finger. The ileum was distended and dark colored. Case XLIX.—A girl, aged 14, previously enjoying excellent health, was seized with symptoms of ileus on the 2d April, 1828. She was treated in the' most judicious manner by Dr. Ross, but without relief, and I saw Jier along with him on the 3d. The pulse was then rapid and feeble ; countenance anx- ious and exhausted ; abdomen distended, tympanitic, and ten- der ; no stool except small discharges of white mucus; fre- quent vomiting. She died on the 5th. Inspection.—The whole tract of the small intestine was in the highest state of distention, and of a livid color, with some exudation of false membrane. This state terminated abruptly 116 STRICTURE OF THE COLON. at about ten inches from the lower extremity of the ileum, and the remainder of the ileum was of a healthy color, but appeared unusually thick, firm, fleshy, and of a tortuous figure. The ca- nal of the intestine, through this portion, was found to be nar- row, tortuous, or,folded, so as to be traced with difficulty. On farther examination it was discovered that this singular mass was formed by numerous small terms of the intestine adhering to each other in a very firm manner; and the outer surface of the mass was so covered over by a new membrane, as to make its external appearance smooth and uniform. When this mem- brane, was removed, and the adhesions were separated, which was done with difficulty, the coats of the intestine appeared to be quite healthy. The disease was evidently of very old stand- ing, but the patient had never been known to complain of any uneasiness in the bowels till the fatal attack. § VI.—Remarkable stricture of the arch of the colon. Case L.—A man, aged 24, had an attack of cholera about a year before his death, and from that time was liable to uneasi- ness in his bowels, with costiveness. After some time, he had great enlargement of the abdomen, which however subsided after some weeks; and the only symptoms then were, progres- sive loss of strength and most obstinate costiveness. When 1 saw him, a few weeks before his death, he was much wasted, had a very small pulse, his belly was tense and a little tender, his bowels were obstinately costive, and the strongest medicines and injections often failed in producing the smallest evacuation. He had occasional vomiting, but it was not urgent; he died, gradually exhausted, without much suffering ; his abdomen had been tense, but not remarkably distended. Inspection.—In the cen'ro of the arch of the colon, there was a remarkable stricture, which only admitted the point of a very small finger from the Left side. On the right side, the opening was covered across its centre by a flap apparently com- posed of fibres from the mucous membrane, which were attach- ed at the upper and lower parts of the opening, and left only a lateral passage on each side of it. The left side of the colon, from the stricture downwards, was completely collapsed into a cord not larger than a finger. From the stricture, the right cide became immediately distended to upwards of twelve inches in circumference; it continued of this size to the caput coecum and the whole was completely impacted with firm consistent STRICTURE OF THE COLON. 117 feces. A great part of the small intestine was also distended with consistent feces. § VII.—Stricture of the sigmoid flexuremqf the colon. The following case shows the disease taking place in the same manner as in the preceding example, viz. by supervening on an acute affection of the mucous membrane ; but the subse- quent course of the symptoms was very different. Case LI.—A gentleman, aged 20, had been long in rather del- icate health, having suffered considerably from pectoral com- plaints, and from scrofulous sores. In December, 1828, he had an attack of an inflammatory character in his bowels, accompa- nied by dysenteric stools, for which he was actively treated by Dr. BaUingall. The urgency of the symptoms subsided in eight or ten days, but he continued from this time in a very deranged state of health. He complained of a constant uneasiness over the abdomen, which he referred chiefly to the lower part, im- mediately above the pubis. He attempted to relieve it by the frequent use of small doses of laxatives, which operated readily, but the motions were in general scanty, and occasionally he had frequent calls with mucous discharges. He had an un- healthy look, with a bad appetite, debility, gradual emaciation, and considerable urinary irritation ; but when I saw him with Dr. BaUingall in April, 1829, the abdomen was free from dis- tention, and no organic disease could be discovered. His bowels at that time were managed with difficulty, being some- times confined, and sometimes rather irritated, with frequent slimy discharges. He continued without any change in the symptoms, except progressive wasting, till about the 26th of May, when suddenly his bowels became completely obstructed, and all the usual means failed in procuring the smallest relief. The abdomen now became distended, tense, and timpanitic. He survived seven days in this state of complete obstruction, but with very little vomiting; and died gradually exhausted on the 3d of June. Inspection.—The peritoneal cavity was distended with gas, and also contained an immense quantity of fluid feces. On the surface of the intestines there was a tinge of recent peritonitis. The small intestines were moderately distended ; the colon ap- peared to have been in a state of extreme distention ; but it had burst at the caput coli by an irregular opening, and had fallen together without contraction. At the bend of the sig- 118 ILEIS. moid flexure next the rectum, the intestine formed a hard mass about two inches in length, and the calibre of the canal, as it passed through this part, was contracted to a space which only transmitted a full-sized catheter. The contraction was occa- sioned by a uniform thickening of the parietes at the part; they were of scirrhous hardness, and the internal surface had an ash-color and an irregular tubercular aspect. The portion thus effected was about two inches in extent, and the intestine im- mediately above and below was entirely healthy. In the following case, for which I am indebted to Dr. Beilby, the progress of the symptoms was different. Case LII.—A lady, aged 63, had been liable for several years 1,o a confined and flatulent state of her bowels. In June, 1829, she had an attack of violent pain of the abdomen with hiccup, which continued for several days. In July, she had diarrhoea; and this was succeeded by another attack of violent pain, which was followed by several evacuations, consisting chiefly of blood. From this time the bowels were very irregu- lar, being sometimes confined and sometimes loose, until August, when, after a severe attack of diarrhoea which continued several days, she was seized with severe pain, followed by tumefaction of the abdomen, with a small rapid pulse, and great failure of strength. The pain now recurred in paroxysms, with intense severity; and there was occasional vomiting. The bowels, which at first were moved with difficulty, after some time be- came entirely obstructed. She died gradually exhausted, about three weeks from the commencement of this attack, and a week from the time whem the total obstruction of bowels took place. Inspection.—The intestines were in a state of extreme dis- tention, especially the colon, which was enormously distended, from the caput coli to the sigmoid flexure. It then became ab- ruptly contracted, and at this place a stricture was found, by which the canal of the intestine was so contracted as scarcely to admit the point of the blow-pipe. The part was of nearly cartilaginous hardness, and was covered by irregular scirrhous indurations. The intestine. below the stricture was collapsed and healthy. APPENDIX TO THE PATHOLOGY OF ILEUS. The two following cases though not immediately connected - with the subject of the preceding section, are given in the form EFFECTS OF GALVANISM. 119 of appendix, as they seem to illustrate points in the pathology of illeus. § I.—General distention and lividity of the intestinal canal, rapidly fatal. Case LIII.—A man, aged 40, had undergone an operation for fistula of small extent, which healed favorably ; and he was preparing to return to the country, when in the night preceding 1st September, 1825, he was seized with vomiting. He vom- ited repeatedly through the night, and his bowels were moved moderately. In the morning he was somewhat feverish; he had pain in his bowels, the abdomen was tense, and there was occasional vomiting, but not urgent. He took laxative medicine, which produced several dark watery evacuations, without relief; and in the evening he was becoming exhausted, with a rapid pulse. I saw him on the morning of the 2d. He was then ex- tremely exhausted ; perspiration standing in drops on his fore- head ; extremities cold ; pulse 160,'and feeble ; abdomen much distended and tympanitic ; it was somewhat pained when pres- sed, but not acutely tender ; some vomiting continued ; bowels moved several times ; stools dark, watery, and scanty ; every attempt was made to rally him without effect; he died early in the afternoon. Inspection.—The whole tract of the bowels, to the very ex- tremity of the rectum, presented one continued state of great tympanitic distention; in some places they were tinged of a deep red color ; in others, of a livid or leaden color, but without any change in their structure. There was a slight appearance of inflammation on the omentum at the lower part, and in the cavity of the pelvis there were a few ounces of a yellowish san- ious fluid, slightly puriform. <§, //.__Effects of galvanism on distended intestine. Case LIV.—A gentleman, aged 50, for whose case I am in- debted to Mr. Clarkson of Selkirk, was affected with vomiting and pain in the right side of the abdomen, which was hard, distended, and acutely tender to the touch. His bowels were obstinately costive, and resisted the action of the strongest pur- gatives, except when assisted by repeated and strong injections. 120 GENERAL CONCLUSIONS. Treatment upon this plan had been continued for a fortnight, with very slight effect, when Mr. Clarkson determined upon try- in°- the application of galvanism to the part of the abdomen which was hard and tense. The application was almost imme- diately followed J>y copious evacuation from his bowels, and it was continued daily for about ten days with the same uniform result. After the application had been made for a few minutes, there usually commenced a commotion of the bowels, with a rumbling noise ; and this was soon followed by a copious evac- uation. The evacuation sometimes did not take place till after the galvanism had been continued for the usual time, which was about twenty minutes ; but, at other times, the call became so urgent during the application, as to oblige him to suspend it, and allow the patient to retire. The tension and tenderness of the right side of the abdomen rapidly subsided, and in a few days every feeling of uneasiness was gone. At first he dischar- ged much black hardened feces, but they became gradually more natural, and at the end of ten days the galvanism was discon- tinued. Farther observations on this curious subject, and on some re- markable affections of the bowels referable to the head of Tym- panites, will be found in a subsequent part of our inquiry; namely, in the appendix to the Pathology of the Intestinal Ca- nal, Section III. SECTION IV. PATHOLOGICAL AND PRACTICAL INDUCTIONS FROM THE PRECEDING FACTS.' From the cases now detailed, illustrative of the various modi- fications of ileus, some principles appear to be deducible, of much pathological interest and practical importance. At the earliest period at which we have an opportunity of seeing the condition of the parts in a fatal case of ileus, it seems to consist in a state of simple' distention without any visible change in the structure of the part.—(Case XXV.) At a period a little more advanced, we find on the distended part a tinge of vivid redness.—(Case XXVI.) In another state of the disease, the distended part presents a leaden or livid color, without any sensible change of texture,—(Case XXVII) ; and, at a period still more advanced, this seems to pass into gangrene, (Case GENERAL CONCLUSIONS. 121 XXV III.) It is probable that these appearances are chiefly seated in the muscular coat, for we see them, in the cases refer- red to, pass through all these stages without any appearance indicating peritonitis. But it also appears that the affection, in its more advanced stage, may be combined with peritonitis, as in Case XXIX, in which we find the gangrene combined with exudation of false membrane. The next interesting point in this investigation is to mark the condition of the muscular action of the bowels, during the progress of these morbid changes. At the more advanced period of them, it is evident that the muscular action is entirely des- troyed ; for we find the part which has been distended fallen flat when it is emptied, and presenting^ broad* surface like an empty bag, without any tendency to contraction, (Case XXVIII.) This case, indeed, shows the disease in a state of perfect gan- grene ; but it appears that the same loss of muscular power may take place at a much earlier period, and in connection with a much lower state of disease. This appears from the very remarkable case, (Case XXXVI.) in which the patient Uved for eighteen hours, with a free external opening directly communi- cating with the distended intestine, but without any discharge taking place, though the part contained only air and fluid feces. In this case the intestine, for a considerable space above the opening, must have been entirely deprived of its muscular action, and yet, upon examination after death, the part presented only a uniform distention, without any remarkable change either in color or texture. A similar condition of the parts must have existed in Case XXXIV, in which the obstruction was within reach by the rectum, and was repeatedly dilated by various mechanical means, without any discharge following. A remark- able illustration of these principles is derived from Case LIV, in which an obstruction, which, had resisted the most active purgatives, and was accompanied by an evident and painful distention of a part of the bowels, was removed by the repeated application of galvanism to the part; each application being immediately followed by a copious evacuation. 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 16 122 ILEUS. a cord ; and there has been supposed to be a difficulty in de- termining 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 dis- tention 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 endeavor to throw any light upon this important pathological question. The following considerations seem to bear upon the inquiry:— 1. The collapsed state, in which it assumes the form of 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 very open 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 assum- ing that the state of uniform contraction of intestine is a state of disease; on the contrary, the facts favor the supposition of this being its healthy condition when it is entirely empty. 2. On the other hand, we learn from various cases, particu- larly from the remarkable case, (Case Lilt,) that a state of uni- form 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 invaria- bly found in a healthy condition at all periods of the disease; the morbid appearances, whether inflammation, lividity, exuda- tion, or gangrene, being almost entirely confined to the dis- tended parts. 4. In Case XXXVI, 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 LIV, the cause, which uniformly acted in so sin- gular a manner, must be supposed to have acted upon a part only whose action was impaired, not upon one which was spas- modically contracted. 6. In Cases XXX, XXXI, and XXXII, 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 XXXIII, XXXIV, and XLV, in which the disease was distinctly traced to a mechanical cause, this peculiar contraction existed below the seat of the obstruction, GENERAL CONCLUSIONS. 123 but could not be considered as having had any influence in producing the disease. In Case XXXIV also, it is to be re- marked, that the contracted part was repeatedly and freely di- lated during the course of the disease, without any effect in relieving the parts above. Farther, it is to be kept in mind, as already stated, that we often see this peculiar state of contrac- tion, without distention and without any symptoms of ileus; and on the other hand, we find extensive distention with the most severe and rapid ileus, existing without any appearance of the contraction. This important fact will be strikingly illus- trated by the next case to be described, (Case LV.) The ex- tent of the contraction, also, in some of the cases cannot be reconciled with the notion, of spasm. For even if we suppose that a small part of the canal might be spasmodically contract- ed, we cannot imagine a spasm which should affect at once the whole of the colon, and a considerable part of the small intes- tine, as occurred in Case XXVI, and, in a less remarkable de- gree in some other examples. 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 muscu- lar action being unimpaired. On a subject of this nature, it is dangerous to speculate be- yond simple induction from the facts which are before us: but there appear to be certain points connected with the action of the intestinal canal, which may be ventured upon in connection with this inquiry. If we suppose then that a considerable tract of the canal is in a collapsed state, and that a mass of alimen- tary matter is propelled into it by the contraction of the parts above, the series of actions which will take place, will probably be the following: When a portion which we shall call No. 1, is propelling its contents into a portion No. 2, the force exerted must be such, as both to propel these contents, and also to overcome the tonic contraction of No. 2. The portion No. 2 then contracts in its turn, and propels the matter into No. 3; this into No. 4, and so on. Now, for this process, going on in a healthy manner, it is necessary, that each portion shall act in consecutive harmony with the other portions ; but there appear to be several ways in which we may suppose this harmony to be interrupted; (1st.) If the portion No. 1 has contracted and propelled its contents into No. 2, and No. 2 does not contract in its turn, the function of the whole will be to a certain extent interrupted, and the contents will lodge in No. 2, as in an in- 124 ILEUS. animate sac. The parts above continuing to act downwards, one of two results will now take place; either the parts above will be excited to increased contraction, and the matters will be forced through into No. 3, independently of the "action of No. 2, and so the action be continued ; or, new matter being propelled into No. 2, this will be more and more distended, until an interruption of a very formidable nature takes place in the function of the canal. (2d.) If, in the series of actions now referred to, No. 2 contracts in its turn, while some obsta- cle exists to the free dilation of No. 3, it is probable the motion may be so inverted, that the contraction of No/ 2 may dilate No. 1, and that the action may thus be communicated back- wards. Something of this kind seems to have occurred in a striking manner in Case XXXV. In the state of parts here referred to, varieties may occur, which appear to give rise to important differences in the phenomena. The obstruction to the dilation of No. 3 may exist in various degrees ; in a smaller degree, it may not prevent it from acting in harmony with the other parts, when the quantity of contents is small, and only a small degree of dilation is required; but, when there is an in- creased distention of the parts above, either from increase of solid contents, or from some accidental accumulation of flatus, then a greater degree of expansion may be required than No. 3 is capable of, and, in this manner, interruption may take place to the harmonious action of the canal. It is probably, in this manner, that, in connection with slight organic affections of the canal, we find the patient liable to attacks of pain and oth- er concomitant symptoms, which at first occur only at long and uncertain intervals, but at length terminate in fatal ileus. This important modification of the disease is strikingly illustrated by Cases XXX, XXXI, and XXXVI; in the two former of which, it is particularly to be remarked, that there was no mechanical obstruction. In such cases, it is also to be observed, that, though the healthy action is interrupted, a portion of the con- tents may pass through. Tins evidently occurred in the very interesting case, (Case XXXV,) in which evacuation from the bowels was regularly procured, though the action of the canal was uniformly inverted whenever it reached the seat of the disease. In proposing the preceding doctrine respecting the pathology of ileus, I would be understood to refer only to the actual con- dition of the parts in what may be called a fully formed case of the disease. To this extent I think we may consider it as es- tablished by the facts which have been stated, that the leading GENERAL CONCLUSIONS. 125 peculiarity which exists in such cases is, that a certain part of the canal is in a state of over distention, and deprived of, or greatly impaired in, its muscular action. A farther question here arises, viz. respecting the manner in which this condition takes place, and what is the first step in the chain of circum- stances which lead to it. This I admit is a question of consid- erable difficulty, and one, perhaps, which we have not at pres- ent the means of answering in a satisfactory manner, in as far as we can approach the truth in regard to it, the probability seems to be, that the affection which we call ileus, expresses a condition of the canal which may arise in very different ways, and from very different causes. These causes seem to be ref- erable to two classes, viz. primary diminution or destruction of the muscular power of a portion of the canal,—and impedi- ments to its action, the consequence of which is, that a part which is at first healthy, becomes impaired under the effects of this interruption. 1. Primary destruction or diminution of the muscular power of a portion of the intestinal canal seems clearly to take place from the poison of lead; and we can scarcely doubt that the same effect arises from inflammation. Thus the part affected in enteritis becomes distended and evidently deprived of its muscular action without any appearance of obstruction in the parts below. In this case, we ascertain the presence and the seat of the inflammation by the pseudo-membranous deposition from the peritoneal coat; but we have also seen reason to be- lieve, that inflammation may exist in the muscular coat alone, giving rise to disease which does not assume the characters of enteritis, but of a peculiarly severe and rapidly fatal form of ileus. This affection, as we have seen, appears to be fatal by extensive gangrene without membranous deposition, as in Case XXVIII. It seems probable that it may also be fatal at an earlier stage, showing only distention and lividity without actu- al gangrene, as in several of the cases which have been describ- ed. It appears to be in this manner that ileus, or extensive tympanites, supervenes upon inflammatory affections either of the peritoneal or mucous coats. Examples of this will be af- terwards mentioned when we come to treat of peritonitis and in- flammation of the mucous membrane; and there seems every reason to believe that an inflammatory affection of the peritone- um was the-first §tep in the important ajid remarkable example, Case LIII. It is probable that primary diminution of the mus- cular power of a portion of the canal may arise from other causes which elude our observation, or perhaps, which have not been investigated. 126 ILEUS. 2. Interruption to the action of a portion of the canal, giving rise to distention and consequent impaired action of the part above, we see taking place from a variety of causes ; such as hernia, partial contractions of the intestine, adhesions, and other circumstances interfering with its healthy action, which have been exemplified in the cases. A similar effect may probably arise in some instances from accumulations of indurated feces ; and one case has been related to me, in which an attack of ile- us seemed to arise from a large quantity of nuts which the pa- tient had ate, and which had been accumulated into a mass in an undigested state. Under this head I am not disposed to de- ny that there may be, in some cases, an irregular or morbid contraction of a portion of the canal, constituting a state analo- gous to that to which the term spasm has been applied ; and that this may sometimes prove the first step in that chain of de- rangements of the harmonious action of the canal, which leads to an attack of ileus. The doctrine of spasm, however, must be admitted to be in a great measure conjectural; but while I do not deny the existence of it to the extent now stated, my ob- jection is to the vague and indefinite manner in which it has' been applied to the whole phenomena of this interesting class of diseases. In finally comparing the two doctrines of spasm, and loss of action with over distention, two points I think must be conce- ded : (1.) That the former is entirely assumed and gratuitous ; and that no direct proof can be adduced of its actual existence in the intestinal canal, or certainly not in such a degree and such continuance as could possibly explain the phenomena of a protracted case of ileus. In regard to the contracted portions of intestine in the cases, also, it may be argued, that their very existence in that condition in the dead body may itself be con- sidered as a proof, that this was the healthy state of empty in- testine, and not the result of spasm; for we cannot conceive such a spasmodic contraction continuing 24 or 30 hours after death : (2.) That the condition of distention and impaired ac- tion is proved actually to exist, and to exist independently of any obstructions in the parts below. This appears from seve- ral of the cases which have been described. With these remarks I dismiss the speculation, merely point- ing it out as worthy of being investigated by farther observa- tion ; and shall only add the following case, which I have re- ceived from my friend Dr. Duncan. Without deducing from it any general conclusions, I think it will appear that it is entirely inconsistent with the doctrine of spasm, and can only be ex- GENERAL CONCLUSIONS. 127 plained by the supposition of sudden distention and loss of muscular power. Case LV.—A man, aged 60, was admitted into the clinical ward on the 26th June, 1829, affected with deep-seated pain in the abdomen, and constant vomiting; the abdomen was hard and very much distended ; the hypogastric and umbilical regions were painful on pressure ; respiration was quick and laborious; countenance anxious. No evireuation for two days, pulse 80, small and weak. He stated that, on the 22d, while perspiring profusely, he drank two quarts of cold beer; that during the following night he was attacked with severe pain and sudden distention of the abdomen, accompanied with a loud noise in the right hypochondriac region." On the 23d, the symptoms continued unabated, with the addition of vomiting ; and various purgative medicines were given without effect, being almost immediately rejected. On the 24th, enema produced several copious bloody stools. It was repeated on the 25th, when it brought off only blood, without any appearance of feculent matter. From the time of his admission on the 26th, every remedy that his situation admitted of was employed in the most as- siduous and judicious manner, but without relief. On the 27th, his strength was still more exhausted, without any change in his other symptoms, and he died early in the evening. Inspection.—The small intestines were much distended and were filled with a fluid of a yellow color, similar to that which had been vomited. They were externally much injected, with some adhesions. In their substance they were easily torn, giv- ing way even when gently handled. The lower end of the ileum and the caput coli were of a deep red or port wine color. The great intestines contained chiefly gas, and a small quantity of fluid feces, and no appearance was discovered of any contraction or obstruction, except what arose from a slight narrowing of the ileum near the ileo-colic valve. At this place there existed an ulcer, which extended quite round the circumference of its inner surface, and was about an inch in breadth. It had gangrenous edges, and the bottom of it seemed to be bounded only by the peritoneum, the mucous and muscular coats being destroyed. The man had enjoyed perfect health up to the period of this attack. I shall conclude this part of the subject by certain inductions of a practical nature, which appear to arise out of the cases which have been described. 128 ILEUS. I. The most uniform morbid appearance, in fatal cases of ileus, is a greater or less extent of the intestinal canal in a state of great and uniform distention. 2. This distention appears to constitute a morbid condition, which may be fatal without passing into any farther state of disease. 3. The usual progress of the disease, in the fatal cases, is into inflammation and its consequences; and we have seen it fatal, while the inflammation was in various stages of its pro- gress, from a recent tinge of redness to extensive gangrene. 4. There seems to be a great variety in the period at which the inflammation takes place. It appeared to be quite recent in Case XXVI. which was fatal on the 9th day, and in Case XXXIV. which was fatal about the 13th, while in Case XXVIII. it had passed into extensive gangrene as early as the 3d day. 5. Pain increased upon pressure does not appear to be a cer- tain mark of inflammation in the bowels ; for it occurred in Case XXV. in which there was no inflammation ; and, in several of the other cases, it was met with before probably inflammation had commenced. From various observations I am satisfied, that intestine, which has become rapidly distended, is painful upon pressure; it is, however, a kind of pain, which, by atten- tion, can generally be distinguished from the acute tenderness of peritonites. 6. Sudden cessation of the pain, and sinking of the vital pow- ers, are not necessarily indications of internal gangrene ; for we have seen these symptoms existing with recent inflammation; and, in a subsequent part of this inquiry, I shall have occasion to refer to several cases in which they were recovered from. 7. On the other hand, we have seen cases of extensive gan- grene, in which the pain continued violent to the last. 8. The pulse appears to be a very uncertain index of the con- dition of the parts in ileus. In Case XXVI. in which there was considerable inflammation, it was less affected than in Case XXV. in which there was none. In Case XLVII. again, there was neither frequency of pulse, nor tenderness of the abdomen, though there was inflammation with exudation to a very consid- erable extent. Many other important circumstances, with re- gard to the state of the pulse, may be remarked in the cases; one of the most important is in Cases XXVIII.—XXXI. which were fatal, with extensive inflammation and gangrene, within eight or ten hours from the time when the pulse was first ob- served above the natural standard. In others, in which the dis- ease was equally extensive, we find the pulse but slightly affect- ed through the whole course of the disease. GENERAL CONCLUSIONS. 129 9. Ileus does not appear to be necessarily connected with feculent accumulation, or with any condition of the contents of the canal; for we have seen it fatal while these contents were of a natural appearance, almost entirely fluid, and in very small quantity. 10. Ileus does not appear to be necessarily connected with ob- struction in any part of the canal; for we have seen it fatal without obstruction, and we have seen every thing like obstruc- tion entirely removed without relieving the symptoms. 11. We must be cautious in forming a favorable prognosis in ileus, from the appearance of feculent evacuations. For these, we have reason to believe, may occur while the disease is never- theless going on to a fatal termination ; and much feculent mat- ter may lodge in the lower part of the intestine, which is healthy, and may be brought off by injections, while the disease above remains unchanged. 12. Organic disease of great extent may exist in the intesti- nal canal, without sensibly interrupting its functions, until at length, from some cause which eludes our observation, it sud- denly produces fatal ileus. (Cases XXXIX, XLVI, XLVII.) 13. On the other hand, such organic disease may be fatal by gradual exhaustion, without ileus. (Cases XXXV, XLVIII and L.). From a review of the whole subject, it .appears, that there is a remarkable variety in the morbid appearances in those cases which are usually included under the term ileus. We have seen simple distention without any change of structure, we have seen extensive inflammation and gangrene. We have seen, in several instances, the distention apparently taking place at an early period, and gradually increasing through a protracted case, and then fatal with little or no change in the texture of the part; and in others, we have seen at a very early period, and with much less distention, extensive inflammation and gangrene. It would, therefore, appear probable, that, in the cases which as- sume the characters of ileus, there is great diversity in the pri- mary state of the affected parts; that, in some, it consists of simple loss of muscular power, though it may pass into inflam- mation at an advanced period; while in others, it is at an early period connected with inflammation as a part of the primary disease. These cases seem to differ from enteritis in their symptoms, chiefly by the absence of fever; and, in the morbid appearances, by being fatal with simple gangrene, uncombined with the flocculent or pseudo-membranous deposition, which is so prominent a character of enteritis. Now, gangrene in the intestinal canal appears to be chiefly a disease of the muscular 17 130 ILEUS. coat. A state resembling it is indeed observed occasionally in the mucous membrane ; but the cases in which this occurs, are accurately distinguished by their own peculiar symptoms, and they do not affect this part of the inquiry. When, in the cases now under consideration, therefore, we find gangrene uncom- bined with any other morbid appearance, we are perhaps war- ranted to conjecture that the muscular coat has been the princi- pal seat of the inflammation. It seems to constitute a modifica- tion of disease of much practical importance, quite distinct from enteritis, and assuming simply the characters of ileus; but a modification of ileus of the most formidable kind, and very rap- idly fatal. We shall afterwards see reason to believe, that in- flammation may be seated in the peritoneal coat alone, produc- ing a disease which may be fatal without any interruption of the action of the canal; or that it may affect the peritoneal and muscular coats at once, giving rise to the disease which we commonly call enteritis. SECTION V. TREATMENT OF ILEUS. In entering upon the treatment of a case of ileus, the first point to be kept in view is, to make an accurate examination in regard to the existence of hernia; and here two circumstan- ces are to be kept in mind,—1st, That hernia may exist without the patient being aware of it, or making any complaint that would lead to the supposition of its existence,—2d, That the hernia may be so very small as to include only a minute portion from one side of the intestine, and yet be the cause of fatal ileus. 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 Jhe 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 TREATMENT. 131 considerable general uneasiness, but without tenderness, and without much acute suffering. 2. The same symptoms, combined with fixed pain and ten- derness, referred to a defined space on some part of the abdo- men, frequently about the head of the colon. 3. Violent attacks of tormina, occurring in paroxysms, like the strong impulse downwards from the action of a drastic pur- gative,—the action proceeding to a certain point,—there stop- ping and becoming inverted,—followed by vomiting,—the vom- iting often feculent. These forms of disease will be recognized by the practical physician, as constituting affections distinct from each other. In a practical v*iew, 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 prac- tical 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 pur- gatives,—or whether there are not modifications of the disease in which its action rather requires to be moderated. The adap- tation 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 others in which 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 medi- cine, such as aloes combined with hyosciamus. The peculiar and intricate character of the disease appears very remarkably from the fact, familiar to every practical man, and 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 dis- cretion. The other remedies on which reliance is to be placed are chiefly the following. (1.) Blood-letting. We have seen the tendency of ileus to terminate by inflammation ; but, besides this obvious fact, I have given my reasons for believing that there is a modification of the disease, depending upon inflammation limited to the mus* 132 ILEUS. cular coat, and therefore not exhibiting the characters of ente- ritis, but simply of ileus, though in a very violent and rapidly fatal form. 'On both these views, therefore, blood-letting is a most important remedy in every case of ileus, except distinctly contra-indicated by the age or habit of the patient; and the fact is familiar to every practical man, that the relief is often so immediate, that there is no time to raise the patient out of bed, or scarcely to tie up the arm, before complete evacuation takes place. (2.) The tobacco injection, as far as my observation extends, is the remedy of most general utility in all forms and stages of ileus. It should be given at first with much caution,—perhaps not more than fifteen grains infused for ten'n.inutes in six ounces of boiling water; after the interval of an hour, if no effect has been produced it may be repeated in the quantity of twenty grains, and so on, until such effects are produced, in slight giddiness and muscular relaxation, as show that its pecu- liar action is taking place upon the system. It may then be repeated at intervals of one or two hours, a great many times, if the case do not speedily yield; and with the precautions now mentioned, I have never seen any unpleasant effect from the free use of this powerful remedy. If, while the tobacco injection is used in this manner, mild purgatives, such as aloes and hyosciamus, are repeated in full doses, every hour or two, the treatment is perhaps that which is most generally adapted to the ordinary cases of ileus; with the assistance of one or two bleedings, especially if the patient should be of a full habit, if the pulse should be rising, or if there should be fixed pain or tenderness on any part of the abdomen. (3.) The application of cold ;—I have repeatedly employed the method so often recommended, of raising the patient into a standing posture and dashing cold water about his legs, but I cannot say that I have seen benefit from it. The best effects, however, I think are often produced by the continued applica- tion of cold to the abdomen by cloths wet in vinegar and wa- ter. In tympanitic states of the abdomen, when not accompa- nied by coldness of the surface, and in cases attended with lo- cal circumscribed pain and tenderness, this remedy is often fol- lowed by the most beneficial results. Cold injections have al- so been recommended. Of these I have had less experience, but, for various interesting statements in regard to the effects of cold in this class of diseases, I refer to a paper by Dr. Smith in the 9th volume of the Edinburgh Medical Journal. (4.) Opiates. I have already alluded to a modification of the disease which yields to a full opiate, more readily than to TREATMENT. 133 any other mode of treatment. The case to which this practice is particularly applicable, is perhaps chiefly characterized by the paroxysms of violent tormina. If these are accompanied by frequency of pulse, and fixed pain or tenderness, a full bleed- ing, followed by an opiate, is often a successful mode of treat- ment ; and, when the patient has been brought fully under the influence of these, the bowels will often be moved without any other remedy, or yield to the very mildest means. The tobacco injection, however, is also peculiarly adapted to these cases, and it is, perhaps, in general a safer remedy than opiates. (5.) In the advanced stages of the disease, when the system begins to become exhausted, stimulants must be given freely ; and under the use of these, a case will often give way which had previously resisted the most active treatment. The aloetic wine is a convenient remedy in this stage of the disease, com- bining the stimulating with the mild purgative quality ; and it is often found of great efficacy when given in full doses, of one or two ounces, repeated at the intervals perhaps of an hour. Tincture of aloes may be given in the same manner; and it is a remarkable fact, that, in this state of the system, and even with a tympanitic state of the abdomen, the tobacco injection, if given with sufficient caution, may still be employed with much advantage along with the use of stimulants. Of a recov- ery under these circumstances, I give the following example, which also tends to show the formidable characters which the disease may assume, without having gone on beyond the chance of recovery. Case LVI.—A woman, aged 20, was affected with the usual symptoms of ileus in a very violent form, which, up to the fifth day, resisted all the usual remedies, assisted by general blood- letting. On the sixth day, her pulse, which had been at first natural, had risen to 120 ; the pain continued very violent over the whole abdomen, with urgent vomiting, and there had been no evacuation from the bowels. Farther bleeding was now employed, and various other means, without relief. In the af- ternoon, the pain nearly ceased ; there was collapse of the feat- ures, with coldness of the surface; the pulse 140 and very weak; the vomiting continued ; and she appeared to be nearly moribund. Wine was now given in the quantity of a glass every hour; and, after a few hours, her appearance being rather improved, the tobacco injection was employed, at first in very small quantity, and was repeated several times. It did not in- crease the sinking, but seemed rather to abate both it and the vomiting. On the following day, there was a decided improve- 134 ILEUS. ment, and some scanty evacuation had taken place from the bowels; wine was continued in smaller quantities, and the to- bacco injection was repeated several times with partial but good effect. The vomiting abated, and some Epsom salt was retain- ed, and operated. In the evening she was free from pain and the pulse 96 ; and from this time she continued convalescent. The remedies which I have now mentioned are those of which I have most experience; but various others are to be kept in mind, as being sometimes useful. The warm bath is often beneficial at an early period of the disease, before there are any inflammatory symptoms. Crude mercury, in doses of one or two pounds, I have tried repeatedly, and in some cases it certainly appeared to allay the vomiting ; I have not observed any other effect from it. The forcible injection of a large quantity of fluid, to the amount of six or eight pounds, is said to have been successful in some cases. In the memoirs of the Medical Society of London, vol. ii. some interesting cases are described in which it was used with advantage. Large blisters over the abdomen are likewise extremely beneficial; also the oil of turpentine applied externally or by injection. When the vomiting is very urgent, so as to prevent medicines from re- maining on the stomach, large doses of calomel, of from fifteen to twenty giains, often remain better than any other medicine, and even seem to allay the vomiting. In such cases, also, I have sometimes found benefit from giving powdered aloes, re- peated at short intervals in combination with the oxide of bis- muth. Whatever practice is employed ought to be zealously persevered in, notwithstanding the most unfavorable appear- ances ; for the disease has been known to resist the most active remedies, and yet terminate favorably, as late as the 17th day. PART IT. INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CA- NAL, INCLUDING PERITONITIS AND ENTERI- TIS. In tracing the phenomena .connected with inflammation in the intestinal canal, we cannot fail to take notice of three remarkable varietiet in the symptoms. We find inflammation existing in the canal, and going on to a fatal termination, with a natural or easily regulated state of the bowels,—with insupe- rable obstruction of the bowels,—and with severe and uncon- trollable diarrhoea or dysentery. In the first of these forms of the disease, we find on dissection extensive adhesion of the parts from pseudo-membranous deposition, and frequently some puriform fluid; in the second, we generally observe this ap- pearance combined with gangrene ; in the third, we find ulce- ration, or some other result of inflammation, on the internal surface of the canal, often without any morbid appearance in the external coats. From what we observe of the results of inflammation in the corresponding structures in other parts of the body, we have every reason to believe, that, in the first of . these cases, the inflammation was seated in the peritoneal coat; that, in the second, the muscular coat was also involved in the disease; and that, in the third, it was seated in the mucous membrane. The grounds upon which these distinctions are made, will appear more particularly in the sequel; but it is ne- cessary simply to state them heie, with a view to an arrange- ment of the subject, in dividing the inflammatory affections of the intestinal canal, into three classes, in reference to the three structures which enter into its formation. We shall then, I think, see reason to believe; (1.) that intestinal inflammation may be confined to the peritoneal coat, and that in this case, it may run its course without interrupting the muscular action of the canal; (2.) that the inflammation may affect the peritoneal and muscular coats at once, in which case, we have the symp- toms of peritonitis, combined with obstruction of the bowels, constituting the disease to which we give the name of enteritis ; (3.) that the inflammation may be entirely confined to the mu- 136 INFLAMMATORY AFFECTIONS. cous membrane, producing a train of symptoms altogether dif- ferent from those which occur in the preceding cases, and often running its course to a fatal termination, without any affection of the other coats. We shall see reason farther to believe, that these forms of disease may pass into each other, by spreading of the inflammation from one structure to another; that a case, for example, may begin as simple peritonitis, and may after- wards pass into interitis; and that another may begin with se- vere diarrhoea, or dysentery, and afterwards terminate by in- flammation of the other coats. In treating of ileus, I have alluded to the important fact, that cases of ileus which have not shown any inflammatory symp- toms, or not till a very advanced period, are sometimes fatal by extensive gangrene, without any inflammatory exudation ; and, as gangrene, in such cases, must probably be considered as an affection of the muscular coat, I have proposed a conjecture, that the worst forms of ileus may sometimes depend upon in- flammation confined to that coat. On the other hand, it will be found, that the cases which exhibit the characters common- ly assigned to enteritis, are fatal either by extensive inflamma- tory exudation and adhesion, or by these combined with gan- grene, never by gangrene alone. This is the result of my obser- vation, as it stands at present; if it shall be verified by farther observation, it will give probability to the following conjectures: 1. That inflammation may exist in the intestinal canal, confined to the muscular coat, and marked by symptoms of ileus, without exhibiting the symptoms usually considered as a characteristic of inflammation. It is unnecessary to add, that this is not meant to imply, that such inflammation occurs in all cases of ileus, but only in one modification of the disease, which is characterized by symptoms of ileus, without exhibiting those of enteritis. 2. That in the more acute affections of the bowels, assuming those characters which are usually considered as indicating inflammation, the disease is primarily seated either in the peri- toneal coat alone, or in both the peritoneal and muscular coats at once. In the practical consideration of this important class of dis- eases, I shall consider peritonitis and enteritis in connection, because they are very generally combined, or pass into each other; and I shall then treat separately of the inflammation of the mucous membrane. PERITONITIS, 137 SECTION I. SYMPTOMS OF INTESTINAL INFLAMMATION UNDER THE FORMS OF PERITONITIS AND ENTERITIS. 1. Simple Peritonitis is distinguished by pain in some part of the abdomen, varying very much in its seat, its degree, and its general characters. It in some cases extends nearly over the whole abdomen, and in others, is confined to a particular space, as one side, or frequently, the lower part, immediately above the pubis. It is increased by pressure, and frequently is little complained of except when pressure is applied ; being an acute tenderness of the parts, rather than an actual pain. In other cases, there is acute pain, frequently coming on in paroxysms, which continue for a short time, and then pass off, leaving in the intervals only the acute tenderness ; but this is sometimes in such a degree, that even the weight of the bed clothes is complained of. This form of the disease is very apt to be mis- taken for a spasmodic or flatulent affection, from the remarkable remissions of the more violent pain. The paroxysms appear to be excited chiefly by flatus moving through the bowels, and dis- tending the inflamed part; and the action of a purgative is often followed by a violent aggravation of all the symptoms. The pain is also aggravated by various exertions, such as cough- ing, sneezing,—often by a deep inspiration ; and sometimes by any kind of muscular exertion, so that the patient lies extended upon his back, being afraid of the least motion out of that posi- tion, or even of the action of the abdominal muscles or of the diaphragm. In some cases the pain is apt suddenly to shift its place from one part of the abdomen to another. According to the seat of inflammation, various neighboring organs become affected. When it is in the lower part of the abdomen, there is often a frequent painful desire to pass urine, and an acute pain extending along the urethra; when it is in the neighborhood of the kidneys, the secretion of the urine is often greatly diminished, or nearly suspended; when it is in the upper part of the canal, there is frequently vomiting, and sometimes a peculiar spasmodic action like the belching of wind, which continues without intermission for a considerable time, and is accompanied by acute pain. In many cases, there is violent hiccup, with quick short breathing, probably connected with the disease extending to the diaphragm. The pulse is often little affected, especially in the early stages; it is perhaps from 80 to 90 or 96, but is often scarcely above the natural standard ; 18 138 PERITONITIS. as the disease advances, however, it is apt to rise, and often rises to great .frequency. A leading peculiarity of the affection is, that the bowels are not obstructed, being either natural, or easily moved by mild medicines ; but these evacuations produce no relief; on the contrary, they are generally attended by violent pain, and sometimes, after the disease appears to have been subdued, the operation of a purgative is immediately fol- lowed by a renewal of the symptoms in all their original vio- lence. This affection differs from enteritis in the bowels being natu- ral or easily regulated,—in the pulse being often little affected, —in the pain frequently occurring in paroxysms,—and in the absence of vomiting, except in certain cases already referred to. These peculiarities are chiefly observed in the early stages; as the disease advances, the pain becomes more fixed and perma- nent, the pulse rises, the belly becomes tympanitic, and, at a certain period, obstruction takes place, and the case assumes all the usual characters of enteritis. It may, however, be fatal without this change, the bowels continuing natural, and the pulse from 80 to 90, until a short time before death. At a certain period of the disease, there is a remarkable tendency to a tympanitic state of the abdomen. This is always a symptom to be watched with much anxiety, but is not necessarily a fatal one. It may either be connected with the progress of the in- flammation, destroying the action of the parts; or it may arise merely from the loss of tone, after the inflammation has been subdued. In the former case, it is generally a fatal symptom, but, in the latter, it may be recovered from. Simple peritonitis may be fatal in three days, but frequently it is more protracted, and in some cases after the first activity of the symptoms has been subdued, the disease passes into a chronic form, and is fatal after several weeks or months. On dissection, we generally find extensive deposition of flocculent matter and false membrane, producing extensive adhesion, and frequently copious effusion of a limpid or milky fluid, and sometimes of a fluid with all the characters of pus. Gangrene is rare, and, as far as my observation extends, does not occur as a prominent appearance; but when it is met with, is slight and partial, and always accompanied with extensive deposition of false membrane. I have already stated my conjectures in regard to the nature of this disease. I conceive that the in- flammation is confined to the peritoneal coat; that in this state it may be fatal without interrupting the muscular action of the PERITONITIS. 139 bowels; or that the inflammation may extend to the muscular coat, and then assume the characters of enteritis. Inflammation of the peritoneum may occur in a more limited form than that which I have now described, and, according to the seat of it, may assume the characters of diseases of other organs, as the bladder, the kidney, or the liver; or, when seat- ed in the membrane lining the diaphragm, may simulate dis- ease of the lungs. I think I have seen it in one case seated in the ligaments of the liver, giving rise to very obscure and anomalous symptoms. When it occurs near the kidney, I think it may give rise to the true Ischuria Renalis, which is fa- tal by coma and effusion in the brain; it may likewise take place in the omentum, as will appear from some of the cases to be mentioned. I do not know whether it ever occurs in the peritoneum lining the parietes, without affecting the covering of the intestine. I have seen some obscure cases, which appeared to be of this nature, but have not ascertained it, the cases hav- ing terminated favorably. Simple peritonitis may occur in a still more limited form, producing no urgent symptoms at the time, but giving rise to partial adhesions, which may afterwards prove the source of much derangement in the action of the canal. Several of the cases described under the head of ileus must have been origin- ally of this nature; and this form of the affection will also be illustrated by Case LXI, in which it was ascertained at an early period in consequence of the patient dying of another disease. A remarkable circumstance in the history of peritonitis is, that the activity of the disease may subside, leaving apparently the patient in a convalescent state, and with all the abdominal functions in a healthy condition, while most extensive disease remains, which may go on for some time without its presence being suspected, until it assumes a fatal character, either sud- denly, or by gradually undermining the health of the patient. This remarkable point in the history of the disease will be strikingly illustrated by Case LXII. II. Enteritis differs from simple peritonitis chiefly in the presence of vomiting and obstinate obstruction of the bowels. The pulse also is in general more permanently frequent, and the pain more violent and constant, often resembling the tormina of ileus. This, however, is not invariably the case ; enteritis, on the contrary, being sometimes characterized chiefly by fever, with urgent vomiting and obstruction of the bowels, with ten- derness of the abdomen, but without much complaint of pain. This variety seems to occur chiefly in young persons, as is exem- 140 PERITONITIS. plified in Cases LXVII. and LXVIII. The pulse in enteritis is generally small and rapid, but not uniformly so, for we may find the disease with a full pulse and little increased in frequency, as in Case LXIV. Enteritis is generally fatal with a tympanitic state of the abdo- men and rapid sinking, and we commonly find on dissection extensive deposition of false membrane, with adhesion, often combined with deposition of flocculent or puriform fluid, and generally lividity, or some degree of gangrene. The disease, we have reason to believe, consists in inflammation affecting both the peritoneal and muscular coats at once ; and it is proba- ble that it may supervene either upon ileus or peritonitis, or may take place at first in its complete form. We shall after- wards see cause to conclude that it may likewise supervene upon inflammation beginning in the mucous membrane. SECTION II. EXAMPLES OF PERITONITIS AND ENTERITIS. § 1.—Simple peritonitis. Case LVIL—A girl, aged 15, on Sunday, 2d March, 1817, was at church, in her usual health ; in the evening she com- plained of some pain of the abdomen; (3d.) had pain of the belly and some vomiting; took castor oil, which operated co- piously ; (4th.) pain continued with some vomiting, but not urgent, and the complaint excited no alarm ; bowels quite open. Was seen by a surgeon, who found her pulse 116 and very small, and the belly painful on pressure. (5.) Belly tense and tympanitic; other symptoms as before. Was bled without relief; sunk rapidly and died at night. I did not see this case during the life of the patient, but was present at the examina- tion of the body. Inspection.—The whole tract of the small intestines pre- sented one smooth uniform surface, being firmly glued together, and the interstices filled up by an immense deposition of coagu- lable lympth which was quite soft and recent; and the mass likewise adhered to the parietes of the abdomen. There was a similar deposition, though in smaller quantity, on the surface of the great intestine ; and it was traced nearly to the extremity of the rectum; it also appeared on the surface of the liver. PERITONITIS. 141 The omentum was inflamed and dark colored ; and there were considerable marks of inflammation on the peritoneum lining the parietes of the abdomen. Case LVIIL—A girl, aged 15, (12th May, 1818) had fever, with pneumatic symptoms ; was bled with relief; the fever sub- sided gradually, and on the 19th she was considered as well. On the 20th, at night, she complained of some pain of the bel- ly, which soon went off, and through the night she felt no unea- siness. On the 21st, had violent pain and tenderness of the abdomen, with some vomiting; pulse frequent. Took an opiate and afterwards some purgative medicine ; the vomiting subsided after the opiate; the pain was also much alleviated, and was only complained of upon pressure. The purgative did not ope- rate during the day, but operated freely in the night, four or five times. I saw her for the first time on the morning of the 22d, and found her moribund ; the pulse not to be counted from its frequency; features collapsed ; belly tympanitic. She died in less than an hour after the visit. Inspection.—On the surface of the bowels on many places, es- pecially on the ileum, there was peritonitis with deposition of false membrane. On the inner surface of the ileum, near the caput coli there was an inflamed portion, in the centre of which, there was a white spot the size of a shilling; and in the centre of this spot a round perforating aperture, which transmitted a quill; the edges of it were rounded, and a little thickened. Much fluid feces and gas had escaped into the cavity of the peritoneum, and the bowels were not distended; there were in some places a few livid spots, but no gangrene. This case illustrates a highly dangerous, or indeed hopeless form of the disease, in which it originates in an ulcer perforat- ing the intestine, and allowing the escape of its contents into the peritoneal cavity; the same form of the disease has already been exemplified in connection with perforating ulcer of the stomach; and we shall have occasion to refer to it again, when we come to the consideration of ulcers of the mucous mem- brane. These cases may be sufficient to establish the existence of the disease alluded to under this section, namely, fatal abdominal inflammation, with an open state of the bowels ; but, as the disease is not of very common occurrence, I shall here introduce the following case described by Dr. Marshall Hall, which illus- trates in a very striking manner the peculiar characters of this interesting affection.* ♦ Edin. Med. Jour. Vol. XII. 142 ENTERITIS. A man, aged 50, had acute pain in the hypogastric region, with frequent desire and difficulty of voiding his urine. After some relief during the night, his complaint was renewed on the following day, and, after the operation of a dose of castor oil, it increased to such a degree as to produce writhing of the body, with urgent ineffectual attempts to void urine ; the pulse natural. Relief was obtained from the warm bath, after which urine was voided. (3d day.) Pain and dysuria continued, and the pain extended more generally over the abdomen ; the blad- der was found empty by the catheter; pulse nearly natural. (4th day.) There had been copious evacuations by stool ; some high colored urine passed ; pulse 90, and soft; tongue white. (5th day.) Pain returned after a saline purgative, which operated scantily ; it was now chiefly referred to a spot on the left iliac region, increased by pressure, but also attended with a more general pain over the abdomen ; great restlessness, and much flatus in the stomach ; a little vomiting for the first time on taking any thing, but no continued nausea or retching; pulse 96 ; in the evening 84, soft, and regular. (6th day.) The chief pain had shifted to the right iliac region,—the former pain in the left having now ceased; pulse 124, and small; features collapsed ; body cold; died at 4, p. m. Inspection.—Much exudation and adhesion over the surface of the bowels; the ileum, coecum, and colon, were injected with numerous vessels in some places, so as to acquire a dark color ; but the texture was firm and entire. The appendicular pinguedinosa; were injected and covered with a viscid effusion, communicating the appearance of a mass of disease. The ex- ternal and posterior portion of the bladder appeared also a little injected ; the other viscera were natural. The following case bears a remarkable similarity in its symp- toms to the very important case of Dr. Hall. Case LIX.—A gentleman, aged 25, (18th Sept. 1816) was affected with pain in the bowels, accompanied by considerable dysuria, and frequent desire to go to stool, with scanty slimy discharges ; pulse natural; took castor oil, which produced several stools, thin, feculent, and copious ; but the pain con- tinued unabated, accompanied with tenderness of the abdomen, and aggravated by motion; the more violent pain was not con- stant, but occurred in paroxysms; pulse in the evening 80. He was bled to 16 ounces, and took a moderate opiate. (19th.) Easy in the night, but, in the morning, the pain re- turned with such violence as to occasion screaming, and ex- treme distress; it was chiefly about the umbilicus, but some- PERITONITIS. 143 times shifted to the stomach ; and there was violent pain in the region of the bladder, extending along the urethra, with much dysuria; great tenderness of the abdomen: some vomiting; pulse from 90 to 100 ; several feculent consistent stools after a mild enema. Was bled to 16 ounces, and took a dose of aloes. After the bleeding, the violent pain subsided, but the tender- ness continued, with occasional short paroxysms of pain, and re- peated vomiting. The dysuria continued, and at one time amounted to retention, which was relieved by a mild enema ; bowels freely opened. At night took an opiate. (20th.) Much depression, sickness, and faintness; abdomen tender, and a little tympanitic ; no constant pain, but occasional paroxysms of short duration ; respiration short and quick ; and, on taking a full inspiration, he felt severely pained, and cramped across the epigastrium. He lay on his back, but could not bear the pressure of the bed clothes; countenance anxious; voice fee- ble ; pulse 100 ; dysuria abated ; some vomiting ; tongue foul. Was bled again from the arm, and took some aloes. Was much relieved after the bleeding, and bore pressure upon the abdomen; breathed more freely, and spoke vigorously; tym- panitic feeling gone; discharged much flatus, and the bowels were mov^d once. At night took gr. vi. of calomel. (21st.) In the early part of the night was restless, with delirium and frequent vomiting. In the morning, his bowels were moved four or five times with much relief; pulse 80; all the symptoms abated. From this time he continued well, but discharged much hardened feces for several days. In this very important case, I believe that bleeding ought to have been pushed more actively in the early stages; and par- ticularly that it ought to have been repeated on the evening of the 19th. § II.—Peritonitis confined nearly to the descending colon and rectum. Case LX'.—A gentleman, aged about 60, (17th May, 1827,) complained of pain about the umbilicus, without fever. Took castor oil, aided by injections, and discharged much scybalous matter with relief; but the pain returned in the evening, and he continued in great pain through the night; was bled from the arm by Mr. White. (18th.) Much pain complained of in the very lowest part of the abdomen, about the region of the bladder; and there were considerable fullness, tension, and a 144 PERITONITIS. tympanitic feeling from the umbilicus downwards, but little or no tenderness. Pulse about 90. He took pills of aloes and colocynth, assisted by injections ; and towards the afternoon his bowels were freely moved ; but the pulse continuing about 90, he was again freely bled from the arm at night. Through the night, his bowels were moved repeatedly and freely, and the mo- tions were feculent and healthy. (19th.) Seemed much reliev- ed ; pulse natural; but the same feeling of tympanitic disten- tion continued in the lower part of the abdomen, though without tenderness ; he took some small doses of laxatives, and had re- peated feculent motions through the day. In the evening he complained of more pain, and the tympanitic feeling was in- creased. Through the night he was restless. In the morning of the 20th, he began to sink, and died at three in the after- noon. Inspection.—The bowels were generally distended, and in many places of a dull leaden color, with very slight patches of false membrane on the small intestines, but they appeared to be quite recent. The chief seat of the disease was on the rectum, the sigmoid flexure of the colon, and the lower part of the de- scending colon. These parts were covered by a very copious deposition of false membrane, producing extensive adhesions ; and the cavity of the pelvis was quite full of thick pus and flocculent matter. The bladder was healthy. § III.—Local peritonitis of very small extent. Case LXI.—A young man, aged 20, was recovering from an attack of natural small-pox; but, going out too soon in cold weather, he was attacked with a febrile affection, and com- plained of a circumscribed pain in the left side of the abdomen near the umbilicus. There was no vomiting, and the bowels were quite natural. General and topical blood-letting were em- ployed, by which he seemed to be entirely relieved; but after two or three days he became delirious, and then comatose. In this state I saw him, and the usual treatment was employed without any relief. He died in two days more. By the medi- cines which were given him during this period, his bowels were moved readily and freely. Inspection.—There was high vascularity of the membranes of the brain, and considerable effusion under the arachnoid. In the left side of the abdomen, there was adhesion of two contiguous turns of the small intestine, through a space about PERITONITIS WITH SUPPURATION. 145 six inches in extent; and the inner surface of one of the por- tions was extensively ulcerated. The other parts were healthy. § IV.—Peritonitis terminating by extensive suppuration. The following remarkable case shows, in a striking manner, what extensive disease may remain after an attack of peritoni- tis, though every symptom has been removed. Case LXII.—A young lady, aged 20, (9th July, 1822,) was seized with symptoms of peritonitis, which were relieved by blood-letting, and the other usual means ; and on the 12th, she appeared to be convalescent. At night she took some pills of aloes and colocynth, which operated frequently with much irri- tation. After this, the pain of the bowels returned, and con- tinued through the 13th. (14th.) There was severe pain of the bowels, with tenderness, and the pulse was again becoming frequent. She was now bled from the arm, and a second time a few hours after ; and, after the second bleeding, she became very faint and low. I now saw her for the first time, and found the pulse extremely frequent and small; she had a look of ex- treme exhaustion ; but there was still much pain and tension of the belly, with great tenderness ; there was no vomiting. She was now treated by weak tobacco injections, cold applications to the abdomen, followed by blistering and small doses of aloes, with extract of hyosciamus, repeated every two or three hours. Under this plan, she gradually improved; the pain and tender- ness subsided ; the pulse came down ; the bowels were moved freely and without irritation ; and after three or four days, she appeared to be convalescent. About the 20th, she complained of some pain in the region of the liver, which was quite re- moved by topical bleeding; and from this time she appeared to be recovering perfect health; the pulse 'and functions of the stomach were natural; the bowels easy, or easily regulated by the mildest medicine ; and her strength improved daily. About the 25th, she began to be troubled with a parotid swelling, which gave her a good deal of uneasiness; but in other respects she was well; she was in the drawing-room the greater part of every day, and every function was natural. The swelling advanced slowly to suppuration, and was of very considerable size ; it discharged a little matter by the ear, but she would not submit to have it opened. On the night of the 2d of August, she went to bed in her usual health, having been 19 146 PERITONITIS WITH SUPPURATION. in the drawing-room through the day, and without any com- plaint except the pariod swelling. Early in the morning of the 3d, she awoke in great distress, with cough and oppressed breathing. When I saw her about 11 o'clock, her face was cadaverous; her breathing frightfully oppressed, with a rattling sound. The pulse was very frequent, and there was in the room an intolerable foetor. My first impression was, that the parotid swelling had burst into the larynx; but upon opening it, healthy pus was discharged, while small quantities of frothy fluid, which she coughed up, were intolerably feted. She died about twelve. Inspection.—Betwixt the diaphragm and the upper surface of the liver, there was found a distinctly defined cavity, lined by a cyst of coagulable lymph, and containing at least a pound of thin puriform matter of intolerable foetor. The right lung adhered extensively to the diaphragm; and the diaphragm was perforated by a small opening, by which the matter from the abscess had passed freely into the bronchial canals, and it was traced as far as the trunk of the trachea. The liver was sound in its internal structure, but on its peritoneal coat there were some marks of inflammation. The intestines adhered to each other, through almost their whole extent, to the omentum, and to the parietes of the abdomen; so that no portion of in- testine could be traced without tearing these adhesions, which were soft. Throughout this mass of disease, there were in several places cavities of various sizes, containing purulent mat- ter ; one of these on the right side seemed to communicate by a small canal with the great abscess above the liver. In the posterior part of the pelvis, behind the uterus, another great ab- scess was discovered, containing nearly a pound of thin, fetid pus. It was formed by adhesions betwixt the intestine, the uterus, and the ovaria, so that it was completely cut off from the other parts, and remained entire, after the examination of them had been concluded. That in this case the bowels should have continued to dis- charge their functions in the most healthy manner for a fort- night, is perhaps one of the most striking^ facts that can be pre- sented in regard to the pathology of the intestinal canal; and can only, I think, be accounted for by the supposition, that this remarkable extent of disease was entirely confined to the peri- toneal coat. Case LXIII.—A woman, aged 40, after exposure to cold in the beginning of November, 1813, was affected with pain in the left side of the abdomen, at first remitting, but afterwards more PERITONITIS PASSING INTO ENTERITIS. 147 constant, though without confining her to bed. This had con- tinued for nearly a month, when I saw her in the beginning t>f December with symptoms of more active peritonitis, from which she was relieved by repeated blood-letting, and the other usual means. The bowels were at first obstinate, but soon yielded to the usual remedies, and the immediate urgency of the symp- toms was thus soon removed; but from this time she continued liable to transient attacks of pain in the belly, which were usu- ally relieved by purgatives and opiates. After one of these attacks, more severe than usual, about the middle of January, 1814, a hard swelling began to be observed on the left side of the abdomen, which gradually increased, with much pain and constitutional irritation, until the second week of February, when it broke and discharged a large quan- tity of very fetid pus. During this time her bowels were open, and the motions were natural. The discharge of matter now continued from the side, and several new openings were formed; but it gradually diminished, and all the openings were healed in the beginning of April. During the discharge she had been much emaciated and hectic, but she now began to improve; she was able to be out of bed in the end of April, and to walk out about the beginning of May. The attacks of pain in the abdomen still returned occasionally, but at longer intervals ; and they were relieved as formerly by purgatives and opiates. On the 5th of May, she was attacked by a violent paroxysm of pain, which did not yield to any of the remedies that were employed, and she died early in the morning of the 6th. Inspection.—Almost universal adhesions of the intestines to each other, and to the parietes of the abdomen; some of these were recent and others of old date. At one place about the middle of the small intestine, its calibre was very much con- tracted, and at this spot the intestine was bound down by ad- hesions to the spine ; above the contraction, the canal was di- lated into a large sac. No trace remained of the abscess ex- cept the cicatrix in the integuments, which nearly corresponded in situation with the place where the intestine was so much contracted. § V.—Peritonitis passing into enteritis. Case LXIV.—A gentleman, aged 20, (3d September, 1812,) had pain and tenderness in the lower part of the abdomen; 148 PERITONITIS PASSING INTO ENTERITIS. pulse from 84 to 90, and full; bowels natural. Was bled and t«ok laxative medicine which operated fully. The bleeding was repeated on the 4th, and on the 5th and 6th, he was much better, complaining only of occasional griping, and his pulse was quite natural. Took laxative medicines which operated fully ; the motions copious but rather watery and of a greenish color. (7th.) Free from complaint in the morning, and the bowels open. In the afternoon, he complained that some laxa- tive medicine had produced most unusual pain ; and at night he had fixed pain in the upper part of the abdomen, with shiv- ering followed by heat; pulse 84. Through the night had co- pious feculent evacuations, without relief of the pain, and re- peated vomiting. (8th.) Pulse 96; fixed pain in the abdo- men, which was hard, tender, and tympanitic; repeated vomit- ing ; the bowels obstructed ; repeated blood-letting and all the other usual remedies were employed without relief. (9th.) Pain unabated; belly tympanitic; but less tender; vomiting abated; no stool except some very scanty discharges of watery matter; pulse from 100 to 126; hiccup. At night the pain abated; the bowels were moved, but sinking took place; and he died at nine in the morning of the 10th. Inspection.—All the intestines much distended and glued to- gether by most extensive adhesions; omentum highly inflamed and adhering to the intestines. At the lower part of the small intestine, an extensive portion was gangrenous, and another at the lower part of the descending colon. The appendix vermi- formis was gangrenous, and an opening had taken place in it through which liquid feces had escaped into the cavity of the abdomen. Case LXV.—A gentleman, aged 20, (10th December, 1817) late at night, was found writhing and screaming from intense pain in the abdomen, every part of which was extremely ten- der to the touch; frequent vomiting; much dysuria; pulse 96 and soft. Had felt pain for several days, but it had increased on the evening of the 9th, with vomiting; took laxative medi- cine on the morning of the 10th, which operated freely three or four times ; but after these evacuations the pain was much increased. He was largely bled; and on the 11th he was greatly relieved; pulse 90. The bleeding was repeated, and his bowels were moved by a mild enema. In the course of the day he had some paroxysms of pain, and vomited twice; but there was much less tenderness of the abdomen, except at one spot at the lower part of the right side, where it was still acutely tender; bowels open. Bleeding was repeated at night. enteritis. 149 (12th.) Pulse 90; no stool; less pain, but much tenderness; very little vomiting. Two small bleedings, no more being borne; large blister, &x. (13th.) Pulse very frequent; abdo- men enlarged at the lower part and tender; no stool; urine scanty and passed with much pain. (14th.) Pulse 120; no stool; no urine ; belly tympanitic ; rapid exhaustion with much vomiting; died at night. Inspection.—Extensive inflammation of the ileum; the in- flamed parts were extensively glued together, and pressed down into the cavity of the pelvis, by the distention of the parts above, which were also inflamed but with less exudation. Blad- der inflamed and collapsed ; omentum inflamed; about a pound of puriform matter in the cavity of the peritoneum. § VI.—Enteritis. Case LXVL—A young lady, aged 18, (4th March, 1813) had pain and tenderness of the abdomen with vomiting; pulse 126. After repeated blood-letting, assisted by cold applica- tions, tobacco injections, various laxatives, &c, continued through the 4th, 5th, and 6th, the inflammatory symptoms sub- sided ; but the bowels continued very unmanageable, and were not moved in a satisfactory manner till the 12th. From the be- ginning of the attack she had complained of pain in the ear, which at first attracted little notice, but afterwards became more severe ; and on the 22d she died of abscess of the cerebellum, as I have fully described in another place.* From the 12 to the 22d the bowels continued to discharge their functions in the most healthy manner. Inspection.—The caput coli and about 18 inches of the low- er extremity of the ileum were of a very dark livid color, with- out any change in their structure. Case LXVII.—A child, aged 3 years and 3 months (12th February, 1812) had urgent vomiting and great thirst; all the liquids taken being vomited almost immediately, mixed with large quantities of a light green fluid ; pulse frequent; counte- nance sunk and anxious ; did not complain of any pain. Had been unwell for four or five days, at first slightly ; bowels moved by medicine on the 9th; and on the 10th she seemed much better, and the bowels were quite open. Had complained once * Researches on the Pathology of the Brain, Case XLIII. (2d Edit.) 150 ENTERITIS. of pain in her bowels, but had not mentioned it again. The vomiting began on the evening of the 10th, and was very urgent through the whole of the 11th; and the bowels had not been moved since the commencement of the vomiting. The usual remedies were employed without benefit; the vomiting con- tinued urgent, and the bowels obstinately obstructed. (13th.) Vomiting abated; medicines were retained but produced no effect. She continued through the day at times restless and feverish, at others oppressed and exhausted; and she died in the night. Inspection.—Stomach externally healthy,—internally showed increased vascularity, and contained much dark colored fluid. About a fourth part of the small intestine, at the upper part, was highly inflamed,—in some places black and gangrenous, in others adhering and covered with false membrane. The dis- eased portion was greatly distended and contained much dark colored fluid, but no feces. Immediately below this part the intestine became at once narrow and contracted, empty, and of a white color, except a few streaks of superficial redness. Case LXVIIL-—A boy, aged 10, (10th May, 1823) was out at play in the morning before breakfast in perfect health : re- turned home about nine, complaining of pain in his belly. Laxative medicine was given him, and was repeated at intervals through the day without effect. In the evening, he began to vomit, and passed a restless night with frequent vomiting; the pain in his belly continuing. (11th.) Pain continued in the early part of the day, but subsided in the afternoon ; was seen by a surgeon, who ordered a succession of purgatives, but they were constantly vomited. I saw him late at night, and found the pulse 120, and of tolerable strength. The pain had, in a great measure, subsided, but great tenderness of the whole belly continued, with frequent vomiting; and there had been no stool. Bleeding from the arm was employed with much apparent relief, followed by leeches, &c. The bowels were now moved by a mild enema, and he had afterwards one or two motions ; but he continued very restless, and died about five in the morning, not more than 44 hours from the first com- plaint of pain. Inspection.—The upper part of the small intestines was much distended ; in the lower part there was high inflammation, with extensive adhesions. By the distention of the upper portion, a great part of the ileum was pressed together into the cavity of the pelvis, forming a mass of disease, the different parts of which adhered extensively to each other, to the rectum, and to the CONCLUSIONS. 151 sides of the pelvis; much force being required either to sepa- rate them from each other, or to raise them out of the pelvis. The inflammation extended over a great part of the small intes- tines, but the principal seat of it was the ileum; and the blad- der also seemed to be affected. In the cavity of the pelvis, there was a considerable quantity of puriform fluid. The high importance of the subject must be my apology for detailing so many cases, calculated to illustrate the pathology of this interesting and dangerous class of diseases. They seem to warrant the following practical conclusions. CONCLUSIONS FROM THE PRECEDING FACTS. 1. Extensive and highly dangerous inflammation may exist in the intestinal canal without obstruction of the bowels: and it may go on to a fatal termination, while the bowels are in a nat- ural state, or easily regulated by mild medicines, through the whole course of the disease. 2. No diagnosis can be founded in such cases on the appear- ance of the evacuations. These may be slimy, and in small quantity; they may be copious, watery, and dark colored; or they may be entirely natural. 3. Extensive and fatal inflammation may be going on with every variety in the pulse. It may be frequent and small; it may be frequent and full; or it may be little above the natural standard through the whole cpurse of the disease. 4. Extensive inflammation may go on without vomiting and without constant pain: the pain often occurring in paroxysms, and leaving long intervals of comparative ease. 5. Keeping in view these sources of uncertainty, our chief reliance, for the diagnosis of this important class of diseases, must be on the tenderness of the abdomen. This symptom should always be watched with the most anxious care, whatever may be the state of the bowels, or of the pulse, or the actual complaint of pain,—and though the tenderness itself should be limited to a defined space of no great extent; for, we have seen, that with every variety in these respects, a disease may exist of a very formidable character, and be advancing to a fatal termi- nation. A certain degree of pain upon pressure we have found attending a merely distended state of the intestine; but this differs from the acute sensibility of peritonitis in such a degree, that an attentive practitioner can in general have no difficulty in making the distinction. When the tenderness exists without distention, as is frequently the case in the early stages of perito- nitis, there can be no difficulty in the diagnosis. 152 TREATMENT OF INTESTINAL INFLAMMATION. SECTION III. OUTLINE OF THE TREATMENT OF INTESTINAL INFLAMMA- TION. In the treatment of this most important class of diseases, the great principle to be kept in view is, that the affection which we have to contend with is simply inflammation. This inflammation may exist with every variety in the state of the bowels ; we have seen them obstinately obstructed, and we have" seen them easily moved through the whole course of the disease; and, when ob- struction had existed, we have found it give way, and free evac- uation take place, without in any degree improving the situation of the patient. Our first great object, then, is simply to combat the inflammation ; and the remedies for this purpose are few and simple. The most important is general blood-letting, re- peated according to the urgency of the symptoms and the strength of the patient, aided by large topical bleeding, blister- ing, &c. In a considerable number of cases, I have used with evident advantage the application of cold, by covering the ab- domen with cloths wet with vinegar and water, or even iced water. Injections of iced water, have been proposed, and I think it probable, might be used with advantage. In all cases of active inflammation, blood-letting can be of comparatively little avail, except it be used at an early period, and pushed to such an extent, as to make a decided impression upon the system, as indicated by weakness of the pulse, pale- ness, and some degree of faintness ; and a practice, to which I am very partial in all urgent inflammatory cases, is to follow up this first full bleeding by small bleedings at short intervals, when the effect of the first begins to subside. In this manner, we prolong, as it were, the impression which is made by the first bleeding, and a twofold advantage arises from the practice ; namely, that the disease is checked at an early period, and that the quantity of blood lost, is, in the end, much smaller than probably would be required under other circumstances. If we allow the patient to lie after the first bleeding 10 or 12 hours, or even a shorter period, the effect of it is entirely lost, and a repe- tition of it to the extent of 20 ounces may be required for pro- ducing that effect upon the disease, which, by the former meth- od, might be produced by five; and, besides, the disease has in the interval been gaining ground, its duration is protracted, and the result consequently rendered more uncertain. The inflam- TREATMENT OF INTESTINAL INFLAMMATION. 154 mation of a vital organ should not be lost sight of above an hour or two at a time, until the force of it be decidedly broken, and, unless this takes place within 24 hours, the termination must be considered as doubtful. The means now alluded to, are those calculated for subduing the inflammation, which is our first and great object in the treat- ment of this disease ; but there is another point which must ever be a prominent object of attention in cases of this class, namely, the state of the bowels. On this head,- we have seen very great diversity ; we have seen the bowels obstinately ob- structed, and we have seen them spontaneously open or easily regulated ; and, in both cases, the disease has run its course with equal rapidity to a fatal termination. We have found no rea- son to believe that the retention of feces was in itself injurious in the one case, or the free evacuation of them beneficial in the other ; on the contrary, we have had evident reason to believe, that in several cases, in which the inflammation appeared to be subdued, the action of a purgative was immediately followed by a renewal of the symptoms. Along with these considerations, we must keep in mind the fact, that, in the ordinary cases of enter- itis, the action of purgatives is in general entirely fruitless ; they are usually vomited as often as they are given, and consequent- ly can only prove additional sources of irritation. I know that much difference of opinion exists among practical men upon this subject; but upon the grounds now referred to, I confess my own impression distinctly to be, that the use of purgatives makes no part of the treatment in the early stages of enteritis; on the contrary, that they are rather likely to be hurtful, until the inflammation has been subdued. When we have reason to believe that this has taken place, the mildest medicines or in- jections will often be found to have the effect, after the most active purgatives had previously been given in vain. In the general treatment of enteritis, indeed, it is desirable to keep the bowels, if possible, free from distention ; but this object, may, I think, in general, be obtained by mild injections, or by the to- bacco injection. I have already alluded to the precautions, with which this powerful remedy ought to be administered ; it is particularly adapted to almost every state of enteritis, because, while it tends to move the bowels, it is also calculated to allay vascular action, and may thus assist in subduing the inflamma- tion. Before concluding these general remarks, I would briefly al- lude to some circumstances which often occur during the treat- 20 154 TREATMENT OF INTESTINAL INFLAMMATION. ment of enteritis, and which are apt to embarrass the young prac- titioner :— I. The pulse continuing very frequent after the inflammation appears to be subdued. In this state digitalis may be given very freely with much advantage. II. Cessation of the pain, sinking of the vital powers, great weakness of the pulse, and coldness of the body. These symp- toms are generally considered as indicating gangrene, and con- sequently a hopeless state of disease. When treating of ileus, I have produced evidence that this is by no means invariably the case ; for I have shown these symptoms connected with slight and recent inflammation, and I have shown them recovered from. I shall now only add the following example:— Case LXIX.—A man, aged 40, was affected with enteritis in the usual form, for which he was treated in the most judicious manner by a respectable practitioner. On the 5th day, the pain ceased; the pulse was 140, and extremely feeble and irreg- ular ; his face was pale, the features were collapsed, and his whole body was covered with cold perspiration ; his bowels had been moved. In this condition, I saw him for the first time. Wine was then given him, at first in large quantities, and, up- on the whole, to the extent of from two to three bottles during the next 24 hours. On the following day, his appearance was improved; his pulse 120 and regular; the wine was continued in diminished quantity. On the 3d day, his pulse was 112, and of good strength, and in a few days more he was well. In such a case as this, there could be no doubt as to the only practice that could be adopted; but there are cases in which, at a particular period of the disease, wine is given with much ad- vantage, though the symptoms are much more ambiguous, and it is difficult to decide upon the practice which ought to be followed. This is strikingly illustrated by the following case :■.__ Case LXX.—A lady, aged 35, on the seventh day after de- livery, was seized with symptoms of peritonitis, with much ten- derness and urgent vomiting; respiration short and oppressed ; pulse 140 and sharp. The pain was aggravated by inspiration, and by every motion of the body. She was bled and blistered, and took laxative medicine, which operated freely. After the bleeding, she was very much relieved, and could breathe without uneasiness; the vomiting subsided, and the pulse was much diminished in frequency; this was in the night. On the fol- TREATMENT OF INTESTINAL INFLAMMATION. 155 lowing day, the pulse rose to 150 ; the breathing was quick, short, and oppressed; some vomiting; countenance anxious; abdomen soft, and without pain or tenderness; lochia natural. Wine was now given in the quantity of a small glass every hour, and injections of beef tea containing bark in powder and laudanum ; and these were repeated as often as they were dis- charged, which was generally once in two hours. Under this treatment persevered in, the symptoms gradually improved. On the second day, the pulse was from 125 to 130; and on the third day, from 112 to 120; but for several days she continued to take a bottle of wine in each 24 hours. For some time she suffered severely from an aphthous state of the mouth and throat, accompanied by a burning uneasiness in the stomach, and pain in the bowels. These symptoms were relieved by a decoction of logwood. III. Hardness and tension of the abdomen, with some de- gree of enlargement, occurring at an advanced period of the dis- ease. This is a very formidable symptom, and gives reason to apprehend, that the disease is passing into a somewhat chronic state, with extensive adhesions and effusion; but that this is not a necessary consequence will appear from the following case. The nature of the affection is obscure. Case LXXI.—A young man, aged 17, was affected with en- teritis in a severe form, which required much active treatment; but the case yielded favorably, and about the 7th day he was free from complaint. On the 9th day, his pulse began to rise again, and the abdomen became enlarged, very hard and tense, and tender to the touch ; the bowels open ; his pulse when sitting up 120. In this state, in spite of every remonstrance, his friends carried him to the country. I expected to hear of his death, but the affection gradually subsided, and he returned to town in a few weeks in perfect health. IV. A tympanitic state of the abdomen. This occurs in con- nection with several forms of the disease, and in every form of intestinal inflammation is a symptom to be watched with the most anxious attention. The most unfavorable is the true tym- panites abdominalis, which arises from perforation of the intes- tine, and the escape of flatus into the cavity of the peritoneum. Some examples of this have been already mentioned, and others will be referred to when we come to treat of ulcers of the mu- cous membrane perforating the intestine. In the early stages of enteritis, a tympanitic state may- occur from a temporary de- 156 TREATMENT OF INTESTINAL INFLAMMATION. rangement of the muscular action, and may subside as the in- flammation is subdued. At a more advanced period of the dis- ease, it must be looked upon with much anxiety. If it occur at this period when the inflammation has not been subsided, it is generally a fatal symptom, depending upon a complete loss of the tone of the bowels; and it is commonly found to be con- nected with very extensive adhesions. Tympanites, however, may occur from mere loss of tone of the parts, after the inflam- mation has been subdued; and in this case, it may be recov- ered from, though the appearance of the patient for the time is most alarming. In this state of the case, it is often impossible to ascertain with certainty on which of these two conditions of the disease the affection depends, but the safe rule always is, to act upon the supposition of it being in the more favorable form, from which the patient may recover. This is to be treat- ed by small quantities of wine or brandy given at short inter- vals ; gentle compression and friction of the abdomen; and in- jections of beef tea, to which may be added considerable quan- tities of bark or sulphate of quinine, turpentine, or tincture of assafoetida, and a moderate quantity of laudanum,—these to be repeated once in two or three hours. The bowels may be moved by very mild laxatives, such as aloetic wine or aloes and hyosciamus; but laxatives require to be given with the utmost caution. The affection is one of very great interest in a practi- cal point of view, because the patient has very often the ap- earance of being almost moribund, and yet by attention may e speedily recovered. On this account, I think it will not be out of place to conclude with the following examples. Case LXXII.—A lady, aged about 36, a few days after her accouchement, was seized with symptoms of peritonitis, which was treated in the usual manner by a judicious practitioner. The activity of the symptoms was subdued by two bleedings; the bowels yielded to laxative medicine, which, in fact, opera- ted rather fully and with irritation. This was followed by a state of exhaustion, in consequence of which I saw her. I found her with a haggard and exhausted look ; the skin clam- my ; the pulse feeble and rapid ; the whole abdomen tympanit- ic and enlarged to the size of the last period of pregnancy; wine was now given her at short intervals, with injections of beef tea containing assafoetida and sulphate of quinine ; under this treatment she improved rapidly, and in a few days was in her usual health. Case LXXIII .—A boy, aged 6, had acute pain in the abdo- TREATMENT QF INTESTINAL INFLAMMATION. 157 men, much increased by pressure and by inspiration; short anxious breaming; pulse extremely frequent. He was bled from the arm, and took some laxative medicine, which operated, and he was very much relieved. He then did well for two days, when on visiting him at night, I found him oppressed and restless; countenance anxious; pulse above 140; the belly en- larged and tympanitic, and painful on pressure. Injections, containing bark in powder with tincture of assafoetida, were given every three hours, aided by friction, &c. with great re- lief. Under this treatment the affection soon subsided, and in a few days he was able to be out of bed ; but he continued feeble and sallow, with cough, bad appetite, frequent pulse, and a withered, emaciated appearance. Being sent to the country, he improved gradually, but it was some months before he recovered perfect health. The condition of the bowels, which occurred in this case, appeared to consist of mere derangement of the muscular power, yet assumed characters which might have been consid- ered as indicating mesenteric disease ; and I believe it is an af- fection of frequent occurrence, especially in children, in whom it often assumes characters resembling those of fixed and seri- ous disease. It is treated by air and exercise, tepid bath, fric- tion of the abdomen, and vegetable bitters, as the Colombo powder combined with small doses of rheubarb or aloes, or small doses of the sulphate of iron combined with rheubarb. A tympanitic state of the abdomen, such as occurred in the above mentioned cases, occurs also from other causes, though putting on the same alarming characters. Case LXXIV.—A lady, aged about 35, had suffered for some days from a loose state of the bowels, accompanied by a good deal of pain and irritation; but the complaint was considered as a common diarrhoea, and attracted little attention. After she had allowed it to go on for several days, her abdomen be- gan to be enlarged, and her strength to sink; and when I saw her a day or two after the first appearance of these symptoms, I found her exhausted to the last degree; countenance ca- daverous ; skin cold and clammy; abdomen very much en- larged and tympanitic; pulse 160, and extremely feeble. Brandy was now given her every hour, with injections of beef tea containing powdered bark ; and under this treatment, with careful watching night and day, she rallied gradually, and was soon in her usual health. 158 ERYSIPELATOUS PERITONITIS. SECTION IV. ERYSIPELATOUS PERITONITIS. In the preceding remarks on inflammation of the peritoneum, I have confined my observations to that which may be con- sidered as the genuine form of simple acute peritonitis. But there is another form of the disease of very .great interest, and, in several respects, remarkably distinct from the former. The rea- sons will appear in the sequel which induce me to consider it as allied to erysipelas ; but I attach no other importance to the name than simply as a title to the section in the general arrange- ment of the subject. In a pathological point of view, the principal character of this affection is, that it terminates chiefly by effusion of fluid, without much, and often without any, of that inflammatory and adhesive exudation, which is so prominent a character of the disease in its more common form. The effused fluid is in some cases a bloody serum or sanies; or this mixture with a propor- tion of pus, which separates and subsides to the bottom of a vessel in which the fluid is left at rest; in other cases it is milky or whey-colored, or contains shreds of flaky matter ; and some- times it is found with all the characters of pus. This effusion is in some cases combined with a degree of pseudo-membranous deposition; but it is in general slight, and is often entirely wanting. The appearance of the intestine varies considerably ; in some cases, the surface is, for a considerable extent, of a uniform dark red color ; in others, there is only a slight in- crease of vascularity ; and frequently little or no deviation can be discovered from the healthy structure. In some cases again, the peritoneal coat, or a portion of it, has a slightly thickened and softened appearance, like a part that has been boiled ; and in some examples of this form of the disease, it appears that the omentum has been a principal seat of the inflammation. The symptoms of this affection are sometimes slight and in- sidious, but sometimes very severe ; and they are chiefly distin- guished by the rapidity with which they run their course, and by a remarkable sinking of the vital powers, which occurs from an early period, and often prevents the adoption of any active treatment. A remarkable circumstance in the history of the affection is its connection with erysipelas, or with other dis- eases of an erysipelatous character. This will appear from the following examples, by which I am anxious to illustrate this af- ERYSIPELATOUS PERITONITIS. 159 fection, as it seems to present a very interesting subject of in- vestigation. Case LXXV.—A lady, aged 50, in June, 1823, was seized with extensive erysipelas of the left leg, accompanied by acute pain, and considerable swelling of the tipper part of the foot. After six or seven days the erysipelas of the leg subsided gradually,—the swelling and pain of the foot continuing undi- minished. After another day these disappeared suddenly, and a few hours after she was seized with acute pain in the region of the stomach, which, after a short time, moved downwards, and settled with great severity in the lower part of the abdo- men, and around the umbilicus. This took place in the night, and I saw her in the afternoon of the following day. She was then moaning with most acute pain, but did not complain much of pressure; great anxiety and restlessness ; pulse about 100 ; bowels open. I advised bleeding, a blister, &c, but the former, I afterwards found, was not done at the*time. At night the pain continued unabated, she was bled without relief. The other usual remedies were then employed, but without benefit. She continued in great pain, without any other marked change of the symptoms ; her strength sunk ; and she died early in the morning of the following day, being little more than 24 hours from the attack. Inspection.—The lower half of the small intestine was of a uniform deep dark red color, but without any exudation : the upper half was of a dull leaden color ; and the whole was con- siderably distended. In the cavity of the peritoneum there was a considerable quantity of bloody sanious fluid. No other mor- bid appearance could be discovered. Case LXXVI.—A woman, aged 30, had been ill for several days with the erysipelatous inflammation of the throat, accom- panied with considerable fever. She felt better and was able to be out of bed, when, having taken some laxative medicine, she was severely pained during its operation ; and in the eve- ning was seized with most violent pain over the whole abdo- men, accompanied by vomiting. I saw her on the following day, along with Dr. Begbie, and found her pulse very frequent and extremely small; skin rather cold ; countenance expressive of exhaustion; severe pain and acute tenderness of the whole abdomen ; some vomiting ; no stool. A bleeding was attemp- ted, but she bore very little ; and it gave no relief. Blistering, opiates, tobacco and other injections, &c, were then employed without benefit. She continued in the same condition, and 160 ERYSIPELATOUS PERITONITIS. died in the evening of the following day, being about 48 hours from the attack ; the bowels had been partially moved. Inspection.—The bowels were in general considerably dis- tended and of a dark livid color without exudation. In the cav- ity of the peritoneum, there was a considerable quantity of pu- riform fluid. There was much appearance of inflammation up- on the omentum, especially at the lower part, where it was for several inches highly inflamed and thickened, and had formed an adhesion to the sigmoid flexure of the colon. In the Merchant's Hospital of Edinburgh, (a charitable in- stitution for the education of girls,) an epidemic appeared in the beginning of March, 1824. Its principal character was a slight erysipelatous affection of the throat, generally beginning with vomiting and accompanied by slight fever ; and in many of the cases, there were swelling of the glands of the neck. It spread with great rapidity, 15 or 20 girls being sometimes in bed at a time ; but was in general a very slight affection, disappearing in " three or four days with little treatment. The epidemic had gone on in this manner for about a week, when, on the 13th, a girl, aged 10, was affected in the same slight manner as in the other cases. On the 14th she seemed much better, and on the 15th she complained only of slight headache, on account of which she was still kept in bed. About two o'clock in the af- ternoon, she suddenly got out of bed in a state of incoherence, and was soon after affected with repeated vomiting and diar- rhoea, by which she discharged a green and watery matter. When asked if she feli pain, she laid her hand on the right side of the abdomen about the seat of the caput coli. After vomit- ing repeatedly, she sunk into a state of great lowness, or almost of insensibility. When seen by Mr. Win. Wood between four and five, she was unable to answer any question; pulse scarce- ly to be felt; body cold; face cadaverous; occasional vomiting continued. Stimulants were ordered, and I saw her along with Mr. Wood between nine and ten at night; she was then lyin» with her eyes open, and seemed to observe those about her, but made no attempt to speak ; pulse scarcely to be felt; action of the heart tumultuous and irregular ; body cold ; occasional vom- iting ; no return of diarrhoea; she died about eleven at night. Inspection.^—Extensive marks of peritoneal inflammation with slight deposition of lymph in flakes on various parts of the intes- tines ; in the cavity of the peritoneum there was a considerable quantity of milky puriform fluid. The appendix vermiformis was large, turgid, and of a very dark color approaching to gan- grene ; the brain, and viscera of the thorax were sound ; and ERYSIPELATOUS PERITONITIS. 161 nothing unusual was remarked in the mucous membrane either of the stomach or bowels. After the occurrence of this case, the epidemic went on in a very mild form, affecting the patients chiefly with feverishness, generally with some vomiting, and swelling of the glands of the neck. In all of them there was more or less of an affection of the throat, which presented, when looked into, an angry raw- ness and redness with little or no swelling; in some there were aphthous crusts, and in others a considerable turgescence of the uvula; and in a considerable number there were small angry ul- cerations about the lips, with spunginess of the gums. It was still, however, a slight affection, requiring little treatment except confinement to bed for a few days, and gentle laxatives ; and no other urgent case occurred until Sunday the 4th of April. A girl, aged 12, had been in the sick ward for three or four days with the usual symptoms, and on Saturday was considered as convalescent. On Sunday she complained of considerable pain in the bowels, with frequent desire to go to stool. An opiate was given her, and afterwards some castor oil, which ope- rated. On the 5th she still complained of some uneasiness in the bowels, but it was not urgent, and excited no alarm, until the morning of the 6th, when Mr. Wood found her complaining of severe pain, with tenderness over the whole abdomen, and the pulse was frequent. He then bled her freely from the arm, and ordered the other usual means. I saw her along with him in the afternoon. Her pulse was 120 and rather small; abdo- men tense and tender ; no vomiting, and not much expression of suffering; bowels not moved since the former day; a number of leeches were ordered, with injections, blister, &c. (7th.) Bowels moved several times ; stools feculent and healthy; ab- domen still tense and tender when touched, but not much com- plained of at other times ; no vomiting; pulse frequent and rather weak, so as to prevent us from using farther general bleeding; free topical bleeding was repeated with apparent relief; and in the afternoon she bore pressure much better, though the tenderness was not entirely removed. In the evening she began to sink without any other change of the symptoms, and died in the night. Inspection.—There were extensive marks of inflammation on the surface of the intestines, with deposition of lymph in flakes in many places, and some slight adhesions; there was extensive deposition of puriform fluid in the cavity of the peri- toneum ; the upper surface of the liver was covered by a thin deposition of false membrane. 21 162 ERYSIPELATOUS PERITONITIS. The remarkable epidemic referred to in the preceding obser- vation, seems to have been very analogous to the Diptherite formerly described, though in its progress and terminations it differed considerably from the epidemic of 1826,—in which, as I have already mentioned, the disease often extended to the larynx. This termination occurred in a large proportion of the cases, and nearly the whole of these were fatal. In the epi- demic in the Merchant's Hospital, there was no example of the larynx being affected, and there was no fatal case, except the two now described from this peculiar affection in the peritone- um. About the time when this epidemic was prevailing in the Hospital, I saw in private a good many cases of the erysipela- tous inflammation of the throatj appearing in persons of all ages. It usually presented a general dark redness of the whole fauces, without swelling, but with aphthous crusts more or less extensive. In several of the cases, after this appearance had continued for some days, there was great uneasiness extending along the membrane of the nose, accompanied with a copious morbid secretion, and great tenderness of the membrane. The inflammation extended gradually forwards, until at last it spread outwards upon the integuments of the nose, and thence over the face in the usual form of erysipelas. These cases showed in a very striking manner the identity of the inflammation which had appeared in three situations with different charac- ters ; namely, in the membrane of the throat with extensive aphthous crusts; in the membrane of the nose, with a copious discharge of morbid mucous; in the integuments of the face in the ordinary form of erysipelas. The following case seems to be referable to this part of the subject, though, in some respects, it differs considerably from the cases now described. Case LXXVII.—A gentleman, aged about 50, of a feeble and broken down constitution, about four weeks before his death, suffered for some days intestine pain in the rectum, which terminated in an abscess; and, in connection with it, sinuses were formed along the buttocks. These were opened, and appeared to be going on favorably; and though he was a good deal confined to bed by them, he made no particular com- plaint until the evening of Monday, the 30th of July, 1827, when he was seized with shivering followed by heat and quick pulse. On Tuesday, the fever was much abated, but he had some diarrhoea and vomiting, with griping pain in the bowels. On Wednesday, the vomiting had subsided, the bowels were ERYSIPELATOUS PERITONITIS. 163 moderately open, and the stools were healthy; but there was much general uneasiness over the abdomen, with some hiccup, and his look was depressed and anxious. His pulse was natu- ral and of good strength. On Thursday the hiccup continued, and gave him at times considerable pain ; and he complained of much uneasiness when he brought up wind from his stom- ach ; his pulse was still natural, and the bowels moderately open. The abdomen was not distended, but he complained of considerable uneasiness upon pressure across the epigastric re- gion. His look was depressed, anxious, and exhausted ; and without any change in the symptoms, he died in the night. Inspection.—The cavity of the peritoneum contained a large quantity of purulent matter of intolerable foetor; three pounds and upwards, were collected besides much that was lost. The surface of the intestines was in general of a dark livid color, but without any appearance of exudation. The right lobe of the liver, on its concave surface, was considerably softened, rugged, and unequal; no disease could be discovered in any other organ. The most diligent search was made for any ab- scess or cavity which might have been the source of the mat- ter, but none was discovered. The affection illustrated by these examples differs from the usual forms of peritonitis; and, without speculating farther up- on the nature of it, we may merely add, that its alliance to erysipelas seems to be an obvious and remarkable character of the disease. We have every reason to believe that inflamma- tion of an erysipelatous character may affect the same parts which are liable to the ordinary acute inflammation, but giving rise to symptoms remarkably different. We see this strikingly exemplified in the erysipelatous inflammation of the throat, compared with the ordinary cynanche tonsillaris; and there are many other facts which tend to show that erysipelatous inflam- mation, when transferred to internal organs, produces diseases decidedly different from the common acute inflammation of the same parts. The subject has not been much investigated, but promises some interesting results; and there is one class of dis- eases to which it seems to point in a peculiar manner, namely, the peritonitis of puerperal women. I have not seen so much of this disease as can entitle me to offer a decided opinion from personal observation; but, from what I have seen, and from all the information which I have been able to collect, I have little doubt that women in the puer- peral state are liable to two distinct forms of peritonitis, which in the discussions on this subject, have probably not been suffi- ciently distinguished from each other They are liable to the 164 ERYSIPELATOUS PERITONITIS. common acute peritonitis,—presenting the usual symptoms,— yielding, in a large propoition of cases, to the usual treatment, —and exhibiting, in the fatal cases, the usual morbid appear- ances of extensive pseudo-membranous deposition and adhesion. But they are likewise liable to another form of disease, in which the symptoms are more insidious, and are accompanied, from an early period, by great prostration of strength, and fever of a typhoid character. This affection runs its course with great rapidity; it does not yield to, or does not bear, the usual treat- ment ; and it shows on dissection, chiefly extensive effusion of a sanious, milky, or puriform fluid, with much less adhesion than in the other case,—often with none; and frequently with- out any sensible change in the appearance or structure of the parts. There is little doubt that it is a contagious disease, or that it is capable of being conveyed from one woman who is af- fected with it, to another who is in the puerperal state. It ap- pears as an epidemic at particular times, being very frequent and very fatal while it prevails; and erysipelas, or other affec- tions of an erysipelatous character, have often been observed to be prevalent at the same time. Some of the cases which 1 have described under this section bear an evident resemblance to this formidable disease. This modification of peritonitis we have seen may be fatal without any remarkable change in the organization of the parts ; and there is ground to believe, that, in some cases, it admits of a cure at an advanced period by the evacuation of the matter. In such cases, we have reason to conclude, that the inflamma- tion had been resolved by the effusion, without leaving any in- jury to the organization of the parts. Several cases of this kind have been reported to me, in which, after symptoms of peritonitis, chiefly in the puerperal state, purulent matter either found a vent for itself through the parietes of the abdomen, or was evacuated by tapping, and the patients recovered. I have even observed some facts which induce me to believe that, in some modifications of this affection, a certain degree of perito- nitis is resolved by effusion ; that the effusion is afterwards ab- sorbed, and that recovery takes place by a process of nature alone. This, of course, cannot be ascertained with certainty ; but I have seen cases, with slight and obscure peritonic symp- toms, leave a tumefaction of the abdomen with much suspicion of effusion, which after some time entirely disappeared. CHRONIC PERITONITIS. 165 SECTION V. CHRONIC PERITONITIS. This insidious affection is more common than persons not familiar with pathological investigations are generally aware of. It is a disease of the utmost danger, yet often extremely ob- scure in its symptoms, and can only be treated with any pros- pect of success by the utmost attention to its very earliest in- dications. The symptoms of chronic peritonitis vary considerably in ac- tivity in the early stages. There is generally pain in some part of the abdomen, which may either be permanent, or only occur in paroxysms. The pain is in some cases referred to one de- fined space, and in others is more general over the abdomen ; it is usually increased by pressure on the part, and is often much aggravated by the erect posture and by motion. In some cases, again, there is no actual complaint of pain, but a peculiar tenderness,—the patient always shrinking from pressure on any part of the abdomen. There is occasionally vomiting, which in som ecases becomes urgent in the more advanced stages. There is in general more or less distention tof the abdo- men, which is very often in some degree tympanitic; and, in some cases, defined spots of deep-seated induration may be felt on various parts of it, and these are generally tender to the touch. In a very important modification of the disease, there is no complaint of pain ; the patient merely speaks of a feeling of distention, with variable appetite and irregular bowels, and, with these complaints, becomes progressively emaciated. In many cases, indeed, the early symptoms are so light, that no at- tention is paid to them until the emaciated appearance of the patient excites alarm. The abdomen on examination is then probably found tumid, and in some degree tender at various parts ; and, upon questioning the patient, it is found that there lias been some degree of pain for weeks or months. In other cases, there has been no actual pain, but a feeling of tenderness which gave rise to uneasiness on pressure, or when any part of dress was tight over the abdomen ; but in many cases, the dis- ease steals on to an advanced period without any complaint either of tenderness or pain. . The bowels are commonly more or less confined, but in general easily regulated by mild medicines; in other cases, lax- ative medicine is very uncertain in its operation, being apt either 166 CHRONIC PERITONITIS. to fail of its effect, or to act too violently. Sometimes there is • an occasional tendency to diarrhoea, and this is particularly apt to take place in the advanced stages; in other cases, as the disease advances, great obstinacy of the bowels takes place. The appearance of the motions varies considerably ; in general, I think, they are of a pale color, and of a peculiar foetor, but sometimes they are dark colored, and sometimes natural. The disease may come on gradually and insidiously, without any cause to which it can be ascribed. In other cases, it super- yenes upon attacks of acute affections of the bowels, or upon other febrile diseases^ as measles and scarlatina; it may also supervene upon injuries, as in Case LXXXV. It occurs most frequently in young persons from 10 to 15, and is, I think, less common in infants and children, though in these it is also met with occasionally, and is generally combined with disease of the mesenteric glands. In persons rather more advanced in life, it is often complicated with disease of the lungs; and in another place I have described a remarkable case, in which it was com- plicated with extensive tubercular disease, both in the lungs and in the brain. The progress of the disease is generally by increas- ing emaciation, with small frequent pulse and hectic symptoms, sometimes with diarrhoea. In some cases matter forms and may find its way outwards, either through the parietes of the abdomen, or by the ring of the external oblique, as in Case LXXXVII. On dissection, the bowels are generally found more or less extensively glued to each other and to the parietes of the abdo- men, and the omentum is often involved in the disease. There is sometimes ulceration of the mucous membrane, and not un- frequently the peritoneum is in many places much thickened and studded with small tubercles; in some cases again there is great thickening of all the coats of the intestine at particular parts. In many cases there are left, amid the adhering portions of the intestine, cavities full of purulent matter, which is gene- rally of an unhealthy or scrofulous character. There is fre- quently disease of the mesenteric glands and of the liver or the lungs. In the treatment of this insidious and dangerous affection, every thing depends upon endeavoring to arrest it at its very earliest period; for after it has advanced but a little way in its progress, it is probably irremediable. It seldom assumes so acute a character as to admit of general bleeding, and we must therefore trust chiefly to repeated and free topical bleeding, blistering, confinement, rest, antiphlogistic regimen, and the mild est possible diet. When, under such treatment, the case tep CHRONIC PERITONITIS. 167 minates favorably, we cannot indeed decide with confidence that this formidable disease had existed; but we have always good reason to suppose its existence, when, in a young person, there is deranged health, with tenderness over the abdomen. All that I can say farther on this subject is, that I have seen cases terminate favorably in families, which had formerly suffer- ed from this affection ; and that their symptoms corresponded wiili those which had been observed in the earlier stages of the cases which had been fatal. The following selection of cases will illustrate this disease; and my apology for entering so fully upon the discussion of it, is founded upon its insidious and dangerous character, and the frequency of its occurrence. <§> J.—Chronic peritonitis in its more distinct form. Case LXXVIII.—A lady, aged 32, had been affected with pain in the abdomen through the winter 1813—14, but was not confined, except sometimes a day at a time, until the middle of April, 1814. I-saw her on the 4th of May, and found her af- fected with great pain over the whole abdomen, accompanied by some diarrhoea; pulse about 90. Two days after this, she was suddenly seized with severe pain and tenderness over the whole abdomen, accompanied with great tympanitic distention, re- peated vomiting, and such a degree of sinking of the vital pow- ers, that she seemed to have but a few hours to live. Pulse 120; and small. Bowels still rather loose. Injections of beef tea, with the addition of laudanum and bark in powder, were now given every two or three hours, and were continued in this man- ner for three days. Under this treatment, she gradually im- proved ; the tympanitic swelling subsided ; the pulse came down to 84 ; the vomiting became less frequent, and in a few days more subsided, so that she was able to retain food and medicine. The bowels now became rather confined, requiring the use of small quantities of laxative medicine; but they were easily acted upon, and the motions were always thin and very copious. There was still some degree of tympanitic distention of the abdomen, and she complained of pain, which was chiefly referred to the left side, near the crest of the ileum. At this place, a deep-seated hardness was felt, and jt was acutely pain- ful on pressure. Under the usual treatment, she seemed now for some time to improve, but soon began to fall back again ; 168 CHRONIC PERITONITI> the pulse became more frequent, with hectic symptoms, loss of appetite, some cough, and increasing debility and emaciation. The tympanitic swelling continued, with the hardness in the left side of the abdomen, which was still acutely tender ; but it did not give her much trouble except when it was pressed. The bowels were easily regulated, but the stools were always thin. She died, gradually exhausted, in the end of June. Inspection.—The cavity of the abdomen presented one uni- form mass, produced by universal adhesion of the bowels to each other, in which it was impossible to trace any part of the intes- tine. The parts appeared to be most diseased at the place on the left side, where she had complained of the greatest pain. Here the agglutinated intestines formed a broad, firm surface, which, adhering by its circumference to the parieties of the ab- domen, produced a large cavity, internally presenting a surface of dark, ragged ulceration. Similar cavities of smaller size were found in other parts of the abdomen, some of which contained a clear gelatinous matter, and others pus. There was an ex- tensive abscess in the left ovarium, and another smaller in the right. The stomach, the liver, and the viscera of the thorax were tolerably healthy. Case LXXIX.—A boy, aged 10, (16th June, 1816) com- plained of pain in the abdomen, which was tense and tympanit- ic, and, in several places, tender to the touch; bowels open ; tongue clean ; little appetite ; pulse about 100 ; for a year had been delicate, and liable to swelled glands ; had complained of his abdomen for several weeks. (5th July.) Little change, ex- cept gradual emaciation; belly swelled and tympanitic; pain chiefly referred to the left side of the abdomen which was tender to the touch; bowels open; pulse from 108 to 112. (1st August.) Progressive emaciation and hectic fever; occa- sional attacks of diarrhoea and of vomiting. (10th.) Almost constant vomiting immediately after taking any thing ; occa- sional diarrhoea. Died on the 16th. Inspection. All the viscera of the abdomen were glued to- gether into one mass, except where their union was interrupted by cavities containing purulent matter of a scrofulous charac- ter, and presenting a surface of unhealthy scrofulous ulceration ; the mass likewise adhered so extensively to the parietes, that it was impossible to open the abdomen without cutting into the cavity of the intestine. The stomach, the liver, and the bladder, were included in the adhesions, but the substance of the liver was healthy. IN ITS OBSCURE FORM. 169 Case LXXX.—A girl, aged 10. In this case, the disease went on for a year or more, and was chiefly distinguished by the peculiar and remarkable tenderness of the whole abdomen, without much complaint of pain. She was thin, and looked ill, and the pulse was rather frequent; but she was cheerful, and able to go about; her appetite was tolerable, and the functions of the bowels were natural; she made little or no complaint when her abdomen was not pressed, but she shrunk from the most gentle touch on every part of it. She went on in this manner, with little change, through the winter and spring of 1823—4. During the summer, she began to fall off more rap- idly, with cough and anasarca, which at last became very ex- tensive ; and she died in August. Inspection.—The omentum adhered intimately to the pari- etes of the abdomen, so that it was separated with difficulty. There was extensive effusion in the cavity of the peritoneum. The bowels at the upper part were tolerably healthy; at the lower part, they adhered most extensively to each other, and to the parietes of the abdomen, so as not to allow of the different parts being separated or traced. The left lung was hard and extensively tubercular ; the right was healthy. § H.— Chronic peritonitis in its more obscure form. Case LXXXL—A young lady, aged 16, (April 5, 1816) for several weeks had been observed to lose flesh and strength, with listlessness, and impaired appetite, but without making any complaint. She was now a good deal debilitated, and easily fatigued ; had a hectic look; pulse 120; tongue rather foul; appetite bad ; abdomen tumid and somewhat tympanitic; made no complaint of any pain; she only said that she felt ' stuffed in the belly.' She had not menstruated. Such was the first report of one of the most insidious cases of this affection that has ever occurred to me. The patient was put upon the use of gentle laxatives, with tonics, and the tepid bath. The bowels were found in a very loaded state, and for about a fortnight she continued without any change; she was restless, and hot in the night, and languid through the day, with bad appetite, and quick pulse, but made no complaint of any uneasiness. In the middle of April, she seemed to im- prove considerably; her appetite was much better, and she slept well in the night. She also improved in looks, in spirits, and in strength ; but the pulse continued frequent, being generally 22 170 CHRONIC riRlTONITIi from 100 to 120, and the abdomen retained a considerable de- gree of tympanitic fullness. The bowels were open, sometimes rather loose, with occasional griping pain, but no fixed uneasi- ness, and the motions were quite natural. In May, she began to decline again, without any particular change in the symp- toms, except progressive loss of flesh and strength. There was still no complaint of pain, except at times a little griping; and the bowels were natural. In the end of May, she began to have some vomiting, and occasional diarrhoea; the vomiting be- came more and more frequent, until at last she could retain nothing; she died early in June, having been confined to bed only two or three days before her death. Inspection.—The whole contents of the abdomen presented one solid mass of adhesion, in which it was impossible to dis- tinguish one intestine from another. The mass likewise ad- hered extensively to the parietes of the abdomen; and, in va- rious parts of it, there were cavities containing purulent mat- ter,and presenting, on their internal surface, unhealthy scrofu- lous ulceration. There was also much purulent matter in the cavity of the pelvis. There was much disease of the mesen- teric glands, and the liver was considerably enlarged. The lungs were sound. Case LXXXII.—A lady, aged 24,' had been in delicate health through the winter, 1823—4, being affected chiefly with cough and palpitation of the heart. In the end of April 1824, these symptoms ceased, and she began to complain of pain in the abdomen, which affected her chiefly in walking; it was sometimes a sharp, stinging pain, and sometimes a dull uneasi- ness. She continued to go about, but her health was some- what impaired. She had dyspeptic symptoms, occasional vom- iting, irregular bowels, hysterical affections, and a long train of symptoms, which were often considered as in a measure imag- inary. On one occasion only she complained of so much pain in the abdomen that a bleeding was employed, and the pain was immediately removed. In this manner the complaint went on till about the middle of July, when she felt herself much better, and was preparing to go to the country. She was then suddenly seized with acute pain and tenderness over the whole abdomen, accompanied with vomiting, costiveness, and frequent pulse. This attack continued two days, and then subsided, having been relieved by topical bleeding and laxatives; and she returned to nearly her former state, except that she was more reduced in flesh and strength, and her pulse continued frequent. Her bowels were now easily kept open; but the IN ITS OBSCURE FORM. 171 stools were thin and very offensive; she was considerably ema- ciated, with a look of exhaustion, bad appetite, and a frequent pulse. The abdomen was natural to the feel, except at the lower part, where there was an irregular, knotty hardness, with some tenderness. In this state I saw her for the first time, along with Dr. Thomson, and Mr. Newbigging, in the end of July. She was much exhausted, with a small, frequent pulse, but without much suffering; the lower part of the abdomen was tumid and painful. On the following day the exhaustion suddenly increased, and she died at night. Inspection.—The first incision through the parietes of the abdomen gave vent to a large quantity of purulent matter of remarkable foetor, which was collected to the amount of several pounds. The lower part of the small intestines, the uterus, and the urinary bladder, were firmly agglutinated to each other, and to the parietes of the abdomen, except where they left irregular cavities, lined with a thick deposition of yellow floc- culent matter, and containing a puriform fluid. In the upper part of the small intestines, there were also very extensive ad- hesions, but of a different character, being pale and membran- ous, and without any of the yellow flocculent matter, which was so abundant below. The peritoneal coat of the liver was covered by an extensive deposition of yellow flocculent matter, and there was a similar deposition on the lower surface of the diaphragm on the right side. The thoracic viscera were healthy. Case LXXXIII.—A child, aged 5 years, had been observed for some months to be rather out of health, but without any complaint that could be discovered, except that the abdomen had become somewhat tumid. The appetite was pretty good, and the bowels were regular. No other symptom was remarked, until about a week before his death, when the bowels became obstructed with some vomiting, and great enlargement of the abdomen. I saw him, along with Dr. Begbie, a few days after the occurrence of these symptoms; the bowels did not yield to any remedies that were employed ; the belly became more and more tumid ; and he died about the end of a week from the commencement of this attack. Inspection.—There were extensive adhesions of the bowels to each other, some of which seemed of old date, and others more recent. There was extensive disease of the mesenteric glands, and of the chain of glands by the side of the spine. 172 CHRONIC PERITONITIS <§, HI.—Chronic peritonitis supervening upon measles. Case LXXXIV.—A boy, aged 5 years, (Sept. 1813,) was much emaciated, with a dry wrinkled skin, and a small frequent pulse. He complained of constant pain in his bowels ; the abdomen was a little enlarged, but soft; he had little appetite, and his bowels were irregular, being sometimes confined, and sometimes rather loose. About two months before I saw him, he had passed through measles in a very mild form; but a few days after the termination of the disease, he began to complain of pain in his belly which had continued from that time with progressive loss of flesh and strength. Various remedies were employed without benefit. He became gradually more and more emaciated, with constant pain in the belly, and occasional diarrhoea ; and died in the end of November. There had been no cough at any period of the disease. Inspection.—In attempting to open the abdomen in the usual manner, it was found impossible, owing to close and extensive adhesions of the intestines to the parietes in every direction. They were also found to adhere so extensively to each other, that it was impossible to distinguish one intestine from another; and the intestines adhered likewise to the stomach, to the liver, and the urinary bladder. In the cavity of the peritoneum, there were found large quantities of coagulable lymph, in the form of a consistent transparent jelly. The mesenteric glands were much enlarged ; and the liver was also somewhat enlarged, but healthy in its structure. The lungs were studded with numerous tubercfes, but they were all in a solid state; and there was considerable effusion in the cavity of the pleura. § IV.—Chronic peritonitis of the colon supervening upon an injury. Case LXXXV.—A man, aged 21, a carter, (July, 1818,) was emaciated to a great degree, with effusion in the abdomen, and anasarca of the legs; some difficulty of breathing; pulse small and frequent; bowels quite open, sometimes rather loose ; complained of pain extending across the upper part of the abdomen; sometime before, it had been chiefly referred to the right hypochondrium, and had been treated as an affection of the liver. In the beginning of the year, he had received a blow on the abdomen, by a piece of coal which fell upon him WITH DISEASE OF THE OMENTUM. 173 as he was unloading a cart, and from that time he had com- plained of-uneasiness in the abdomen, but not so severe as to confine him from his work, until some weeks after, when he received another injury by being squeezed between his cart and a wall. After this the pain in his bowels increased, and he had frequent attacks of nausea and some vomiting; but these symptoms ceased after a short time, and the complaint then went on in a gradual but obscure manner, till the time when I saw him. He died in the end of July. Inspection.—The liver was healthy. The arch of the colon, and the descending colon, were covered by an extensive depo- sition of coagulable lymph, and had formed most intimate ad- hesions to the parietes of the abdomen, and to all the neighbor- ing parts. They formed a mass of disease, the parts of which could not be separated from each other, and in which were in- cluded the stomach and several turns of the small intestine. The coats of the colon were much thickened, especially on the left side, where they were in some places half an inch in thickness. The pancreas was hard, and contained several small abscesses. In the cavity of the peritoneum, there was copious effusion of a whey colored fluid. The lungs were healthy. "§> V.—Chronic peritonitis complicated with disease of the omentum. Case LXXXVI.—A gentleman, aged 54, of a full habit, and previously enjoying good health, about Christmas, 1823, com- plained of nausea and loss of appetite. After a few days, he was seen by Dr. George Wood, who found his tongue white, his bowels irregular, and his pulse a little frequent. His nights were restless, and his general feelings extremely uncomfortable, but without any defined uneasiness, except some obscure and wandering pains extending along both sides of the abdomen, sometimes into the back, and sometimes along the sides of the thorax. He had continued in this state for about three weeks, when I saw him along with Dr. Wood in the middle of January, 1824. His look was then anxious, but without much wasting; tongue white ; pulse about 96 ; little appetite; a good deal of thirst. He complained of an undefined uneasiness across the epigastric region, and about the sides of the abdomen, which was increased by the horizontal posture, so that he was either out of bed and dressed, or sitting in bed supported by pillows. The abdomen was somewhat tumid, with an obscure feeling of 174 CHRONIC PERITONITH fluctuation. Immediately below the epigastric region, there was a deep-seated hardness, extending across for five or six inches ; and there was another hard spot of small extent, about half way betwixt the umbilicus and the pubis. Pressure occa- sioned little uneasiness. The bowels were easily moved, and the motions were natural, but scanty. He had a constant feel- ing of nausea, which, in fact, was the principal uneasiness that he complained of. Various remedies with little benefit, and, for some time, there was little or no change in the symptoms. He then began to have occasional vomiting; his nights became very disturbed; and he frequently laid his hand across the upper part of the ab- domen, as being the seat of much undefined uneasiness ; his bowels continued to be easily regulated. The vomiting increas- ed in frequency, and at last he had retching of dark brown and black mucus. His strength then sunk rapidly, and he died in the end of February. Inspection.—The tumor in the epigastrium was formed by the omentum drawn up into an oblong mass, nearly two inches in thickness, and internally of a pale color and firm tubercular subsistence. The intestines were of a very dark color, and ad- hered extensively to each other, and to the parietes of the ab- domen. The hard spot which had been felt below the umbili- cus, was produced by one of these adhesions of a part of the ileum to the parietes. The peritoneum lining the parietes of the abdomen was diseased through its whole extent; in many places much thickened and in some almost cartilaginous. Its in- ternal surface presented a variegated appearance of dark red por- tions mixed with others which were almost black; and in some places there were spots resembling small superficial ulcers. In the cavity of the abdomen there was considerable effusion of a clear serous fluid. § VI.—Chronic peritonitis with extensive suppuration mak- ing its way outwards by the ring of the external oblique. Case LXXXVIL—A man, aged 40, (August, 1814,) had severe pain of the abdomen, which was hard and tense, with occasional vomiting; much wasting; bowels irregular; had been ill for four or five months. A short time after I first saw him, he was suddenly seized with a swelling, which appeared at the ring of the external oblique of the left side, and extend- ing rapidly along the scrotum. After watching the progress of WITH SUPPURATION. 175 this swelling for some days, the scrotum was punctured, and discharged very fetid purulent matter, in such quantity as im- mediately showed a communication betwixt the swelling and the cavity of the abdomen; and pressure upon the abdomen made it flow very freely. About a week after this, a fluctuating swelling appeared on the right side of the abdomen, which was opened, and discharged much purulent matter; he became more and more exhausted, and died in the middle of Septem- ber. Inspection.—The abdomen was much diseased, being thick- ened, ulcerated, and studded with numerous tubercles; and it adhered intimately both to the intestines and to the parietes of the abdomen. The intestines likewise adhered most extensive- ly to each other, and to the parietes ; the peritoneum was in general much thickened. On the right side of the abdomen, there was an extensive collection of purulent matter, which ex- tended upwards behind the intestines as far as the liver. It had eroded the peritoneum by a small round opening, about an inch in diameter ; and had spread itself among the muscles, and under the integuments, forming the swelling which was opened on the right side. On the left side, the matter seemed to have been contained in a cavity betwixt the peritoneum and the ab- dominal muscles. To this outline of a subject of much practical importance, I have only to add, that cases referable to it, sometimes terminate favorably under circumstances apparently most unpromising. During the present season, I saw, along with my friend Dr. Ross, a girl about twelve years of age, whose case he had been watching with much anxiety and interest. Her complaints be- gan with symptoms of a peritonic character, which at first were acute, and afterwards assumed a chronic form, with various re- missions and relapses. After several weeks, a defined, deep- seated swelling was felt in the left side of the abdomen, which gradually increased, with much constitutional disturbance, de- bility, and emaciation. At the end of about two months, this swelling suddenly diminished, and she then began to discharge from the bowels purulent matter, in large quantities, and often without any mixture of feces. Her general health was now much impaired, and the case had a most unpromising aspect; but the discharge of matter, after continuing for many weeks, gradually subsided; the swelling in the abdomen disappeared in the same gradual manner, and she has recovered excellent health. The whole duration of the complaint was about five months. PART III. INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL. The inflammatory affections of the mucous membrane of the intestinal canal presents a subject of great interest and con- siderable difficulty. In the diagnosis of them, much attention is required in their earlier stages; because it is only at this period that many of them can be treated with any prospect of success ; and because, without very great attention, they are apt to be confounded with diseases of a much less dangerous character. This arises from the circumstance, that symptoms, very similar to those which proceed from extensive disease of the mucous membrane, may be produced by various irritations applied to the membrane in a healthy state, constituting two classes ot disorders, very different in their nature, and implying very dif- ferent degrees of danger. Thus, we may have the symptoms of diarrhoea or cholera, arising either from the presence of acrid matters, or from disease of the mucous membrane; in the one case, constituting an affection of little danger; in the other, a disease of the most alarming kind. In the former manner are produced the common diarrhoea and cholera of this country, which are seldom fatal affections; in the latter, the various forms of dysentery, and the cholera of India, one of the most formidable diseases with which the human race has ever been visited. It is necessary to keep in mind certain sources of fallacy, in regard to the morbid appearances of mucous membranes. From numerous observations, we may now consider it as ascer- tained, that many of the appearances in mucous membranes, which have often been considered as marks of disease, are merely changes of color, or accidental vascular congestions, which may take place a short time before death, or even after death. They are accordingly met with in the bodies of per- sons who have died of other diseases, without any symptoms referable to the bowels ; and of those who have died from vio- lent deaths, as execution or drowning, without any suspicion of previous disease. Among the appearances referable to this head, may be reckoned the following: suffusion or increased MUCOUS MEMBRANE OF THE INTESTINE. 177 vascularity of particular parts of the mucous membrane, or a uniform redness of portions of it, more or less extensive; spots and patches of various sizes, and various colors, as red, blue, green, livid, brown, or black, without any change of texture of the part; and ecchymosis or slight extravassion of blood into the cellular texture connected with the membrane. These and some similar appearances, not connected with any change of texture, and not showing any of the actual results of inflam- mation, are not worthy of any confidence in a pathological in^ quiry. In entering upon this subject, therefore, I shall first describe the principal changes, observed in the mucous membrane of the intestinal canal, which we are warranted to consider as morbid. I. Portions of the membrane of greater or less extent, show* ing a uniform and high degree of rednesr, with slight flakes of coagulable lymph, or a more continued ceating of false mem« brane, attached to its surface in various places. This appear-. ance is seldom observed in this country, but it seems to mark the intense form of the disease, such as occurs in the most rapid cases of the cholera of India. It is exemplified in Case XCIII, and probably marks the earliest period of that form of the disease, which, in its more advanced stage, may terminate in extensive gangrene of the membrane, as exemplified in Case LXXXIX. In a modification of the disease, which seems to be different from the former, the affected portion is covered by a thin uniform coating, like the crust of aphthae; the mem* brane beneath showing a high degree of redness when the crust is removed. This uncommon appearance is shown in Case XCIV; but the phenomena connected with it have not been sufficiently investigated. II. The mucous membrane covered to a greater or less ex* tent with irregular patches, of a bright red color, and sensibly elevated above the level of the surrounding parts. These poj> tions vary in size, being in general, one or two inches in diam- eter, with sound portions of considerable extent interposed be* tween them. They are, in some cases, covered by a brownish tenacious mucus; in others, by flakes of false membrane; and frequently the surface of them is studded with minute vesicles, which at a more advanced period seem to pass into very small ulcers. These are the appearances most commonly observed in the simple dysentery. In this affection, they are generally confined in a great measure to the lower part of the colon au4 23 17.^ INFLAMMATORY AFFECTIONS. the rectum; when they are seated in the small intestine, and the colon is healthy, the symptoms differ remarkably from those which commonly receive the name of dysentery, as we shall see in the sequel. The appearance of circumscribed elevated portions of the membrane is also met with in a chronic form, gradually fatal by long protracted disease, as in Case XCIX. III. An extensive portion of the mucous membrane exhibit- ing a soft consistence of a uniform black color, or what may be properly termed gangrene of the membrane. This appear- ance is illustrated by cases LXXXIX, and XCVI. The result of it has sometimes been the separation of considerable por- tions of the membrane, so as to expose the muscular coat, or even to leave the cavity covered only by the peritoneal coat, the muscular being involved in the disease. It has not been sufficiently investigated, whether the morbid appearances described under the preceding heads indicate dif- ferent periods of the same affection, or are distinct forms or degrees of the disease. The latter seems to be more probable supposition; and there is every reason to believe, that the dis- ease differs in its nature, by being, in some cases seated in the mucous membrane itself, in others, in the mucous follicles; and in others, by involving both these structures at once. Another form has likewise been supposed to exist, in which it is prima- rily seated in the cellular texture betwixt the mucous and mus- cular coats; but this must be considered as in a great measure conjectural. The most common form which the disease exhib- its in this country, when it is fatal at an early period, consists of the irregular elevated patches of inflammation as in Case LXXXVHI; and this, at a more advanced period, seems to pass into the irregular continued ulceration to be afterwards described. It appears to be a different state or form of the disease from that which terminates by the uniform covering of false membrane, as in Case XCIII, or by the actual gangrene, as in Cases LXXXIX, and XCVI. IV. Minute dark colored spots spread extensively over a por- tion of the membrane and each surrounded by a small but dis- tinct areola of inflammation. This appearance I have observed only when the patient has died of another disease, the symptoms in the bowels having been nothing more than a tendency to di- nfthTm 1S e,Xnmflified in Case CL It is probably a disease wh ch SI f°"1CleS? and the earliest Peri°d of an affection, ulcers ^dhave terminated in the formation of small detached exemmifi.H " r ^1 An°ther disease of these Glides is fionT hi'" aSG CXIL m Which the Pr°S'ess of the affec- bercle iT™" ""! lnterest^ man^r : being first a solid tu- bercle—then a pustule—and then an ulcer. MUCOUS MEMBRANE OF THE INTESTINE. 179 V. Small round or oval portions of the mucous membrane, of a dark gray color, and soft pultaceous consistence. These are easily separated, and leave ulcers, or rather excavations, cor- responding to their size. This appearance seems to be the ter- mination of inflammation confined to small defined portions of the membrane; or, perhaps, is primarily situated in the mucous follicles, and involves a small portion of the membrane immedi- ately sourrounding them. VI. The surface of the mucous membrane covered by nume- rous small spots of an opake white color, which are found, upon -„ examination, to be vesicles, very slightly elevated, but contain- ing a small quantity of clear fluid. This uncommon appearance is exemplified in Case CXIX. VII. Ulcers of various appearance and extent. The princi- pal varieties of these seem to be referable to the following heads : (1.) Small defined portions of excavation rather than actual ulceration, as if a portion of the membrane had been dissected out. This appearance is probably produced in the manner re- ferred to under the fifth head. (2.) Portions of various extent in a state of more decided ul- ceration ; covered at the bottom with yellowish or dark colored sloughs, and often having irregular and elevated edges. These may be detached and at some distance from each other, and vary in size from that of a sixpence to a shilling or more ; or an extensive portion of the membrane may be in a state of al- most continued ulceration,—the diseased surface being merely variegated by portions in a state of dark red fungous elevation, running irregularly over it, and separating the ulcerated spaces from each other. .This appearance generally occurs in chronic cases,-and is exemplified in Cases CII and CIII; but is also met with in connection with recent and acute disease in the very remarkable case (Case XC.) In other examples, the elevated inflamed patches described under the second head are found covered with small ulcers, sometimes not more than a line in diameter. (3.) Small round well defined ulcers like the deep' pits of small pox, or sometimes very much resembling chancres ; deep- ly excavated with round and elevated edges. They are gener- ally at a considerable distance from each other, and the inter- vening membrane is healthy. The cases in which these occur are generally chronic, as in Case C, but they are found in con- nection with acute disease in Cases XC and CXII. The prima- ry seat of them is probably in the mucous follicles ; and the ap- pearance described under the fourth head seems to mark their earliest stage. They are evidently quite distinct in their nature from the more extensive form of ulceration previously referred to. 180 INFLAMMATORY AFFECTIONS. (4.) Large and deep ulcers with elevated fungous edges, and a dark fungous appearance in the bottom. These differ from all the former, in not appearing in numbers covering some con- siderable extent of intestine ; but perhaps, only one or two of them may be met with, of the size of a shilling or upwards ; and they are generally accompanied by some degree of thickening of the portion of intestine in which they are situated. The his- tory of these is obscure. There is reason to believe that they may exist for a considerable time with very slight symptoms, or without any symptoms which lead to a suspicion of their exis- tence. They may be fatal by*hsemorrhage, as in Case CX ; or ^ by perforating the intestine and leading to rapid peritonitis. They are also met with in acute diseases very rapidly fatal, as in Case CXI; but we are not prepared to say, whether in such a case they had been the cause of the symptoms, or had existed previously, and by the acute attack, been hurried on to a fatal termination. Ulceration of the mucous membrane, under all its forms, frequently goes to scch a depth as entirely to perforate the intestine; and the cuse is then speedily fatal by a very rapid peritonitis. In such cases, we sometimes see -several of the appearances now described combined in the same diseased por- tion, so as to show the affection in its different stages. We may find, for example, a small deep ulcer, which has perforated the intestine by an aperture, which would admit a quill; this surrounded by a circle in a state of superficial ulceration, and this by a ring of inflammation. VIII. Portions of the mucous membrane are sometimes found covered by small, firm tubercles. Pustules ^resembling small pox are also occasionally met with. During the whole progress of the various diseases of the mucous membrane, the peritoneum sometimes continues entirely healthy, so that, on first opening the abdomen, even in very protracted cases, there is no external appearance of disease. In others, there are patches of a deep red or livid color, as if shining through the peritoneal coat, or the uniform black tinge of actual gangrene, as in Case LXXXIX,—the peritoneum itself, however, still continuing entirely healthy. The affection sometimes passes into extensive peritonitis a short time before death, and this happens in two ways. In the one, a small ulcer perforates the intestine, and the inflammation spreads iapidly in all directions, probably produced by the escape of the con- tents of the intestine into the peritoneal cavity, as is exemplified in Cases LVIII—XCVII, and CXII. In the other, the peri- MUCOUS MEMBRANE OF THE INTESTINE. 181 tonitis seems to take place more directly from the inflammation extending through all the coats, without any appearance of per- foration. This probably occurred in Case XCI. In many of the acute cases, the diseased intestine acquires a soft and thickened appearance, which has been compared to that of boiled tripe; in the chronic, thickening is still more common,—the affected part acquiring a great degree of thick- ness, and an almost cartilaginous hardness, which seems to involve the whole structure of the intestine. In some of these the intestine becomes contracted at the thickened portion; in others, it becomes distended into large defined cysts, with an internal surface of dark, ragged ulceration; and the parietes of these cysts sometimes acquire such a degree of thickness and hardness, as to exhibit, during the patient's life, the characters of a mass of organic disease. This affection is strikingly illus- trated by Cases CVII and CIX. Extensive adhesions of the peritoneal surface likewise occur, so that the whole bowels may be glued together, as in the common cases of chronic peritonitis. The appearances now described may probably be considered as the principal morbid conditions of the mucous membrane of the intestine; and the enumeration seems to include all those which, in the present state of our knowledge, can be consider- ed as essential in this investigation. The inquiry has been in- volved in much obscurity by a practice prevalent among conti- nental writers, of giving a place in the pathology of mucous membranes, to mere changes of color, and these often of very small extent. The principal varieties of these changes have already been briefly referred to; and it seems to be of the ut- most consequence to have it distinctly admitted, that in our researches on the pathology of mucous membranes, they are entirely unworthy of confide/ice. Among the symptoms which chiefly engage our attention in reference to the diseases of the mucous membrane, the state of the bowels is naturally prominent; but I think we are often, in such cases, too apt to form a judgment of the affection from the character of the evacuations, and to conclude that no seri- ous disease exists, when they are feculent and of a healthy appearance. We shall see reasons in the sequel to be satisfied of the fallacy of this conclusion ; and to be convinced that most extensive and deep seated disease may be going on, with feculent and healthy evacuations. The effects upon the functions of the bowels in connection with these diseases, are chiefly referable to the following heads: (1st.) A simply irritable state of the bowels, with thin feculent 182 INFLAMMATORY AFFECTIONS. discharges. (2d.) Morbid discharges from the diseased sur- faces of various kinds, as watery, mucous, bloody, puriform. (3d.) Various mixtures of these matters with the feculent evacuations. (4th.) Various changes in the appearance of the feculent evacuations themselves, in consequence of articles passing through in a partially digested state, or frequently almost entirely unchanged; also from the mixture of bile or other matters from the upper part of the bowels. In this gen- eral outline it is impossible to give a full account of the diffe- rent appearances which the evacuations assume, in connection with the various forms of the disease; but the following brief statement may be given, with reference to the morbid condi- tions which have been mentioned. I. In the morbid condition described under the first head, there may be merely a highly irritable state of the bowels, in which the evacuations are at first thin and feculent. In other cases, we find evacuations of watery matter of a bloody or a dark brown appearance, and of great foetor. But in regard to all the forms of the disease, it is to be kept in mind, that the pe- culiar discharges from the diseased surfaces are only to be dis- tinctly recognized when the disease is in the colon ; when it is in the small intestine, the appearances are disguised or modified by the mixture of these discharges with thin feculent matter, or with articles of nourishment partially changed. II. The appearances described under the second head pro- duce, when seated in the lower part of the intestine, the dysen- teric stools commonly so called ; namely, frequent scanty dis- charges of bloody mucus, while the natural feces are retained, or discharged only in small scybalous masses. These seem to take place when the disease is confined to the rectum and the lower part of the colon,—a form of the disease which is of fre- quent occurrence, and probably constitutes the dysentery of systematic writers. When the whole tract of the colon is affect- ed, there are no scybala?, but occasional discharges of thin fecu- lent matter from the healthy parts above; while the more fre- quent evacutions consist of the bloody mucus, dark watery mat- ters, or. muco-purulent discharges from the diseased surface, coming off sometimes alone, and sometimes mixed with the fec- ulent matter from the parts above. But when the disease is in the small intestine, and the colon healthy, the appearances are entirely different. The proper discharges from the diseased sur- face are then seldom seen uncombined, and their characters are disguised by being mixed, either with thin feculent matter, or with articles of food or drink partially changed. The chronic MUCOUS MEMBRANE OF THE INTESTINE. 183 form of the disease referred to under this head, I think in gen- eral produces merely an irritable state of the bowels, without any thing particularly morbid in the character of the evacua- tions. III. The discharge connected with the appearance under the third head, appears to be a dark brown or black watery matter of remarkable foetor, which has been compared to the washings of putrid flesh. IV. The condition described under the fourth head seems merely to produce a very irritable state of the bowels, without any sensible discharge from the diseased surface, and without anything particularly unhealthy in the evacuations. V. The same observations will probably apply to the appear- ance described under the fifth head, except that it may occa- sionally be possible to recognize in the evacuations the softened and separated portions of the mucous membrane, which however is not probable. VI. The discharges connected with the case more particular- ly referred to under the sixth head, consisted of large quantities of very firm tenacious mucus, assuming sometimes the form of tubes,.and sometimes that of solid cords of remarkable density; and these were varied at other times, by the evacuation of large quantities of semi-transparent gelatinous matter. These dis- charges, however, had entirely ceased for a considerable time before the death of the patient. VII. The appearances connected with ulceration of the mem- brane vary exceedingly, according to the extent of the disease, and the seat of the ulcers. (1.) The ulcers described under the first and third varieties, I think merely produce an irritable state of the bowels, with gra- dual wasting, without any peculiar discharge. (2.) The ulceration described under the second head pro- duces copious discharges of muco-purulent matter, generally streaked with blood, and sometimes mixed with shreds of flaky matter. When the disease is in the colon, this discharge comes off in large quantities,—sometimes quite uncombined, and at other times mixed with feculent matter. When it is confined to the rectum or the lower part of the colon, this feculent matter may be consistent, formed, and entirely healthy ; but, when the whole tract of the colon is diseased, the feculent matter is thin, and comes off more mixed with the morbid discharge. On the other hand, when the disease is in the small intestine, and the colon healthy, the peculiar discharge will seldom be seen un- combined, as it will generally come off mixed with thin feculent matter. Portions of flaky matter may occasionally be seen in 1*4 INFLAMMATORY AFFECTIONS. such cases floating in the evacuations ; but in other cases, they have merely a thin feculent appearance, and are generally of a pale color, and of a remarkable and peculiar foeter. (3). The symptoms connected with the large ulcers, No. 4, are very obscure. They have been found where no symptom had indicated their existence, previously to the attack which was suddenly fatal, as in Cases CXIII. and CXIV. In other cases, they appear to have been productive of deranged health, with impaired digestion and an irregular state of the bowels, but without any symptom which had distinctly indicated the nature of the disease. The preceding outline, I am aware, may be considered as te^ dious and uninteresting, but it appears to be of importance in the pathology of the mucous membrane of the intestinal canal. In a practical point of view, the affections seem to arrange themselves into three classes. I. Active inflammation of the mucous membrane, which va- ries considerably in its characters, according to the extent and the seat of the disease. It may be fatal in the inflammatory stage,—by gangrene,—by ulceration,—and by passing into peri- tonitis. II. Chronic disease of the membrane. This may supervene upon an acute attack, or may come on in a gradual and insidi- ous manner without any acute symptoms. It generally goes on for a length of time, and is fatal by gradual exhaustion; and shows upon dissection fungoid disease of the membrane,—ul- ceration of various characters,—or thickening and induration of all the coats of the intestine. It may be fatal more suddenly by perforation of the intestine and rapid peritonitis. III. An interesting modification of the disease may be con- sidered separately, as a matter of practical interest, though there is no real distinction in its pathological characters. It is that in which ulcers of some extent seem to exist for a length of time in the mucous membrane, without producing any symptoms which lead to a knowledge of their existence, until they are un- expectedly fatal in a manner to be hereafter mentioned. The phenomena connected with these various states of dis- ease present a subject of much interest, of which I cannot hope to give more than a slight and imperfect outline. INFLAMMATION OF THE MUCOUS MEMBRANE. 185 SECTION I. ACTIVE INFLAMMATION OP THE MUCOUS MEMBRANE OF THE INTESTINE. The symptoms accompanying active inflammation of the mu- cous membrane vary considerably according to the seat and ex- tent of the disease. There is generally pain in the abdomen, in some cases permanent, in others occurring in paroxysms of tormina; and it is usually accompanied by considerable tender- ness when rather severe pressure is made, but distinct from the acute sensibility which accompanies the inflammation of the peritoneum. There is more or less irritability of the bowels, sometimes in the form of diarrhoea, with copious stools; and sometimes of painful tenesmus with frequent scanty discharges of bloody mucus. There is generally some degree of fever, with thirst, febrile oppression, and a parched tongue; but oc- casionally the pulse is little affected through the whole course of the disease. There is frequently vomiting, but not urgent; sometimes hiccup ; and sometimes a peculiar irritability of the stomach and bowels,—articles taken exciting a burning uneasi- ness, succeeded by irritation, and a sensation as if they almost immediately passed through the canal. The calls to stool are sometimes very frequent, occurring, perhaps, every ten or fifteen minutes, with much painful tenes- mus ; but in other cases the disease may be going on in the most alarming manner, while the bowels are not moved above four or five tines a-day. The evacuations vary exceedingly in their character; consisting in some cases, of small quantities of bloody mucus, or almost pure blood; in others, of a tenacious semi-purulent matter of a peculiar foetor, without blood, or with only slight streaks of it; and sometimes membranous crusts are discharged, like coagulable lymph, in irregular por- tions ; but in some instances, the evacuations are more abundant and consist of a watery matter of a dark brown color, and re- markable foetor ; or of a bloody watery fluid like the washings of flesh. The natural feces are in some cases retained, or dis- charged only in small scybalous masses mixed with the morbid evacuations. On the other hand, it is a most important fact, in the history of the disease, that the evacuations are, in some cases, thin and feculent, like those of a common diarrhoea; that they may continue so through nearly the whole course of the disease; or, that they may consist of thin and healthy feces in 24 186 INFLAMMATION OF THK MUCOUS MEMBRANE. the early stage of the attack, and that the morbid discharges may not begin to appear until it has gone on for several days. In certain states of the disease, again, the evacuations are far- ther varied by a mixture with bile, either in a healthy or a morbid state, and by articles of food or drink which pass through near- ly unchanged. I have endeavored to state the principles which appear to regulate these important varieties. The disease seems to ex- ist in several different forms, in one of which the discharge from the diseased surface consists of mucus, more or less tinged with blood ; in another, of a red or brown watery matter; in a third, of a muco-purulent fluid ; and there seems to be a fourth," in which the effect is chiefly a morbid irritability of the parts without much discharge from the affected surface. When the disease is confined to the rectum and lower part of the co- lon, the discharge from the diseased surface comes off uncom- bined, while the healthy feces are apt to be retained, or dis- charged only in small scybaloe, except when, by the operation of purgative medicine, natural feces are brought down from the healthy parts above. When the disease extends along the whole course of the colon, or into the small intestine, the first effect of the increased irritability of the parts appears to be, to empty the lower bowels of all their feculent contents ; after which, the evacuations will consist, at one time, of the morbid discharges from the diseased surface, at another, of fluid feces from the parts above, and of various combinations of these with each other. On the other hand, if the disease be chiefly seat- ed in the small intestine, while the colon is healthy, the morbid discharges will be less apparent, because they will seldom come off uncombined. The effect in this case will probably be, a general increasedj action of the whole canal; and the matter evacuated will be either fluid feces, more or less mixed with the morbid discharge, articles of food or drink partially changed, or various combinations of these three substances, producing frequent changes in the appearance of the evacuations. In other cases, again, when the appetite and digestion are much impaired or nearly suspended, the first effect of the disease may be to clear the canal of all healthy feces, after which no more may be produced. In such a case, therefore, the evacua- tions may at first be healthy, like those of a simple diarrhoea, and afterwards consist of the morbid discharges from the dis- eased parts. These statements agree with what we actually observe in the history of the disease, and on dissection. In some cases, healthy feces in a firm state may be found retained above the seat of the disease; and in Case XCVIII. there was SYMPTOMS. 187 fluid feces of a perfectly healthy appearance in immediate con- tact with the diseased surface. On the other hand, in Case LXXXVHI. in which, after the period when the description begins, the evacuations consisted entirely of small quantities of bloody mucus, there was no appearance of feculent matter in the whole course of the canal. We shall also see the affection running its course to a fatal termination, with feculent evacua- tions of a healthy appearance, when the disease is seated in the small intestine ; and in one very severe example, we shall find the evacuations sometimes feculent and healthy, and sometimes consisting chiefly or entirely of articles of food which had passed through unchanged. Bampfield remarks, that he has seen milk which had been taken, pass through four hours after in the form of soft curd, moulded into shape by the action of the intestine ; and he adds, that it occasioned excruciating pain, and required constant fomentation to allay the tormina which it excited in its passage through the diseased portion of intestine. The principles now referred to indicate the sources of im- portant varieties in the phenomena of this class of diseases; but there are other circumstances worthy of much attention. Inflammation of mucous membranes exists in different states or degrees ; in some of which it has a tendency to a spontane- ous cure,—the discharge from the membrane gradually under- going certain changes, during the progress of which the in- flammation subsides. This is most remarkably exemplified in the catarrhal inflammation of the bronchial membrane; but we see also that the danger of this disease, in its mildest form, is in proportion to its extent; and Laennee has a case beginning like a simple diarrhoea, and, after several days, exhibiting symptoms which mark the presence of this dangerous affection. In a less active form, it accompanies or follows many diseases of a scrofulous nature, forming what is commonly called the colliquative diarrhoea. When the disease is confined to the lower part of tfie bowels, it forms the dysentery of systematic writers ; but this is only one modification of it, and not the most dangerous; and we shall see abundant reason to believe, that its characters vary in a remarkable degree, according to its seat,— and that some of the most dangerous modifications of it are those which, according to the characters laid down by systemat- ic writers, ought to receive the name of diarrhoea, not of dysen- tery. The dysentery of this country is, in many cases, a mild dis- ease, attended with little danger ; and the affection seems to be seated, in a large proportion of cases, in the rectum or the lower part of the colon. It is accompanied by tenesmus, with scanty discharges of bloody mucus, and but little appearance of healthy feces : there is generally some degree of fever, with more or less of constitutional disturbance, and frequently vomiting. When- ever such symptoms however, occur, a disease is present which SYMPTOMS. 189 requires to be watched with much attention. While it is limit- ed to a defined portion of the lower part of the intestine, it may be a disease of little danger ; but it is to be kept in mind, that its danger is generally in proportion to its extent. If it be at- tended with pain and tenderness extending above the pubis, and along the course of the ascending colon, the case is becoming more precarious. If there be tenderness and tension extending along the epigastric region, so as to give reason to apprehend that the arch of the colon is involved in the disease, the case is more and more alarming; when there is reason to fear that it affects the whole course of the great intestine, the danger is ex- treme. There is generally, in this case, much constitutional disturbance, with quick pulse, thirst, anxiety, vomiting, hiccup, and rapid failing of the vital powers ; the evacuations from the bowels vary in the manner which has been already referred to ; being cither mucous, watery, or feculent, or consisting of various combinations of these matters with each other. In all affections of the mucous membrane, the appearance of the tongue is deserving of particular attention. In many cases it shows no peculiar character, or only the usual appearances of febrile diseases ; but in others its indications are more impor- tant ; and there are two conditions of it which are to be con- sidered as marking dangerous conditions of the disease. The one is the dark parched tongue of typhus ; the other is a pecu- liar rawness, redness, and tenderness often accompanied with aph- thous crusts ; and frequently these crusts may be seen extending along the pharynx. A very interesting modification of the disease of the mucous membrane occurs in the course of continued fever. This may either have been known to exist for sometime by the Usual symp- toms, or it may not have been discovered until it proves rapidly fatal. In either case the affection may be fatal by exhaustion, by peritonitis, or by haemorrhage. There is also a modification of the disease of very great im- portance, which affects infants. Though the phenomena ac- companying this form accord with the general history of the af- fection, yet in a practical point of view it will be worthy of a separate consideration. Inflammation of the mucous membrane of the intestine may terminate in several ways, the most important of which are the following:— I. It may be fatal in the inflammatory stage,—a greater or less extent of the membrane presenting numerous patches of redness, which are in general sensibly elevated above the level 190 INFLAMMATION OF THE MUCOUS MEMBRANE, of the surrounding parts; and in some cases, these elevated portions present on their surface numerous minute vesicles. These are most commonly observed in the disease as it appears in infants ; and at a certain period of their progress, the vesicles seem to pass into minute ulcere. II. By gangrene, a portion of the mucous membrane ap- pearing of a uniform black color, and of a very soft consistence, in which the muscular coat in some cases appears to participate. Vesicles full of a putrid, fetid fluid have also been observed upon the membrane. III. By ulceration of various extent and appearance, gener- ally mixed with fungous elevations. IV. By passing into peritonitis or enteritis. This takes place in two ways. In the one, the inflammation seems to extend uniformly through the coats, until they are all affected; in the other, one of the ulcers perforates the intestine, its contents-es- cape into the peritoneal cavity, and very rapid peritonitis imme- diately follows. The leading phenomena connected with the various forms of this important class of diseases will be illustrated by the following examples. <§> I—Inflammation of the mucous membrane of the intestine, confined to the rectum and part of the ascending colon. This is the dysentery of systematic writers, in which there is much tenesmus with scanty discharges of bloody mucus, and retention of the natural feces, or the occasional appearance of scybalae. I have not seen it as a fatal disease; but it is evi- dently the affection described by Dr. Donald Monro and other writers of his period, and the disease on which Dr. Cullen has founded his definition of dysentery. Dr. Monro gives few de- tails of individual cases ; but his account of the appearances on dissection, even in the older cases; is, < in all of them the rec-. turn was inflamed, and partly gangrened, especially the internal coat; in two, the lower part of the colon was inflamed, and there were several livid spots on its great arcade.' In one, whose body was much emaciated, and who had been seized with violent pain of the bowels a few days before death all the small guts were red and inflamed; and in another, there were livid gangrenous spots in the stomach. In his account of the symptoms which attended this affection, he says, 'the stools EXTENDING ALONG THE COLON, &C. 191 were chiefly composed of mucus mixed with bile, and more or less with blood; though sometimes no blood could be observed in them.' He then describes the state of the febrile symptoms, and adds, ' it often happened that after the dysentery had con- tinued for sometime, the sick complained for a day or two of severe gripes, and then discharged along with the stools little pieces of hardened excrement.' At other times, though more rarely, little pieces of white stuff like .tallow or suet were dis- charged ; and frequently filaments or pieces of membrane were found floating in the evacuations.* In some of Bampfield's cases, the sensation of the patient was described to be as if a stake or hot iron were forcibly perforating the rectum ; and in many of these, the verge of the anus in its whole circumference appeared red, inflamed, and tumid. The tenesmus in cases of this class, goes on with scanty morbid discharges from the dis- eased surface, while the colon above may contain much har- dened feces, which are retained by the interruption of the pe- ristaltic motion, arising from the morbid constriction of the parts below. Laxatives, in this case,, bring off hard or natural feces ; and the spontaneous appearance of these is the attendant on the resolution of the disease, being not the cause, but the effect or the sign, of the removal of the morbid condition of the lower part of the canal. <§> II.—The disease extending along the whole course of the colon and rectum, fatal in the inflammatory stage. Case LXXXVHI.—A gentleman, aged 60, had been for some years liable to an irritable state of the bowels which affected him chiefly after exposure to the cold, and was generally accompa- nied by mucous discharges tinged with blood. He was seized with one of these attacks, while he was at a distance from home, in September 1827, which seems to have been more protracted than usual, and on his return home, in the end of September, he was again seized in a still more violent degree. When I saw him along with Mr. Gillespie, about the third or fourth day of this attack, he had a look of much exhaustion and febrile anxiety ; his tongue was parched, and his pulse was frequent and rather small. He complained of much general uneasiness of the abdomen, especially across the epigastric region, where * Monro on the diseases of the British Military Hospitals in Germany, pages 61 and 63. 19? INFLAMMATION OF THE MUCOUS MEMBRANE, there was some degree of tension and considerable tenderness. He had frequent calls to stool, and the evacuations consisted of small quantities of mucus deeply tinged with blood, and some- times almost entirely of blood. He had occasional hiccup and some vomiting. All the usual remedies were employed without benefit; the symptoms continued unabated; the vomiting be- came more urgent; his strength sunk rapidly ; and he died in four days more, being about the eighth from the commencement of the disease. The evacuations retained throughout the same character, without the least appearance of feculent matter, even when laxative medicine was given. Inspection.—The \\ hole tract of the colon appeared mode- rately and' uniformly distended. Externally, it presented no morbid appearance, except some degree of that softened and slightly thickened state which has been compared to boiled tripe. Internally, it showed most extensive disease of the mu- cous membrane. This consisted of portions of the membrane, of various forms and degrees of extent, being of a fungous ap- pearance and bright red color and sensibly elevated above the level of the more healthy portions that were interposed between them; this morbid appearance, in patches separated by healthy portions of the mucous membrane extended through the whole course of the colon and rectum; and it preserved throughout nearly the same character, without any appearance that could be considered as ulceration or even abrasion of the membrane. The small intestine and all the other parts were entirely healthy ; and there was no appearance of feculent matter in any part of the canal. § HI.—The disease occupying the whole colon and rectum, fatal by gangrene. Case LXXXIX.—A man, aged 50, (7th Oct. 1827) was seized with general uneasiness over the abdomen. On the 8th he took castor oil, from the operation of which he had nume- rous evacuations consisting almost entirely of blood. On the 9th, he was seen by Mr. White, who found him complaining of great uneasiness in the bowels, chiefly referred to the lower part, but without much tenderness. He had frequent calls to stool, with scanty discharges which seemed to consist almost entirely of blood. His tongue was parched, but his pulse was little af- fected. (10th.) The pulse was still nearly natural, but there was much pain and tenderness of the lower part of the abdomen COLON, &C.--FATAL BY GANGRENE. 193 with some dysuria. The evacuations were now more abundant in quantity, and were remarkably changed in their character, being watery, dark colored, and with a remarkable and peculiar foetor ; they are compared by Mr. White to the washings of pu- trid flesh. For several days from this time there was little change. The evacuations continued watery, of a dark brown- ish color, and remarkable foetor, and without any appearance of feculent matter. They varied much in frequency, sometimes occurring every ten minutes, and sometimes leaving him quiet for several hours. There was much thirst, and the tongue was parched; but the pulse continued little affected till an advanced period of the disease. He had some hiccup, and vomited a few times, but it was not urgent. I saw him for the first time on the 15th. He was then languid and exhausted, with an anxious typhoid look, a small frequent pulse, and a parched tongue. He had much uneasiness with some tension and tenderness of the abdomen, especially across the epigastric region; there were frequent painful calls to stool, with scanty discharges of dark watery matter, some vomiting and considerable hiccup. He died early on the 16th. Inspection.—On laying open the abdomen, the whole tract of the great intestine, from the caput coli to the extremity of the rectum, was found to be greatly and uniformly distended. From the extremity of the rectum to nearly the middle of the arch of the colon, the intestine was of a uniform black color, as if completely gangrenous. From the middle of the arch to tho caput coli, the appearance was more healthy, but was variegated by numerous patches of a deep red or livid color. These seemed to be deep seated, and were seen shining through the peritoneal coat, which appeared to be healthy. The large in- testine being laid open, the mucous membrane at the black parts was throughout of a deep uniform black color, very soft and easily separated; the muscular coat was black and easily torn; the peritoneal coat was healthy. These appearances were continued from the extremity of the rectum to nearly the centre of the arch of the colon ; the mucous membrane then as-« sumed an appearance more resembling that described in the former case,—being elevated into irregular patches of a dark red color, with interspersed portions in a more healthy state. To* wards the lower part of the right side of the colon, there was an appearance of erosion or superficial ulceration; and on the inner surface of the caput coli, there were several distinctly de^. fined ulcers. The ileum, for a few inches from its junction with the caput coli, was slightly distended, and its mucous 25 194 INFLAMMATION OF THE MUCOUS MEMBRANE, membrane was reddened ; the other parts of the canal were healthy. The inner surface of the urinary bladder, at its poste- rior part, showed a considerable degree of increased vascularity. It may be of importance to mention, that the wife of this man was affected with the same disease in a very protracted form, and had not entirely recovered from the effects of it at the end of two months. One of his sons, a boy of 14, was seized a few days after the death of his father, and died after a short illness. Two other sons more advanced in life were afterwards affected and recovered. The two cases now described, I conceive to be of very great value in this investigation; for they show the disease running its course in about the same period; affecting the same extent of intestine, and showing similar constitutional symptoms,— while the actual morbid condition of the parts was remarkably different. The following case shows the affection fatal in nearly the same period, and with a remarkable extent of disease; but with a very important difference in the character of the evacuations. $ IV.—The disease occupying the whole colon, and rectum, and part of the ileum. Case XC.—A lady, aged 35, on Monday, 7th July, 1828, was suddenly seized with vomiting and purging, accompanied by considerable uneasiness in the abdomen; various remedies were employed without relief. On the 8th, the symptoms continuing and the pain very severe, a bleeding was attempted, but only a very small quantity was obtained. I saw her on the afternoon of the 9th; she had then occasional but not freqnent vomiting; she had frequent calls to stool, and the motions were copious*, liquid, and of a feculent appearance ; there was much pain and some tenderness of the abdomen; pulse 120; skin hot; countenance febrile and anxious; tongue very loaded. A Yull bleeding was now employed with very great relief, but there was no encouragement for carrying it farther. It was followed by blistering, calomel and opium, opiate injections, &c., but on the following day the symptoms had returned, and from this tjme they resisted every remedy. The pulse continued from 120 to 130, and it soon became weak, with a parched tongue and typhoid aspect, so that it was necessary to give her COLON, RECTUM, AND PART OF THE ILEUM. 195 wine and brandy. The vomiting recurred occasionally, but it was not urgent; the evacuations from the bowels were, on some days, rather frequent; on others, not above three or four in the day; and she sometimes passed a whole night without any dis- turbance ; but, however she might be in this respect, her aspect never improved from a febrile and anxious expression, character- istic of much disease. There was occasional pain in the bowels, but not much tenderness after the first three days. On the fourth day of the disease, I saw one motion which was scanty and consisted of bloody mucus, but the evacuations were in general copious, thin, and of a feculent appearance. In the early period of the case, they presented nothing different from those of diarrhoea; about the fifth and sixth days, they became extremely fetid, and, though of a feculent appearance when they were first discharged, they separated on standing, and de- posited at the bottom of the vessel, a quantity of a thin puriform fluid of a remarkable foetor, and variegated with small round spots of blood ; on the two last days of her life, they became of a dark brown color, and of a more watery consistence, with less appearance of feculent matter. She had now the aspect of an advanced state of typhus, with a small frequent pulse and some delirium, and she died on Tuesday the 15th, being the ninth day of the disease. Inspection.—The small intestines were externally healthy, except a tinge of redness on the lower part of the ileum; the colon had a thickened appearance, with a tinge, on various pla- ces, of a dark red color, which seemed deep seated as if shining through the peritoneal coat; about the sigmoid flexure and the upper part of the rectum, there was slight deposition of false membrane. The mucous membrane was healthy in the stom- ach, and in the upper part of the small intestines. In the ileum there began to appear spots of increased vascularity, which were at first at considerable distances from each other, but af- terwards became more numerous ; and, for about twenty-four inches at the lower end of the ileum, the whole mucous mem- brane was of a uniform deep red color, without any remarkable change in its structure. In the caput coli, the same dark red state of the membrane continued; and it was here covered by numerous well defined ulcers, some of them the size of a sixpence. In the ascending colon, there was a more irregu- lar state of disease, consisting of wandering undefined ulceration, variegated with dark fungoid elevations of portions of the mu- cous membrane. In the arch of the colon, the disease assumed a different character: for it there consisted of small well de- fined ulcers, the size of split peas or smaller; they were quite 196 INFLAMMATION OF THE MUCOUS MEMBRANE. distinct from each other, and the mucous membrane betwixt them was of a pale color and quite healthy. In the desending colon, the whole of the mucous membrane showed one continu- ed surface of disease,—being of a dark brown color, fungoid and spongy, without any defined ulceration. It is difficult to describe the appearance at this place ; it might perhaps be com- pared to the surface of very coarse cloth of a loose fabric, and of a dull brown color; and the mucous membrane, along the part so affected, was uniformly and greatly thickened. Along this portion, also, all the coats of the intestine were considera- bly thickened, and in some places were almost of cartilaginous hardness. This state of disease extended from near the com- mencement of the descending colon to within two inches of the extremity of the rectum; here it ceased abruptly, and the small portion that remained showed only marks of recent in- flammation or increased vascularity. This very remarkable case shows nearly all the modifications of disease of the mucous membrane; and I confess I found it difficult to believe that it had been the result of a disorder of only nine days' duration. But the body was full in flesh, and showed no appearance of previous disease; and all that I could learn was, that, about four years before her death, the patient had an attack which was said to have been similar to that of which she died ; and that she occasionally complained of some uneasiness in her bowels ; but that, up to the day of the attack, she was apparently in perfect health, and able for a great deal of exercise. I likewise ascertained, that her bowels were ha- bitually rather costive, requiring the frequent use of gentle laxa- tives. $ V.—The disease in the colon fatal by extensive ulceration with peritonitis. Case XCL—A girl, aged 8. I saw her for the first time on the 9th of January, 1826, and obtained but an imperfect ac- count of the history of her complaints. She had been confined to bed about five days, and had repeated vomiting ; but it had not been urgent, having occurred chiefly when medicine was given her. The bowels had been loose, but not very trouble- some ; the motions had been sometimes mucous, but not re- markably morbid; and some that I saw were quite healthy. ±ne belly had been for some days tense and tympanitic, with much tenderness upon pressure, but no actual complaint of COLON, FATAL BY AN AFFECTION OF THE BRAIN. 197 pain. When I saw her on the 9th, the pulse was frequent, the face pale, but full, as if from oedema, and there was some oedema of the legs ; breathing oppressed and anxious; bowels mod- erately open, and the stools feculent and healthy; the abdomen Was tumid, and at the upper part tympanitic ; and there was some tenderness upon pressure. I saw her again on the 10th, and found that the bowels had been moderately moved, and the stools were feculent and healthy; there had been some vomiting but not urgent; the pulse was weak, and her strength was sinking; and she died suddenly in the afternoon. On far- ther inquiry, I learned that she had been liable to cough for several months; but that no alarm had been taken, until about five weeks before her death, when some anasarca was observed in her legs. For this she had been under medical treatment, but her general health had been so little affected, that she had danced at a children's party on the 2d of January, two days be- fore the commencement of the fatal attack. Inspection.—The left lung was a mass of tubercular disease; the right was tolerably healthy. In the cavity of the abdomen, there was more than a pound of purulent matter with much flocculent deposition. The spleen was enlarged and entirely enveloped in a covering of false membrane ; the liver was com- pletely covered in the same manner. The whole tract of the small intestine was contracted and healthy. The colon, through its whole extent, was distended, and of a bright color; it was thickened in its coats, and its appendicular were very turgid and of a bright red. This appearance was presented by the whole tract of the colon and the caput caecum; and the mesocolon was also of a bright red color, and much thickened. Internally, the colon presented nearly one continued surface of ulceration of the mucous membrane, which was most remarkable about the sigmoid flexure, in the ascending colon, in the left side of the arch, and in the caput caecum. There was a little of it at the commencement of the ileum, but the rest of the small intes- tine was healthy. § VI.—The disease confined to the caput coli and part of the ascending colon,—The patient dying of an affection of the brain. Case XCII.—A girl aged 6, was affected with severe and obstinate diarrhoea, which reduced her to great weakness and 198 INFLAMMATION OF THE MUCOUS MEMBRANE. emaciation. It subsided after three or four weeks, and was succeeded, after a short interval, by severe pain in the belly, headache, and vomiting, the bowels being rather bound ; the pulse was from 30 to 40 in a minute ; the urine was high- colored, and diminished in quantity. The headache continued, with vomiting, and a constant spasmodic action of the right arm and leg; and after seven days, she sunk into coma, and died in two days. The pulse continued from 30 to 40, till a few days before death, when it rose to 70, and occasionally to 80. I did not see this case during the life of the patient, but was present at the examination of the body. Inspection.—There was considerable effusion in the ventri- cles of the brain, with ramollissement of the septum and of the cerebral substance surrounding the ventricles. The inner sur- face of the caput coli, and of a great part of the ascending colon, was of a dark red color, and covered with numerous patches, also of a dark red color and fungous appearance, which were considerably elevated above the level of the sur- rounding parts. $ VII—Fungous ulceration of the caput coli and recent in- flammation of the ileum, with a coating of false membrane. Case XCIII.—A seaman, for whose case I am indebted to the late Dr. Oudney, was affected with dysentery, accompanied with the usual symptoms. The stools were in general copious, and varied very much in their appearance, being sometimes slimy, sometimes watery, and sometimes consisting of mucus mixed with green matters of various shades. There was fever with rapid emaciation; at first, he had acute pain, and after- wards a dull uneasinesxover the lower part of the abdomen; and towards the conclusion, there was a sharp pain increased by pressure confined to a small spot on the lower part of the abdomen towards the right side. He died in about five weeks. Inspection^-There were some superficial ulcerations of the mucous membrane towards the lower extremity of the colon • SS^n ShHP^h,,eat0f"thediWMe appCared tobethe caPui coli, in which there were numerous fungous projections ulce- rated upon the surface. In the ileum four inchSomTt lower extremity, there was a portion in a state of recent infemmS and covered with false membrane. There were small absce es in the liver, and the mesenteric glands were enlarged SCeSS6S ILEUM, WITH DEPOSITION OF FALSE MEMBRANE. 199 § VIII.—The disease in the ileum with deposition of false membrane. Case XCIV.—A woman, aged about 30, in November, 1827, was received into the clinical ward of the Royal Infirmary of Edinburgh, affected with symptoms of continued fever in a very mild form ; and after five or six days she was considered as convalescent. She recovered strength so slowly, however, that she was allowed to remain in the hospital; and she went on for ten days without any symptom except weakness. She then seemed to relapse, complaining chiefly of headache and pain of the back. After this, she had sickness and a good deal of vomiting, and complained of pain with some tenderness, re- ferred to the region of the liver, which was relieved by topical bleeding. She still had sickness, with occasional vomiting; the pulse continued frequent and weak ; her strength sunk rapidly; and she died in four days from the commencement of this re- lapse. There had been no diarrhoea; stools had been produced by enemata, and they were tolerably healthy. Inspection.—In the lower end of the ileum, a portion of the mucous membrane, eighteen inches in extent, was covered by a thin uniform film like the crust of aphthae ; beneath it the mem- brane showed a high degree of redness. The peritoneum cov- ering this portion of intestine showed some minute flakes of co- agulable lymph for three or four inches. All the other parts were healthy. For this important case I am indebted to Dr. Alison. The appearance described in it, and which also occurred in the ileum in the preceding case, is rather uncommon. It differs entirely from the appearance of the disease as it occurred in the colon in the former cases, and which also will be found occurring in the ileum in the cases to be next described. In the present state of our knowledge, it is doubtful whether it is to be considered as a different stage of the disease, or as a state of the inflamma- tion altogether distinct. The deposition of false membrane on the surface of the mu- cous coat, however, is described by Dr. O'Brien* as a frequent appearance in the epidemic dysentery of Ireland. It occurred in his dissections both in the large and small intestines, but * Trans, of King's and Queen's Colleges, vol. v. 200 INFLAMMATION OF THE MUCOUS MEMBRANE. seems to have been most frequent and most remarkable in the colon and rectum. He describes it in some cases as occuring in patches; but in others, the mucous membrane was covered by a uniform layer of white lymph, which was in greatest quan- tity in the neighborhood of the rectum ; and it adhered to the surface of the membrane in rugged folds. Dr. Cheyne has mentioned the same appearance as occurring in the small intes- tine, in his able account of the Dysentery of Dublin of 1818 * The appearances to be described as occurring in the ileum in the following cases, correspond with the appearances described in regard to the colon in cases LXXXVHI and LXXXIX, § IX.—The disease in the ileum fatal in the state of red ele- vated portions with incipient ulceration. Case XCV.—A girl, aged 3 years, about three weeks before her death was attacked with vomiting, frequent calls to stool, and pain in the abdomen; the evacuations were reported to have been frequent, slimy and fetid. After eight or ten days, when she was first seen by the late Dr. Oudney, she had fre- quent irregular febrile paroxysms; she had vomiting and fre- quent stools, which were of a clay color, and the abdomen was tender upon pressure. Her tongue was white, and there was urgent thirst, especially during the febrile paroxysms. In this state she continued until a few days before her death, when she became oppressed and partially comatose, with frequent screaming and great unwillingness to be moved. The pulse varied from 13Q to 150, and she had frequent stools whioh were now of a dull green oolor, mixed with specks of yellow. The pupil was natural, and continued sensible to light, until a few hours before death, which happened on the 8th of February* 1820. J Inspection.—The ileum, from its termination in the colon to near the jejunum, was highly vascular, its minute vessels appear- ing as if injected. Its mucous membrane was covered with nu- merous irregular inflamed patches, which had a fungous appear- ance ; they were considerably elevated above the level of the sound parts, and were covered with minute ulcerations. Some of these patches were the size of a shilling, others smaller- they were generally at the distance of an inch or two from each oth- + Dublin Hospital Reports, vol. iii. ILEUM FATAL BY GANGRENE. 201 er, and the membrane in the intervals was healthy. The me- senteric glands were greatly enlarged and v^ry vascular. § X.—The disease in the ileum fatal by gangrene. Case XCVI.—A woman, aged 25, was admitted into the in- firmary of Edinburgh, affected with pain over the abdomen, ten- esmus and diarrhoea. The pain intermitted occasionally, and was most severe on going to stool and on passing urine. The evacuations were free from scybalae or blood. She had head- ache, thirst, some cough, nausea, occasional vomiting, and a pale emaciated look ; pulse 72. She ascribed her complaints to cold, and they had been gradually increasing for three weeks. Various remedies were employed without benefit, consisting chiefly of opiates, absorbents and calomel. The disease went on for eight days more, and the following selection from the re- ports show a state of the functions of the bowels, which, when compared with the morbid appearance to be described, presents a case of very great importance. (2d day) Two stools ; severe tormina, which were relieved by fomentation. (3d day) Nearly free from tormina ; one stool; which seem- ed to consist of broth which she had recently taken, little chan- ged. (4th day) Two scanty evacuations without griping; abdomen hard and painful; vomited once ; a mild enema produced a co- pious discharge and relieved the pain. (5th day) Less pain ; vomited several times ; one stool thin and feculent; pulse 78 ; took six grains of calomel. (6th day) Two stools; one of them thin and feculent, the other much tinged with blood ; much pain before the evacu- ations ; abdomen tense and painful; pulse 80 ; vomited a con- siderable quantity of slimy matter tinged with blood, and hav- ing some purulent matter mixed with it. She took gr. viii. of calomel. (7th day) Two stools, thin, feculent, and of a natural ap- pearance, but preceded by much pain ; vomited repeatedly some greenish slimy matter, mixed with bloody pus ; less tension of the abdomen ; pulse from 60 to 70; took some calomel with opium. (8th day) No stool and no vomiting ; died in the night. Inspection.—The vessels on the stomach, duodenum and je- junum were usually distended with blood. The ileum was li- 26 $02 INFLAMMATION OF THE MUCOUS MEMBRANE, vid, with some adhesions; its internal surface was quite black ; and it contained dark colored slimy matter, mixed with very fetid pus. The colon, on the left side, was found livid, with adhesion to the abdominal parietes, and to the lower part of the omentum, which also was of a livid color : and between these parts there was much fetid pus. $ XI—The disease in the ileum, with ulceration, fatal by a perforating ulcer and peritonitis.. Case XCVIL—A woman, aged 38, had been ill for more than a week with fever, want of appetite, frequent diarrhoea, and much pain in the abdomen. On the 19th of June, 1819, she was suddenly seized with the most violent pain of the abdomen, which began at the lower part, hut afterwards extended over the whole. On the 20th the pain continued most violent, and was increased by pressure and inspiration; urgent vomiting; pulse 130. An attempt was made to bleed her, but very little blood was obtained ; and soon after the pulse sunk, with cold-. ness of the body ; there was some discharge from the bowels. (21st) I saw her for the first time. Pain still severe; urgent vomiting and hiccup; no stool; pulse 140. Died in the after- noon. Inspection.—Extensive inflammation on the outer surface of the small intestine, especially at the lower part, where there were considerable exudation and gangrene. There was exten- sive inflammation of the mucous membrane of the small intes- tines, in various places; and the inflamed portions were cover- ed with minute ulcers. At one place, at the lower part of the ileum, there was a more extensive ulcer about the size of a shil- ling ; this was surrounded by a ring of inflammation, which was covered by minute ulcers; and in the centre of the large ulcer, there was a small opening which perforated the intestine ; the outer surface at this place was of a dark, livid color. § XH.—The disease occurring in continued fever with ul- ceration. Case XCVIIL—A girl, aged 9, was seen by Dr. Alison, in December, 1819, affected with the usual symptoms of conta- gious fever which was very prevalent in a narrow and crowded WITH ULCERATION--IN CONTINUED FEVER. 203 lane where she resided, and had affected a person in an adjoin- ing rofmi. From the commencement of the disease she had diarrhoea, with griping, and considerable tenderness of the ab- domen ; and the evacuations were thin, feculent, and of a healthy appearance. These symptoms continued, with fre- quent pulse and foul dry tongue, till about two days before her death, when the diarrhoea suddenly subsided, and was succeeded by violent pain, acute tenderness of the abdomen, and every symptom of peritoneal inflammation. The duration of the .case was about three weeks. I am indebted to Dr. Alison for the above outline of it, and for an opportunity of being pres- ent at the examination of the body. Inspection.—There was considerable peritoneal inflamma- tion, especially on the ileum, where there was extensive adhe- sion, with considerable deposition of flocculent matter. The intestine was also seen to be in several places perforated by small ulcerations, through which feculent matter had escaped into the cavity of the peritoneum. The ileum being laid open, discovered a most extensive tract of disease on its inner sur- face, the mucous membrane being extensively eroded, and in many places completely destroyed, by round well defined ul- cers, many of them as large as a shilling. This state of dis- ease extended over the greater part of the ileum, and, in seve- ral places, its coats were considerably thickened. It contained a considerable quantity of fluid feculent matter, which was quite healthy in its appearance. . The higher parts of the small intestine were healthy, and contained a small quantity of a dark green viscid fluid, like inspissated bile. The colon was colapsed, and externally healthy ; internally, there were in sev- eral places, especially on the left side, patches of redness on its mucous membrane, but without any appearance of ulceration; it contained only a small quantity of healthy mucus. The other viscera were healthy. As in this case there was every reason to believe that the original disease was contagious fever, the affection of the bow- els may perhaps be considered as symptomatic. This occurred still more distinctly in a case mentioned by Dr. Duncan in his . clinal reports. The patient (a woman aged 60) seemed to be convalescent from fever with petechiae, when, about the 23d day of the disease, she was attacked with diarrhoea, without any complaint of pain ; the stools fetid and dark colored; the pulse varying from 80 to 100. About the 7th day from the commencement of these symptoms, began to have pain and bloody evacuations, and died on the 9th day. On inspection, 204 REVlfW OF THE SUBJECT. the disease was found nearly in the state'of simple inflamma- tion At various parts of the mucous membrane, from «c je- junum to the rectum, there were purple patches, occurring at fir^t at intervals of one or two inches, and then running grad- ually more and more into each other. There was the same appearance in the caput coli, but the arch was entirely tree from it. It occurred again at the sigmoid flexure ; and, in the rectum, in addition to this appearance, there were numerous fungous looking patches, from a quarter, to half an inch broad, and elevated fully an eight of an inch above the surface of the intestine; they had a very vascular appearance, and their sur- face was covered with a thin yellowish crust. The various observations which have been detailed in this section, appear to illustrate the principal phenomena connected with inflammation of the mucous membrane of the intestine; and they lead to some conclusions of much practical impor- tance in regard to this interesting class of diseases. I. It is probable that the inflammation of mucous membrane exists in various conditions. In some of these, it is dangerous, chiefly in proportion to its extent, by the constitutional dis- turbance with which the more extensive degrees of it are at- tended. In others, it seems to be highly dangerous from the intensity of the inflammation and its consequences, whatever may be the extent of the surface that is affected. This impor- tant distinction in the nature or form of the disease is well il- lustrated by Cases LXXXVHI, and LXXXIX. II. It appears that the more intense forms of the disease may be fatal, though of small extent, by gangrene or by ulce- ration ; and that the ulceration may perforate the intestine, and terminate speedily by extensive peritonitis. III. We see some evidence of the contagious, or at least the epidemic character of the disease; as, in the family in which Case LXXXIX occurred, five individuals were affected in quick succession, and two of them died. IV. It is probable that the symptoms vary considerably, ac- cording to the extent of the disease, and the part of the canal which is the primary seat of it. This appears most remarkable in the character of the evacuations. 1. When the disease is confined to the rectum or the lower part of the colon, the evacuations appear to be scanty, and mu- cous or bloody, with retention of natural feces, or small scybalous discharges—the dysentery of systematic writers. 2. When the disease extends through the whole of the colon, REVIEW OF THE SUBJECT. 205 or through a considerable part of the small intestines, we may have copious discharges,—at times, of thin healthy feces, at other times, varied by mixtures of morbid discharges, and by articles of food or drink little changed. This appears to be the colonitis and the tropical dysentery of practical writers. 3. It is probable that we have the disease of still greater ex- tent, affecting at once a great part of the bowels, especially of the small intestine, and constituting the most formidable of all the modifications of it,—the Indian cholera. The important practical conclusion from the whole view of the subject, is, that this highly dangerous disease may be going on with every variety in the appearance of the evacuations ; and this conclusion is in accordance with the statements of the best practical writers. It will now perhaps be generally admitted, that in talking of dysentery, we have been too much influenced by the distinctions of systematic writers, in applying this term to an affection which is characterized by tenesmus and scanty discharges of bloody mucus. We have seen that such a modi- fication of the disease does exist; but practical writers of the first authority describe another form of the affection, in which the evacuations are copious, and vary exceedingly in appearance, at different periods of the disease,—being sometimes dark, wa- tery, and sanious, and sometimes quite natural. Sir James M'Grigor has particularly remarked, that the tropical dysentery which was so fatal to the troops under his inspection, differed extremely from the dysentery of Cullen, and ought rather to belong to the form of disease which he has classed with diar- rhoea. ' I have ever,' he adds, ' found difficulty in distinguish- ing dysentery from diarrhoea, and I am inclined to think, that in Cullen's definition of diarrhoea, he meant tropical dysentery.' The testimony of Dr. BaUingall is strongly in favor of the same important fact. In his description of that formidable modification of the disease, which he has termed colonitis, he distinctly de- scribes the evacuations as being in the early stage of the disease generally copious, of a fluid consistence, and without any parti- cular foetor. In a private communication, in reply to certain queries which I addressed to him on this subject, he farther states, that 'at this period of the disease, the evacuations differ only in consistence from healthy feces ; as the disease advances, important changes take place in this respect, the evacuations becoming more scanty, and of a morbid appearance,' that is, probably, after, by repeated evacuations, the canal has been cleared of healthy feces, and the subsequent evacuations consist chiefly of the morbid discharges from the diseased parts. This 206 DVSENTERY. is probably the state of the disease referred to by another intel- ligent practical writer, Avhen he says, ' I had been taught to believe that the proper dysentery, or that which is most distinct from diarrhoea, is the most formidable disease, but I found, con- trary to expectation, that the dysenteries which began with diarrhoea, often proved the most violent.'* Now, in the dysen- tery of Cullen, as described by Dr. Donald Munro, the primary seat of the disease appears to have been the rectum and the lower part of the colon,—often the rectum alone; while, in the colonitis of Dr. BaUingall and the tropical dysentery of other writers, the disease extended through the whole course of the colon, and often affected a considerable part of the small intes- tine. If we are asked, therefore, what is the difference betwixt diarrhoea and dysentery, we must reply, that it consists in the nature of the disease, and can be learned only from a diligent attention to the concomitant symptoms, not from the character of the evacuations. Diarrhoea is an increased action of the canal, produced by various irritating causes applied to the mu- cous membrane in a healthy state,—the highest degree of it is the cholera of this country, which may be dangerous by the rapid exhaustion with which it is sometimes accompanied. Dysentery is a similar state of increased action, arising from inflammation of the mucous membrane; and the highest state of it appears to be the cholera of India. Dysentery may in some cases be distinguished by the morbid discharges from the diseased surface; but these are often entirely wanting, or are so mixed up with the feculent evacuations as not to be recognized ; and in point of fact, it will be found that the cases in which the evacuations most nearly resemble those of diarrhoea, are very often the most untractable and most dangerous. Dysentery is often accompanied by diseases of neighboring organs, especially the liver, in which are found in some cases abscesses, and in the protracted cases, chronic induration. 1 hese are probably to be regarded as accidental combinations, though they may considerably modify the symptoms. It has likewise been supposed, that impeded circulation through the liver may lead to disease of the mucous membrane by accumula- tion of blood in its more minute vessels; but this must be con- sidered as in a great measure conjectural. Dysentery was formerly supposed to have an intimate de- pendence upon the liver, and a modification of it has been de- in Eg;;"0" UW Dia"'h4 CHRONIC DISEASES OF THE MUCOUS MEMBRANE. violent aggravation of the pain, with tension and extreme ten- derness of the abdomen, and this attack was speedily fatal. Ulceration of greater or less extent was found in the mucous membrane, with perforation of the intestine by one of the ulcers, and the usual appearances of recent peritonitis.* $ IV.—Ulcers of this class, without any previous illness, suddenly fatal by perforation. Case CXIII.—A, stout man, aged 36, who had previously enjoyed good health, was suddenly seized, while engaged at his usual employment, with violent pain in the abdomen and vom.it- ing; the pulse was not affected. He was seen by Mr. William Wood, to whom I am indebted for the history of the case ; and blood-letting and the other usual remedies were employed with- out benefit. The symptoms continued, the pain extending over the wfrble abdomen ; the pulse became quick and feeble, with rapid sinking of the vital powers, and he died in 18 hours. Inspection.—Nothing could be discovered in the cavity of the abdomen except a considerable quantity of thin feculent fluid ; and it was only after a long and minute examination, that a perforation was discovered in the lower part of the duo- denum, capable of transmitting a large quill; it had its origin in an ulcer of the mucous membrane, which was considerably lar- ger than the perforation. Case CXIV.—A gentleman, aged 60, had enjoyed excellent health, except habitual costiveness. On 6th December, 1810, he was sitting after dinner reading aloud to some friends who were with him, when he suddenly complained of most violent pain in the lower part of the abdomen and vomited repeatedly. His countenance became pale, and his hands rather cold; and his pulse, when he was seen by Mr. William Wood, was feeble and not frequent. The most judicious practice was employed without benefit; the pain continued ; the vomiting recurred at intervals; the pulse became frequent and feeble, with rapid sinking of the vital powers; and he died in about six hours. Inspection.—There was much feculent matter in the cavity of the abdomen, which was found to have escaped through a perforation of the colon at its lower part, a little above its junc- * Nouveau Jour, de Med., Tom. i. ULCERATION--WITH OLD OBSCURE SYMPTOMS. 2$5 tion with the rectum. The opening was larger than a shilling', and was surrounded by a mass of induration ; and for several inches the intestine was hard and thickened, and on its internal surface extensively ulcerated. At the lower part of the diseas- ed portion, about two or three inches below the rupture, the in- testine was contracted by a hard ring, so as scarcely to trans- mit a finger. $ V.—Ulcers of this class found connected with obscure symptoms of long standing. There is reason to believe that ulceration of the mucous membrane, of limited extent, sometimes exists in connection with obscure and protracted symptoms, without assuming any characters that distinctly indicate the existence of such disease. A gentleman aged 34, who had formerly suffered from dysen- tery, but had been free from any symptom of it for several years, was observed to look ill and to lose flesh without any defined complaint, except nausea and indigestion; his spirits were depressed and his bowels were irregular, being sometimes loose but more frequently confined. After several months had passed in this manner, he had frequent vomiting and a distress- ing sensation of heat in the stomach and oesophagus. He some- times took food with eagerness, and sometimes refused it. His pulse continued natural until three days before his death; he then had convulsive affections and delirium, with frequent pulse, and died in the state of coma which continued about 12 hours. • His death happened about a fortnight after the commencement of the vomiting. On inspection, all the viscera were found healthy, except about eighteen inches of the lower extremity of the ileum. The coats of this portion were livid, and several indurations were felt through them. Its internal surface was covered with ulcers of various sizes, from the size of a bean to that of a half-crown piece; they were circumscribed, but very rugged, from a great quantity of fungous which wasf thrown out both from their surfaces and edges.* A woman, aged 55, was affected with weakness, emaciation, and loss of appetite, without any complaint except of occasional cholic pains, which were slight and transient; and she had some discharge of blood by stool, which was considered as haemor- * Mem. of ilic Med Soc. London, vol. vi. p. 123. 29 226 INFLAMMATION OF MUCOUS MEMBRANE. rhoidal. After she had been affected in this manner for six months, she became suddenly comatose, and died on^the follow- ing day. On inspection no disease could be detected in the brain. Nearly the whole extent of the rectum was occupied by cancerous ulceration; the remainder of it, and the left side of the colon, were red and purple as if sphacelated,—the other vis- cera were sound.* By a minute examination in cases of this kind, the seat of the disease may sometimes be detected by tenderness upon pres- sure, limited to a circumscribed space. It is also a good rule in all obscure affections of the bowels to make a careful exami- nation of the rectum. I have in several cases discovered can- cerous ulceration there, in connection with derangements of the bowels of a slight and obscure character. SECTION IV OF THE TREATMENT OF THE AFFE'TIONS OF THE MUCOUS MEMBRANE. § 1.—Treatment of the acute cases. If to the class of diseases now described, we simply apply the term inflammation of the mucous membrane of the intes- tine, we can be at little loss in fixing upon the first and great principle to be followed in the treatment; while, if we use the term dysentery, we in vain endeavor to find our way amid the various courses that have been proposed for the treatment of the disease. But upon a fair and candid review of all the facts which are now before us on this important subject, I think we are fully warranted in assuming the principle, that dysentery is primarily an inflammation of the mucous membrane of the in- testine ; and that the first principle in the treatment is precise- ly the same as that which applies to other inflammations. There is, however, a circumstance to be kept in mind, which perhaps may be considered as the source of some of the diver- sity of opinion in regard to the nature and treatment of dysen- tery ; namely, that inflammations, of all mucous membranes ex- ist in a state in which they admit of a spontaneous cure,—cer- * Pinel Med. Cliniqjie, p. 257. DYSENTERY--TREATMENT. 227 tain changes taking place in the discharge from the morbid sur- face, in the course of which the parts gradually recover their healthy condition. Of remedies which are given while this pro- cess is going forward, some may assist it, some may be totally inert, and some may perhaps even have a tendency to retard it, and the process may notwithstanding goon to a resolution of the disease. The most obvious illustration of these facts is from the inflammatory affections of the bronchial membrane. In a certain form, even of considerable extent, they get well under the use of trivial remedies, or without any treatment at all; and at a certain period,of this progress, active treatment is not only useless, but hurtful. But these facts%do not affect our opinion in regard to the pathology of the disease; for we know it to exist in another degree, in which, if not actively treated in its early stage, it is speedily fatal. On the same principle, we can- not doubt that dysentery, in all its forms and all its degrees, is an inflammatory affection of the intestinal membrane; that it exists in a degree in which it admits of a spontaneous cure, and that this may perhaps be assisted by various remedies of no very active kind; but that it exists in another degree, in which, if not treated with the utmost activity, it may be speedily fatal, or may terminate by incurable ulceration. The general principles of treatment appear to be the follow- ing :— I. To subdue the inflammation. II. To quiet the general irritation of the canal. III. To correct the morbid secretions from the diseased sur- face. I. For answering the first of these indications, the remedies on which we rely, when the case is seen at a period adapted to the use of tnem, are general and topical blood-letting, blistering, diaphoretics, and antiphlogistic regimen. On this subject, on which my own experience has been limited, I may now refer to the best practical writers on dysentery, as it is seen in various parts of the world, particularly Dr. BaUingall, Dr. Bampfield, and many others ; and the practice has also received the high sanc- tion of Sir James M'Grigor, under whose instructions it has be- come the established treatment of dysentery by the medical de- partment of the army. Dysentery, indeed, may exist in a de- gree in which it may get well without bleeding, but so also may peripneumonia or bronchitis; and it may occur in unhealthy, debilitated subjects, or in combination with low malignant fever, and may thus noT admit of active treatment: but these circum- 228 INFLAMMATION OF MUCOUS MEMBRANE. 6tances only introduce new difficulties in regard to individual cases, and do not affect the general principles which regulate the treatment of the disease. The use of general bleeding must of course be regulated by the activity of the symptoms, the constitution of the patient, and the period of the disease; for it is probable that in general the period for active treatment is soon over. Much benefit is often derived from local bleeding, which may be accomplished, by leeches, applied either to the abdomen, or, when the disease is seated in the lower part of the bowels, to the verge of the anus. As diaphoretics, the best is perhaps Dover's powder; ipecacuan in powder, in doses of gr^i. or ii. three or four times a day has also been much recommended, and James' powder, given in the same manner ; but in all inflammatory affections of the mucous membrane of the intestine, the effect of antimonial preparations would appear to be rather questionable. II. The second indication, which is to quiet the general irri- tation of the canal, will be chiefly answered by mucilaginous ar- ticles and opiates, particularly Dover's powder, perhaps combin- ed with chalk, with the mildest kinds of farinaceous food, in very small quantity ; and 1 imagine that much will be gained in the early period of the disease, especially when the affection is ex- tensive, by taking into the stomach as little as possible of either food or drink ; as from the morbid irritability of the parts, the mildest articles often produce great 'irritation. Suet, dissolved in milk, has been much recommended ; and a favorite remedy in the time of Sir John Pringle was a combination of yellow wax and Spanish soap, melted together over a gentle fire, and then rubbed up with water. The warm bath is often beneficial, and equal gentle pressure of the abdomen, by a roller of elastic flan- nel, is a remedy which has been strongly recommended as of much efficacy in all stages and forms of dysentery.* III. For correcting the morbid condition of the membrane, after the force of the inflammatory symptoms has been subdued by the necessary means, various remedies appear to be useful, in different states and different stages of the disease. In the earlier stages, benefit is frequently obtained from doses of Do- ver's powder, of from 5 to 10 grains, combined with 1 grain of calomel, repeated, at first, every four or five hours, and after- wards at longer intervals. This applies to the dysentery of this country ; in the more severe cases, which occur in warmer cli- * See Dewar on Dysentery. DYSENTERY--TREATMENT. 229 mates, Dr. Ferguson has strongly recommended a grain and a half of calomel, with one grain of ipecacuan, to be repeated every hour until the mouth is affected, when, he says, the dys- enteric symptoms always cease. In the dysentery of tropical climates, calomel is given in still larger doses as from 10 to 15, or even 20 grains, repeated three or four times a-day, generally combined with opium. Of this mode of treatment, as applied to the dysentery of tropical climates, I would not presume to give an opinion, because I have had no experience ; but when I have seen a similar practice attempted in the dysenteric affections of this country, it has appeared to be decidedly inju- rious ; and when mercury is given, it appears that the small do- ses of calomel combined with Dover's powder, in the manner which I have mentioned, is the form best adapted to the earlier stages of the disease. In a more advanced stage, when the morbid secretion continues after the inflammatory symptoms have been subdued, various remedies of a tonic and astringent nature ap- pear to be useful,—such as, cusparia, lime water, oxide of bis- muth, nitric acid, sulphate of alum, logwood, balsam of copaiva, acetate of lead, and various combinations of these with each other, and with small opiates, especially a strong decoction of cusparia with nitric acid and laudanum; and oxide of bismuth^ with cusparia and Dover's powder. Charcoal has been strongly recommended, and in one very severe case, in which it was given in combination with »Dover's powder, it appeared to Mr. Gillespie and myself to be decidedly useful. Nitric acid, com- bined with opiates, I conceive to be a remedy deserving of much attention even in the earlier stages, after the necessary evacua- tions. When the disease is chiefly seated in the lower part of the colon and rectum, various substances may be given in the form of injections. Of these, the most useful seem to be, in the early stages, mucilaginous articles, or thin arrow-root with an opiate, an infusion of tobacco, or an infusion of ipecacuan. After the first urgency of the inflammatory state has been sub- dued, I have seen decided benefit in relieving the tenesmus from injections of lime-water, at first diluted with equal parts of milk or thin arrow-root, and with the addition of an opiate. In the above observations, I have said nothing of the use of purgatives in this class of diseases, because I do not consider them as forming a regular or essential part of the treatment; but it comes to be a question of much interest, what is the principle to be kept in view in regard to the use of purgatives, and what are the cases to which they are adapted. 230 CHRONIC DISEASES OF MUCOUS MEMBRANE. It is clear that a modification of the disease exists, in which it is confined to the lower part of the bowels, and is accompa- nied by retention of feces in the parts above. This state of the upper part of the bowels is to be considered, in such cases, as requiring distinct attention, because, in a febrile and irritable state of the system, it must prove an additional source of irri- tation, or may even pass into a state bordering upon ileus. It must, therefore, be counteracted by the occasional use of the mildest laxatives, as castor oil, or small doses of the neutral salts. But by laxatives in such a case, I imagine we are to consider ourselves as only obviating bad effects from feculent accumulation in the parts above, rather than as acting upon the disease with which we are contending. By laxatives, indeed, the evacuations may become healthy, but these are brought down from the healthy parts above, and cannot be considered as having any beneficial operation upon the part which is the primary seat of the diease. The spontaneous improvement of the evacuations, in conection with the resolution of the disease, is to be considered, I imagine, as an effect and a sign, rather than a cause of that resolution, and as a state which cannot be imitated or forced by the use of purgatives. In the earlier stages of this modification of the disease, indeed, it is highly necessary and proper to ascertain by the operation of some mild medicine, that there is no accumulation of feculent mat- ter ; but we have seen in the most satisfactory manner that the bowels may be entirely without feculent matter, though the evacuations have consisted entirely of bloody mucus from an early period of the disease. In such cases as these, the use of purgatives must be unnecessary ; and, when the inflammation is extensive, producing a morbid irritability of a great part of the canal, we can scarcely doubt that they must be injurious. Though the evacuations, in such cases, may be of an unnatu- ral appearance, it is to be remembered that this is the result of morbid secretion, not to be corrected by purgatives, but to be removed only by curing the disease on which they depend. In regard to the dysentery of this country, the most exten- sive field of observation has been in Ireland, and we have the advantage of a full and able account of it by Dr. Cheyne.* According to the extensive experience of this eminent physician, the remedy ' least equivocal in its effects, and the most uniformly useful,' was blood-letting. The mercurial treatment was tried * Dublin Hospitable Reports, vol. iii. D5TSENTERY--TREATMENT. 231 in all its forms, but often failed ; and it did not appear worthy of the same degree of confidence as in other climates. In some cases, the mouth could not be affected; in others, the worst description of mercurial mouth was produced. But even when salivation took place at an early period, it was in many instances unequal to the cure; and in cases in which the disease was supposed to have passed into the ulcerative stage, mercury was injurious. Of the cases which were not accom- panied by much pain or fever, many got well with a saline pur- gative, followed by two or three doses of Dover's powder; and even of the more severe cases, attended with fever and tender- ness of theabdomen, many recovered under the same remedies preceded by blood-letting. But in many cases, purgatives seemed greatly to aggravate all the sufferings of the patient. They often failed in producing any change in the appearance of the motions; while on the other hand, a large feculent loose stool was not unfrequently passed after a bleeding, by patients who, for several days before, had passed nothing but mucus mixed with blood. The practical result of Dr. Cheyne's ob- servation seems to be, that the mode of treatment most gene- rally useful was,—blood-letting, followed by calomel and opium, and this by the balsam of copaiva, with farinaceous diet; but next to full bleeding, his chief reliance seems to be in opium; and on a review of his whole experience in the epidemic to which his valuable paper refers, he says, ' were the same cases again to be placed under my care, I would not hesitate to give opium in doses of four or five grains, as it was the opium chiefly that seemed to arrest the progress of the inflammation; and whatever, in such a case, procured respite to the patient from agony, sometimes proved of permanent benefit.' The preceding observations were written, and ready to go to press, before I had an opportunity of seeing the second volume of Mr. Annesley's splendid work on the diseases of India. It gives me much satisfaction to find that they agree, in all the more essential respects, with his observations in regard to dysen- tery. The point on which I am chiefly disposed to differ from this eminent writer, or I ought rather to say, in which I am dis- posed to think that his treatment is not entirely adapted to the dysentery of this country, is in the frequent or almost daily use of purgatives. I have already stated my opinion on this sub- ject, and the grounds which induce me to believe that the use of purgatives in dysentery is a practice requiring the utmost dis- cretion, being in some cases proper, in others unnecessary, and in not a few decidedly injurious. I have also stated the expe- 232 CHRONIC DISEA9ES OF MUCOUS MEMBRANE. rience of Dr. Cheyne, that purgatives in many cases produced no beneficial result, and in others greatly aggravated all the suf- ferings of the patient. The subject is one of the highest practi- cal importance, and deserving to be investigated with the ut- most attention. Mr. Annesley begins the treatment of dysentery in a robust patient with free general and topical bleeding, and a large dose of calomel combined with opium or Dover's powder,—in de- bilitated habits, topical bleeding is employed. These are fol- lowed at the distance of a few hours by a purgative of castor oil, or jallap and cream of tartar, and a purgative injection. The calomei and opium are also repeated after a few hours interval; and this treatment is assisted by warm fomentations, warm bath, and anodyne injections in very small bulk. These remedies are afterwards repeated according to circumstances, with blistering on the abdomen if necessary ; and a purgative is generally given every morning. In the more advanced stages of the disease, when there is reason to believe that ulceration has taken place, he trusts chiefly to blistering, anodyne injections, Dover's pow- der with camphor and catechu, nitric acid, and the external ap- plication to the abdomen of the nitro-muriatic solution. Mr. Annesley gives no countenance to the empirical and in- discriminate use of mercury, which has become so much in fash- ion with some writers in all stages and all conditions of dysen- tery. He gives calomel with opium in the early stages, along with the necessary evacuations, but chiefly as a purgative. ' When given late in the disease with the intention of affecting the system, or when its exhibition is continued with this inten- tion for too long a period, it often seems to precipitate the mal- ady to an unfavorable termination, by inducing or keeping up irritative fever, and lowering the powers of life.' In regard to the difficulty often experienced in affecting the system with mercury in the early stages, he states, that it is occasioned by the existence of active inflammation, and that the appearance of mercurial action in these cases is often to be regarded as a sign rather than a cause of the resolution of the disease. In many instances, both of simple dysentery, and of dysentery combined with disease of the liver, he has seen the mercurial action take place in the fullest manner, and yet the disease was not only not arrested, but seemed to run its course more rapidly to an unfavorable termination. And even in the milder cases which got well under the constitutional effects of mercury, there was often a protracted recovery from the diminished energy of the powers of life occasioned more by the mercurial action than by the disease. TREATMENT. 233 Since the publication of the first edition of this volume, I have found decided benefit, in several dysenteric affections, from the use of sulphur ; and to several friends who have em- ployed it at my suggestion, it has appeared to have very bene- ficial effects in various affections of the mucous membrane. It has generally been given in small doses, such as 10 grains, repeated three times a day, combined with small opiates, or with Dover's-powder; and in the chronic cases frequently with angustura. M. Mayer, in Hufeland's Journal, has strongly recommended a nitrate of soda as of most remarkable efficacy in dysentery. It is probable also, that the internal use of borax might be useful in certain states of the disease. <§> //.—Treatment of the chronic cases. In the chronic form of the disease, the morbid conditions which we have chiefly to contend with, are either the chronic fungoid inflammation, or ulceration. The treatment is ex- tremely precarious, and but few of the cases comparatively do well. The remedies which appear to be most generally useful are the following: lime-water; vegetable bitters and astringents, especially the cusparia and logwood; preparations of iron; small quantities of mercury with opium, especially calomel with Dover's powder, or small doses of calomel with opium and ipecacun ; the resins, as turpentine, balsam of copaiva or tolu, with small opiates; sulphur with opium; nitric acid ; various combinations of these remedies with each other, as a strong decoction of cusparia with nitric acid and laudanum. Repeated blistering on the abdomen is often very beneficial, also bandag- ing with a broad flannel roller, and tepid salt water bath. Sul- phate of copper has lately been recommended by Dr. Elliotston in various protracted affections of the bowels ; and in any trials of it which I have had an opportunity of making in this class of diseases, it appears to be a remedy deserving of much atten- tion. It is given in doses, at first, of half a grain, combined with an equal quantity of opium, and is gradually increased, if necessary, sometimes to the extent of gr. iii. with half a grain or a grain of opium, three times a-day. In the treatment of all the affections of this class, much de- pends upon the most rigid attention to diet. Animal food in every form seems in general to be hurtful; and the greatest benefit results from a diet strictly confined to farinaceous articles and milk. 30 231 INFLAMMATION OF MUCOUS MEMBRANE A modification of the disease appears to exist, affecting the whole course of the mucous membranes, and going ori or a length of time with characters of an alarming kind, while it is still under the control of medical treatment. The following case will illustrate this modification of the disease, which in practice, is one of considerable interest. Case CXV.—A lady, aged 30, came under my care in spring, 1813, affected in the following manner. She had a remarkable tenderness of the inside of the lips, the tongue, and the throat; a constant discharge of saliva; a burning uneasiness in the tongue, throat, breast, and stomach ; and great uneasiness in swallowing, and for sometime after it. She had a constant tendency to diarrhoea, and a feeling as if food or drink did not remain in the stomach, but passed almost immediately through the bowels. There was some cough, with frequent pulse, great debility, and increasing emaciation. The throat appeared raw, and a little inflamed ; the edges of the tongue and the inside of the under lip were excoriated, and covered with small ulcers, having inflamed margins; there was also a painful excoriation about the anus and the labia. The complaint was of about three months' standing, and had 'begun while she was in the puerperal state in England. A variety of treatment was employ- ed without benefit; she became emaciated and debilitated to the greatest degree; the diarrhoea became incessant, with much pain, and a feeling as if every thing she swallowed passed through her immediately. She had no relief but from large opiates, and that relief was but slight and temporary. When the case appeared to be hopeless, she began to take a decoction of logwood (1 oz. to 1 lb.) a wineglass full four times a day, combined with a small opiate. From this time she recovered daily, and in two or three weeks was in perfect health. Affections of the mucous membrane of the bowels seem to occur in a slighter form than in any of the cases referred to in the preceding observations, and to prove the source of protract- ed bad liealth, with obscure and undefined symptoms, such as a superficial observer is apt to consider as hypochondriacal. There is variable appetite, with impaired digestion, and a variety of uneasy feelings about the bowels, sometimes described as a .rawness and tenderness, and sometimes as a feeling of heat, as if hot water were passing through them. A painful feeling of distention is often complained of, especially after meals, though no actual appearance of distention can be perceived. In some cases, the tongue is loaded; in others, there is a peculiar raw IN INFANTS. 235 appearance of the tongue and throat; and sometimes the tongue has a peculiar red, dry, and glazed appearance. Along with these feelings there is occasionally a slight and protracted fever- ishness, but, in some cases, the pulse is not at all affected. The bowels are often tolerably natural, or easily regulated; but laxative medicine is in general uncertain in its effects, and is apt to operate too violently. The motions are sometimes natu- ral, but frequently they are mixed with mucus in a very concrete or tenacious state, assuming various forms, as irregular crusts, like the crusts of aphthae, or masses of a rounded or tubercular form, which are apt to be mistaken for worms. The affection is often extremely tedious and untractable ; and it is often difficult to say what treatment is most beneficial. The remedies deserv- ing of attention are chiefly those already referred to, in regard to the diseases of the membrane, especially bismuth, lime-water, cusparia, balsam of capaiva. Mercury in any form appears in general to be hurtful. Much depends upon diet; and the great- est benefit is often obtained from a regimen restricted entirely to farinaceous articles and milk. Stimulation, and friction of the abdomen is often useful; also warm clothing and the tepid salt water bath. SECTION V. OF THE INFLAMMATION OF TH'S MUCOUS MEMBRANE IN INFANTS. Acute inflammation of the mucous membrane of the intes- tine is a frequent disease of infants, about the age of 6 or 8 months ; and though the general principles which are applicable to it, do not differ from that already referred to in regard to adults, it is an affection of so much practical importance, as to be deserving of separate description. The most important point in the investigation refers to the means of distinguishing the disease, in its early stages, from the ordinary bowel com- plaints of children about the period of dentition; and this is often a matter of considerable difficulty. The principal cir- cumstance to be kept in view in the diagnosis is, that it is a fe- brile disease. The infant is usually hot and restless in the early stages, with thirst; and the tongue is dry, or coverd with a brownish crust; there is in general a good deal of screaming 236 INFLAMMATION OF MUCOUS.MEMBRANE and fretfulness, disturbed sleep, frequently vomiting; and, in many instances, pressure on the abdomen appears to give un- easiness. The bowels are loose, but this is not in every case a prominent symptom; for even in the advanced stages, the bowels may not be moved above three or four times in 24 hours, while the disease is advancing rapidly to a fatal termination. In other cases, however, this symptom is more urgent,—the evacuations being very frequent, and preceded by much rest- lessness and appearance of pain; and the matters evacuated are sometimes discharged with a remarkable degree of force, so as to be propelled to a considerable distance. The evacua- tions vary exceedingly in appearance, and I have never been able to satisfy myself that any reliance is to be placed upon them in ascertaining the disease. They sometimes consist chiefly of a reddish brown mucus, sometimes of a pale clay- colored matter, and sometimes of a dark watery fluid ; but in many cases they show little deviation from the healthy state, while, in others, their appearance is evidently disguised or modi- fied by articles of nourishment, which pass through nearly un- changed. The disease often goes on for some time without exciting alarm, or being distinguished from an ordinary diarrhoea, until attention is strongly and suddenly directed to the danger- ous nature of it, by the occurrence of constitutional symptoms. These consist in some cases, of a great degree of febrile op- pression, with dry crusted tongue, thirst and vomiting; in others, of a very sudden and rapid exhaustion of the vital pow- ers, which is unexpected, and is not accounted for by the fre- quency of the evacuations ; and sometimes the first appearance of unfavorable symptoms consists in the sudden occurrence of coma, with a peculiar hollow languid look of the eye, and a pale waxen aspect of the whole body, while the pulse perhaps con- tinues of tolerable strength. These symptoms may appear while the disease has been going on but for a short time, and while the evacuations have been by no means frequent; while the affec- tion, in short, had not been distinguished from the ordinary bowel complaints of infants, which often go on for a long time without producing any inconvenience. The causes of this affection are not well ascertained. It fre- quently occurs about the period of dentition, and in many cases appears to be connected with weaning. The fatal terminations are either by a rapid and peculiar sinking of the vital powers or by coma. The appearances on dissection are nearly uniform. In various parts of the inner surface of the intestine, especially the ileum, we find irregular patches of inflammation, sensibly IN INFANTS. 237 elevated above the level of the surrounding parts, and generally covered, either by minute vesicles or by minute ulcers. The disease seems in general to be fatal in this early stage, and I have not seen it, as in adults, either pass into more decided ul- ceration, or terminate by peritonitis. In the cases which termi- nate by coma, effusion in the brain is met with, and this termi- nation is often preceded by a remarkable diminution of the secretion of urine, amounting, in many cases, nearly to suppres- sion. This termination seems to bear a considerable analogy to the Ischuria Renalis, which usually terminates by coma, after the^uppression has continued for two or three days. In regard to the treatment of this highly dangerous affection, it is difficult to determine which is the best; because in cases which terminate favorably, we cannot say with certainty that they really were examples of the disease. In some cases in which there is no vomiting, a gentle emetic seems to be useful in the early stages; afterwards, Dover's powder combined with chalk, opiate glysters, opiate or stimulating frictions to the ab- domen, tepid bath, and small doses of calomel combined with Dover's powder. In some cases the free use of digitalis seems to be extremely useful, also blistering on the abdomen; and, when the disease exhibits much activity, topical bleeding may be employed in the early stages. In the advanced stages, when there is a tendency to sinking, wine must be given freely ; when there are threatenings of coma, blistering on the neck must be employed. From both these conditions infants often make most unexpected recoveries. When there is urgent vomiting, blister- ing on the epigastrium appears to be the most effectual remedy; considerable benefit in settling the stomach is also obtained from small doses of the vegetable bitters and the oxide of bismuth. The state of the teeth is to be attended to, and the gums are to be divided wherever they appear to be producing irritation. In the protracted bowel complaints of infants, in which there was reason to suspect the existence of this affection in a chronic form, I have found nothing so useful as lime-water. The two following cases will be sufficient to illustrate the principal phenomena connected with this interesting and highly dangerous affection. ^ Case CXVL—An infant, aged 6 months, (13th May, 1817,) had been affected for about a week with looseness of the bowels and occasional vomiting. The affection had been considered as the common bowel complaint of dentition, but the stools were scanty, offensive, and dark colored ; and though they were 238 INFLAMMATION OF MUCOUS MEMBRANE. by no means frequent, there was observed a considerable ten- dency to sinking, with paleness and coldness of the body. After several days, the stools became natural, the vomiting ceased, the appetite returned, and the looseness was extremely moderate, but these favorable appearances were of short con- tinuance. On the evening of the 18th the diarrhoea suddenly increased; it was excited by every thing that was taken into the stomach, and the articles that were taken seemed to pass through the bowels with great rapidity. On the morning of the 19th, she was pale and exhausted ; and though the looseness was checked by opiate injections, every attempt to support^her was in vain. She died in the afternoon, having lain through the day in a state resembling coma. Inspection.—The bowels were externally healthy, except some spots of superficial redness. On the inner surface of the small intestines, there were, in many places, irregular patches of inflammation ; in other places there were circumscribed spots of a dull ash color, which were sensibly elevated above the level of the surrounding parts, and were covered by minute ulcers, so as to give them a peculiar honeycomb appearance. On the external surface of the intestine, corresponding with many of these portions, there were defined spots of redness and increased vascularity; the mesenteric glands were enlarged; the other viscera were healthy. Case CXVII.—An infant, aged 7 months, soon after wean- ing was suddenly seized with vomiting and diarrhoea ; was op- pressed, fretful and feverish ; the motions were scanty, and varied in their appearance, being sometimes brownish, and sometimes pretty natural. After a day or two the vomiting cea- sed ; the diarrhoea continued, not severe nor frequent, but accom- panied by much oppression and feverishness, a brown fur on the tongue, and a remarkable dryness of the gums ; the motions varying in appearance as before. Various remedies were now employed with little benefit. After four or five days, the child became comatose ; this was relieved by blistering on the neck, and a dose of calomel. The motions then became green, but were generally scanty and watery ; ^he febrile state continued, with the fur on the tongue ; the child sunk gradually, with op- pressed breathing, and died on the ninth day. Inspection.—The bowels were externally* healthy, except spots of redness on various parts of the small intestine, which appeared deep-seated, as if shining through the peritoneal coat. At the parts corresponding with these spots, the mucous mem- DEATH FROM OTHER CAUSES. 239 brane was elevated into irregular patches of inflammation, and the inflamed surfaces were covered by very minute ulcers; in the neighborhood of these portions the mesentery was unusually vascular. The caion was collapsed and externally healthy; its inner surface was covered in many places by very small vesicles, which were scarcely elevated above the surface of the membrane, but appeared as if shining through it, clear, transparent, and watery; they were most numerous in the caput coli, but were also observed through the whole course of the colon; and they preserved the same character through the whole extent of it, without any appearance either of inflamma- tion or ulceration. SECTION VI. CASES SHOWING THE STATE OF THE MUCOUS MEMBRANE AFTER THE CESSATION OF THE SYMPTOMS, THE PA- TIENTS DYING OF OTHER DISEASES. To thWacts which have been related in connection with this interesting inquiry, I shall only add the following examples, calculated to show the state of the parts, when the symptoms had ceased, after long continuance, and the patients died of other diseases. The second showed a very remarkable and rather uncommon variety of the matter evacuated from the bowels. Case CXVlII.-^-A lady, aged 24, had been of a feeble and delicate habit from her early years, and from the age of sixteen, had been almost constantly in a more decided state of bad health. She was generally confined during the whole winter, with cough, pain in the bowels, and diarrhoea; she got a little better during the summer, but was constantly more or less af- fected with diarrhoea, and occasional pain of the bowels, with variable appetite, bad digestion, and general debility. She had passed six or seven years in this manner, when she came to Scotland in the summer of 1815. She was then much emacia- ted, with a constant loose state of the bowels ; the evacuations were fluid, and of a whitish color, and usually occurred four or five times every day ; when at any time they were less frequent, she became much oppressed about the stomach, and extremely 240 CHRONIC DISEASES OF MUCOUS MEMBRANE. uneasy. She had frequently pain in the bowels ; her appetite was bad, but the pulse was natural. In the winter, the same state of her bowels continued, and she had loud noisy cough with expectoration. In summer >816 she began to improve considerably, having appeared to derive much benefit from large doses of muriated tincture of iron, combined with tincture of hyosciamus. The bowels got into a natural state, the stools being consistent and healthy, and from this time there was no return of diarrhoea; but her appetite and digestion continued very bad, and she made little improvement either in flesh or in strength. In the following winter her cough returned, at first without expectoration; but afterwards she had pain in the breast, purulent expectoration, and hectic fever; and died of phthisis in May, 1817, without any return of the complaint in the bowels. Inspection.—The lungs were extensively tubercular, with nu- merous vomicae. The lower half of the stomach was contract- ed and considerably thickened, and the pylorus was a little thickened, but not indurated. On the internal surface of the intestine there were many portions, several inches in extent, of a dark red color, and more vascular than the other parts ; and in many places there were, on the mucous membr^ie, small circumscribed smooth spots, which had every appearance of the cicatrices of ulcers which had healed. The other viscera were healthy. Case CXIX.—A lady, aged 18, had suffered for a year or more from a disordered state of the bowels, accompanied by a most remarkable and unmanageable degree of tympanitic disten- tion. When I saw her, along with Dr. Combe, in the summer of 1826, she was affected with a variety of hysterical symptoms, with much weakness, impaired appetite, and a very disordered state of the bowels. Under a course of mild laxatives, com- bined with tonics, these symptoms gradually subsided; and when she returned to the country in August, she was in very good health, except that the bowels required the frequent use of medicine and that she occasionally complained of headache, and of a feeling of heat in the epigastric region. In November the bowels again became more obstinate, and she was considerably annoyed with acidity. In the beginning of December, her throat was covered with aphtha?, and she brought up from it considerable quantities of thick white matter; and about the same time, the evacuations from the bowels began to contain much viscid mucus, and afterwards portions of a DEATH FROM OTHER CAUSES. 241 white substance. She now had thirst, was feverish in the even- ings, and complained of pain in the right side of the abdomen in the seat of the ascending colon. The pulse through the day was generally from 74 to 80. The aphthous state of the throat disappeared in the course of December, and afterwards the tongue was only occasionally observed to be red and tender; but the other symptoms continued to recur from this time, with nume- rous variations, for six or seven months, during the greater part of which period she was entirely confined to bed, and was re- duced to a state of the greatest weakness. The prominent symptom now was frequent discharge from the bowels of im- • mense quantities of a substance, which sometimes appeared in the form of pure transparent jelly; at other times of a long fibrous stringy matter, and frequently of large pieces of firm, uni- form, tenacious membrane. These last were occasionally discharg- ed in flat portions several inches in extent, and frequently formed distincttubes ; sometimes they were in masses resembling hydatids, and sometimes in membranous bags which enclosed healthy feces. The membranous crusts or tubes now mentioned were frequently four or five inches in extent, and sometimes portions of white matter resembling cream were observed in the evacuations. The discharges of these various matters frequently ceased for several days together, the motions then becoming quite natural. The re-appearance of the morbid discharges was generally pre- ceded by constipation, and a sense of heat along the intestinal canal, with a sensation of craving at the stomach, thirst and headache. The pulse generally continued from 70 to 80. The feculent matter, which came off mixed with the morbid dischar- ges, was of a natural appearance, but hard and lumpy. Her appetite was generally variable, and her digestion bad. To- wards the end of April 1827, the symptoms began to subside, so that she was able to be out of bed daily for some hours. During May and June, the mucous and membranous discharges continued to recur occasionally, but in smaller quantities, and with longer intervals ; and in July they entirely ceased. The bowels from this time continued natural, or were easily regulated by very mild medicines, and the evacuations were quite healthy. But from the middle of June, when the more decided improve- ment took place in the state of her bowels, she began to have slight cough, and in July she was again confined to bed. In the beginning of August she was brought to town, when the promi- nent symptom was a distinct paroxysm of fever which attacked her daily, beginning sometime betwixt twelve and two o'clock, and continuing till the evening. There was not much emacia- 31 242 CHRONIC DISEASES OF MUCOUS MEMBRANE. tion, but a pale unhealthy aspect; there was slight cough with- out expectoration, and occasional uneasiness in the left side of the thorax, where the respiration was very imperfect. The fe- brile paroxysms continued to increase in severity, with rapid fail- ure of strength. In the beginning of September she began sud- denly to expectorate large quantities of matter, which had a de- cidedly tubercular character; and she died on the 9th. Inspection.—The left cavity of the pleura contained air and much sero-purulent fluid, in which wasva large floating mass of flocculent matter. The left lung was a mass of disease, pre- senting various morbid conditions, from hepatization to total dis- organization, with much infiltration of puriform matter, and nu- merous small tubercles. In one place, a small aperture made a communication betwixt the cavity of the pleura and an irreg- ular ulcerated cavity in the substance of the lung, about four inches in diameter; and there were several other small cavities which communicated with it. The right lung was healthy, ex- cept a small cavity at the upper part; the bronchial glands at the root of the lungs were much enlarged and tubercular. The viscera of the abdomen presented no appearance of disease, ex- cept the mucous membrane of the colon. Through its whole extent, it was thickly covered with small spots of a clear white color, which were remarkably distinguished by their color from the mucous membrane surrounding them. Few of them were larger than the diameter of large pin heads, and, on minute ex^- amination, they were distinctly ascertained to be vesicles, very little elevated, but, when punctured, discharging a small quan- tity of clear fluid. The whole surface of the membrane pre- sented a very peculiar appearance, from the immense number of these spots with which it was covered, but the other coats were entirely healthy. In the mucous membrane of the caput coli, there were two distinct spots in a state of ulceration. The small intestine was healthy. In the preceding observations I have endeavored to give an outline of the pathology of the mucous membrane of the in- testinal canal, in as far as, in the present state of our knowl- edge, the facts appear to be worthy of confidence; but it is well known, that, among the pathologists of France and other parts of the continent of Europe, the subject has been made to assume a much more extensive form. In the investigations of CONJLUDING OBSERVATIONS. 243 the writers whom I now refer to, inflammation of the gastro- intestinal membrane, in an acute, sub-acute, or chronic form, is considered as being the origin of a great variety of diseases, particularly of almost every modification of dyspeptic affec- tions, and all the varieties of fever. This system has not been received to any extent by the pathologists of this country; and the grounds on which we differ from the eminent persons by whom it is supported are chiefly three, namely, in regard to the facts,—their generalization,—and their causation. • I. We do not recognize the facts upon which this system is founded ; because, according to it, many appearances are con- sidered as indicating inflammation of the gastro-intestinal membrane, which we believe to take place after death or imme- diately before it, and consequently not to be considered as in- dicating disease. The nature of these appearances has already been mentioned, as well as the grounds on which we conclude that they are not worthy of confidence in this pathological en- quiry. They consist of livid, red, or brown spots on the mem- brane, portions showing a violet or rose color, enlarged vessels, varicose veins, slight extravasations of bood under the mem- brane, and various other appearances, consisting of mere change of color without any change in the organization of the part. Such appearances we now consider as fully ascertained to occur in a great extent in the bodies of persons who have died from execution or drowning, or from diseases not at all connected with the bowels; and, consequently, that they cannot be con- sidered as indicating a morbid condition of the mucous mem- brane. II. While we set aside, as foreign to the enquiry, a large proportion of the appearances described by these writers, we admit that others are indicative of real and important disease ; but we do not admit that these are uniform appearances in the diseases to which they refer. In a pathological point of view, for example, it is an important fact, that in a considerable pro- portion of the fatal cases of fever, inflammation or ulceration is found in the gastro-intestinal membrane ; but we are far from admitting that it is met with in all these cases, which we should consider as essential to the doctrine of inflammation of the gastro-intestinal membrane being considered as the cause of fever. III. But, even on the supposition that these appearances were met with in all the fatal cases of fever, the question still remains, whether they are the cause of fever or the effects of it; and upon this head, a very slight view of the facts will 244 DISEASES OF MUCOUS MEMBRANE. show that they are decidedly in favor of the supposition of these appearances being the effects rather than the cause of fe- ver. This conclusion we must consider as resulting, in the first place, from the fact already mentioned, that they are often wanting; and, secondly, because that, in their degree, or the stage of their progress, they bear no relation to the period of the fever, but are often found existing, in their slightest or ear- liest stage, in cases which have proved fatal at a very advanced period, and with symptoms of the utmost malignity ; while, on the other hand, they exist in a very high degree, and are appa- rently the immediate cause of death, in cases which have proved fatal at an early period, and in which the proper symp- toms of the fever had been slight and moderate. On all these grounds, therefore, we think we are warranted in concluding, that the affections of the gastro-intestinal mem- brane which are met with in connection with continued fever, are to be considered either as incidental concomitants, or as ef- fects of the disease, and as giving rise to peculiarities of symp- toms in particular cases, but that they cannot, upon any princi- ple of sound reasoning, be regarded as the cause of fever. The truth seems to be, that the morbid conditions observed in the gastro-intestinal membrane, in fever, or only a part of a series of changes which take place in various tissues of the body, espe- cially in those forming surfaces, whether mucous, serous, or cu- ticular. We observe them vary remarkably in the skin. In one stage we find the cutis anserina with suspension of the nat- ural exhalation; in another the dry pungent heat, often with deep redness; in a third, a morbid discharge in the form of clammy unhealthy perspiration ; in a fourth, a variety of spots, vesicles, papula?, petechiae, vibices, portions of erysipelas, and gangrene, and actual sloughing. These changes though more familiar to us, are scarcely less remarkable than those which are observed in the gastro-intestinal membrane. They have accordingly been attended to as important phenomena in the history of the disease; but I am not aware that any one has proposed to consider them as the cause of fever. These observations apply to the general appearances of the mucous membrane, to which so much importance has been at- tached by the pathologists of the continent; but some of the later writers have taken rather a new view of the subject. Un- der the name of Dothinenterite, they describe an affection which they conceive to depend upon active inflammation of the mucous glands of Peyer, and the follicles of Brunner. Their observations on this subject are worthy of attention as far as CONCLUDING OBSERVATIONS. 245 they consist of facts ; but we suspend our confidence when we are farther informed, that the dothinenterite is synonymous with the malignant fever of Sydenham, the hospital fever of Pringle, the typhus of Cullen, the putrid and petechial fever of other writers ; in short, that every variety of fever, continued, intermittent, and remittent, arises from the inflammation of these follicles. As the symptoms of the dothinenterite, they of course describe all the phenomena of continued and malignant fever, accompa- nied by a loose state of the bowels and some degree of tender- ness of the abdomen. The morbid conditions which they des- cribe in these cases are, that, in the early stages, the crypts or follicles appear rather more prominent than natural, and slightly injected, especially in the upper part of the canal; as the dis- ease advances, they become more prominent, with softening of the mucous membrane which covers and surrounds them; and that, at a period still more advanced, this passes into ulceration. These observations are worthy of attention as facts; but when, in describing the symptoms of the dothinenterite, all the usual symptoms of fever are detailed, with the addition of diarrhoea, and tenderness of the abdomen, the statement merely amounts to the fact, with which we are well acquainted, that when in a fatal case of fever, there has been tenderness of the abdomen with diarrhoea, we may expect to find disease of the mucous membrane or its follicles. When we are farther told, that this takes place in every case of fever, and consequently that fever in all its modifications depends upon the inflammation of these follicles, we hesitate alike about the doctrine and the generalization on which it is founded. This we do upon two grounds, namely, that, in many fatal cases, of fever, we cannot detect any disease of these follicles ; and, secondly, that, when we do find such disease, the degree of it, or the stage of its progress, bears no relation to the period of the fever, or the in- tensity of its symptoms. This will appear from a slight exami- nation of the cases related even by the writers referred to. Thus, in a case by Landini, which was drawn out to the 21st day, with every symptom of the most severe form of typhus, the only morbid appearances found in the mucous membrane were,—in some places a grey color; the crypts of Brunner, little developed; those of Peyer slightly enlarged, and a few of them presenting traces of erosion. In another patient, who lay with every bad symptom for twenty-eight days, the glands of Peyer offered some points which were red and denuded of their mucous membrane ; those of Brunner were almost all in their 246 DISEASES OF THE MUCOUS MEMBRANE. natural state, except a few which showed ulcerations, and a very small number which offered traces of melanism; the mu- cous membrane of the great intestine was of a pale rose color, and appeared thickened.* We must suspend our confidence, when we find a system, which professes to account for the whole phenomena of fever, founded upon such inadequate appear- ances as these. The fair conclusions from a view of the whole subject appear to be, that, in certain cases of continued fever, the gastro intestinal-membrane or its follicles become inflamed, pustular, or ulcerated; and that, as facts in the history of fever, these are worthy of much attention, but certainly do not war- rant, in the slightest degree, any general deduction in regard to its nature or cause. * See Landini sur la Dothinenteiite.—Revue Medicale, 1816. APPENDIX TO THE PATHOLOGY OF THE INTESTINAL CANAL. In this appendix, I mean to introduce a few observations on some points of practical importance, connected with the pa- thology of the abdomen, but not requiring a detailed conside- ration. SECTION I. DISEASE OF THE MESENTERIC GLANDS. The disease of the mesenteric glands is so familiar to every practical man, that it may appear superfluous to add any ob- servations on it. There are, however, some points relating to the affection, which present an interesting subject of investiga- tion. It appears that the origin of the disease may in some cases be traced to ulceration of the mucous membrane of the intestine, the chain of diseased glands being first traced in the part of the mesentery most contiguous to the seat of the ul- cers. To what extent this connection exists has not been in- vestigated, but it is worthy of attention. In the progress of the affection there are some facts of considerable interest. In the earliest period at which we have an opportunity of exam- ining the diseased glands, they present, when cut into, a pale flesh color, and a soft fleshy texture; and we sometimes find them of very considerable size, though presenting merely this texture. As the disease advances, they seem to become firmer, 248 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. and to lose the flesh color, assuming first a kind of semi-trans- parency, and afterwards a firm opake white structure, resem- bling the white tubercle of the lungs. In a mass of considera- ble size, we often observe these various structures in alternate layers ; but in the more advanced stages, the opake white tu- bercular matter is the most abundant; and this afterwards ap- pears to be gradually softened, degenerating into a soft cheesy matter, or ill-conditioned suppuration, so familiar to us in dis- eases of this nature. When a gland in the first state of soft fleshy enlargement is plunged into boiling water, its color in- stantly changes to an opake white or ash color; its texture be- comes much firmer; it contracts very much in its dimensions; and by a short boiling, it loses a great part of its weight, leav- ing a residium of an opake white color and great firmness, hav- ing the appearance of concrete albumen. In the more ad- vanced stages of the disease, the glands lose less and less by boiling; and the opake white tubercular matter, when it can be obtained pure, scarcely loses anything. In the first volume of the Medico-chirurgical Transactions of Edinburgh, I have men- tioned some experiments which render it probable, that during these changes in the structure of the glands, there is a gradual deposition of albumen, at first in a soft, afterwards in a con- crete state ; and that the peculiar character of glands in a state of tubercular disease, depends upon the presence of albumen in a very concrete condition, and without organization. It is, however, a matter of curiosity merely, leading to no practical results. Some singular modifications occasionally occur in the state of the diseased mesenteric glands. I have mentioned a case in which they contained calcareous matter, and their cysts were so distended with a gaseous fluid, that they burst with a very sharp explosion, when slightly touched with a knife. A case occurred to Dr. Kellie, in which the diseased glands were enveloped in a very firm covering of bone. Disease of the mesenteric glands is generally to be consider- ed as a scrofulous affection, occurring chiefly in children, and frequently combined with other affections of a scrofulous char- acter, or with chronic peritonitis. But it is met with under other circumstances, and at advanced periods of life. I shall only add the following example of this, which is rather a rare occurrence. Case CXX.—A lady, aged about 40, mother of a large fami- ly, and previously enjoying excellent health, was affected with a deep-seated painful tumor in the left side of the abdomen, which DISEASE OF MESENTERIC GLANDS. 249 was at first considered as an affection of the kidney. After some time a similar tumor was felt below the umbilicus; and soon after a third betwixt the umbilicus and the region of the stomach. They were of large size, and somewhat painful on pressure. The functions of the stomach and bowels were little impaired; but her general health soon began to suffer. The inguinal glands next began to swell, and increased to a great size ; and chains of enlarged glands were traced from them un- der Poupart's ligament, and within the abdomen. Enlargement then took place in the glands of the axilla, and on both sides of the neck. Finally, she had cough, with great irritation about the trachae, fits of dyspnoea, hectic paroxysms, and progressive failure of strength; and she died, gradually exhausted, after an illness of nearly two years. Inspection.—The abdominal tumors were entirely masses of diseased mesenteric glands, some of which were the size of large oranges, and of a firm white tubercular character. There were chains of diseased glands running from Poupart's ligament by the side of the spine; but the abdominal viscera were otherwise healthy. Behind the trachae, and along the posterior medias- tinum, there were large masses of diseased glands; and there were some tubercles in the lungs, but of no great extent. SECTION II. DISEASE OF THE OMENTUM. In the preceding cases several examples have occurred, in which there was disease of the omentum complicated with dis- ease of the neighboring organs. The following case, for which I am indebted to Dr. Storer of Nottingham, shows uncombined disease of the omentum, and must be considered as a very uncommon affection. Case CXXI.—A lady, aged 60, of a full habit, had com- plained for some months of prominence, weight, and habitual uneasiness in the front of the abdomen. In November, 1823, the complaint assumed an acute character, with severe pain, affected by respiration, and fever, but without obstruction of the bowels. The pain was increased by pressure, and a soft diffused tumor was felt to occupy the epigastric and umbilical regions, without any distention of the abdomen. The usual antiphlo- 32 250 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. gistic treatment was now adopted, but with only partial and tempo- rary benefit. After two or three weeks, the pain had become much less urgent ; but she then passed into a state of low fever, with occasio nal delirium, and she died at the end of five weeks from the commencement of the acute attack. For the last week of her life, there was retention of urine, requiring the use of the catheter. Inspection.—The disease was found to be entirely in the omentum, which formed a thick, fleshy mass between three and four pounds in weight. It was of a dark color and soft con- sistence, and no disease was detected in any other organ. Another form of disease and of the omentum is described by Dr. Strambio, in the Anrali di Med. It formed an immense tumor of the consistence of brain, and involving in the mass, the spleen, the left kidney, the ovaria, uterus and rectum. The other viscera were healthy. The disease was ascribed to an injury from a fall about a year before death. The symptoms were vom- iting, with enlargement of the abdomen and febrile paroxysms. SECTION III. TYMPANITES. Tympanites has been usually distinguished into abdominalis and intestinalis. I have never seen such a disease as the tym- panites abdominalis, except when air has escaped into the peri- toneal cavity, in consequence of perforation of the intestine. Several examples of this have been given. It often requires a great deal of time and attention to discover the perforation, which may very often have escaped notice ; and in this manner, probably, has arisen the doctrine of tympanites abdominalis. The important division of tympanites is into two forms, which, for the sake of names, we may call acute and chronic. I. Acute tympanites, or that which occurs in connection with acute disease, we have seen taking place in various forms. In its relation to active abdominal inflammation, we have seen rea- son to believe, that it may occur at an early period, while the inflammation is still in its active state, and be removed when this is subdued; that it may take place at a more advanced pe- riod in connection with extensive adhesion, or disorganization of the parts, marking a hopeless state of the disease ; or that it ifcay ^ left as an effect of the disease, from derangement of the TYMPANITES. 251 muscular power, after the inflammation has been removed, and may, by attention, be entirely recovered from. In Case LXXIV, again, we have seen tympanites supervening upon diarrhoea, and assuming a very alarming aspect; affd in Case LI.II, we have seen it very rapidly fatal, and affecting the whole course of the canal, apparently connected with a general loss of its mus- cular power. The treatment adapted to this form of the disease has been mentioned in treating of the cases now referred to. It also takes place in connection with continued fever, and is in general rather an unfavorable symptom. In all cases of acute disease, tympanites requires to be watched with some anxiety ; but we have seen that it may be recovered from, even under circumstances apparently the most alarming. II. Chronic tympanites is met with most frequently in females ; and it often proves most untractable. When it is accompanied with any degree of wasting, and impaired general health, there is reason to suspect chronic peritonitis, especially if there should be any pain or tenderness of the abdomen. It also occurs in connection with chronic disease of the mucous membrane, as we have seen in Case CXIX, and it may be left as the effect of an acute attack, as in Case LXXIII. When it does not arise from such causes as these, the treatment must consist chiefly of attention to the general health, with regular exercise, cold bath, and careful regulation of the bowels ; especially by small doses of aloes or rhubarb, combined with tonics and stimulants, as sul- phate of iron, quinine, and the stimulating gums. Small doses of turpentine may often be useful; also friction of the abdo- men ; compression by a roller, and perhaps galvanism. An affection of a singular nature is often met with in females, which appears to be a modification of tympanites, though assum- ing characters different from the ordinary cases. The abdo- men becomes gradually and uniformly enlarged, and is through- out firm and tense, and without the usual feeling of tympanites. It sometimes assumes the character of a mass of organic disease ; and has not unfrequently been mistaken for pregnancy, espe- cially in females who have been married late in life. It is often in such cases accompanied by suppression of the menses, and all the usual symptoms of advancing pregnancy; and not a few examples have occurred, in which every preparation was made for approaching accouchement, before the nature of the affec- tion was ascertained. If taken at an early period, it generally disappears in a short time under a course of mild purgatives, as Harrowgate water. If neglected, it is apt to become permanent, but without appealing to have any very considerable effect upon the health of the patient, though it often assumes in a great mea- 253 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. sure the appearance of extensive organic disease. I have had no opportunity of examining the parts in a case of this kind. In its early stages, the affection must consist entirely in a state of distention of the bowels, but the characters of it are very pecul- iar ; and it is probable, that in the advanced stages, some change takes place in the parts, which has not yet been investigated. A remarkable circumstance in the history of some of these af- fections is, that, after continuing in a most extraordinary degree for a length of time, and resisting every remedy, they some- times disappear spontaneously. In the Edinburgh Medical Es- says, Dr. Monro has described the case of a young woman, whose abdomen became so enormously distended, that it often seemed in danger of bursting. This affection continued three months, and then disappeared by a prodigious discharge of flatus both upwards and downwards. A remarkable distention sometimes takes place in circumscri- bed portions of the intestines, forming defined enlargements, with such a degree of firmness, as gives them very much the char- acters of solid tumors ; and I have seen several cases in which, on a superficial examination, such affections were mistaken for mas- ses of organic disease. I have described several cases in which this occurred from remarkable thickening of the coats of the in- testine at particular parts: but, in the cases which I now refer to, the coats appear to be healthy, and the affection seems to de- pend upon a very singular state of distention confined to a small part of the canal. Several years ago, a gentleman from Eng- land consulted mc respecting a tumor in the right side of the abdomen. It seemed as large as the head of a child ; and, when examined while he was in the erect posture, felt quite hard, un- yielding ; but on laying him in the horizontal posture, and mak- ing pressure upon it, the whole swelling disappeared suddenly with a girgling noise. It appeared to be the caput coli in a singular state of distention. The affection had existed for a considerable time, and though he was subject to flatulence and indigestion, his general health was little impaired. In my trea- t se on the Affections of the Brain, I have described the case of a woman, who had swelling and hardness occupying the whole right side of the abdomen, and conveying the impression of an extensive mass of organic disease. But when she died soon after, of an affection of the brain, no vestige of disease could be discovered in the abdomen. It appears-that symptoms assuming the most alarming char- acters, may arise from a merely distended state of the intestines, the nature of which has not been fully investigated. The fol- TYMPANITES. 253 lowing cases, for which I am indebted to Dr. Cheyne of Dublin, will illustrate this singular affection. Case CXXII.—A lady, aged 23, had been long affected with pain in the right hypochondrium, and a very confined state of the bowels, for which a great variety of treatment was adopted with little benefit. In the autumn of 1822, the abdomen became greatly enlarged, tense, and painful. Some relief was obtained from topical bleeding, blistering, and purgatives ; but after a severe pulmonary attack in winter, the pain and weight were aggravated, and extended into the left side in the direction of the arch of the colon, with increased tenderness of the abdo- men. In spring 18^3, she was somewhat improved, but in June and July, there was again an increase of the abdominal pain, which became very severe in the course of the transverse colon, with obstinate costiveness, dry tongue and thirst. Some relief was again obtained from topical bleeding, purgatives, and enemata ; the latter bringing off frothy discharges, and much flatus. In the beginning of winter 1823—4, she had two pul- monary attacks, after which the abdomen became again very tumid and painful. In April, 1824, she had pain in the right shoulder, pain and numbness of the right thigh and leg, and she often complained of a feeling as if scalding water were pass- ing along her right side. In June, the abdominal pain and ten- sion being very great, a caustic issue was inserted on the right side of the linea alba ; purgatives were persevered in ; and she went to the country, were she remained during the summer and autumn, and improved considerably in strength. From this time her complaints continued to abate, and she has since en- joyed very tolerable health. The uterine functions had been through the whole course of this affection, quite natural. A sister of this lady was affected in a similar manner, suffer- ing most intense rain in the abdomen, and such tumefaction that she was supposed to have ascites, and was several times on the point of being tapped. She died after protracted suf- fering, which continued for several years ; and, on examination, the disease was found to consist entirely of an enlargement of the colon. A portion of it 44 inches in length is preserved ; the largest circumference of which is 25 inches, the smallest 16. It was in many parts ulcerated. The existence of ulceration in this case gives reason to be- lieve that the disease was originally connected with inflamma- tory action of a low chronic kind, which gradually destroyed the natural action of the part. But without any cause that can be traced of this nature, there appears to be a disease of the in- 254 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. testinal canal depending upon a gradual loss of its muscular power, the cause of which eludes our researches. An interest- ing example is related by Dr. Parry, in the case of a medical gentleman who had been long liable to dyspeptic complaints, great flatulence, and irregularity of his bowels. After suffering, for a fortnight, great pain in the bowels, with nausea and cos- tiveness, he was seized with symptoms of ileus, accompanied with severe pain, which was most violent in the epigastrium and left hypochondrium. Under the usual treatment this attack subsided after several days ; but he continued from this time to be liable to similar attacks, which were accompanied by vomit- ing, obstinate costiveness, and severe pain, with hardness and distention in the epigastric and left hypochondriac regions. The bowels were at all times unmanageable, and the motions thin, scanty, and not formed. The pulse was little affected. The matter vomited at length became feculent, and he died with symptoms of peritoneal inflammation, about six months after the commencement of these attacks. On inspection there were found marks of peritonitis with adhesions ; and the omen- tum was in a thickened and hardened condition. But the prin- cipal appearance was an enormous and uniform distention of the colon, the arch of which occupied entirely the epigastric and hypochondriac regions, so that the stomach and the liver were pressed upwards, high into the thorax. Its coats were in some places slightly thickened, and the peritoneum covering of it was of a dark color, but there was no appearance of contrac- tion or obstruction in any part of its course. The enormous distention extended from its commencement to the sigmoid flex- ure, and it contained an immense quantity of feculent matter. partly solid and partly fluid. The sigmoid flexure and rectum were perfectly healthy. The ileum was distended, and dark colored, but in a much less degree than the colon.* I have already alluded to the remarkable effects of galvanism in some obstinate affections of the bowels ; and I am indebted to the kindness of Dr. Cheyne -for an additional illustration. A gentleman had been under the care of the most eminent phy- sicians in England and Ireland for an obstinate state of the bow- els, which was originally ascribed to having slept in a newly painted room. From being of a full habit, he became greatly emaciated, and the complaint went on'in this manner for about two years Dr. Cheyne then recommended galvanism, which in about three weeks restored the natural action of the bowels and he soon recovered perfect health. ' ♦ Collections from the unpublished Medical Writings of Dr. Parry, vol. ii. ARTERIAL HEMORRHAGE FROM THE RECTUM. 255 SECTION IV. ARTERIAL HEMORRHAGE FROM THE RECTUM. I have seen a good many cases of arterial haemorrhage from the rectum, and they presented some facts worthy of being re- corded. The discharge is usually at first considered as haemor- rhoidal, and does not excite any apprehension, especially as the quantity of blood lost is often not great. But after some time, the patient begins to look pale, haggard, and exhausted ; palpi- tation and breathlessness are excited by any exertion, frequent- ly with attacks of giddiness and a sense of severe throbbing in the head, and sometimes there is anasarca of the legs. The pulse becomes small and frequent, and is excited to the highest degree of frequency by very moderate exertions, perhaps by walking across a room. He becomes more and more exhausted, till he acquires all the appearance of a person sinking under the advanced stage of some deep-seated disease. During this time, he probably complains of nothing except extreme weakness: and says he is sensible of no disease, except a degree of piles, which bleed regularly, but in no great quantity. On examining the parts immediately after he has been at stool, or on making the extremity of the rectum protrude by means of a stimulating injection, a small fungous mass is discovered within the verge of the anus, on the apex of which a minute artery is seen bleed- ing per saltum. The remedy is simple and effectual, and con- sists in taking up the bleeding point with a tenaculum, and ty- ing it, so as to include a part of the fungus. It is not necessary to go to the base of it, and in this manner much irritation is prevented, while the cure is equally effectual. The patient soon begins to recover strength, and it is astonishing with what ra- pidity every appearance of disease vanishes. It is difficult to say what is the source of the alarming character of the symp- toms in these cases ; whether the greater permanency of the discharge,—or that there is more exhaustion from the loss of arterial than venous blood; for the quantity of blood lost is often not so great as, certainly not greater than, is often lost from haemorrhoids for a length of time, without any effect upon the general health. When the ligature does not entirely com- mand the haemorrhage, the free application of the nitrate of sil- ver is often very beneficial. The affection is, upon the whole, one of extreme interest, from the alarming appearance of the patient, and the rapid improvement which he makes after the vessel is tied. The disease is sometimes distinguished by the 256 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. blood coming off in coagulated masses; and it would appear that in these cases the minute vessel is nearly at all times bleed- ing a little, and that the blood coagulates in the rectum, and accumulates, till such a quantity is collected as excites the pa- tient to go to stool. This I think, does not take place with the discharge of haemorrhoids. The affection is also distinguished by the arterial color of the blood,—that which is haemorrhoidal being probably always venous. SECTION V. OF A VERY OBSCURE AFFECTION, IN WHICH THE SYMP- TOMS ARE CHIEFLY REFERABLE TO THE BOWELS. The affection which I refer to under this head, would appear to be connected with some morbid condition of the mucous membrane of the intestinal canal, the precise nature of which eludes our observation. The patient is found thin, pale and weak, with a withered look, a peculiar dry state of the skin, and a small weak pulse. His appetite is variable and capri- cious, and he feels uncomfortable after eating. The bowels are slow, though easily regulated ; and the evacuations are always of a remarkably dark color, like dark mahogany, or almost black. The obscure nature of the affection will appear most strikingly from the following case which was fatal. Case CXXIII.—A lady, aged about 30, had been in bad health for four or five months ; and when I saw her, was wasted like a person in an advanced slage of phthisis. She had a small frequent pulse and bad appetite, but complained of no- thing except some undefined uneasiness in the abdomen. The bowels were slow, requiring the constant use of medicine; the motions were consistent and formed, but always of the deep brown color of dark mahogany or rose wood, and no treatment had any effect in correcting that color. The abdomen was col- lapsed, and nothing could be discovered by examination. Sometime after I saw her, she began to have uneasiness in her chest, with slight cough"; she then became liable to fits of coma, in which she lay with her eyes open, but unconscious of any- thing; at length she had repeated paroxysms of convulsion, and she died in a state of the most extreme emaciation, after an illness of eight or nine months duration. Inspection.—No disease could be discovered in the brain, and the lungs were quite healthy, except some very old adhe- DISEASE OF RECTUM--STRICTURE OF CiOLON. 257 sions of the pleura. The intestinal canal was throughout so thin, as to be transparent like goldbeater's leaf. On the mucous membrane there was in many places a tenacious mucus of a dark brown color, but no disease could be discovered in the membrane itself, and no morbid appearance could be detected in any organ. I do not attempt to explain this case. The only conjecture that can be offered in regard to it is, some morbid condition of the mucous membrane interfering with digestion, and prevent- ing the nourishment of the body. I have seen some other cases which showed similar characters, and proved very tedious and unmanageable. The peculiar character in all of them was the remarkably dark color of the evacuations, which nothing had any effect in correcting. The last case that occurred to me seemed to derive most benefit from the sulphate of iron; and this remedy, which in general makes the evacuations very dark or nearly black, made them in this case decidedly lighter than their usual color. Another seemed to derive benefit from small quantities of mercury. The patients had in general a peculiar emaciated withered aspect, with a dry state of the skin, a weak pulse, and a variable and capricious appetite; but no actual disease could be discovered capable of accounting for their unhealthy appearance, SECTION VI. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI. Case CXXIV.—A young man, aged 19, on the evening of 16th September, 1827, was seized, after eating freely of pears, with pain of the bowels, accompanied with much vomiting and purging. These symptoms were relieved by the usual means, but were immediately followed by fixed pain in the right iliac1 region, a little below and inwards of the superior spinous pro- cess of the ileum. At first nothing unusual was discovered by examination of the part; but after a few days, a deep-seated circumscribed swelling, about the size of an egg was felt; it was exceedingly painful to the "touch and gave much pain in motion, but the skin covering it was healthy. The functions of the stomach and bowels were now in a natural state, but there was much fever with high delirium. General and topical bleeding, and all the other usual remedies, which were careful- ly administered by Dr. Begbie, failed in giving any relief. Fe- 258 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. ver continued with high delirium; the swelling was still very tender to the touch, and there were frequent attacks of strong rigors. In the beginning of October, the swelling became more diffused and less painful, and an obscure feeling of fluctuation was discovered in it. On the 3d he was seized with severe diarrhoea, accompanied by a tympanitic state of the abdomen; the local affection then became less urgent, but the constitu- tional symptoms continued and assumed the characters of the advanced stage of low fever, and he died, gradually exhausted, on the 14th. Inspection.—Immediately above the caput coli, the omentum had contracted a very firm adhesion to the ascending colon and to the parietes of the abdomen ; and in this manner was formed a circumscribed cavity, bounded by this portion of omentum, the posterior surface of the caput coli and the portion of perito- neum lining the parietes at the part. This cavity contained a small quantity of ill-conditioned pus, and three or four bodies, which were found to be the seeds of fruit, covered by an earthy incrustation; it communicated with the caput coli by a small irregular opening, and the mucous membrane around the open- ing was thickened and highly vascular. The cavity of the abscess was also found to extend behind the peritoneum cover- ing the iliac muscles, and upwards along the whole extent of the lumbar vertebrae. There is an obscurity in the pathology of this singular case; and it seems difficult to say, whether the abscess had been ori- ginally formed and had burst into the caput coli, or whether the perforating ulcer of the caput coli had been the primary disease, and the escape of its contents had given rise to the abscess. The exigence of the seeds of fruit, covered by an earthy in- crustation, in the cavity of the abscess, would appear to favor the latter supposition. SECTION VII. EXTENSIVE DISEASE OF THE RECTUM AND PROSTATA GLAND-STRICTURE OF THE ARCH OP THE COLON &t Case CXXV.—A gentleman, aged 72, had been liable for n"een y?""Sto frequent desire to pass urine, which generally obliged him to get up five or six times in a night, and it was usually accompanied at each time by a desire To go to stool £fl h f A TTd t0 Th a deSree'that for s*ve^ years h,/ hL 'i*' Sx5arCely CVer made water wi*hout having his bowels moved. His general health, however, continued DISEASE OF RECTUM--STRICTURE OF COLON. 259 good, until about a year before his death, when he began to fall off greatly in flesh and strength. Soon after his legs became cedematous, and his pulse feeble, and he was greatly distressed with flatulence. The frequent desire to pass urine continued, but it was passed without pain. On examination the prostate was found so much enlarged as to prevent the passage of the finger into the rectum. The abdomen was now tense and tympanitic, and hard deep-seated tumors were felt in various parts of it, especially in the left side, where they were painful on pressure. The bowels continued quite open or easily regu- lated, and his motions were of a healthy appearance and rather fluid. He died, gradually exhausted, in July, 1827. Inspection.—The prostate was very much enlarged, and of a soft cheesy consistence, so that it broke down under slight compression. The coats of the rectum were much thickened, and it adhered extensively to the neighboring parts. The sig- moid flexure of the colon adhered to the brim of the pelvis. The bladder was much thickened and contracted, but its internal surface was healthy. In the caput coli there was a small ulcer, and in the right side of the arch of the colon there was a thick- ened and contracted portion about an inch in extent, which admitted only a small finger. The other parts of the colon, both above and below this contraction were distended with large hard masses of feculent matter, many of them the size of large eggs; and it appeared that they had formed the tumors which were felt during the life of the patient. It is unnecessary to point out the pathological points which are illustrated by this case. One not unworthy of attention consists in the masses of hard feces in the colon, assuming, in a great degree, the characters of glandular tumors, and some of them being even painful on pressure. It also illustrates in a striking manner that singular state of the bowels, in which fluid feces may be discharged regularly, and freely, and appa- rently in abundant quantity, while there is going. on for a length of time an immense accumulation of feculent matter, in a very hardened state, extending through the whole of the colon. SECTION VIII. EXTENSIVE DISEASE OF THE BLADDER, AND COMMUNICA- TION BETWEEN IT AND THE INTESTINAL CANAL, AT THE EXTREMITY OF THE ILEUM. The following remarkable case, for which I am indebted to Dr. Hay, illustrates several points connected with the preced- 260 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. ing inquiries, particularly the translation of erysipelatous inflam- mation from the surface of the internal parts; and the forma- tion of a communication betwixt the intestine and the bladder. Case CXXVI.—A lady, aged 63, in the end of June, 1829, was seized with rheumatic symptoms, accompanied by an erythematic blush on the ankles. After 8 or 10 days, these symptoms disappeared rather suddenly, and she was seized wite dysuria and considerable uneasiness in the region of the bladder. On the following day, (the 9th of July) there was complete retention of urine, with pain and distention of the abdomen, and continued vomiting; her pulse became extremely feeble and rapid, and the skin cold. On the 10th the vomit- ing had subsided—the retention of urine continued, requiring the regular use of the catheter, the urine being abundant in quantity and bloody. From this time she required the regular use of the catheter; the bloody tinge in the urine gradually dimin- ished, and after 8 or 10 days ceased; but as this change took place, it became highly offensive, depositing purulent matter, and some portions of slough, and on several occasions, a quan- tity of fetid gas escaped through the catheter. The abdomen continued much distended; and the motions were liquid, and generally very offensive. From the 15th to the 20th she seemed to rally a little in point of strength, but from that time sunk progressively, and died on the 28th. Urine, mixed with pus, was regularly drawn off by the catheter until 36 hours before her death, from which time nothing but purulent matter seemed to be discharged from the bladder. Inspection.—The omentum adhered to the bladder and to the ascending colon. The caput coli was greatly enlarged, and the extremity of the ileum adhered to the posterior part of the bladder. The bladder adhered extensively to all the parts within the pelvis, and in attempting to separate it, a large quan- tity of pus escaped. Its inner surface was sloughy, and shreds of its mucous coat were hanging into its cavity. An opening capable of transmitting a goose quill was found to exist betwixt «ie bladder and the portion of the ileum which adhered to it The left kidney was healthy; the right was wasted, so as to leave only the calyces and cellular texture without any of the glandular structure. PATHOLOGY OP THE LIVER. In a short dissertation on the pathology of the liver, my intention is to do little more than attempt a slight outline of the morbid conditions to which that organ is liable, without entering minutely either upon the symptoms or the treatment. My rea- son for doing so is, that acute affections of the liver are com- paratively rare in this country, so that I cannot speak of them from much personal observation ; and that the chronic diseases are generally obscure in their symptoms, until they are detected by manual examination, and, in point of treatment, are in gen- eral beyond the reach of medical aid. I must at the same time confess my suspicion, that it has be- come a kind of fashion to refer symptoms to morbid conditions of the liver, without any good ground for considering them as being really connected with that organ. This is so common in the modern phraseology of medicine, that it seems a very deli- cate task to start a doubt in regard to a doctrine so generally received. But, as a practical man, anxious to be guided by observation alone, there are three classes of facts which have appeared to me worthy of much attention in reference to this subject; namely, 1. That I frequently see such complaints get well under very mild treatment, as regulation of the bowels, and a little attention to diet; 2. That I have seen such patients put through long and ruinous course of mercury, without any ben- efit, and afterwards found the complaint removed by a course of mild laxatives ; and, 3. That I have known patients die of other diseases, while these alleged affections of the liver were going on, without being able to discover in the liver, upon dissection, the smallest deviation from the healthy structure, I am ready to admit, that in such an organ as the liver there may be morbid 262 PATHOLOGY OF THE LIVER. actions which do not leave any appearance that can be discov- ered on dissection, though they may be the source of uneasy sensations and derangements of function. But such actions, if they leave no trace of their existence, must have been of a very temporary kind. If the symptoms have been of any conside- rable standing, we are certainly entitled to look for some trace of disease, or else to doubt whether the liver was really the seat of the disorder,—particularly if the symptoms were of such a kind as might with equal plausibility be referred to other sources, such as disordered conditions of the stomach or bowels, especially the duodenum or the arch of the colon. The structure of the liver, on a superficial examination, has a uniform appearance ; but when minutely examined, it is found to consist of two textures, which in certain states of disease can be clearly distinguished from each other. The one is a cellular or spongy texture or network, which appears to be of a yellowish white or ash color, and to possess comparatively little vascularity. The other is a substance of a red or reddish brown color, Contained in the cells of the former; it is highly vascular, and is supposed to be capable of very rapid increase or diminution of its volume, in a manner almost resembling the erectile tissues. This however, is probably in some measure hypothetical, and it is probable, that the rapid changes in vol- ume to which the liver appears to be liable, may be rather referred to the great vascularity of its structure, arising from the two distinct sets of blood-vessels which ramify through it in a manner quite peculiar to itself, namely, the hepatic artery and the vena portae. A considerable part of the structure of the liver is also composed of the biliary vessels. In endeavoring to trace a slight outline of the actual morbid conditions of the liver, it is natural to arrange them into two classes, namely, the acute and chronic. There is, however, a difficulty in this arrangement, because the two classes run 'so much into each other, that cases which begin with very acute symptoms, often become in their progress protracted and chronic In using the terms, then, as a mere arbitrary division of the subject, I do it with the understanding, that, under the class of acute affections, I include those which are at an early period marked by acute symptoms distinctly referable to the liver though they may afterwards become protracted; and under the chronic diseases, those in which the affection steals on in an obscure and insidious manner, perhaps only with dispeotic symptoms,—or m which the affection of the liver is not ascer tamed till after protracted illness, or when the patient has died INFLAMMATION OF THE LIVER. 263 of another disease. The distinction is sufficiently correct for practical purposes; and an attempt at minute pathological arrangement on such a subject is often made at the expense of utility. In the following outline I mean to describe the liver diseases of this country as they have occurred to myself, though with occasional reference to those of India, as they are de- scribed by the best practical writers. SECTION I. OF THE MORBID CONDITIONS OF THE LIVER, WHICH APPEAR TO BE CONNECTED WITH ACUTE DISEASE. <§> J.—Inflammation of the liver. The symptoms of inflammation of the liver seem to vary ex- ceedingly, according to the activity of the disease, and the part which is the primary seat of it. There is generally pain in the right hypochondrium, increased by pressure, and frequently by inspiration, with tension, considerable disturbance of the func- tions of the stomach, and often urgent vomiting. There is gen- erally fever, but this is often in a very slight degree; there is sometimes jaundice, but this is often entirely wanting ; and fre- quently there is pain extending to the right shoulder, but this also is by no means a uniform symptom. When the inflamma- tion affects the peritoneal coat, it appears that the pain is in general more acute and defined, and accompanied by a higher degree of fever, than when it is^_ confined to the parenchyma- tous substance. When the upper surface of the liver is the chief seat of the disease, there is often cough, with symptoms closely resembling pneumonia; when it is chiefly in the concave surface, the stomach is more affected ; and, when in this situa- tion, jaundice is more likely to take place, which may not ap- pear at all if the disease be chiefly in the convex surface. When the inflammation is seated in the substance of the liver, the symptoms seem to admit of great variety, and are often very obscure,—the pain being frequently slight and dull, with very little fever; and it appears that the complaint may continue in this state for weeks or months, or may terminate more speedily by abscess or softening, though with very obscure symptoms to the last. The symptoms, however, attending inflammation of the substance of the liver are by no means uniformly obscure, 264 ACUTE DISEASES OF THE LIVER. for, in some of the following cases, terminating by abscess, it will appear that they are of a very acute character. I have not seen inflammation confined to the peritoneal covering of the liver, except when combined with extensive and general perito- nitis. , The terminations of inflammation of the liver, seem to be chiefly the following. 1. It may be fatal in the inflammatory stage. 2. Suppuration. 3. RamoUissement or softening of the substance of the liver, which appears under various forms, to be afterwards more par- ticularly described. 4. By passing into chronic disease. As some of the appearances, however, which will be referred to under these heads, have not been absolutely ascertained to be terminations of inflammation of the liver, I shall not describe them under this arrangement; but, following the course which I have already proposed, I shall simply refer to them in the general in- vestigation of the actual morbid conditions which we find in the liver after death. § II.—The mass of the liver more or less enlarged, especially on the right side ; externally of a very dark color, or nearly black ; its substance, when cut into, also very dark colored, and giving out a large quantity of very dark blood. In other cases, the black color is only on the surface, the inter- nal structure being tolerably healthy. This appears to be a frequent morbid appearance of the liver in India, in cases which are rapidly fatal. The symptoms de- scribed as connected with it are chiefly a febrile state, with anxious expression of the countenance, nausea, impaired appe- tite, and very bad digestion, pain, or a sense of weight and ful- ness in the region of the liver, and great oppression across the praecordia, often oppressed breathing, headache, disturbed sleep, turbid urine, and a sallow color of the complexion. The disease has been called congestion, but this is merely a name accom- modated to the appearance and explains nothing. It appears to be nearly allied to inflammation, and there seems much rea- son to believe that this is to be considered as inflammation of the substance of the liver, fatal in the inflammatory stage, or in a stage immediately succeeding the state of active inflammation. The following is the best marked case that I have seen of BLACK CONDITION OF ITS SUBSTANCE. 265 the appearance referred to under this section, and the morbid condition appeared to have been very superficial. Case CXXVII.—A gentleman, aged 28, (6th September, 1822,) was seized with vomiting, and for three days vomited ^every thing which he took into his stomach. There was an ob- scure uneasiness across the epigastric region ; the tongue was foul; the bowels were reported to have been easily regulated ; the pulse from 120 to 130. The vomiting abated after three days, but returned after another day, though with less severity ; then subsided again; and in this manner were passed three days more, being six days from the commencement of the at- tack, without any other symptom. He was then seized with very deep jaundice, and I saw him for the first time on the fol- lowing day, 13th September. The jaundice was then very deep ; pulse 120 and strong ; no vomiting; no complaint of pain, even upon pressure ; tongue white ; bowels open ; stools very daik, Blood-letting was now employed followed by the other usual remedies. For two days there was little change ; the pulse continued at 120, but less strong ; the bowels open ; the stools dark ; the urine deeply tinged with bile. On the 16th and 17th, the pulse came down, but very deep jaundice continued, with a look of much febrile oppression, but no complaint of pain; the bowels were freely moved by repeated purgatives, and the mo- tions showed no want of bile. On the 18th, he was seized with hiccup, which continued very troublesome through the whole day; the tongue assumed a parched and typhoid character ; the pulse 108, and of good strength; jaundice continuing very deep. He became from this time progressively worse, and died on the 20th. Inspection.—The liver was uniformly of a very dark color, almost black, without any sensible increase of size. When cut into, it appeared that the black color was very superficial, the internal parts being tolerably healthy. The gall bladder was empty and flaccid ; no obstruction could be discovered in any of the ducts ; and no morbid appearance could be detected in any other organ. That this black condition of the substance of the liver is a state connected with inflammation, is rendered probable by an interesting case mentioned bf Portal, in which it was combined with abscess. A gentleman, aged 50, was seized with shiver- ing, followed by fever, pain in the right side under the false ribs, vomiting, cough, and dyspnoea, and died in seven days, without any particular change in the symptoms, except that a day or two before death, much tension appeared in the region of the liver, 34 866 ACUTE DISEASES OF THE LIVER. In the peritoneal cavity there was much bloody fluid, with floc- culent filaments floating in it. The liver was enormously enlar- ged : externally, it was of a deep red color, with pseudo-mem- branous deposition on its upper surface, and adhesion to the diaphragm ; internally, it was of a deep black color, and dischar- ged, when cut into, much black blood ; and there were in va- rious places vomicae, full of purulent matter.* The combination* of this black condition of the substance of the liver with suppu- ration will also be found in Case CXXVIII. The earliest stage, perhaps, at which the morbid appearances of the liver can possibly be seen, occurred in a remarkable case also mentioned by Portal. A lady, aged 28, suffered a sudden cessation of the menses from a violent mental emotion. She was immediately seized with severe vomiting, and complained of acute pain in the epigastric region, extending along the right hypochondrium. After a few hours, deep jaundice took place, with fever, distention of the abdomen, hiccup, and very difficult breathing ; and she died on the following day. The liver ap- peared much enlarged, and when cut into, seemed to be infil- trated with a bloody serous fluid. Its upper surface was cover- ed with false membrane, and the right side of the diaphragm was inflamed. The lungs were much gorged with blood. The other viscera were healthy. § III.—Abscess of the liver. This must be considered as the result of inflammation of the substance of the liver, but the symptoms appear to vary exceed- ingly in activity,—in some cases being such as distinctly indi- cate active disease; in others, stealing on insidiously with little more than a feeling of weight and fullness ; and in many cases, most extensive abscesses have been met with, when the symp- toms had been merely dyspeptic, or perhaps had been consider- ed as hypochondrical. The following cases will exhibit the principal varieties of this affection as it occurs in this country. Case CXXVIII.—A gentleman^aged 22, (15th June, 1817,) was affected with pain across the epigastric region, increased by pressure, and accompanied by vomiting and frequent pulse. * Pprta!,—Maladies du Foie. ABSCESS. 267 The case was considered by an intelligent surgeon as Gastritis, and was actively treated by repeated blood-letting, blistering, purgatives, &,c. Under the use of these means, the pain was very much relieved, and the vomiting subsided; but on the 18th, being the third day from the commencement of the symp- toms, he was seized with very deep jaundices. I saw him on the 20th. His pulse was then from 90 to 96> and soft: the bowels were open; very deep jaundice continued, but there was very little complaint of pain, except some uneasiness on very firm pressure in the region of the left lobe of the liver. On the 21st, there was no change, and very little complaint ; but on the*22d, the pulse rose suddenly to 140, without any other change in the symptoms. It subsided at night, but on the 23d was at 160; there was much febrile oppression, and very deep jaundice, with restlessness, slight pain upon pressure, and some tension in the region of the left lobe of the liver. The usual remedies were persevered in without any effect in controlling the^ disease. On the 24th, he continued in the same state, with an anxious febrile look, and died on the 25th. Inspection.—The left lobe of the liver contained several small abscesses, full of purulent matter; and there were also several abscesses in the right lobe in the part most contiguous to the left. In other respects, the whole substance of the liver, except a small part at the lower extremity of the great lobe, was very much softened and broken down, and of a very dark or nearly black color. Both the hepatic duct and the ductus communis were obstructed by large calculi, and a large accu- mulation of bile appeared to have taken place in the substance of the liver, which flowed out freely when the ducts were laid open. The other viscera were healthy. Case CXXIX.—A lady, aged 51 (23d October, 1816,) was affected with incessant vomiting, and severe pain in the region of the stomach, much increased by pressure, and extending downwards towards the umbilicus; bowels open; pulse 84; the symptoms had continued 20 hours. She was treated by repeated blood-letting, blisteiing, full doses of calomel, &c. In the evening of the 24th, there was considerable relief of the pain, but it returned on the 25th with much severity : it was fixed in the region of the stomach, and was increased by inspira- tion ; and tenderness on pressure extended over a great part of the abdomen. There was less vomiting; pulse 120 and small; bowels open ; after further bleeding, there was again much relief of the pain ; she breathed with more freedom, and 268 acute diseases of the liver. was free from vomiting; pulse 108. On the 26th, the pain re- turned with much severity, and continued with little abatement on the 27th and 23th. It was chiefly referred to a spot imme- diately below the ensiform cartilage, and extended into the re- gion of the left lobe of the liver, where there were some tension and tenderness on pressure. She was now free from vomiting ; the bowels were quite open, and the motions daik colored ; the pulse varying from 100 to 120. She was now chiefly treated with calomel, digitalis and blistering. On the 29th, the symp- toms began to subside, and in a short time, she was able to be out of bed, and seemed to be convalescent. But it soon appear- ed that she was not free from the effects of the atrack. She had occasional uneasiness in the region of the stomach and liver, with severe nausea, occasional vomiting, and oedema of the legs; pulse sometimes natural, and sometimes rather fre- quent. The pain recurred in paroxysms, which often extended through the whole abdomen ; and she was liable to attacks of vomiting, which continued severe for a day or two at a time, and then subsided : her most permanent and uniform complaint was of constant and severe nausea ; and her general aspect was pale and exhausted, but without any appearance of jaundice. Some tension was felt in the region of the liver, but it was very obscure. With various remissions and aggravations of the symptoms now mentioned, the case was protracted for four months, and she died gradually exhausted on the 27th of Feb- ruary. Inspection.—On the upper surface of the liver, towards the left side, there was an abscess, covered by little more than the peritoneal coat, and containing about a pound of thick purulent matter. The greater part of the liver in other respects was much softened and broken down ; and the gall bladder con- tained a great number of biliary calculi of various sizes. There were some small abscesses in both kidneys. All the other vis- cera were healthy. Case CXXX.—A gentleman, aged 67, and previously enjoy- ing good health, except frequent dyspepsia, had occasionally complained for some time of a pain in his right side, which affected him chiefly when he walked quickly. But he made little complaint, and was not confined to the house, until about three weeks before his death, when he had some irritation of his bowels, with loss of appetite, and an obscure uneasiness across the epigastric region. After another week he was con- fined to bed, his chief complaint being the frequent irritation of his bowels ; the stools were scanty, and composed chiefly of ABSCESS. 269 bloody mucous. I saw him only a few days before his death ; he was then considerably exhausted ; the pulse feeble, but little increased in frequency ;. the bowels still troublesome, but kept in check by opiates. There was obscure uneasiness across the epigastric region, but without tenderness ; and no fullness or hardness was to be discovered either there or in the region of the liver. There was an aphthous state of the mouth, with great difficulty of swallowing, a great deal of hiccup, but no vomiting and no jaundice. From his exhausted state there was no room for active treatment; he died gradually exhausted, a fortnight from the time when he was first confined to bed. Inspection.—The liver appeared to be considerably enlarged, and the right lobe was found to have almost entirely degenerat- ed into a large abscess, containing fully three pounds of thick purulent matter, the proper substance of the liver merely form- ing a very thin cyst around the cavity. At the cardiac orifice of the stomach there was evident inflammation of the mucous coat, with a deposition of flocculent matter; and this appear- ance extended along the whole course of the oesophagus, with much deposition of flocculent matter in thin layers indifferent places. There" were various adhesions of the intestines to each other; internally, the small intestine was healthy ; but in the mucous coat of the colon, there was extensive ulceration, mixed with fungous elevations, which extended in a greater or less degree along the whole course of it, and even into the rectum. These examples will be sufficient to illustrate the remarkable diversity of symptoms which accompany abscess of the liver,— being in some cases so acute as distinctly to indicate the nature of the affection, and in others so obscure as scarcely to direct our attention to the liver, as the seat of disease. In cases of this last kind, the affection, as we have seen, may supervene Upon an acute attack, even after we have reason to hope that the inflammation has been subdued ; or it may come on in a more obscure-manner, without any acute symptoms. In both forms of the disease, the abscess is sometimes found of a most extraordinary size, occupying nearly the whole substance of the liver. A man, mentioned by Hasenoehrl, had hapatitis, from which he was supposed to have entirely recovered, and he had returned to his usual occupations; but he soon after began to have febrile attacks, with progressive wasting, and at last died, gradually exhausted, six months after the acute attack. The first incision into the liver gave vent to an immense quantity of very fetid pus, and when it was entirely evacuated, what re- mained seemed to be little more than the empty cyst of the 270 ACUTE DISEASES OF THE LIVER. abscess. In a similar case by Bonetus, there was found, in place of the liver, a great cyst, formed by its investing mem- brane in a thickened state and full of fluid like the washing of flesh. This man also lived six months from the period of an acute attack, and died gradually exhausted by diarrhoea, in which he passed quantities of a fluid resembling that which was contained in the cyst. I have the report of a case that oc- curred in Edinburgh, in which an abscess occupying the greater part of the liver, was found in the body of a man who died gradually worn out by complaints, which, almost to the time of his death, had been considered as hypochondrical. In a case by Annesley, an abscess of the liver contained 90 ounces of matter, and the parenchymatous substance of the right lobe was entirely destroyed. In other cases again the disease appears in the form of nu- merous small abscesses, having no communication with each other. In a case by Andral which was fatal in thirteen days, the liver was beset with numerous small abscesses no larger than nuts, but each lined by a firm cyst of false membrane, the in- tervening substance being of a bright red color and softened. The symptoms were pain and tenderness in the region of the liver, with fever and jaundice. He found however, the same- appearances in a man, who died with symptoms of peripneumony without jaundice, and without any symptom referable to the liver. There were ten small abscesses in various parts of the liver, with a red and softened state of the intervening sub- stance ; the right lung was hepatized, with deposition of false membrane. Small cysts containing a thick puriform matte r, are sometimes found in chronic cases, and appear to be softened tubercles. When the parts which cover an abscess of the liver, form ad- hesions to the parietes of the abdomen, the abscess may burst externally, or be opened, and may heal. In the same manner, by means of adhesions, the matter may be discharged into the stomach or the intestines, especially the colon. In a case by Malpighi, the biliary duct was found to communicate with the cavity of an abscess. But the most remarkable course by which it sometimes finds an outlet is through the lungs, by means of adhesions formed both by the liver and the right lung to cor- responding parts of the diaphragm. Numerous instances are on record in which this was ascertained by dissection ; and not a few, in which there was every reason to believe that it had taken place though the cases terminated favorably. The following is the most remarkable example of this kind which has occurred to me ; and ABSCESS. 271 which, there seems every reason to consider, as being of the nature now referred to, from the total absence of pulmonary symptoms in the early stages, the tumefaction in the region of the liver, and the immense discharge which took place on the first appearance of expectoration. Case CXXXI.—A lady, aged about 40, had been affected for some months with uneasiness in the region of the liver, when, on the 5th of November, 1815, she was seized with vio- lent pain in that situation, accompanied with vomiting. By the usual remedies she was much relieved, but some degree of uneasiness continued in the liver for several weeks; it then seemed to subside, but, after a short interval, returned with vio- lence accompanied by vomiting and by fits resembling syncope. The pain was now so violent that for many nights together she was unable to lie down in bed ; these paroxysms alternated with intervals of comparative ease, but, by the frequent repetition of them for nearly three months, her strength was very much re- duced. The whole region of the liver was tense and tender to the touch, with evident enlargement; the pulse was sometimes small and frequent, and sometimes quite natural. In the end of December, she began to have cough, with some expectoration, which had a purulent appearance. This had continued about a fortnight, the expectoration being in small quantity, when, on • the 14th of January, she was seized with a violent fit of cough- ing, and expectorated purulent matter to the amount of at least two pounds. On the 15th she expectorated in the course of the day at least one pound, and about the same quantity on each of the two following days. The quantity then diminished considerably till the 25th, when she again brought up about a pound of matter, and the same quantity a few days after. Dur- ing this time the enlargement and tension in the region of the liver had rapidly subsided, and was now entirely gone. She then continued to have cough with purulent expectoration, but in no unusual quantity, with great weakness and emaciation. These symptoms continued for several weeks, with all the cha- racters of the most advanced stage of consumption; but the expectoration then began to diminish, and gradually ceased. She then progressively recovered strength, and by the end of May was free from complaint. She has enjoyed good health ever since. In such a case as this it has been supposed that the diagnosis may be founded upon a mixture of bile with the matter which is expectorated; but this appears to be-without foundation; for as the abscess of the liver is generally lined by a cyst of coagu- 272 ACfTE DISEASES OF THE LIVER. lable lymph, it is cut off from any connection with the biliary ducts. <§> IV.—Simple ramollissement of the liver. This consists of a broken-down, friable, and softened state of a part of the substance of the liver, without any change of color. It is in general most remarkable on the convex surface, extend- ing to a greater or less depth ; it is accompanied by a separa- tion of the peritoneal coat at the part, and sometimes there appears to be a loss of substance, as if a portion had been torn out, leaving a ragged irregular surface below. The softened portion has commonly so far lost its consistence that the finger can be pushed through it with very little resistance ; and in some cases the affected part is infiltrated with sanious or puri- form fluid, not collected into abscesses, but mixed irregularly through the substance of the softened part. This appearance we have every reason to consider as the result of inflammation. It is found in combination with abscess or other marks of in- flammation, and I have very often observed it on the upper sur- face of the liver, in connection with extensive inflammation of the right lung. In these cases there was not in general any symptom indicating that the liver was affected. Mr. Annes- ley states, that this appearance is frequently met with in India in persons who have died rapidly from cholera or dysentery. <§> V.—The black ramollissement of the liver. I use this term simply to express the appearance, without im- plying any opinion in regard to the nature of this remarkable affection. It consists in a greater or less extent of the liver being reduced to a black mass of very little consistency, some- times resembling a soft coagulum of venous blood, and occa- sionally accompanied by a remarkable foetor. There is every reason to believe that it is the result of inflammation, and that it is analogous to gangrene. We have seen it complicated with abscess, and, in some observations by Andral, it was met with in cases in which fatal disease of the liver supervened upon ex- ternal injuries. It appears, however, to occur without any acute symptoms, for in a case by Boisment * the symptoms were * Boisment.—Obs, sur quelquea Maladies .Ju Foic-Archives Generalei torn. xvi. • BLACK RAMOLLISSEMENT. 273 chiefly vomiting, wjth a slight yellow tinge of the skin. The following is the best marked example of the affection which has occurred to me. Case CXXXII.—A lady, aged about 50, of a full habit and florid complexion, was suddenly seized in the beginning of June, 1821, with very deep jaundice, for which no cause could be traced. There was no pain, no tenderness, and no fullness in the region of the liver; the pulse was natural, and rather weak ; there was little appetite, and some nausea, but no other com- plaint. The bowels were easily moved, and the motions were dark or brownish. After the free use of purgatives, &c, she began to take a little mercury ; for a week after this she seemed to be improving, but she then became more oppressed, with fre- quent complaint of nausea, and a feeling of languor; the tongue was white, but the pulse was natural. No other symptom was complained of, and nothing could be discovered in the region of the liver. On the 16th she began to have some vomiting, which occurred occasionally for three days, without any other change in the symptoms, until the 19th, when streaks of a black substance were observed in the matter which was vomited. The vomiting now became more and more urgent, with increase of the quantity of this black matter, and she died gradually ex- hausted on the morning of the 21st. Inspection.—The liver was reduced to little more than a third of its natural size ; it was of a very dark or almost black color, and internally soft and disorganized, like a mass of coag- ulated blood. The gall bladder was empty and collapsed. The stomach and bowels contained a considerable quantity of black matter, similar to that which had been vomited, but were in other respects quite healthy. The appearance described under this head is probably a se- quel to the condition described under <§> H* > and it appears to admit of various modifications. In a case by Boisment the tis- sue of the liver was infiltrated with dark blood ; the substance, in other respects, was dark and friable, and beset with small fri- able tumors of a reddish brown color; in other places there were small cavities, containing a soft semi-liquid fluid like gra- mous blood. Little account is given of the symptoms; but the case seems to have been protracted, and to have been accompa- nied, towards the conclusion, by hsematemesis. 35 274 . ACUTE DISEASES OF THE LIVER. § VI.—The white or encephaloid ramollissement of the liver. The nature of this affection has been little investigated. I have placed it among the acute diseases on account of the de- gree of pain which occurred in the following case, which is the best example of it which I have met with. Case CXXXIII.—A gentleman, aged 65, in September, 1820, was seized, during a journey on horseback, with diarrhoea, the motions being black and pitchy. He then had pain in the re- gion of the liver, which for several days was so severe that he could not bear the motion of his horse. It then subsided con- siderably, and after his return home, in the end of the month, he was able to walk about a good deal without appearing to suffer much uneasiness. On the 1st of October, there was in- crease of the pain, with fever, and the pain extended to the right shoulder. He was now largely bled and blistered, &c, and the acute symptoms were soon removed; but he was never free from pain in his right side, and after some time he began to have cough, with copious mucous expectoration. He took mer- cury with apparent relief, and for a short time was better;, but in the end of November, he began to lose flesh, and the pain in the right side continued. I saw him for the first time on the 11th of December; he was then much emaciated, with some anasarca of the limbs; there was still fixed pain in the re- gion of the right lobe of the liver, but nothing could be discov- ered by pressure, and there was no appearance of jaundice ; the pulse was frequent and weak. The debility and dropsical symptoms increased progressively, and he died, gradually ex- hausted, on the 5th of February. Inspection.—The liver scarcely exceeded the natural size ; its edge projected somewhat below the margin of the ribs, but had not been felt on account of a very firm attachment to the arch of the colon, by which it was bound down and thrown backwards. Its whole structure was altered in a remarkable manner from the healthy state ; externally, it was closely cov- ered by innumerable small semi-transparent tubercles, set very close together, and the'largest of them scarcely exceeding the size of a split pea ; internally, it was soft and of a white or ash color, very much resembling the substance of the brain, and in many places almost of pulpy consistence ; scarcely the smallest portion could be discovered which retained anything like the healthy appearance. There was considerable effusion in the abdomen; the other viscera were healthy. CHRONIC DISEASES OF THE LIVER. 275 § I'll.—Copious deposition of gelatinous matter of a soft consistence and a reddish color. This appearance is described by Portal as occurring both throughout the substance of the liver and on its surface, raising the peritoneal coat into irregular soft tumors, accompanied with great enlargement of the liver. The case was of several months' standing, and was distinguished by pain in the epigastric region and vomiting, at first occasional, but becoming gradually more frequent; there was progressive wasting, and at last dyspnoea and anasarca. $ VHI.—Remarkable distention of the biliary vessels. This occurred in a case by Boisment to such an extent as to give the liver the appearance of a large undulating cyst. The ap- pearance was found to depend upon a remarkable distention of all the biliary vessels, with dark colored bile, and was accompa- nied by wasting of the proper substance of the liver. The affection seemed to depend upon a singular obstruction of the common duct by a membranous band which passed over it. SECTION II. OF THE CHRONIC AFFECTIONS OF THE LIVER. I have already stated, that by chronic affections of the liver I mean chiefly those in which the symptoms steal on in a slight and obscure manner, without any complaint distinctly referable to the liver, until an advanced period of the disease, when per- haps the liver is felt to be enlarged, or symptoms occur which point out the seat of the affection. In other cases the morbid condition of the liver is discovered only when the patient has died of some other disease. The distinction, I have already ad- mitted, is entirely arbitrary, but it seems to answer the purposes of practical utility in the division of the subject. The morbid changes of the liver which come under this class appear to be chiefly referable to the following heads :■— S76 CHRONIC DISEASES OF THE LIVER. § /.—Chronic inflammation of the liver. This term is applied to a morbid condition of the liver which often remains after an acute attack, and a corresponding condi- tion may come on gradually without any acute symptoms. The symptoms are chiefly those of deranged functions. ' There is more or less pain or feeling of weight in the region of the liver, sometimes accompanied by a degree of tenderness; there are severe and untractable dyspeptic symptoms, wasting, and some- times jaundice ; in other cases, pale evacuations without jaun- dice. There is generally a feeling of distention and oppression in the epigastrium and right hypochondrium, often vomiting, and pain, or a dragging sensation referred to the right shoulder. The bowels are generally slow, the tongue loaded, and the nights restless; there is commonly a leucophlegmatic aspect, often with febrile paroxysms towards the evening, and a peculiar burn- ing sensation in the hands and feet. On examination, some degree of enlargement of the liver can often be discovered, but this is frequently wanting or very obscure ; or the principal seat of the disease may be in the posterior parts, where it cannot be discovered by examination. The morbid appearances in these cases usually consist of some degree of enlargement of the liver, especially of the right lobe ; the substance is generally dark col- ored or variegated in various ways, with streaks of a lighter col- or ; its consistence is frequently more dense than natural, but in other cases it is soft and friable ; abscesses are met with in some cases, and in others tubercles. § H.—Simple enlargement of the liver without change of texture. This, I think, is most frequently observed in young persons of a scrofulous habit, but is occasionally met with at a more advanced age; the liver perhaps descending as low as the umbilicus, without any remarkable change of its texture. It appears in some cases to be connected with a low and protracted inflammatory action; and in others to depend upon causes impeding the return of the blood from the liver towards the heart. In this manner the liver is frequently found to be en- larged in connection with diseases of the heart. In a case by Andral, v\ which the patient was liable to severe paroxysms of the symptoms arising from disease of the heart, the liver was TUBERA WITHOUT OTHER DISEASE. 277 distinctly felt to become enlarged during the paroxysm, and to subside again when the attack was relieved by blood-letting. When this simple enlargement is of a more permanent kind, the symptoms seem to consist chiefly of derangements of the stomach, arising probably from the increased bulk of the liver; in some cases there is jaundice, and in others dropsy ; but upon the whole, simple enlargement of the liver, without any con- siderable change of its texture, must perhaps be considered as a rare affection in adults. The following case will illustrate the appearance, as it occurs in young persons of a scrofulous habit. Case CXXXIV.—A boy, aged 11, in winter 1811—12, was seized with great enlargement of the glands under the jaw, his neck being completely beset with a chain of them of a very large size, extending from ear to ear. He improved considera- bly during the summer, but in the following winter he became languid and impaired in strength, with variable appetite and irregular attacks of fever. In the following summer, he was affected with cough and dyspnoea, and it was now discovered that his liver was so much enlarged, that the edge of it was distinctly felt as low as the umbilicus. He had a wasted and withered look, with cough, frequent pulse, enlargement of the abdomen, and anasarca of the legs; the latter increased to a prodigious degree, and he died after protracted suffering in October, 1813. Inspection.—The liver extended rather below the umbilicus, and so much into the left side as to fill the upper half of the abdomen. It was a little paler than natural in its color, but in other respects was scarcely altered from the healthy structure. There was extensive disease of the mesenteric glands. The lungs were slightly tubercular, and there was a chain of enlarged glands, some of them as large as walnuts, extending behind the lungs from the bifurcation of the trachea to the diaphragm; some of these were of cartilaginous hardness, others contained thick purulent matter, and in others there were hard calcareous particles. There was considerable effusion in the abdomen. § III.—Tubera of the liver without other disease of its struc- ture. These tubera present externally a surface elevated into nu- merous irregular knobs, of a yellowish or ash color, and per- 2*3 chronic disea-;:s of Tin: liver. haps from two to three inches in diameter. Internally they exhibit a variety of textures—in some cases fibrous, in others, tubercular, or cheesy, and frequently there are cysts containing a viscid fluid. It appears that they produce marked symptoms only when they are numerous, or accompanied by enlargement of the liver, or disease of its general structure ; but that, when the structure is otherwise healthy, they may exist without any symptom calculated to produce a suspicion of their presence. Of this 1 shall only add the following example. Case CXXXV.—A gentleman, aged 80, had enjoyed unin- terrupted good health until a few weeks before his death, when he became one day suddenly incoherent. This was removed by purgatives, and he had not shown any other symptom of dis- ease, when one morning he was found dead in bed. Inspection.—No morbid appearance could be discovered to account for his sudden death, except that all the cavities of the heart, the aorta, and the vena cava, were completely empty of blood. On the convex surface of the liver, there was a tumor about three inches in diameter, elevated into irregular knobs ; on cutting into it, a cavity was exposed capable of holding about oz. 8. and full of an opaque ash-colored fluid, which could be drawn out into strings. The liver in other respects was perfectly healthy. For a more particular account of these tubera, I refer to the description and engravings of Dr. Farre. § IV.—The pale degeneration of the liver, consisting of change of color without remarkable alteration of texture. Under this head I mean to include a class of morbid changes of the liver of frequent occurrence, though presenting con- siderable varieties. The liver so affected has lost, in a greater or less degree, the healthy appearance, and has become of a paler color, without any considerable alteration from the health) texture. This change, in some cases, consists merely of a much paler shade of the natural color; in others, it is a dull white or ash color, and frequently a uniform dull yellow, closely resembling the color of impure beeswax. The liver thus affect- ed may be of the natural size, or it may be increased in size, or it may be diminished. The symptoms accompanying these changes have not been well investigated; they are chiefly PALE INDURATION. 279 observed when the patient has died of some other affection, and are scarcely themselves to be considered as fatal diseases, though there may have been symptoms indicating some de- rangement of the functions of the liver or the stomach. The most remarkable of these changes is the yellow degenera- tion of the liver, which, from its resemblance to wax, has re- ceived from the French writers the name of Cirrhose. It is sometime s found in irregular portions, mixed with the healthy structure, and sometimes in small nodules like peas, dispersed through the substance of the liver ; but, in many cases, the whole liver is found changed into one uniform mass of this appearance, exactly resembling a mass of impure wax, and it seems to pos- sess very little vascularity. A case described by Clossy,* in which the structure of the liver was wholly constituted of a congeries of little firm globules, ' like the vitellarium of a laying hen;' it occurred in a boy of K3, who had immense ascites. In a case by Boisment, these nodules were as large as peas, and the liver was diminished in size ; the case was chronic with ascites. The French writers have a controversy whether the Cirrhose or yellow degeneration of the liver be a new formation, or a hypertrophia of a yellow substance, which they suppose to constitute a part of the structure of the liver in its healty state. No good can arise from such discussions, as it is impossible to decide them. § V.—Pale color of the liver with induration. The degree and aspect of the pale induration of the liver varies in different cases, from an appearance resembling a mass of tubercular lung, fb that of true scirrhus, or to a texture in some places almost cartilaginous; and, in some cases, there is a firm fibrous texture with a softer matter in the interstices. These morbid appearances may be confined to portions of the liver, or the whole organ may be entirely changed from the healthy structure. The color of the diseased parts varies con- siderably ; the most common is a dull ash color, sometimes with a considerable tinge of yellow. The disease may be com- plicated with hard tubercles of various sizes, embedded in the substance of the liver, or spread over its surface under the pe- * Clossy.—Observations on some of the Diseases of the Parts of the Human Body. 280 CHRONIC DISEASES OF THE LIVER. ritoneal coat; or there may be thickening or tubercular disease of the peritoneal covering itself. A liver in this state of disease may be not at all altered in its size, or it may be much increased, or it may be very much diminished. The symptoms, of course, will differ in some re- spects in connection with these varieties. The following cases will illustrate the principal modifications. (A). Pale indurated liver almost cartilaginous, of the natural size. Case CXXXVI.—A man, aged 45, in the beginning of May, 1813, was affected with severe pain in the region of the stomach, which soon shifted into the right hypochondriac re- gion among the lower false ribs ; it was much increased by res- piration; there was some cough ; pulse 120. In the course of two days and a half, he was bled to the extent of oz. 145; the symptoms then yielded, and soon after he went to the country. But he did not recover sound health : he had some cough and dyspnoea, with much debility ; after some time he became drop- sical ; the dropsical symptoms increased with pain in the rio-fit side, and he died in the beginning of August. Inspection.—There was extensive effusion in the abdomen. The liver was completely changed in its texture, being through its whole structure, of a dull white color, and very hard, in many places almost cartilaginous. There was not the smallest portion of it that retained the healthy structure or color but it was entirely of the natural size. The lungs and all the other viscera were healthy. There is every reason to believe, that in this important case the remarkable disease of the liver supervened upon the acute attack, which occurred three months before the patient's death • and therefore, according to the division upon which I have pro- ceeded, it ought to have been included among the acute affec- tions. I have introduced it here, because the pale induration appears in general to be a chronic disease; but it will at the same time, be right to keep in mind the evidence afforded by this case, that an inflammatory attack may lay the foundation PALE INDURATION, WITH ENLARGEMENT. 281 (B.) Pale indurated liver with enlargement. Case CXXXVII.—A lady, aged 45, had long been liable to dyspeptic complaints ; but she was often for a considerable time together entirely free from them, so that no suspicion had been ever entertained of the presence of organic disease. She also frequently complained of pains in the back, neck, and shoul- ders, which had merely a rheumatic character. In autumn, 1S18, she went to Harrowgate, and seemed to derive much benefit from the use of the water. In the following winter, she was again a good deal confined, complaining chiefly of wandering rheumatic pains, with bad appetite, very bad diges- tion, and a feeling of oppression across the region of the stom- ach. On examination, the liver was now found to be much enlarged and very hard, but without pain or tenderness. In January, 1819, she began to lose flesh and strength ; the pulse became small and frequent, with difficulty of breathing, and ef- fusion in the abdomen; and she died, gradually exhausted, in the end of February. Inspection.—The liver was very much enlarged, so as to ex- tend quite into the left side of the abdomen, and to descend three or four inches beyond the line of the ribs; in the epigas- tric region, its margin formed an adhesion to the parietes of the abdomen. Internally, it was entirely changed from the healthy structure, being of pale or ash color, and very firm in its tex- ture, in many places nearly cartilaginous; scarcely any part of it retained the healthy appearance. There was considerable effusion both in the abdomen and the thorax, but the intestines and.the lungs were healthy. Case CXXXVIII.—A lady, aged 50, had for some time com- plained occasionally of an uneasy feeling across the epigastric region, which chiefly impeded her in stooping. About three weeks before her death, she first consulted me on account of a disease of the mamma, and the affection of the liver was then ascertained only by accident; it filled the upper part of the ab- domen, extending from side to side, and on the right side de- scended as low as the region of the kidney. The whole felt as hard as bone, and was so much elevated, that, even when she lay on her back, the margin of the ribs could not be traced ; but the bones of the thorax and the surface of the tumor felt like one continued bony substance as low as the umbilicus. At this time her general health was little affected ; but after a short 36 2&2 CHRONIC DISEASES OF THE LIVER. time she had some vomiting of blood ; she was then confined to bed, and died after nine days, without any urgent complaint except occasional retching. Inspection.—The swelling consisted of an immense irregular enlargement of the liver; it was variegated in its appearance, being partly of a pale ash color, and partly of a dark reddish brown; internally it was uniformly pale and hard in its texture. (C.) Pale indurated liver, with great diminution of size. Case CXXXIX.—A man, aged 40, was first affected with pain in the right side, not increased by pressure, and not im- peding respiration ; he had then severe cough, at first dry, afterwards with mucous expectoration, which was very copious and often tinged with blood. He had afterwards hectic par- oxysms with progressive emaciation, and at lasf general dropsy ; and died, gradually exhausted, after an illness of about 18 months. Inspection.—There was some effusion in the cavity of the pleura, but the lungs were quite sound. The liver was so re- markably diminished in size, as scarcely to exceed the bulk of the hand half-folded; it was closely drawn up under the ribs, and adhered intimately to the diaphragm. Its surface was stud- ded with numerous tubercles ; internally it was of a pale color, and very hard in its texture. Many cases are on record, in which the indurated liver was much diminished in size, but in few perhaps to the extent which occurred in this case. A man mentioned by Andral, had weak- ness, loss of appetite, and pain of his loins and shoulders, which affected sometimes the one shoulder, and sometimes the other. He had at length slight yellowness of the skin and of the eyes, and then asthmatic attacks, and died after 6 months. The liver was very much diminished in size, and internally was of a scir- rhus hardness; its surface was covered with a kind of sandy matter. A man mentioned by Boulland,* had pain in the region of the liver, and very deep jaundice ; he died the day after his admission into the Hotel Dieu, and nothing was known of his history except that the jaundice was of six weeks' standing. The liver was found much diminished in size and indurated •" internally it presented a variegated surface of gray and yellow' with numerous small portions of an orange color. In other * Mem. de la Soc. Med. D'Emulation. Tom. i DARK INDURATION. 283 cases, this state of disease has been marked merely by wasting, with obscure dyspeptic symptoms, and at last dropsy, without any thing calculated to point out the liver as the seat of the disease. A remarkable peculiarity in Case CXXXIX, was the violence of the pectoral symptoms. This effect of certain diseases of the liver will be afterwards more particularly referred to ; it seems to be occasioned by the irregular tuberculated state of the con- vex surface of the liver, keeping up a constant irritation of the diaphragm. § VI.—Dark induration of the liver. The following case will illustrate this modification of the dis- ease, which differs from the pale induration only in its patholo- gical characters, the symptoms being the same. Case CXL.—A gentleman aged about 60, in spring 1821, was observed to look ill, and had a yellow tinge of his eyes, but without any particular complaint till the middle of June, when he became dropsical in his legs, and soon after in the abdomen ; pulse natural; breathing easy ; appetite tolerable ; urine scanty. Nothing could be detected in the region of the liver. There was much distention of the abdomen, which appeared to be partly from fluid, but to be in a great measure flatulent. He took a variety of diuretics with a little mercury, for sometime with very little effect; on the contrary, the distention of the abdomen seemed gradually to increase, with an evident fluctua- tion. He then used mercurial friction over the abdomen, when the diuretics began to take effect: and in the end of July, there was much increase of urine, and the swellings were diminished. This favorable state continued till the 7th of August. On the morning of that day, as he was preparing to get up at his usual time, after a tolerable night, he became suddenly livid in the face, and instantly expired. The only previous change in his symptoms had been, that, for about two days before death, his appetite had been somewhat impaired, and his pulse, which had been previously quite healthy, was occasionally observed to be slightly irregular. Inspection.—There was an effusion in the abdomen to the amount of about 10 lbs. The liver was entirely of the natural size, but very dark in the color, nearly black, and covered on the 284 CHRONIC DISEASES OF THE LIVER. surface with small hard black tubercles. Internally, it was much indurated throughout, and of a very dark brown color, interspersed with streaks of deep yellow. The heart was re- markably soft and flaccid, and all its cavities were empty ; there was extensive ossification of the coronary arteries, and several of the valves were also partially ossified. The brain and the lungs were healthy. <§> VII.—Tuberculated disease on the surface of the liver with- out disease of its structure. The symptoms arising from these affections vary according to the part of the liver which is the principal seat of the disease, as they consist chiefly of irritation of neighboring organs, par- ticularly the stomach and the diaphragm. The disease in these cases seems in some instances, to consist of a tubercular affection of the peritoneal covering of the liver ; in others, there appears to be an elevation of portions of the substance of the liver form- ing nodules or tumors of various sizes, which in their internal structure do not present anything remarkably morbid; in others they consist of tubercular masses, partly imbedded in the sub- stance. When the disease is so situated as to irritate the stom- ach, we find protracted vomiting, with gradual loss of strength ; but one of the most remarkable effects of it, when the disease is so situated as to produce constant irritation of the diaphragm, is to prove fatal with protracted pulmonary complaints, with- out any symptom referable to the liver. The following case will illustrate this modification of the disease. Case CXLI.—A lady, aged 35, had severe cough with dys- pnoea, which was sometimes severe, especially in the night. There was occasional pain of the chest and sides, with frequent pulse, restless nights, febrile paroxysms and perspirations in the morning. There was considerable expectoration, which con- sisted chiefly of viscid mucus, but was frequently mixed with portions of a puriform character, and occasionally with blood. She was liable to periodical fits of vomiting, which attacked her generally in the evening, and she frequently complained of pain, which was referred to the left side of the abdomen, about the region of the spleen; but no disease could be detected either there or in the liver. These complaints went on for upwards of two years, without materially injuring her strength ; but in TUBERA, &C. 285 the third year she became gradually exhausted. She then had diarrhoea, anasarca, and gradual emaciation, and died at the end of the third year from the commencement of the complaint. Towards the end of her life, the vomiting became less frequent, but she continued to suffer from most severe paroxysms of cough, with copious expectoration and fits of dyspnoea. Inspection.—No morbid appearance could be detected in any part of the thorax. The spleen was enlarged and hard. On the convex surface of the liver there was a remarkable tumefac- tion pressing against the diaphragm, and pushing it upwards ; and the surface of the tumefied part was studded with small hard tubercles. The liver was not in other respects diseased, and the other viscera were healthy. Another case has been formerly described, showing the pro- duction of severe pectoral symptoms by disease on the surface of the liver: and various cases are on record, showing the same result from diseases of other organs, situated in the neighbor- hood of the diaphragm. In a case by Portal, similar symptoms appeared to arise from scirrhus of the pancreas, and in one by Bonetus, from disease of the spleen. In a case by Morgagni, there was a tumor, which weighed a pound, attached to the posterior part of the stomach. A young woman, mentioned by Laennec, had cough, dyspnoea, copious expectoration, hectic fe- ver, and great wasting. After these symptoms had gone on for some lime, and she was considered as decidedly phthisical, she was seized with violent pain in the epigastrium, and soon after discharged by stool an immense quantity of hydatids; from that day she recovered rapidly, and was soon well. The production of severe pectoral complaints by disease of the liver, is also strik- ingly illustrated by the following case. <§, VIII.—Tubercular disease of the liver, with severe pectoral complaints and ulceration of the stomach. Case CXLII.—A woman, aged 30, for whose case I am in- debted to Dr. Huie, was affected with cough, copious expecto- ration of viscid mucus, night sweats, and great prostration of strength. Soon after she was first seen by Dr. Huie, (in No- vember, 1824) she was seized with vomiting of a very dark mat- ter resembling venous blood in a state of partial decomposition, and she discharged large quantities of a similar matter by stool. A hard movable tumor was discovered in the epigastric region, '2^0 CHRONIC DISEASES OF THE LIVER. the size of a walnut, which was painful on pressure. Her strength now sunk rapidly, and she died on the 3d of December. The vomiting ceased several days before death, but the cough continued severe and the matter expectorated was of a very dark color. The bowels were obstinate, and the motions con- sisted entirely of a black pitchy matter, without any appearance of natural feces. Inspection.—The tumor that had been felt in the epigastrium was found to be a tubercle, the size of an egg, attached to the left lobe of the liver. It adhered firmly to the stomach, near the pvlorus? and on the internal surface of the stomach, at the place of the adhesion, there was an ulcer the size of a shilling; this ulcer appeared to have been the source of the black dis- charge, a considerable quantity of which was still found in the stomach and intestines. The coats of the stomach, along near- ly the whole of the smaller arch, were much thickened and in- durated, and the pylorus was considerably contracted in its aperture. The tubercle presented, when cut into, a variegated texture, partly a firm white tubercular matter, and partly a red- dish substance resembling the structure of the liver: but the wliite matter was the more abundant. There were four or five similar tumors, the size of walnuts, in various parts of the liver. The left extremity of the pancreas was of a soft cheesy consis- tence, and adhered to the stomach. The other abdominal vis- cera were healthy. After the most careful examination, no dis- ease could be discovered in the viscera of the thorax, except a few slight adhesions between the pleura costalis and pulmona- lis, which were evidently of long standing. § EX-—Tubercules and tubera of various characters diffused through the substance of the liver, with disease of the inter- vening structure. The mixed masses of disease which I include under this head, seem to derive their character, in some instances, from new for- mations imbedded in the substance of the liver, in others from morbid degeneration of portions of the liver itself. The ap- pearances vary in different cases; in some there are portions or nodules of a true scirrhus character, in others tubercular or cheesy, in others of the consistence of the brain ; some portions are of a yellow color resembling the cirrhose, others of a dark brown or nearly black appearance. These various states of (lis- TUBERA, &C. 287 ease may sometimes be traced in the same liver; they may be interspersed with portions in a tolerably healthy state, and they may be farther varied by the appearance of small cavities con- taining a glairy fluid, or by the presence of real hydatids. The liver which is the seat of these varied forms of disease may be' little altered from the natural size, or it may be very much en- larged. A remarkable circumstance in the history of the affec- tion is the slight and obscure symptoms with which the disease may advance even to a prodigious degree of enlargement. I shall only add the following example. Case CXLIII.—A gentleman, aged 67, had been for many years dyspeptic, but without any affection of his general health till the spring of 1820, when he began to decline considerably in flesh and strength, and complained chiefly of a feeling of op- pression about his chest. He went to the country and improved considerably, but in May he became worse. His chief complaint was then of a fixed pain in the lower part of his back, with restless nights ; he was able to take a good deal of exercise on horseback, but complained that, after riding, the pain in his back was increased. He came to Edinburgh in June. He was then a good deal fallen off in flesh and strength, and his pulse was a little frequent; but his appetite was good, and he made no complaint of his digestion ; his chief complaint was still of a fixed pain in the lower part of the back. On examination no- thing was discovered in his back ; but a mass of disease was felt in the abdomen, entending from the ribs to near the spine of the ileum chiefly on the left side. It was not at all painful on pressure, and he could give no account of the origin or pro- gress of it, having never taken notice of it until it was pointed out to him. There was now a gradual failure of strength with- out any urgent symptom. His appetite and digestion continued tolerable until eight or ten days before his death, when he began to have nausea with thirst, foul tongue, and impaired appetite ; and he died gradually exhausted in the beginning of August. His bowels had been throughout natural or easily regulated, and the motions quite natural. Inspection.—The whole liver was enormousjy enlarged, es- pecially the left lobe, which descended nearly to the spine of the ileum. Externally, it was of a very dark color, variegated* with light ash-colored spots. Internally, it was composed chiefly of numerous round tubera, of the size of small oranges; they were generally of a white or ash color, some of them approach- ing to a scirrhus hardness, others of a softer consistence, and 288 CHRONIC DISEASES OF THE LIVER. some of them contained a fluid of a puriform character. In the interstices betwixt these tubera there were portions which retained the appearance of the proper structure of the liver, but ♦hey were of very small extent, dark colored, and of a soft con- sistence. It appears that the form of disease which occurred in this case is sometimes much more rapid in its progress. A man men- tioned by Andral, died with fever, vomiting, and pain in the right hypochondrium, having begun only about a month before to complain of some uneasiness in the region of the liver. The liver was much enlarged, and presented a mixed mass of dis- ease, scirrhus, encephaloid and tubercular. § X.—Hydatids. Hydatids are of frequent occurrence in the liver, and are found either in cysts attached to its outer surface, or imbedded in its substance. The cysts in which they are contained are sometimes lined with a thick coating of false membrane, and not unfrequently there are found in them portions of bone. A liver which contains hydatids may be enlarged and otherwise diseased, or it may be quite healthy except with respect to the cyst which is imbedded in it. There are no symptoms which mark the presence of hydatids in the liver, distinct from those of the other chronic affections, and they have been found where patients died of other diseases without any symptoms referable to the liver. $ XI—Large cysts containing watery matter confined under the peritoneal coat of the liver. These cysts may appear either upon the convex or concave surface of the liver. The following is the most remarkable example that has occurred to me. Case CXLIV.—A man, aged 32, was affected with an im- mense tumor of the abdomen, which filled the greater part of extending from the region of the liver considerably below he umbilicus and into the left side. At the upper part nZ the nbson the right side, there was an evidem^uSuation CYSTS FULL OF WATERY FLUID. 289 this was most remarkable when he was in the erect posture; in the horizontal posture it seemed as if the fluid retired under the ribs; no fluctuation was perceived in any other part of the mass. His breathing was much oppressed and laborious, es- pecially when he attempted to turn on the left side; he then seemed in danger of instant suffocation, for several minutes gasping in the utmost agony before he recovered his breath; similar attacks were produced by other causes, especially any bodily exertion. He was much emaciated; and the complaint was of about one year's standing. A puncture was made on the spot where the fluctuation was felt; clear serous fluid was drawn off to the amount of nine or ten pounds, and the open- ing continued to discharge freely for a good many days. By this evacuation, he was very much relieved, but his strength con- tinued to sink, and he died about ten days after the operation. Inspection.—The liver was very little enlarged. The tumor was found to consist of an immense sac formed on the convex surface, under the peritoneal coat; it was of such a size that it had, on the one hand, pressed down the liver below the umbi- licus, and on the other, had pressed the diaphragm upwards as high as the second rib. The right lung was consequently com- pressed into a small flaccid substance, less than a kidney ; the left lung also was much diminished in size, and the heart was as small as that of a child of five or six years. This immense cyst adhered firmly to the posterior half of the diaphragm, but betwixt it and the anterior part of the diaphragm there was a distinct cyst, containing a watery fluid. It was this which had been opened in the operation; the great cyst was entire, and contained lb. 18 of transparent colorless fluid. Its parietes were firm and dense, like the peritoneum very much thickened. In the bottom of this cyst there were found two singular bodies, consisting of flat cakes of a soft gelatinous matter rolled up into solid cylinders; when unrolled, they were about ten inches in diameter, and about one-eight of an inch in thickness, and had the appearance of a deposition which had been separated from the inner surface of the cyst. The liver was not diseased in its structure, and the other viscera of the abdomen were healthy, but remarkably displaced, the stomach being on the left side and the pylorus towards the left os ileum. A remarkable circumstance in this case was the uncommon firmness of the tumor, which imparted the idea of an immense mass of organic disease, without any fluctuation, except at the part which was opened. A case considerably similar occurred 290 CHRONIC DISEASES OF THE LIVER. in the Infirmary of Edinburgh many years ago, under the care of the late Dr. Gregory. It was supposed to be an immense enlargement of the liver ; but one day the whole hardness sud- denly disappeared, with a feeling to the patient of something bursting internally. Fluctuation then became evident, though none had been perceived before. The patient died next day, and it was found that this remarkable change had taken place by the cyst bursting into the cavity of the peritoneum. Mr. An- nesley mentions a case in which there was attached to the con- cave surface of the liver a cyst containing a quart of watery fluid, with a hydatid floating in it. Dr. Hastings has described a simi- lar case, in which a week before the death of the patient nine pounds of fluid were drawn off from a cyst of this kind.* Mr. Brodie has described two cases which were supposed to be of this nature, but which were relieved by the evacuation of the fluid. In the one, a young lady of 20, the relief was permanent; the quantity of fluid evacuated was three pints. The other was an hospital case, a boy who was dismissed in good health after the evacuation of a pint and a half.f A cyst of this kind also occurred in a case described under a former part of our subject. (Case CIX.) The above outline, which was intended to be merely an enu- meration of the principal morbid conditions of the liver, has ex- tended to a greater length than I expected; and I shall there- fore allude but very briefly to what remains of the subject, name- ly, the treatment of these affections. I have already referred to a fact which I conceive to be of the utmost importance, and de- serving the most serious attention of practical men. I allude to a prevailing doctrine, or rather prevailing phraseology, by which numerous symptoms are ascribed to disease of the liver upon very vague and inadequate grounds ; while, in many of these cases, a little attention would show, that the affection is seated entirely in the stomach or bowels, especially in the arch of the colon. The prevalence of this doctrine, and the indiscriminate employment of mercury, which has arisen from it, I must hold to be evils of no small magnitude, and the utmost attention and caution ought to be used before pronouncing a train of symptoms to be dependent upon the liver. We have seen abundant grounds for believing, that there is no class of diseases in which the symptoms are often more obscure, and the diagnosis more difficult : and, consequently, that there is none in which the * Midland Medical and Surgical Reporlc-r, No. V t Medical Gazette No. XII. TREATMENT. 291 scientific practitioner will find himself constrained to use greater circumspection. v The real diseases of the liver resolve themselves into two great classes, the acute and the chronic. The acute affections are to be combated by the means adapted to other inflammatory diseases, namely, general and topical blood-letting, blistering and saline purgatives. In the less active cases, indicated by lo- cal pain and tenderness, without constitutional disturbance, we rely chiefly upon repeated topical bleeding, blistering, issues, free and continued purging, and a careful regulation of diet. In both cases, when the activity of the disease is subdued by these means, benefit is obtained from the cautious use of mer- cury ; and it seems in general to be most advantageously ap- plied by friction. In regard to the chronic affections of the liver, under the va- rious forms which have been detailed in the preceding observa- tions, it will probably be admitted that a large proportion of them are beyond the reach of any human means. The treat- ment of these ought to be entirely palliative, consisting of a careful regulation of the diet and the bowels, with mild tonics, &c. This I conceive to be a point of much practical import- ance, because these affections often exist for a long time with- out materially injuring the health of the patient; and by treat- ment entirely palliative, his life may be perhaps prolonged, and certainly rendered more comfortable. But when such cases are treated actively by courses of mercury, the strength uniformly sinks in a very rapid manner, and the patient's life is often evi- dently shortened. In several cases of chronic affections of the liver, accompanied by jaundice, I have seen very good effects from the external use of Iodine, in an ointment containing dr. ss to oz. 1 of axunge. In the preceding observations I shall probably be charged with attaching too little importance to mercury in the treatment of this class of diseases, and I am well aware of the delicate ground on which I tread, when I venture to express a doubt of its adap- tation to all stages and all forms of diseases of the liver. In doing so I would be distinctly understood to express myself in regard on- ly to the liver diseases of this country, having no experience of any other ; but in respect to these I have no hesitation in saying, that. mercury is often used in an indiscriminate manner, and with very undefined notions as to a certain specific influence which it is believed to exert over all the morbid conditions of this organ. If the liver is supposed to be in a state of torpor, mercury is 292 CHRONIC DISEASES OF THE LIVER. given to excite it; and if it is in a state of acute inflammation, mercury is given to moderate the circulation, and reduce its ac- tion. Effects the most indefinite, if not contradictory, are also sometimes ascribed to it in regard to its influence on the secretion of bile, and in those affections which are commonly called bilious. Upon the principles of induction with regard to cause and effect, which are recognized in other sciences, it may be doubted whether all these maxims can be right, but I will not take upon me to decide which of them is wrong. I leave the subject, therefore, with merely throwing out these doubts, the force of which must be felt by every pathological inquirer; and with hazarding the opinion, that much of the prevailing doctrine on derangements of the liver requires to be revised, and perhaps corrected. There are certainly many parts of -it, of which the pathologist must be allowed to doubt, whether they are not at variance with the principles of philosophical inquiry. APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. HAEMORRHAGE FROM THE LIVER. A gentleman mentioned by' Andral, previously in perfect health, on getting up one morning complained of some uneasi- ness in the abdomen, and returned to bed, where he was left alone for some time; when his attendants returned to the room he was dead. On inspection, much extravasated blood was found in the cavity of the abdomen, which appeared to have proceeded from a lacerated opening in the substance of the liver; this led to a small cavity full of coagulated blood, and the haemorrhage was distinctly traced to the rupture of a branch of the vena portae. SECTION II. RUPTURE OF THE LIVER BY EXTERNAL VIOLENCE. Case CXLV.—A man sitting carelessly upon the edge of a cart was thrown from it by a sudden jerk upon the road. He immediately got up and scrambled into the cart, which was still in motion, and he did not appear to a person who was along with him to have received any injury, but he soon became faint, and in a few minutes was dead. On inspection, the liver was found to have been ruptured through a great part of the right lobe, and there was extensive haemorrhage in the cavity of the ab- domen. •291 DEATH FROM A (J.YLL STONE. SECTION III. DISEASES OF THE GALL BLADDER. I. The most common affection of the gall bladder consists in the formation of biliary calculi; but I do not enlarge on this subject, having nothing of any interest to offer beyond the facts which are familiar to every one, and shall only add the follow- ing case in which a gall-stone sticking in the common .duct was fatal. Case CXLVI.—A lady, aged'60, had been for several years liable to attacks of acute pain in the right hypochondriac re- gion, which generally continued in great severity for a few hours, and then subsided suddenly. On Wednesday, 14th January, 1824, she was seized with pain corresponding to her former attacks, but which did not subside as usual. It con- tinued through the night, accompanied by frequent vomiting and constitutional disturbance. On the 15th there was fever, with frequent vomiting and obstinate costiveness, and the pain was more extended,—being referred to a considerable space on the right side of the abdomen. Belly tense and rather tumid. The case had assumed the characters of ileus, and all the usual means were employed with little relief.—16th. There was some discharge from the bowels after a tobacco injection, but it was very scanty. Severe pain continued, with every expres- sion of intense suffering. Her strength sunk, and she died on the morning of the 17th. Inspection.—Every part of the intestinal canal was perfectly healthy, except the upper part of the duodenum, where there was considerable appearance of inflammation, with remarkable softening, so that it was very easily torn. A large irregular calculus was found sticking in the ductus communis, and the parts were so softened that it came through the side of the duct when it was very slightly handled. In the texture behind the duodenum there was considerable appearance of inflammation. No morbid appearance could be detected in any other organ. II. Perforation or rupture of the gall bladder, or one of its ducts, and escape of the bile into the peritoneal cavity. The immediate effect of this accident is rapid peritonitis, fa- tal in eighteen or twenty-four hours. The symptoms preced- ing it will depend upon its cause, and consequently may be CHANGES OF THE BILE. 295 either very obscure, or such as indicate great distention of the gall bladder, wkh obstruction of the bile in its passage out of it. The causes of the affection are chiefly referable to two classes. (1.) Obstruction of the common duct. This may take place rapidly by adhesive inflammation, or more slowly by gradual obliteration. In the former case the symptoms are rapid, as in a man mentioned by Andral, who had acute pain, followed by jaundice, and a pyriform swelling rising up from under the margin of the ribs. On the fifth day he was suddenly attacked with peritonitis, and died in twenty-four hours. The ductus communis was found much contracted, and at one place ob- literated. The gall bladder and the hepatic and cystic ducts bore marks of having been much distended; the rupture had taken place in the hepatic duct, and much bile was found in the peritoneal cavity. In another, the symptoms of obstruction to the passage of the bile had been going on for between two and three months before the fatal attack, and in this case both the cystic and common ducts were found much contracted. (2.) Perforation of the coats of the gall bladder by ulcera- tion. A man mentioned in the Nouveau Journal de Medicine for 1821, had been affected for more than a month with pain in the abdomen and fever which had various remissions and aggravations. On the 37th day of the disease, he was sudden- ly seized with symptoms of the most violent peritonitis, and died on the following morning after suffering inexpressible ago- ny. On inspection, there were found marks of most extensive peritonitis. The inner surface of the gall bladder presented numerous small circular ulcers from one to three lines in diam- eter ; two of them had entirely perforated its coats, so as to allow the escape of the bile into the peritoneal cavity. SECTION IV. CHANGES IN THE Q.UALITY AND Q.UANTITY OF THE BILE. The chronic diseases of the liver seem to impair the func- tions of digestion, partly by the actual pressure upon the stom- ach, when the liver is enlarged or hardened: and partly by morbid changes in the secretion of the bile from that condition which we know to be necessary to healthy digestion. There is 296 PATHOLOGY OF THE I.IVF.R.--APPENDIX. a good deal of hypothesis on this subject; but there are cer- tain points, in regard to the changes of the bile, which we may consider ascertained with some degree of precision. I. We can have little doubt that the bile is often deficient in quantity, producing dyspeptic symptoms, with paleness of the stools. This seems to arise chiefly in connection with the pale degeneration of the liver, especially when the organ is much diminished in size; but in some of the extraordinary masses of disease which have been described, showing almost every point of the liver altered from the healthy structure, there were no symptoms indicating that the bile was either deficient or viti- ated,—the motions being healthy, and the digestion little im- paired, until a very short time before death. This occurred in a very remarkable manner in Case CXLIII. 2. The bile appears to be sometimes much altered in quality. The only means by which we can judge of this with any de- gree of precision, is from the appearance of the bile which is found in the gall bladder. In some diseases of the liver, ac- cordingly, we find there a fluid of an albuminous or watery ap- pearance, without any of the sensible qualities of bile. When we observe a change so very remarkable as this, we may con- clude that other changes may take place in the quality of the bile, less cognizable to our senses, though they may impair in a great degree the functions of digestion ; but this subject is at present involved in much obscurity. 3. It is probable that the bile may be increased in quantity ; but it must at the same time be admitted, that our prevailing notions on the subject are rather hypothetical than founded upon facts. The bile is a viscid fluid of a green color, and, when it is mixed with the usual contents of the intestinal canal, it im- parts to them a bright yellow. When the motions become of a dull white or ash color, we judge with tolerable precision of the deficiency of bile ; but I am not aware of any test by which we can judge with precision of its redundancy; and I must confess my suspicion, that the term bilious stools is often applied, in a very vague manner, to evacuations which merely consist of thin feculent matter mixed with mucus from the intestinal membrane. On this subject I find a late intelligent writer on the diseases of India, expressing himself in the following manner, after alluding to the doctrine of several systematic writers in regard to bilious diarrhoea, arising from increased secretion of bile: < not a single JAUNDICE. 297 fact is produced by either of these authors in support of their opinion, and it seems to rest merely upon the popular notion that the color of the feces is derived from the bile; but this doctrine seems rather to be taken for granted than proved.' * SECTION V. PATHOLOGY OF JAUNDICE. Jaundice is produced by the absorption of bile into the circu- lation, and this is generally connected with some obstruction to its passage from the liver into the duodenum. It must be con- fessed, however, that there is much obscurity in the pathology of many cases of jaundice, and that seme of the causes which have been assigned for it are in a great measure hypothetical. Among these perhaps may be reckoned morbid viscidity of the bile, spasm of the ducts, overflow of bile, and what has been termed bilious congestion. These and some others of the same kind must be perhaps considered rather as hypothesis framed to correspond with the facts, than as deductions from them, and therefore not entitled to much confidence. When, with a view to practical utility, we consider the cir- cumstances under which chiefly jaundice takes place, they seem to be referable to the following heads. I. The passage of a gall stone. Jaundice takes place from this cause, when tlie calculus is a considerable time in passing, so as to produce an obstruction of some continuance in the duct; when it passes in a shorter time, though the symptoms may be equally severe, no jaundice follows. The precise period which is necessary for the production of jaundice has not been ascertained ; it is probable that it varies in different cases. This form of the disease is in general distinguished by the violence of the pain, but cases have occurred in which the dis- ease was distinctly referred to this cause, while the symptoms had been severe vomiting and jaundice, with very little pain. This occurred in a woman, mentioned in the fifth volume of the Medical Repository, who was suddenly seized with jaundice accompanied by vomiting, and died the same night in a state of * Mr. Tytler,—Calcutta Transactions, vol. iii. 38 298 PATHOLOGY OF THE LIVER.--APPENDIX. coma. A calculus was found sticking in the gall duct, and the duct Avas ruptured. On the other hand, I have described a remarkable case in which a calculus impacted in the common duct was fatal in three days with symptoms of inflammation and ileus, without jaundice. Several cases are on record in which large calculi, after pro- ducing jaundice, and the other symptoms indicative of having been impacted in the duct, have worked their way outwards, and have been extracted from an opening in the parietes. In a case of this kind mentioned by Dr. George Gregory, after the gall-stone was extracted, the ulcer healed up, the jaundice went off', and the patient, who had suffered excessively for several months, rapidly got well. Several cases of the same kind are mentioned by Morgagni and Haller. In one of them, the abscess speedily healed; in another, it continued open, dis- charging a yellow fluid ; in a third, it discharged calculi at in- tervals. I have seen, along with Mr. Lizars, a man, about 50, who has had a biliary fistula discharging for nearly four years. The complaint began with pain in the region of the liver, ac- companied by vomiting and jaundice. After these symptoms had continued about three weeks, a tumor formed in the region of the gall bladder, which was opened, and discharged much fluid of a mixed green and yellow color, and some small biliary calculi. This opening closed, but another soon took place, which has continued to discharge ever since. The discharge varies in quantity, but is often so profuse as in a very short time to wet his clothes as far as his knee, and in the night to soak through his bed to a great extent. Mr. Lizars at one time collected, in the course of a visit not exceeding fifteen or twenty minutes, about four ounces of a fluid, which, on chemical ex- amination, exhibited all the properties of pure bile. The man has every appearance of good health, and, except the fistulous opening, there is no appearance of disease in the region of the liver. His appetite and digestion are good; his bowels are reg- ular, and the evacuations of a natural appearance. A case occurred to the late Dr. Graham of Dalkeith, in which a very arge calculus was extracted from an abscess in the parietes of the abdomen ; and 1 believe ultimately did well. It has been doubted whether the very large biliary calculi, which are some- times discharged by the bowels, had really passed through the duct, or whether they had worked their way by a process of ulcerative absorption into the duodenum, or the colon. But I tit 5^ k J* CaSG i" Wh;ch a larSe ca,culus P^duced fata ileus, after it had passed as far as the middle of the small intos- JAUNDICE. 299 tine. The common duct was found so dilated as to admit a full-sized finger, but without any other appearance of disease. It has been disputed whether biliary calculi are ever formed in the substance of the liver, or in the gall bladder only. But Morgagni mentions several instances in which they were found in the liver, and even of great size; and therefore there is no doubt of another point which has been disputed, namely, that they may produce jaundice by sticking in the hepatic duct. By far the most common formation of them, however, is in the gall bladder, and here they generally exist in numbers, more or less extensive, so that a patient who has once suffered from a gall stone is always in danger of suffering in the same manner again. We frequently find thirty or forty of them in the gall bladder; Morgagni refers to cases in which there were several hundreds, and to one in which there were 3646. They vary exceedingly in size. Hildanus mentions one which weighed eighteen drachms ; and I have mentioned one which measured in its longer circumference four inches, and in its smaller three inches and a half. Biliary calculi seem in general to produce no inconvenience while they lodge in the gall bladder ; but in some cases they appear to produce considerable derangement of the stomach, and of the general health, without entering the duct, and consequently without producing either pain or jaundice. I have mentioned the case of a woman, who died gradually exhausted by daily vomiting, which had continued more than a year, and in whom no morbid appearance could be discovered, except that the gall bladder* was distended with calculi which entirely filled it. A case has also been related to me of a gentleman who was affected with much derangement of his health, accompanied by great and increasing emaciation, for which no cause could be discovered. After the affection had continued for a year or more, he discharged some large biliary calculi, and speedily re- covered perfect health. The passage of biliary calculi, when they are producing urgent symptoms, can be promoted only by opiates, warm bath, laxatives, and perhaps the tobacco injection. The only means likely to prevent the formation of them are probably regular exercise, and constant attention to the bowels. Tt is said that a peculiar disposition to the formation of them has been remarked in persons, who, while in good health, have been sub- jected to much confinement, as in criminals during a long im- prisonment. 300 PATHOLOGY OF THE LIVER.--APPENDIX. II. Inflammatory affections of the liver. Jaundice appears to be often connected with an inflammatory condition of the liver, existing in an obscure form, and often of small extent. It may be suspected when the disease is attended with pain or tenderness in the region of the liver, though without rising probably from the mipeded return of the blood from the liver; and it JAUNDICE. 301 has been known to supervene upon suppression of the haemor- rhoidal discharge and other evacuations which had become ha- bitual. Portal has seen it supervene upon suppression of leu- corrhcea ; and he also mentions a woman who had been long affected «with a copious and very fetid discharge from the arm- pits, and immediately became jaundiced, when she suppressed it by means of a preparation of alum. When jaundice appears to be connected with any affection of the liver of an inflammatory character, it must of course be treated by the appropiate remedies,—as general or topical blood-letting, blistering, antiphlogistic regimen, and very free and continued purging. When the activity of the symptoms has been subdued by these means, benefit is often obtained from mercurial friction, and I think likewise from friction with Iodine. III. There can be little doubt of the fact, that jaundice is often produced by affections of the bowels, though the precise manner in which it arises from such causes is not easily ascer- tained. Large collections of hardened feces in the colon have been supposed to be capable of producing it; and Dr. Marsh has described several cases calculated to show, that jaundice may arise from an inflammatory state of the mucous membrane of the duodenum, acting directly, by obstructing the mouth of the duct.* IV. A singular fact in the history of jaundice is afforded by those cases, in which it is distinctly induced by passions of the mind. A woman mentioned by Hoffman was affected with jaundice every time that her mind was agitated ; and a medical gentleman, mentioned by Mr. Cooke, became jaundiced almost invariably when he had a dangerous case under his caie.f The doctrine of spasm has been applied to such cases; but it is time that we should discard this hypothesis, which is used to explain every thing that we do not understand, and content ourselves with the facts when we can really go no farther. Jaundice, however, even when arising from causes apparent- ly transient, is never to be looked upon as free from danger. For many cases are on record in which death took place in a very unexpected manner, and in which no morbid appearance could be discovered capable of accounting either for jaundice, or for the fatal event. Several years ago, I saw a woman who * Dublin Hospital Reports, vol. iii. f Cooke on Derangements of the Digestive Organs. 302 PATHOLOGY OF THE LIVER.--APPENDIX. became suddenly jaundiced a day or two after accouchement. There was no other symptom, and no danger apprehended, until after two or three days she became comatose and died. There was very slight effusion in the brain ; no morbid appearance could be discovered in any other organ. A young man, men- tioned by Morgagni, was seized with jaundice after agitation of mind. It was attended with pain of the stomach, and vomiting, but no fever. On the second day, he was dull and forgetful; on the third he was convulsed and then comatose; and he died on the fifth. The liver was found only flaccid and pale; there were some red points on the mucous membrane of the stomach, and turgid glands in the abdomen. In the head there was slight effusion on the surface of the brain, and a considerable quantity about the spinal cord. Another young man, mentioned by the same writer, was very much frightened by having a mus- ket pointed at his breast. Next day he was jaundiced ; soon after delirious ; then convulsed ; and he died in twenty-four hours from the first appearance of the delirium. No disease could be detected, except turgescence of the vessels on the surface of the brain. Dr. Marsh also mentions two cases in which jaundice came on suddenly during the use of mercury, and was fatal with delirium and coma. In some cases, however, in which jaundice comes on in this manner, and is suddenly fatal the chain of events that seem to lead to the fatal result is traced in a more distinct manner,—as in a lady mentioned by Portal, whose case was formerly referred to. After great agitation of mind, she was seized with suppres- sion of the menses; this was speedily followed by very deep jaundice ; and she died next day. The liver in this case show- ed marks of extensive disorganization. V. The cases of long-continued jaundice are generally refera- ble to two heads, namely, chronic disease of the liver, or tumors, or other diseases of neighboring organs, compressing the duct. Of the former class, we have seen various examples under the head of diseases of the liver; and we have also seen, on the other hand, chronic diseases of the liver of most extraordinary extent, without any appearance of jaundice. Among causes of the second class, are enlargements of the spleen and pancreas; masses of disease attached to the pylorus • thickening and indu- ration of the coats of the duodenum, and tumors°of various characters compressing the common duct. In the Journal de Progres, a case was mentioned some time ago, which after con- tinuing for several months, was found to be connected with a JAUNDICE. 303 flat tumor the size of a crown piece, involving the coats of the duodenum and the mouth of the biliary duct. There is also reason to believe that old cases of jaundice are sometimes pro- duced by contraction of the calibre of the common duct, arising from chronic inflammation of the coats of the duct itself. In this outline, I have alluded only to those sources of jaun- dice which may be considered as ascertained with some degree of correctness. Others are mentioned, but are probably in a great measure conjectural; and lam not entirely satisfied of the correctness of the doctrine by which jaundice has been consid- ered as an effect of injuries of the head. The source of hesita- tion here is a doubt, whether, in the cases referred to, the inju- ry of the head could be considered as the cause of the jaundice ; or whether the liver had not also received an injury at the time of the accident. The yellow tinge in jaundice is said to have been observed in all the fluids of the body, except the milk. But Dr. Marsh men- tions, that, in examining the body of a woman who died in the Lock Hospital of Dublin from protracted disease, connected with jaundice, the mammae appeared full ; and by moderate pressure, there were obtained from them several ounces of a yellow tenacious fluid, having all the visible properties of pure bile. He also mentions a case related to him by Dr. Cheyne, of a lady affected with jaundice, whose linen was distinctly tinged by the exhalation from her skin. PATHOLOGY or THE SPLEEN. The morbid conditions to which the spleen is liable appear to be chiefly the following: § J.—Inflammation. Inflammation may be seated either in the substance or the peritoneal coat of the spleen. Active inflammation of the sub- stance of the spleen is rarely observed; but Portal found proofs of its existence in a man who died of acute fever, with pain in the left side, cough, dyspnoea, and violent palpitation of the heart. The lungs were sound, but there was inflammation of the spleen and the left side of the diaphragm. In other cases, vomiting has occurred. It is probable that the symptoms are in general more acute when the inflammation is seated in the peritoneal coat, than when it is in the substance of the spleen. I have not seen this affection in the idiopathic form ; but I have repeatedly seen the spleen completely enveloped in a thick and dense covering of false membrane, in connection with peritonitis, without any disease of its substance. Inflam- matory action of the spleen seems to occur more frequently in a chronic form, and to terminate in some cases by suppuration, in others by a peculiar black degeneration or softening. In both cases, the disease is generally protracted, and the symp- toms are often exceedingly obscure. 39 306 PATHOLOGY OF THE SPLEEN. § II.—Suppuration of the spleen. The following is the only case of suppuration of the spleen that has occurred to me. Case CXLVII.—A gentleman, aged 52, who had enjoyed previously very good health, was affected in January, 1821, with cough and slight feverishncss like a common cold. After a short confinement, the cough disappeared, and he felt other- wise much better; but after some time, he was confined again, though without any defined complaint except weakness. When closely questioned, he sometimes mentioned an unde- fined uneasiness across the epigastric region, but it was slight and transient: his appetite was variable and capricious, but, upon the whole, not bad, and he had no dyspeptic symptom ; his bowels were rather slow, but easily kept open ; his breath- ing was natural; and every other function was in a healthy state, except that his pulse continued a little frequent, and that he was becoming progressively more weak and emaciated. In this manner, the complaint went on during the remainder of the winter; in the beginning of the summer he went to the country, where he made no improvement. He was now greatly reduced in flesh and strength ; his pulse was from 96 to 100 and weak; his nights were generally good, but sometimes feverish ; his appetite was bad, but he still took a good deal of nourishment, and never complained of his sto- mach ; there was no cough and no pain ; the urinary secretion and bowels were natural; but the debility and emaciation con- tinued to increase piogressively. On the 2d day of July, he was seized with diarrhoea, and died on the 5th. Before the at- tack of diarrhoea, there had been little change for several weeks; he had been able to be out of bed the greater part of the day, and occasionally out in a carriage or in a garden chair. Inspection.—The spleen was somewhat enlarged, and in the centre of it there was an irregular cavity containing several ounces of purulent matter; the surrounding substance was soft and easily lacerated. The liver was pale, but otherwise healthy ; the kidneys were pale, with a peculiar degeneration of some parts of them into a firm white matter. After the most careful examination, no appearance of disease could be detect- ed in any other part of the body. From the commencement of his illness, this gentleman was under the care of Mr. William Wood, and in the progress of it he was occasionally seen by Dr. Thomson and myself; but we ABSCESS. 307 never could detect a symptom from which we could infer what was the seat of his disease. There are few cases on record of suppuration of the spleen, and the symptoms in general appear to be protracted and often obscure. A young man, mentioned by M. Jacquinelle, (Jour- nal de Med. torn. 88,) had pain and fullness in the left hypo- chondrium, with palpitation of the heart, faintings, and progres- sive emaciation; and he died gradually exhausted, at the end of a year. A short time before his death, there was a cessation of pain, followed by discharge of very fetid and dark colored matter by stool. The heart was found enlarged, with dilatation of the aorta. The spleen was much enlarged, and contained an abscess which had burst into the colon. A similar case is mentioned by Grotanelli; and another, in which the abscess burst into the cavity of the abdomen, and was fatal in three days. A man mentioned by the same writer, after various at- tacks of ague, had tumified spleen with hectic paroxysms and night sweats. In a quarrel, he received a blow on the left side, after which the tumor subsided, and he discharged much thick and fetid matter in his urine. This continued about three weeks ; he then recovered good health, and had continued well for seven years, when the account was published. In a woman mentioned by Heide, who had long been affected with a swelling in the left hypochondrium, a tumor formed at the umbilicus which discharged purulent matter; after it had dis- charged for a month she died hectic. A cavernous ulcer was found extending from the umbilicus, betwixt the peritoneum and the abdominal muscles, and forming a communication with an abscess of the spleen.* Abscess of the spleen may likewise burst into the stomach, as in a very interesting case mentioned by M. Cozef. The pa- tient had pain in the epigastric region, with a remarkable feel- ino- of pulsatioll at the stomach, which was increased by exer- cise and by any excess in the diet; he had occasional vomit- ing and slight uneasiness in breathing, was easily fatigued by exercise and a sense of suffocation was induced by any exer- tion On examination nothing could be discovered but a slight tension across the epigastrium, and little change took place for ten or twelve months, except that his skin became slightly yel- low. He was then seized with vomiting of blood mixed with putulent matter, after which the pulsation at the stomach sub- ♦ Heide Centuria Observ. Med.—Obs. xiii. t Jour, de Med.—Tom. 82. 308 PATHOLOGY OF THE SPLEEN. sided, and he felt easier than he had done for a long period. But the vomiting returned in a fortnight, and he died in the third attack, after another week. The spleen adhered intimate- ly to the stomach, and formed a bag full of purulent matter and clots of blood. The parietes of it were in general about six lines in thickness ; and it communicated, by a free opening with the cavity of the stomach at the place of the adhesion. In some cases, the abscess of the spleen appears to have ob- tained a most remarkable size. In a case mentioned in the Memoirs of the Academy of Sciences, it contained 30 lbs. of matter. In another case mentioned in the same work by M. L'Hermite, 8 lbs. of matter were drawn off by tapping. The patient died next day, and the spleen was found still to contain 7 lbs. of matter, and to form a sac eighteen inches long and twelve inches in diameter. In some of the soldiers who suffer- ed from the Walcheren fever, Mr. Wardrope found the spleen entirely reduced to a cyst full of puriform fluid.* $ III—Ramollissement or black degeneration of the spleen. This I believe to be the result of a low degree of inflamma- tory action; and it is found as the only morbid appearance in cases in which the patients have died with obscure and pro- tracted symptoms. The spleen so affected may be enlarged or it may be of the natural size; but the whole substance of it is reduced to a soft black broken-down mass like grumous blood "earl? fl.nT ^ "*"' *** °f * **^™^«^ «, Z^hiLTerd Hmuf fUt & ZF^ vomited three or&four times a-da• Te had little^ ^^ tongue loaded; bowels rather costive hn*'e°.r noaPfetlt^ to his edition of the wo.ks of Dr. B.. RAMOLLISSEMENT. 309 Inspection.—No morbid appearance could be discovered after the most careful examination, except in the spleen, which was of a very dark color, and the whole substance of it was broken down into a soft mass like grumous blood. Case CXLIX.—A gentleman, aged about 45, consulted me in summer 1827, on account of a deep-seated painful swelling in the left side. On examination, it was found to be exactly in the region of the spleen ; it was well defined, and very pain- ful ; and no cause could be assigned for it. His general health was considerably impaired ; and the functions of the stomach were a good deal deranged. After a variety of treatment, he regained pretty good general health ; and the swelling was very much reduced. I then lost sight of him for a year, during which I learned that he enjoyed tolerable health, though he occasion- ally felt uneasiness in his side. He died in August, 1828, after an illness of about three weeks, which had the characters of continued fever. I did not see him in this illness, but was present at the examination of the body. Inspection.—The spleen was very much enlarged, probably to at least ten or twelve times its natural size. When first taken out, it had a remarkably soft and fluctuating appearance, as if its peritoneal coat contained a large quantity of fluid. But on cutting into it, this appearance was found to be owing to its whole substance being reduced to a soft black mass, like grum- ous blood. The liver was of a remarkably dark green color, but without disease of its texture. The condition of the spleen here referred to has been taken notice of by various writers ; some of them compare it to a bag of very fetid pitch, others to the lees of oil; some call it putre- faction, and others gangrene ; and upon the whole, there seems every reason for concluding it to be an affection which may be fatal without any other disease. A lady, mentioned in Dr. Johnson's Journal, vol. iii., died at the end of a fortnight, with- out any other symptoms than nausea and'frequent vomiting; the pulse and bowels being quite natural. On inspection, there was found some slight appearance of inflammation on the lower intestines; the spleen was very soft, and broken down into a mass like coagulated blood. A man, mentioned by Sen- nertus, had been affected for some weeks with loss of appetite and pain in the left side; he was then seized with discharge of blood by stool, and died in fifteen days. The pancreas was found slightly diseased; but the principal morbid appearance was in the spleen, which was entirely reduced to a bag full of 310 PATHOLOGY OF THE SPLEEN. a matter like the lees of oil, and somewhat fetid ;—no part of the natural substance remaining. In other cases, there has been more acute pain, referred to the region of the spleen ; and in some, it has been found combined with evident marks of in- flammation in the neighboring parts. This occurred in a case by Lossius; and, in two cases by Crendal, it was found con- nected with extensive peripneumony. I have likewise observed it in several cases in which there had been extensive inflamma- tion of the lower part of the left lung. A gentleman whom I saw lately, had been for several months remarkably fallen off in flesh and strength, without any defined complaint which could account for the change in his appearance. He was at last seized with a large carbuncle on the side of his head, ac- companied by considerable constitutional irritation, under which he sunk rather suddenly. The spleen was found remarkably soft without enlargement, and when cut into, discharged from every part a thick fluid of a reddish brown color. The left extremity of the pancreas was indurated, and slightly tubercu- lar. No other disease could be discovered, after the most minute examination. § IV.—Simple enlargement of the spleen. When simple enlargement of the spleen is seen at an early period, it is accompanied with a state of highly increased vas- cularity. In the older cases, the structure is sometimes of a bluish purple color, and breaking down under slight pressure; in others it is hardened, though of the natural appearance ; and sometimes the spleen has been found of an enormous size, without appearing to deviate in any degree from the healthy structure. This occurred in a case mentioned in the Medical Commentaries, in which it weighed 11 lbs. 13 ounces. In other cases, again, the disease presents a mixed character, re- • sembling some of the chronic affections of the liver;__some parts being of a tolerably healthy appearance, others indurated, approaching to scirrhus ; and perhaps, there may be hydatids or cysts containing a thick matter like pus or softened tubercles. One of the most singular facts in the pathology of the spleen, is the very rapid manner in which enlargement of it takes place, and the equally rapid manner in which it subsides. Some of the cases of this kind which I have seen, appeared so very ex- traordinary, that I suspected some fallacy, until I found similar SIMPLE ENLARGEMENT. 311 cases described as of frequent occurrence by writers on the dis- eases of India. Several years ago, I saw, along with Dr. Combe ot Leith, a seaman who had contracted ague in England a few weeks before, and had returned to Leith with the disease going on in the usual manner. In the left hypochondrium, there was a firm defined tumor arising from beneath the margin of the ribs, and projecting downwards several inches. We agreed that our first object was to arrest the fever by the usual means, leaving this remarkable tumor for future consideration ; but on returning about a week after, I found that the fever had been easily arrested, and that the tumor was entirely gone. The simple enlargement of the spleen occurs chiefly as the result of intermittent and remittent fevers ; but it is also said to occur from other causes, as in young women in connection with suppression of the menses, and in persons more advanced in life from the suppression of long continued haemorrhoidal discharge. It is also met with, especially in warm climates, in feeble un- healthy children, and seems to be produced by damp situations and bad nourishment. Patients affected with tumid spleen are generally of a sallow and unhealthy aspect; the bowels irregu- lar ; the motions generally dark colored. They are said to'be liable to haemorrhage from various parts of the body; there is deranged digestion, with muscular debility ; and often a general unhealthy state of the system with a tendency to sloughing sores from slight causes. There is frequently a dry cough; and in protracted cases, haematemesis, and at last general dropsy. In other cases, the disease seems to have wonderfully little effect upon the general health. Dr. Crane mentions that he has known individuals in Lincolnshire affected with it for twenty years, though they had generally a pale or yellowish aspect; * and Lieutaud mentions a spleen which weighed 32 lbs. in a woman who had had the disease in a greater or less degree for seventeen years. It is now generally admitted, that, in the treatment of enlarged spleen, mercury is uniformly and highly injurious, producing mortification of the mouth, and rapid failure of strength. In the earlier stages, when there is any considerable degree of ten- derness, repeated topical bleeding should be employed, followed by blistering or a seton. In other respects, the chief reliance of those who have seen most of the disease, appears to be upon free and continued purging, and especially purgatives combined with tonics. The spleen powder, and spleen mixture of Bengal, * Dr. Crane, Edin. Med. Jour. Aprif, 1823. 312 PATHOLOGY OF THE SPLEEN. are combinations of rhubarb, jallap, scammony, and cream oi tartar, with Colombo powder and sulphate of iron, taken three times a-day, in such doses as to keep up regular but moderate purging. About 20 days are stated by Mr. Twining,* as the period which is generally required for reducing by this treat- ment a very considerable tumefaction of the spleen, if the case has been recent. Others employ nitric acid with- regular aloetic purges. The natives of India employ the actual cautery, and a combination of aloes, garlic and vinegar. They also employ aloes, combined with the sulphate of iron. It is probable that the external application of Iodine might be useful. During the present season, I have seen, with Dr. Hay and Dr. Macwhirter, a little boy, aged 3, who was sent here from- India with a mass of disease in the left side of the abdomen, be- lieved to be an enlargement of the spleen. It occupied the whole space from the ribs to the os ilium, and the apex of the tumor extended considerably to the right of the umbilicus. It was of a smooth uniform surface, and firm texture, somewhat movable, and not painful on pressure. The child had a pale sickly aspect, with a small rapid pulse, and was liable to attacks of haemorrhage from the nose. The affection had a most un- promising appearance, but it has gradually subsided, and is now scarcely perceptible. The treatment consisted chiefly of the use of the sulphate of iron, of which he took at first gr. 1. three times a-day with 1-3 of a grain of aloes ; afterwards gr.ij. twice a-day. The aloes was after some time omitted, the state of the bowels rendering it unnecessary. § V.—Tubercles. Tubercles are of very frequent occurrence in the spleen,— generally in combination with tubercular disease in other parts of the body ; and it may be seen completely studded with them, even in the bodies of infants a few months old. In these cases, they are generally very small and in the solid state ; but in more advanced life, they may attain a very considerable size, and by suppurating pass into numerous small abscesses. A woman, mentioned by Grotanelli, had nausea, bad appetite, occasional vomiting, some cough, and pain in the left side; she lost her color, and the abdomen became tumid. The vomiting increased, with a quick pulse and anasarca; and she died in five months. * Calcutta Transactions, vol. iii. HEMORRHAGE. 313 Considerable effusion was found in the abdomen ; the spleen was enlarged and contained twenty tubercles full of thick puru- lent matter. § VI.—Pale induration of the spleen approaching to scirrhus. Ths appearance, I have not seen, but it is mentioned by Por- tal and Lieutaud. An indurated friable state of the spleen is also mentioned as occurring in India, in which it breaks down, when handled, like a piece of old cheese. A black induration with great enlargement is mentioned by Diemerbroeck. $ VH—Hydatids. Hydatids are of frequent occurrence in the spleen; they may be imbedded in its substance, but I think are more commonly met with in cysts formed by its peritoneal coat. In one case of this kind, in which there was immense swelling in the region of the spleen, I found the disease to consist entirely of a bag of hydatids covered by its peritoneal coat, the substance of the spleen being little altered from the natural appearance. § VIH.—Haemorrhage from the spleen, and laceration by ex- ternal violence. Case CL.—A woman, aged 20, was admitted into the Infirm- ary of Edinburgh, on 16th June, 1829, under the care of Dr. Duncan. Her complaints were chiefly of a rheumatic charac- ter, with considerable nausea, some fever, anxiety, and restless- ness. She stated, that, a fortnight before, she had been sud- denly seized with severe pain in the stomach, followed by nau- sea and vomiting, and that these symptoms continued to recur at intervals for a week. On-the 17th, there was vomiting, with much anxiety and restlessness, and she complained of pain on pressure in the left side beneath the false ribs. On the 18th, she became low and cold, and died in the evening. Inspection.—A quantity of coagulated blood was found in the cavity of the abdomen, which was ascertained to have pro- ceeded from a laceration of the spleen. That organ was of a paler color than natural, and its substance was soft and easily 40 314 PATHOLOGY OF THE SPLEEN. torn. There was a sacculated disease of the right ovarium : but no other appearance of recent disease could be detected in any organ. A man, mentioned by Fournier, had suffered from quartan ague for several months, but was considered as convalescent, when he died suddenly after a hearty supper. The spleen was found enlarged and ruptured; and there was much coagulated blood in the cavity of the abdomen. Several cases are on record of laceration of the spleen by ex- ternal violence; in some of them, death seems to have taken place from haemorrhage, in others from inflammation. Cases of the former kind are mentioned by Lieutaud and Tulpias. A man, mentioned by Dr. Chisholm, fell while carrying a burden, and struck his left side against a stone. He felt little uneasi- ness at the time, and next day was able for his work as a black- smith ; but he was then seized with pain in the side, fever, de- lirium, and muscular spasms, and died on the fourth day from the injury. All the viscera were found in a healthy state, except the spleen, which was somewhat enlarged, and, on the anterior surface of it there was a laceration through its whole extent to the depth of two inches; the edges of the laceration were in some places florid, in others sphacelated. Various other morbid conditions of the spleen are occasion- ally met with, but they are distinguished by no particular symp- toms ; consequently it would answer no purpose to detail ex- amples of them. Among these may be reckoned infiltration of the substance of the spleen with a gelatenous fluid ; deposition of fatty matter throughout its structure: ossification or carti- laginous hardness of its external surface ; remarkable diminu- tion of its bulk; stony concretions, and a stony induration of its whole structure. A woman, whose case is quoted from the Swedish Transactions, in Dr. Johnson's Journal for 1828, had, after exposure to cold, suppression of the menses, pain and swelling in the epigastric region, and haemorrhage from all the natural outlets of the body. When this had ceased, the spleen was found to be enlarged ; she had then effusion in the abdo- men, and return of the haemorrhage to such an extent as to be fatal;—the dates are not mentioned. The spleen was found of enormous size, and its substance was transformed into a grumous glutinous fluid, enveloping three bony concretions, one of which was two inches and a half in length. The liver was found in a state of atrophy. PATHOLOGY OF THE PANCREAS. Facts are wanting upon this subject; but it appears that the morbid conditions to which the pancreas is liable, are chiefly the following: J.—Inflammation and its consequences. Inflammation of the pancreas seems to be rather a rare dis- ease ; but several cases are on record in which it was found suppurated and gangrenous. The symptoms do not appear to be very distinctly defined. There was in general pain, which was chiefly referred to the back, while in others it had more the appearance of colic; vomiting occurred in a few of the cases, but does not appear to have been a uniform symptom. Dr. Bailie found an abscess of the pancreas in a young man who had a good deal of pain in different parts of the abdomen, with spasms of the abdominal muscles, but did not complain of any fixed pain in the region of the pancreas ; there was sick- ness with distention of the stomach, especially after eating, and a tendency to diarrhoea, and at length he became dropsical. A gentleman mentioned by Dr. Percival, had jaundice and bilious vomiting; a tumor appeared at the epigastrium; his strength failed; blood and fetid pus were discharged by stool; and he died exhausted in three months. The pancreas was found greatly enlarged, and contained a considerable abscess; the ductus communis was obliterated by the pressure. Portal found a complete suppuration of the pancreas in a man who 316 PATHOLOGY OF THE PANCREAS. died suddenly after two or three attacks of vomiting, followed by syncope; he had previously suffered from a paroxysm of gout, from which he was supposed to be convalescent. Ab- scess of the pancreas is also mentioned by Tulpius and Bar- tholinus. In two cases by the former, it was connected with quartan fever; and in a case of continued fever, in which there was much pain of the back, Guido Patin found an immense abscess occupying the whole of the pancreas. A sphacelated state of the pancreas was found as the only morbid appearance by Barbette, in a man who died of urgent vomiting after a short illness. The same appearance occurred in a man men- tioned by Greizel, who had been liable to colic pains, and died rather suddenly, having complained only of a feeling of inter- nal coldness; and Portal found the pancreas softened and gan- grenous in a man who died of obscure pain in the abdomen, accompanied by wasting, with occasional nausea and diarrhoea. A gentleman, mentioned by Dr. Parry was first affected with loss of appetite, and a painful feeling of distention after taking a small quantity either of food or drink. He then had vomit- ing of almost every thing that was taken, and complained of pain which extended along the sternum to the throat, and was felt also between the shoulders, with much flatulence, and a burning sensation in the breast and throat. He died, gradu- ally exhausted, about two months after the commencement of the vomiting. On inspection, the principal appearance was an abscess, four inches in diameter, formed between the upper sur- face of the pancreas and the lower surface of the left lobe of the liver. The sides of the abscess were rugged and uneven, and it contained a thick curdy matter. The pancreas and the adjoining portion of the liver were hardened; and there was hardness with contraction of the oesophagus, extending along its thoracic portion. H.—Enlargement, with a mixed state of disease, partly con- sisting of induration, and partly of a softened state re- sembling the medulary sarcoma. Case CLI.—A lady, aged about 40, came to Edinburgh in May, 1829, affected with very deep jaundice, which was of several months' standing. There was occasional uneasiness in the abdomen, but it was not severe; and the general health was little impaired. No disease could be discovered in the re- ENLARGEMENT. 317 gion of the liver: in the centre of the abdomen, near the um- bilicus, there was a slight feeling of knotty irregularity, but it was obscure, and could only be felt occasionally. I saw her along with Dr. Macwhirter, and a great variety of treatment was adopted without benefit. She at length became dropsical, and returned to the country, where she died, gradually ex- hausted, in August.—I am indebted to Mr. Syme of Kilmar- nock, for the account of the morbid appearances. Inspection.—There was a gallon of fluid in the abdominal cavity. The gall bladder was very large, and was distended with very black bile. The liver was of a deeper color than natural, but otherwise sound. The whole of the peritonaeum was somewhat thickened. The pancreas was enlarged to the size of two fists, and embraced the ductus communis so firmly, that it was found impossible to pass a probe from the gall blad- der into the intestine. It was of a mixed texture, some por- tions being soft, resembling the medullary sercoma, and others of schirrous hardness. The other viscera were healthy. Case CLII.—A man, aged 56, had pain in the left hypochon- drium, extending into the back, with oppression at the stomach, indigestion, and gradual emaciation ; and he died gradually ex- hausted after two years, without any other symptom, except that for a week or two before his death, there was a considera- ble degree of jaundice. He never had any vomiting, and his bowels were easily regulated. No disease could be discovered by examination during life, even after he became to the last de- gree emaciated. Inspection.—The stomach and the intestines were healthy ; behind the stomach, in the seat of the pancreas, there was a morbid mass four or five inches in breadth, and somewhat less in thickness; it was closely attached to the spine, and sur- rounded the aorta. It varied in its structure, some parts being of almost cartilaginous hardness, others soft and composed of alternate layers of yellowish and white matter. The liver was somewhat enlarged and soft; the other organs were healthy. Case CLIII.—A young man, aged 16, in May, 1812, began to complain of pain in the region of the stomach, extending through to the back. It increased very gradually, but without confining him from his usual employment, until July, when he began to be affected with vomiting, which generally occurred two or three hours after dinner. At this time, he commonly retain- ed his breakfast; but, in September, when I saw him, he vom- 318 PATHOLOGV OF THE PANCREAS. ited every thing. He was then much wasted; and a large ir- regular tumor was distinctly felt in the epigastrium, which was painful on pressure. He died, gradually exhausted, in the end of December ; for 8 or 10 days before his death, the vomiting had ceased, and he was then affected with severe diarrhoea. Inspection.—The pancreas was enlarged, so as to form a mass seven or eight inches long, five inches broad, and three in thickness; and internally showing a mixed state of disease as in the former case. The stomach, the duodenum, and the arch of the colon, had formed adhesions to the mass; and the stomach seemed somewhat thickened in its coats; the other viscera were healthy. HI.—Scirrhus induration with little enlargement. Case CLIV.—A woman, aged about 40, had vomiting and slight uneasiness in the region of the stomach. The vomiting gradually increased in frequency, until she vomited almost every thing she took into her stomach; and she died, without any other prominent symptom, after the vomiting had continued about a year. A remarkable circumstance in this case was, that, though she died with gradual and progressive loss of strength, there was no emaciation; and that a coating of fat, two inches in thickness, was cut through in opening the abdo- men when the body was examined. Inspection.—The pancreas was found in a state of uniform scirrhus hardness, without much enlargement; no other morbid appearance could be detected in any part of the body. In this case there was every reason to consider the disease of the pancreas as the cause of the urgent and long continued vomiting ; but there is also ground for believing, that a diseased state of the pancreas has a most important influence upon the functions of digestion and assimilation, and that it may produce in this manner many serious effects upon the system, while the local symptoms are so obscure as not to indicate what organ is the seat of the disease. I shall only add the following remarka- ble example of this kind. Case CLV.—A gentleman, aged 35, died after an illness of about eighteen months' duration, in which it was to the last im- possible to say what organ was the seat of the disease. His complaints began with a febrile attack, which left him weak j SCIRRHUS INDURATION. 319 and from that time he was liable to dyspeptic symptoms, with variable appetite, and undefined uneasiness in the epigastric re- gion. He gradually lost flesh and strength, and when he con- sulted Mr. Newbigging in January 1822, he was found thin and weak ; but Mr. N. was particularly struck with his remarkable paleness,—even his lips and the inner surface of his mouth be- ing entirely without color. About this time he had some vom- iting, and was feverish for a day or two ; but these symptoms soon subsided and left him in his former state ; appetite variable and capricious; bowels sometimes costive and sometimes rather loose; he had frequently perspirations in the night time, and appeared at all times languid and faint, but his pulse was natu- ral ; he took a good deal of food, and there was no symptom that accounted for his emaciated appearance. In February he became rather worse, with some diarrhoea and scanty urine; but these symptoms soon subsided, and he afterwards com- plained chiefly of throbbing in the head and a constant noise in the left ear. When I saw him in the middle of April he was reduced to the last degree of paleness and debility, but his pulse was full, strong, and regular. He took a good deal of food, and complained of nothing except the painful pulsation in his left ear. The action of the heart was rather strong, and he felt a sensation of throbbing over his whole body. He died in the end of April without any change of the symptoms, ex- cept that his pulse became frequent a few days before death. Inspection.—All the internal parts were found remarkably pale and void of blood; the heart was sound but remarkably empty. The pylorus was thickened and firmer than natural, and had contracted an adhesion to the pancreas. The pancreas was considerably enlarged, and of nearly cartilaginous hardness, except some spots, which were soft, with the appearance of the medullary sarcoma. No other disease could be detected in any part of the body. Many cases are on record of chronic diseases of the pancreas, exhibiting the same diversity of symptoms_ which occurred in the examples now described, and nearly in the following pro- portion. Of twenty-seven cases which I find mentioned by various writers, six were fatal with gradual wasting and obscure dyspeptic complaints, without any urgent symptom. In eight, there was frequent vomiting, with more or less pain in the epigastric region; and thirteen were fatal, with long continued pain without vomiting. In some of these, the pain extended to the back; and in others, it was much increased by taking 320 PATHOLOGY OF THE PANCREAS, food. In several, there were dropsical symptoms; and in three or four there was jaundice from the tumor compressing the bilia- ry ducts. In the morbid appearances, also, there was great va- riety ; the pancreas being in some of the cases much enlarged, in others, in a state of scirrhus hardness with very little enlarge- ment. It does not appear that any distinct relation can be traced betwixt the urgency of the symptoms and the degree of enlargement; for this existed in a great degree in some of the cases in which the symptoms were slight and obscure; and there was hardness with little or no enlargement in others, in which the symptoms were defined and violent. IV.—Calculous concretions. De Graaf found seven or eight calculi, of the size of small peas in the pancreas of a man who had been long liable to vom- iting and diarrhoea, and died, gradually exhausted at the age of thirty. Portal found the pancreas much enlarged and contain- ing twelve calculi, some of them the size of nuts, in a man who died of disease of the aorta. In a case mentioned by Dr. Bailie, the calculi were about the size of the kernel of a hazel nut with a very irregular surface, and were found to be composed of carbonate of lime. MEDICAL AND SURGICAL BOOKS. PUBLISHED BY LEA & BLANCHARD, PHILADELPHIA. 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" To execute such a work requires great I structed under the immediate eye of the au erudition, unwearied industry, and exten- j thor, who is most favourably circumstanced sive research, and we know no one who for adding to the previous edition what- could bring to the task higher qualifications \ ever could give it additional claims on the of this description than Profe.-sor Dungli- j score of accuracy. Here are eight hundred son."—American Medical Journal. and twenty-one pages, large octavo, in "This is an excellent compilation, and | double eolums, distinct type, of which no one that cannot fail to be very much re- lone ought to complain. Finally, althouch. ferred to. It is tlve best medical lexicon in ' most of our readers may be owners of the the English languagaahat has yet appeared. | first edition, we cordially and conscientioua- We do not know any volume which con-ly recommend to all future purchasers to tains so much information in a small com-1 procure this in preference to any medical pass. The Bibliographical notices, though so short, are very important and useful; and altogether we can recommend to every medical man to have this work by him, as the cheapest and beit dictionary of re- lexicon extant. Its true and sterling va-lue, as a key to medical science, and its mode- rate price, are so many comnwn-sense re- commendatipns which should not be for- gotten."—Boston Medical and Surgical Journal. PUBLISHED BY LEA AND BLANCHARD. 27 A NEW AND VALUABLE WORK FOR PHYSICIANS, APOTHECARIES, AND STUDENTS. NEW REMEDIES, The jflcthoel of Preparing A" Administering them; THEIR EFFECTS UPON THE BY ROBLEY DUNGLISON, M. D. Professor of the Institutes of Medicine and Materia Medica in Jefferson Me- dical College of Philadelphia; Attending Physician to the Philadelphia Hospital, 8,'C. IX ONE VOLUME, OCTAVO. "The value of this book is hardly to be . practitioners. It is creditable to the in- estimated ; to be without it, would be very dustry and wise discrimination of the au- much like obstinacy, and amount to the j thor, and quite necessary to the libraries eame thing as saying, like the Austrians in i of those who feel the necessity of keeping regard to their government, nothing can be \ pace with the improvements and discoveries improved, for we already live in a state of; in the broad but imperfectly exploded do- perfection. Dr. Dunglison, the author, has ' main of medicine."—Boston Medical and done an essential service to all classes of | Surgical Journal. A Third Edition, Improved and Modified, of DUNGLISON'S HUMAN PHYSIOLOGY: Illustrated With Numerous Engravings. IN TWO VOLE " We are happy to believe that the rapid sale of the last edition of this valuable work may be regarded as an indication of the ex- tending taste for sound physiological know- ledge in the American schools: and what we then said of its merits, will show that we regarded it as deserving the reception it has experienced. Dr. Dunglison has, we are glad to perceive, anticipated the recommendation which we gave in regard to the addition of references, and has there- by not only added very considerably to the value of his work, but has shown an extent of reading which, we confess, we were not prepared by his former edition to expect. He lias also availed himself of the addi- tional materials supplied by the works that I JMES, OCTAVO. have been published in the interval, espe- cially those of Miiller and Burdach. So that as a collection of details on human physiology alone, we do not think that it is surpassed by any work in our language: and we can recommend it to students in this country (England) as containing much with which they will not be likely to meet elsewhere."—British and Foreign Medi- cal Review. This work exhibits another admirable specimen of American industry and talent, and contains an account of every discovery in Europe up to the period of a few months prior to its publication. Many of the au- thor's views are original and important."— I Dublin Journal of Medieal Sciences. 28 MEDICAL AND SURGICAL WORKS, GENERAL THERAPEUTICS; OR, PRINCIPLES OF MEDICAL PRACTICE. J fllh Tables of the Chief Remedial Agents and their Preparations, and of the Different Poisons and their Antidotes. Bv Robert Dunglison, M. D., &c, &c. One Volume, large 8vo. "There being at.prescnt before the public several American works on Therapeutics, written by physicians and teachers of distinction, it might be deemed unjust in us, and would certainly be invidious, to pronounce any of them superior to the others. We shall not, therefore, do so. If there be, however, in the English language, any work of the kind more valuable than that we have been examining, its title is unknown to us. " Wc hope to be able to give such an account of the work as will strengthen the desire and determination of our readers to seek for a farther acquaintance with it, by a candid perusal of the volume itself. And, in so doing, we offer them an assurance that they will be amply rewarded for their time and labour."—Transylvania Journal, Vol. IX, No. 3. THE MEDICAL STUDENT; or, Aids to tho Study of Medicine. Including a Glossary of the Terms of the Science, and of the Mode of Prescribing; Bibliographical Notices of Medical Works; the Regula- tions of the Different Medical Colleges of of the Union, &c. By Rohley Dunglison, M. D., &.c, &.c. In one volume, 8vo. ELEMENTS OF HYGIENE; on the Influence of Atmosphere and Locality; Change of Air and Climate, Seasons, Food, Clothing, Bathing, Sleep, Corporeal and Intellectual Pursuits, &c, on Human Health, Constituting Elements of Hygiene. By Robley Dunglison, M. D. &c, &c. In 1 vol. 8vo. MEDICAL ESSAYS. THE CYCLOPEDIA OF PRACTICAL MEDICINE AND SURGERY, Or Essays on ASTHMA, APHTHA, ASPHYXIA, APOPLEXY, ARSE- NIC, ATROPA, AIR, ABORTION, ANGINA-PECTORIS, and other Subjects Embraced in the Articles from A to Azote, prqmredfor the Cyclo- pedia of Practical Medicine by Dr. Chapman, Dr. Jackson, Dr. Horner, Dr. Hodge, Dr. Wood, Dr. Dewees, Dr. Hays, Dr. Dunglison, Dr. Mitchell, Dr. Bache, Dr. Coates, Dr. Condie, Dr. Emerson, Dr. Geddings, Dr. Griffith, Dr. Harris, Dr. Warren, Dr. Patterson, Each article is complete within itself, and embraces the practical experience of its tl^pmfcsln! 7 ^ °n'y l° ^ had m th]8 C°lleCli0n wiI1 ^ found of'great vaKle to VThe two volumes are now offered at a price so low, as to place them within the reach of every practitioner and student. ' wimm tne PUBLISHED BY LEA AND BLANCIIARD. 29 GIBSON'S SURGERY. A NEW EDITION OF GIBSON'S SURGERY. THE INSTITUTES AND PRACTICE OF SURGERY; being the Outlines of a Course of Lectures. By William Gibson, M. D., Professor of Surgery in the University of Pennsylvania, &c. &c. Fifth edition, greatly enlarged. In 2 vols. 8vo. With thirty plates, several of which are coloujijed. "The author has endeavoured to make this edition as cffniplete as possible, by adapting it to the present condition of surgery, and to supply the deficiencies of former editions by adding chapters and sections on subjects not hitherto treated of. And, moreover, the arrangement of the work has been altered by transposing parts of the eecond volume to the first, and by changing entirely the order of the subject in the second volume. This has been done for the purpose of making the surgical course in the university correspond with the anatomical lectures, so that the accouut of sur- gical diseases may follow immediately the anatomy of the parts." DEWEES'S WORKS. A PRACTICE OF PHYSIC, com- prising most of the diseases not treated of in Diseases of Females and Diseases of Children. By W. P. Dewees, M. D., formerly adjunct professor in, the University of Pennsylvania. In one volume, octavo. A COMPENDIOUS SYSTEM OF MIDWIFERY. By Dr. Dewees. Chiefly designed to facilitate the Inqui- ries of those who may be pursuing this branch of Study. Illustrated by occasional cases and with many plates. The ninth edition, with additions and improvements. In one vol. 8vo. DEWEES ON THE DISEASES OF FEMALES. The seventh edition, Revised and Corrected. With additions, and Nu- merous plates. In one vol. 8vo. DEWEES ON THE PHYSICAL AND MEDICAL TREAT- MENT OF CHILDREN. With Corrections and Improvements. The seventh ed. In one volume, 8vo. The objects of this work are, 1st, to teach those who have the charge of children, ei- ther as parent or guardian, the most ap- proved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render available a long experience to these objects of our af- fection when they become diseased. In at- tempting this, the author has avoided as much as possible, "technicality;" and has given, if he does not flatter himself too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being confounded together, with the best mode of treating them, that either his own experience or that of others has suggested. HORNER'S SPECIAL ANATOMY. A Treatise on Special and General Anatomy. By W. E. Horner, M. D., Profes- sor of Anatomy in the University of Pennsylvania, &c. Sic. Fifth edition, Revised, and muoh improved. In two volumes, 8vo. 30 MEDICAL AND 8UROICAL BOOKS, ELLIS' MEDICAL FORMULARY. The Medical Formulary, being a collec- tion of prescriptions derived from the writ- ings and practice of many of the most emi- nent Physicians in America and Europe. To which is added an appendix, containing the usual Dietetic preparations and Anti- dotes for Poisons, the whole accompanied with a few brief Pharniacuetic and Medi- cal observations. By |tenjamin Ellis, M. D., Fifth edition, with1'additions. In one vol. Broussais on Inflammation, 2 vols. Svo. Broussais' Pathology, 1 vol. Svo. Colles' Surgical Anatomy, 1 vol. Svo. Costers' Physiological Practice, 1 vol. Svo. Greys' Chemistry applied to the Arts, 2 vols, with numerous plates. ELEMENTS of PHYSICS, or NATURAL PHILOSOPHY, GE- NERAL and MEDICAL, explained independently of TECHNICAL MA- THEMATICS, and containing New Disquisitions and Practical Suggestions. By Neil Arnott, M. D. In two volumes, octavo. " Dr. Arnott's work has done for Physics as much as Locke's Essays did for the science of mind."—London University Magazine. " We may venture to predict that it will not be surpassed."—Times. " Dr. A. has not done less for Physica than Bluckstone did for the Law."—Morn- ing Herald. "Dr. A. has made Natural Philosophy as attractive as Buflbn made Natural His- tory."—French Critic. " A work of the highest class among the productions of mind."—Courier. ROGET'S PHYSIOLOGY AND PHRENOLOGY. OUTLINES OF PHYSIOLOGY; WITH AN APPENDIX ON PHRENOLOGY;* BY P. M. ROGET., M. D. Professor of Physiology in the Royal Institute of Great Britian, &c. &c. FIRST AMERICAN EDITION, Revised, with numerous notes, In one volume, 8vo. From the American Preface.—" Of the \ to him erroneous or doubtful, and to the fur- tne Author squalificationsasa physiological writer it is scarcely requisite to speak. The fact of his having been selected to com- pose the Bridge water Treatise on Animal and Vegetable Physiology, is sufficient evi- dence of the reputation which he then en- joyed; and the mode in which he executed nishing of references to works in which the physiological inquirer might meet with more ample information. " In Phrenology, the Author is a well- known unbeliever, and his published ob- jections to the doctrine have been regarded as too cogent to be permitted to pa°ss un- the task amply evinces that his reputation heeded. It will be seen on farthe^ exami- re ed on a solid basis. nation in the interva, of m "' The present volume contains a con-1 has elapsed since the publication of the 21?: 7l\ e" ePl!°me °f l?e present' sixth t,dilion (,f ^ Encyclopedia? I»b not copious details and deve.opments to be'n^et £'a^ttn^aui^WOTJv of with in the larger treatises on the subject; the positions of the Ph enolog t as he Ls but enough to serve as an accompaniment at any former period." g* ""Thfaien^oHh^ (KrThis work will be introduced into K.= u a.t.tent,°" of lie American Editor many of the Medical Colleges of the union f»™ of note, rf TI^P£, V£ifc | I^^KB"PI^J^1"'» <° «» cation of some of the points that appeared y-«""0y. PUBLISHED BY LEA AND BLANCHARD. 31 COATES POPULAR MEDICINE: POPULAR MEDICINE; OR, FAMILY ADVISER. Consisting of outlines of Anatomy, Physiology, and Hygiene, witn such Hints on the Practice of Physic, Surgery, and the'Diseases of Women and Children, as may prove useful in families when regular Physicians cannot be procured : Being a Companion and Guide for in- telligent Principals of Manufactories, Plantations, and Boarding Schools; Heads of Families, Masters of Vessels, Missionaries, or Travellers, and a useful Sketch for Young Men about commencing the Study of Me- dicine. BY REYNELL COATES, M. D. Fellow of the College of Physicians of Philadelphia—Honorary Member of the Philadelphia Medical Society—Correspondent of the Lyceum of Natural History of New York—Member of the Academy of Natural Sciences of Philadelphia—Former- ly Resident Surgeon of the Pennsylvania Hospital, &c. Assisted by several Medical friends. In One Volume. " It is with great satisfaction that we an- nounce this truly valuable compilation, as the most complete and interesting treatise on Popular Medicine ever presented to the public. Simple and unambitious in its language, free from the technicalities, and embracing the most important facts on Ana- tomy, Physiology and Hygiene, or the art of preserving health; and the treatment of those affections which require immediate attention, or are of an acute character, this should be in the hands of every one, more particularly of those who, by their situations are prevented from resorting to the advice of a physician, nor would the careful peru- sal of its pages fail to profit the inhabitants of our cities, by giving them a more accu- rate knowledge of the structure of the hu- man frame, and the laws that govern its various functions; whose perfect integrity is absolutely essential to health, and even to existence; the various systems of medical charlatanry, daily imagined to take advan- tage of the credulity and ignorance of man- kind, would be rendered far less prejudicial j to the community than they now are. We would particularly direct attention to the Chapter on Hygiene, a science in itself of the ut nost importance, and ably treated in the small space allowed to it in this vol- ume."—New York American. DR. CLARK ON CONSUMPTION. A Treatise on Pulmonary Consumption, comprehending an inquiry into the Nature, Causes, Prevention, and Treatment of Tu- berculous and Scrofulous Diseases in Ge- neral. By James Clark, M. D., F. R. S. As a text-book and guide to the inexpe- rienced practitioner we know none equal to it in general soundness and practical utility—to the general as well as to the professional reader, the work will prove of the deepest interest, and its perusal of un- equivocal advantage."—British and Fo- reign Medical Review. *' The work of Dr. Clark may be regard- ed as the most complete and instructive Treatise on Consumption in the English language."—Edinburgh Medical and Surgical Journal. CIIITTY'S JURISPRUDENCE. A Practical Treatise on Medical Juris- prudence, with so much of Anatomy, Phy- siology, Pathology, and the Practice of Medicine and Surgery, as are essential to be known by Members of the Bar and Pri- vate Gentlemen; and all the laws relating to Medical Practitioners; with explanatory plates. By J. Chitty, Esq. Second Ame- rican edition: with Notes and Additions, adapted to American works and Judicial Decisions. 8vo. A TREATISE ON THE PRACTICE OF MEDICINE, or a Systematic Digest of the Principles of General and Special Pathology and Theraputics. By E. Ged- dings, (now preparing.) 32 MEDICINE AND SURGICAL WORKS'. SMITH ON FEVER* A Treatise on Fever. By Southwood Smith, M. D., Physician to the London Fever Hospital. Fourth American edition. In 1 volume Svo. FITCH'S DENTAL SURGERY. A Treatise on Dental Siirgery. Second edition, revised, corrected, and improved, with new plates. By S. S. Pitch, M. D. 1 vol. '"-VO. ABERCROMBIE ON THE BRAIN. Pathological and Practical Researches on Diseases of the Brain and Spinal Cord. Second American, from the third Edingburgh edition, enlarged. By John Abercrombie, M. D. In 1 volume Svo. ABERCIiOMBIEON STOMACH. Pathological and Practical Researches on Di.-eases of the Stomach, the Intestinal Canal, the Liver, and other Viscera of the Abdomen. By John Abercrombie M. D., third American from the second London edition enlarged. In 1 vol. 8vo. EWELL'S MEDICAL COMPANION. » The Medical Companion or Family Phy- eician: treating of the Discuses of the United States, with their symptoms, causes, cure, and means of prevention. BERTIEN ON THE HEART. A Treatise on Diseases of the Heart and Great Vessels. By J. R. Bertien. Edited by G, Bouillaud. Translated from the French. Svo. BOISSEAU ON FEVER. Physiological Pyretology; or a Treatise on Fevers, according to the Principles of the New Medical Doctrine. By F. G. Boi6»eau, Doctor in Medicine of the Facul- ty of Puris, &.c. &c. From the fourth French edition. Translated by J. R. Knox, M. D. 1 vol. Svo. IIUTIN'S MANUAL. Manual of the Physiology of Man; or a conci.M- Description of the Phenomena of his Organization. By P. Hutin. Trans- lated hum the French, with notes, by J. 'ivjun. In l'-'mo. BELL ON THE TEETH. The Anatomy, Physiologv, and Diseases of the Teeth. By Thomas" Bell, F. R. S.» F. L. S. &c, third American edition. In 1 vol. Svo. With numerous plates. WILLIAMS ON THE LUNGS. A Rational Exposition of the Physical Signs of Diseases of the Lungs and Pleura; Illustrating their Pathology and facilitating their Diagnosis, By Charles J. Williams, M. D. In Svo. with plates. THE BRIDGE WATER TREA- TISES, COMPLETE IN SEVEN VOLUMES, OCTAVO. Embracing1. I. The Adaptation of External Nature to the Moral and Intellectual Constitution of Man. By the Rev. Thomas Chalmers. IK The Adaptation of External Nature to the Physical Condition of Man. By John Kidd, M. D., F. R. S. in. Astronomy and General Physics, Considered with References to Natural Theology. By the Rev. Wm. Whewell. IV. The Hand: Its Mechanism" and Vital Endowments as Evincing1 Design. By Sir Charles Bell, K. H., F. RT S. With numerous wood cuts. V. Chemistry, Meteorology, and the Function of Digestion. By Wm. Prout, M. D., F. R. S. VI. The History, Habits and Instincts of Animals. By the Rev. Wm. Kirby, M. A., F. R. S. Illustrated by numerous En- gravings on Copper. VII. Anatomy and Vegetable Physiology Considered with Reference to Natural Theology. By Peter Mark Roget, M. D. Illustrated with nearly Five Hundred Wood Cuts. VIII. Geology and Mineralogy, Con- sidered with Reference to Natural Theo- logy. By the Rev. Wm. Buckland, D. D. with numerous engravings on copper, and a large coloured map. V Tlie work of Buckland, Kirby and Rojct may be had separate. ADVERTISEMENT FOR A NEW SERIES OF THE AMERICAN JOURNAL OF MEDICAL SCIENCES, A New Series of this Journal will commence with the next Number, which will be published January 1st, 1841. These changes, it is believed, will be agreeable to the friends of the Work. The commencement of a New Series will afford an opportunity to many to subscribe to the Journal, who are anxious to do so, but are unwilling to possess an incomplete series, or to purchase so many back volumes. The extent also to which this work has now reached, 52 Nos., renders the cost of the whole greater than many young physicians are able to incur; and^further, some of the Numbers are nearly exhausted and in a short time com- plete copies cannot be furnished. The change in the months of publication is made in order to obviate the mis- conceptions and confusion that has frequently arisen from the year of the Journal having hitherto commenced with the November Number. No Number will con- sequently be issued before the 1st of January next, which will be the commence- ment of a new year. The Journal will continue under the same editorial management as heretofore, and no change will be made in its aim or principles, but such improvements will be introduced into the plan as the enlarged experience of the editor and his able colleagues may suggest. The great object proposed in the institution of this Journal was to establish a National Work, devoted exclusively to the improvement of Medical Science, and to the elevation of the character and dignity of the profession, to the entire rejection of all local and individual interests and party views. To accomplish this, a number of the most distinguished men in various parts of the Union associated, and have contributed to its pages the rich results of their experience. The object aimed at has been attained, and this Journal is regarded by the great mass of the American medical profession as their representative, and as such is received and quoted abroad. The first part of each Number consists of original memoirs and cases, in the selection of which those of a practical tendency have always the preference. The department of Monographs which has given so much satisfaction will be continued, and every effort made to increase its interest and usefulness by the selection of subjects of practical importance. Monographs on scarlet fever, laryn- gitis, bronchitis, and other important diseases are in preparation. The Reviews and Bibliographical Notices, present critical and analytical ac- counts of the principal works, domestic and foreign. In this department entire freedom of criticism is allowed, always however, marked by candour, and in that 1 o ADVERTISEMENT. courteous tone which alone comports with the true dignity of science. The ar- ticles are always authenticated by $he writer's signature, which, as it secures to him the credit of his labour, affords a stimulus to perform it well, and at the same time subjecting him to the responsibility of authorship, affords a security against hasty opinions. The editor also exercises the strictest watchfulness over these departments, to exclude all personalities and undue harshness of expression, and to prevent the influence of personal friendships or private enmities. The Summary contains a condensed digest of the discoveries and improve- ments in every branch of the healing art, and as the means at the disposal of the editor are unusually ample, this department is particularly useful and interest- ing. We are happy to announce that Dr. T. R. Beck, well known as the author of one of the best works on Medical Jurisprudence extant, will contribute to this department a summary of all the discoveries, and improvements in the important branch to which he has devoted so much attention. The period of publication will be Quarterly as hitherto, as this is believed to possess great advantages, in allowing of the insertion of elaborate and comprehen- sive memoirs entire, which can not be inserted in a weekly journal of small size, or if published, could only be so in detached pieces, which destroys their interest and impairs their value. It affords also time to compare the various accounts of dis- coveries, asd thus to select the best and most authentic. The very extensive corres- pondence of the editor, and the numerous journals he receives, with the arrange- ments that are made to have them forwarded by the speediest conveyances, enables him to give early intelligence of every novelty. Established on a broad and liberal foundation, and favoured by the support of many of the most distinguished men in every part of the Union, this Journal will continue to be devoted exclusively to upholding the dignity and advancing the great interests of the profession. Practitioners in every part of the Union, disposed to aid in the advancement of Medical Science, are invited to contribute the results of their experience. All articles inserted will be liberally paid for, and such persons as are disposed to aid in the circulation of the work, are requested to hand this prospectus among their medical friends. The subscription will he five dollars a year, payable always in advance; any person forwarding twenty dollars, can have five copies of the work forward.ed as they may direct. Each number will contain about 261 large and closely printed pages as heretofore, illustrated when necessary with cuts and engravings, and published quarterly, on the first of January, April, July and October. Subscribers who may be in arrears, are urged to forward the amount of their dues, that the new series may be continued to them, it being the intention of the publishers not to send to such persons as are tardy in their remittances. Such subscribers as wish to commence with the new series, will see the advantage of forwarding their names early, for but few will be printed over the number sub- scribed for. „,,,,, LEA & BLANCHARD. Philadelphia, August 1st, 1840. PROSPECTUS OF THE LIBRARY OF MEDICINE: CONDUCTED BY ALEXANDER TWEEDIE, M.D., F.R.S., PHYSICIAN TO THE LONDON FEVER HOSPITAL AND TO THE FOUNDLING HOSPITAL; EDITOR OF THE CYCLOPAEDIA OF PRACTICAL MEDICINE, &C, WITH THE ASSISTANCE OP NUMEROUS CONTRIBUTORS. Now publishing by Lea $r Blanchard, Philadelphia, and for sale by all Booksellers. The design of this work is to supply the want, generally admitted to exist in the medical literature of Great Britain, of a comprehensive System of Medicine, embodying a condensed, yet ample, view of the present state of the science. This desideratum is more especially felt by the Medical Student, and by many Members of the Profession, who, from their avocations and other circumstances, have not the opportunity of keeping pace with the more recent improvements in the most interesting and useful branch of human knowledge. To supply this deficiency, is the object of The Library of Medicine; and the Editor expresses the hope, that with the assistance with which he has been favored by Contributors, (many of great eminence, and all favorably known to the Public,) he will be enabled to produce a work, which, when completed, will form a Library of general Reference on Theoretical and Practical Medicine, as well as a Series of Text Books for the Medical Student. It is intended to treat of each Department, or Division of Medicine, each Series forming a complete Work on the subject treated of, which may be purchased separately at a very moderate price, or it will constitute a Part of The Library of Medicine. This arrange- ment is made with the view of giving those persons who may wish to possess one or more of the Series, the opportunity of purchasing such Volumes only, and thus avoid the inconvenience of making a larger addition to their stock of Books than their wants or circum- stances may require. Each Treatise will be authenticated by the Name of the Author; 1 4 PROSPECTUS. and from the care bestowed in the arrangements, it is confidently- hoped, that the want of uniformity noticed in works of a similar kind, will be obviated, at least, as far as is compatible with the execution of the work by a numerous body of united Authors. The First Series will comprehend Practical Medicine. The Second Practical Surgery. The Third will include Midwifery, the Diseases of Women, and the Diseases of Children, &c. t The other Departments of Medical Science will be treated of in successive Volumes. A work of this description is a greater desideratum in this country than even in Great Britain, from the great number of country prac- titioners here who have not access to libraries, and whose circuit of practice is so extensive as to afford little leisure for consulting elaborate treatises. To supply it the republication of the Library has been undertaken and the first volume is now presented to the American medical public. Should sufficient encouragement be afforded, the subsequent volumes will appear in quick succession. The American Publishers invite particular attention to the fact, that each volume is complete in itself, and will be sold separately: the acquisition of any one will not, therefore, necessitate the purchase of the others. The whole will, however, form a complete Medical Library. Should it be hereafter deemed expedient, such notes or additions as may seem to be required will be supplied for the subsequent vol- umes. The second volume, which has been received, is devoted to the Diseases of the Nervous System, and embraces the following sub- jects:— On the Pathology of the Nervous System, by Dr. Bennett. In- flammation of the Brain, by Dr. Hope. Hydrocephalus and Apo- plexy, by Dr. Bennett. Insanity, by Dr. Prichard. Delirium Tre- mens, Cephalalgia, Epilepsy, Catalepsy and allied affections, Spinal Meningitis, Inflammation of Spinal Cord, Hydrorachis, and Spinal Apoplexy, by Dr. Bennett. Chorea and Hysteria, by Dr. Theophilus Thompson. Tetanus and Hydrophobia, by Dr. Bennett. Neuralgia, by Dr. Theophilus Thompson. Paralysis and Barbiers, by Dr. Ben- nett. Inflammation of the Eye, and Amaurosis, by Dr. Taylor. In- flammation of the Ear, by Dr. Bennett. CONTENTS OF THE FIRST VOLUME OF THE LIBRARY OF PRACTICAL MEDICINE. SOLD SEPARATE. INTRODUCTION. (Dr. Symonds.) General Observations on the Nature of Disease.—Principles of Association of morbid Phenomena.—Symptoms and Signs.—Causes.—Investigation of the most simple Forms of Disease.—General Pathology.—Arrangement.—Diseases of the Capillary System.— I. Disordered Circulation.—Congestion.—Local Anemia.—Inflammation.—Hemorrhage. —II. Diseased Secretion—Fibrinous—Serous—Purulent—Heterologous Formations— Tuberculous—Carcinomatous—Melanotic—Gaseous.—HI. Diseased Nutrition.—Hyper- trophy.—Atrophy.—Softening.—Induration.—Transformation.—Ulceration.—Mortifica- tion.—Diseases of the Blood.—Plethora.—Anemia.—Cachemia.—Diseases of Nerves and contractile Fibres.—General Observations.—Hyperesthesia.—Anaesthesia.—Dyses- thesia.—Spasm,—Paralysis.—Neurotic Diathesis. INFLAMMATION. (Dr. Alison.) General View of the Phenomena of Inflammation.—Present State of our Knowledge of its essential Nature.—Causes.—Anatomical Characters.—General View of the Symptoms.— Varieties and Complications.—Modes of fatal Termination.—Outline of the Treatment of Inflammation, particularly in internal Parts. FEVERS. General Doctrines of Fever. (Dr. Christison.) Definition.—Forms of Fevers.—Local Diseases in Fever.—Theories respecting the Nature of continued Fever.—Exanthematous or eruptive Fevers.—Classifications of Fevers. CONTINUED FEVER. (Dr. Christison.) Symptoms of continued Fever.—Secondary Affections.—Affections of the Head—of the Throat—of the Chest—of the Abdomen—of the Skin.—Sequela?.—Relapse.—Partial Rheumatism and Neuralgia.—Partial Palsy.—CEdema.—Acute febrile Inflammations.— Supervention of Phthisis Pulmonalis.—Mania—Prevalence, Duration, and Mortality.— Anatomical Characters.—Causes.—Prognosis.—Treatment.—Prophylaxis. PLAGUE. (Dr. Shapter.) Characteristic Symptoms.—Varieties—Simple or Glandular—Eruptive—Malignant—Se- quelae and Complications.—Anatomical Characters.—Diagnosis.—Prognosis.—Statistics. —Nature.—Causes.—Prophylactic Measures.—Treatment. INTERMITTENT FEVER. (Dr. Shapter.) Characteristics of Intermittent Fever.—Premonitory or forming Stage.—Symptoms of the Paroxysm.—The cold Stage.—The hot Stage.—The sweating Stage.—Apyrexial Period. —Anomalous Symptoms occasionally observed in the different Stages and in the Inter- vals.—Circumstances which determine the Type or Form of Intermittents.—Description of the Quotidian Intermittent—of the Tertian—of the Quartan.—Deviations from the ordinary Course of the Paroxysm.—Modifications of Type—Inflammatory—Congestive— Malignant.—Complication of Intermittents with local Affections.—Gastric Complication. —Cerebral Complication.—Pulmonary Complication.—Cardiac Complication.—Syncopal or Fainting Ague.—Splenic Complication.—Diagnosis.—Prognosis.—Terminations.— Anatomical Characters.—Numerical Statement of the Frequency of Lesions.—Statistics. —Nature. —Exciting Causes. —Treatment. G CONTENTS OF LIBRARY OF PRACTICAL MEDICINE. REMITTENT FEVER. (Dr. Shapter.) Nomenclature—Svmptoms which characterise the simple Form.—Varieties—Bilio-Inflam- matory—Inflammatory—Malignant.—Complications.—Terminations.—Anatomical Cha- racters.—Diagnosis.—Duration.—Prognosis.—Nature.—Treatment. YELLOW FEVER. (Dr. Shapter.) Nomenclature.—Premonitory Symptoms.—Symptoms of the first Stage—of the second—of the third.—Inflammatory Form.—Adynamic Form.—Malignant or Congestive Form.— Terminations.—Anatomical Characters.—Statistics.—Prognosis.—Diagnosis.—Nature.— Causes. —Treatment. INFANTILE GASTRIC REMITTENT FEVER. (Dr. Locock.) Division into the Acute and the Chronic Forms.—Symptoms of Complications of the acute Form.—Causes.—Diagnosis.—Treatment.—Symptoms of the Chronic Form.—Complica- tions.—Treatment HECTIC FEVER. (Dr. Christison.) Definition.—Symptoms.—Diagnosis.—Causes.—Treatment. SMALL POX. (Dr. Gregory.) Description and Varieties.—Variola benigna discreta.—Variola confluens.—Secondary Fever and its Consequences.—Cutaneous Inflammation.—Variolous Ophthalmia.—Cere- bral Complication.—Thoracic Complication.—Abdominal Complication.—Other acci- dental Complications.—Variola semiconfluens,—Variola corymbosa.—Variola maligna.— Variole anomale.—Variola confluens mitigata.—Variola varicelloides.—Febris variolosa sine Eruptione.—Diagnosis of Small-pox.—Prognosis.—Mortality.—Anatomical Charac- ters.—Causes.—Susceptibility of Small-pox.—Recurrent Small-pox.—Treatment.—Vac cination—History and Progress of.—Phenomena of Vaccination.—Circumstances which. influenced the Protecting Power of Cow-pox. MEASLES. (Dr. George Burrows.) Definition.—History.—Varieties.—Rubeola Vulgaris.—Rubeola sine Catarrho.—Rubeola Maligna.—Sequele.—Anatomical Characters.—Diagnosis.—Prognosis.—Causes.—Treat- ment. SCARLATINA or SCARLET FEVER. (Dr. George Burrows.) Characteristic Smptoms.—Varieties.—Scarlatina simplex.—Scarlatina anginosa.__Scarla- tina maligna.—Scarlatina sine Exanthemate.—Seqnele.—Anatomical Characters.__Causes. —Diagnosis, Prognosis and Mortality.—Treatment.—Prophylaxis. PUERPERAL FEVERS. (Dr. Locock.) General Observations on Puerperal Fevers.—Acute Puerperal Peritonitis.—Symptoms Morbid Appearances and Treatment.—Adynamic or malignant Puerperal Fever.__Symp- toms.—Morbid Appearances.—Treatment.—Puerperal Intestinal Irritation and its Treat- ment—False Peritonitis and its Treatment.—Nature of Puerperal Fever.—Predisposing Causes.—Milk Fever and its Management ° DISEASES OF THE SKIN. (Dr. H. E. Schedel.) Definitions.—Classification.—Erythema.—Erysipelas.—Roseola.—Urticaria—Eczema- Herpes.—Scabies.—Miliaria.—Varicella.—Pemphigus.—Rupia.—Ecthyma.—Imneti-o —Acne.—Mentagra.—Porrigo.—Equinia.—Lichen.—Prurigo.—Psoriasis.—Pityriasis*5— F.cthyosis.—Lepra Tuberculosa.—Lupus.—Molluscum.—Frambesia.—Cheloidea —Len Ugo.—EphelKles.—Nasvi and Vitiligo.— Purpura.— Pellagra.—Radesyge.—Lepra Astral chamca.—Malum Alepporum.—Elephantiasis Arabica.—Syphilitic Eruptions or Syphi- I J I a Jfl JO ABV II I 1 A \ = x-w \ :iNE NATIONAL LIBRARY OF MEDICINE N A T I O N A I 11 B R A R Y OF M E D I C I N E N A T I O N A I I I B R A R Y 0 ! V N 1NI3I09W JO l««llll IVNOIIVN 1 N I 3 I 0 3 W JO ABVBBI1 IVNOIIVN 1NI3I01W JO A « V a 11 iivn iNDiojw jo Aavaan ivnoiivn in i 3 \o iw jo abv aa n 1 vnoiiv n in i 3 iaiw jo Aavin "T US \ NATIONAL LIBRARY OF MEDICINE NLM D3EDbflSD 5 NLM032068505