& ■■>*■*%:&*<:■■**£& f ft * SURGEON GENERAL'S OFFICE & % flj Section, - ________ JP & PATHOLOGICAL . 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 PHYSICIAN TO HIS MAJESTY IN SCOTLAND. PHILADELPHIA: CAREY AND LE A--C HESTNUT STRE 1830. E. & G. Merriam, Printers, Brookfield, Mass. A/'M-p /^'/^ S-ct^O^ JC*«»»> y PREFACE. Nothing appears to have had greater influence in retarding the progress of knowledge, than mis- conception in regard to the proper objects of sci- entific inquiry. It was in this manner that so much talent was wasted and lost in former times, when learned and able men devoted their atten- tion to searching after the hidden causes of events ; and the great purpose of the illustrious fathers of modern science was accomplished, by bringing back the attention of inquirers to objects which are within the reach of the human faculties. We often talk of the philosophy of Bacon, without fully recognising the important truth, that the philosophy of Bacon and of Newton consists en- tirely, to use the words of an eminent writer, in " ascertaining the universality of a fact.,J This cannot be better illustrated than by a re- ference to that department of science, in which IV PREFACE. the philosophy of modern times is so distinguish- ed above the conjectures 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 car- ried on independently of any attempt to dis- cover it. " When Newton (says Mr. Stewart) shewed 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 to- wards this distinction will be made, when medical inquirers agree to restrict their in- vestigations to ascertaining the universalitv of a fact. By adhering to this rule, we shall avoid two errors, which will probably be ad- mitted to have been frequent in medical rea- sonings, and to have had no inconsiderable influence in retarding the progress of medical science. The one is the construction of hypo- thetical theories," or the assumption of principles which are altogether gratuitous and imaginary ; the other is the deduction of general principles or PREFACE. V conclusions from a limited number of facts. Doc- trines 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 remarkable with which general state- ments of this last description are often brought forward, and the facility with which they are re- ceived, without due examination, as established principles. We even find some writers expressing such confidence in these deductions, 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 overlook- ed or forgotten. Such a phraseology, indeed, must probably be considered 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, because we know the precise extent to which the rules apply, and the exact number of instances which form the excep- tion ; but, in physical science, to speak of excep- tions to a general rule cannot be regarded in any other light, than as an admission that the rule is not general, and consequently is unworthy of con- fidence. 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 ob- • m ject of physical science is " to ascertain the uni- VI PREFACE. versality 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 researches has been, to furnish facts in a concise and accessible form, and to advance to conclusions by the first step of the most cautious induction. If, in following out this course of investigation, he has sometimes had oc- casion 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 received 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 calculated to ascertain, whether they are facts, and whether the facts are universal. • He is deeply sensible of the favourable manner in which the profession have received his Re- searches on the Pathology of the Brain. The vo- lume 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 tiiey are founded ; and, with regard PREFACE. Vii 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 observations on the same subjects. This volume is divided into five parts, in refer- ence 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. CONTENTS. V ■'"*?' Page VIEW OF THE STRUCTURES CONCERNED IN THIS IN- QUIRY, AND THE PRINCIPAL MORBID CONDITION TO WHICH THEY ARE LIABLE . . .25 I. Peritoneum . . . . .25 II. Muscular Coat • . . .27 III. Mucous Membrane . . .29 PATHOLOGY OF THE STOMACH 33 SECTION I. INFLAMMATORY AFFECTIONS OF THE STOMACH AND ULCERATION ...... 35 General Observations on Acute Gastritis . . 35 -----------------on Chronic Gastritis . 88 2 \ X CONTENTS. Page Progress and Terminations of Chronic Gastritis . 40 § 1. Succession of small Ulcers of the Mucous Mem- brane of the Stomach,—fatal by gradual ex- haustion . . • .44 §*2. Circumscribed Ulceration with Thickening,— fatal by gradual exhaustion . .46 § 3. Extensive Ulceration with Thickening, com- " l plicated with remarkable disease of the Omentum and Peritoneum,—fatal by grad- ual exhaustion . . • 50 § 4. Ulcer of the Stomach,—fatal by Haemor- rhage . . • • 54 § 5. Simple Ulceration of very small extent,— suddenly fatal by Perforation of the Stom- ach .... 57 § 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 Peritoneal covering of the Stomach,—suddenly fatal by that giv- ing way at the part . . 61 § 7. Perforating Ulcer of the Stomach, and com- munication with the Arch of the Colon 63 § 8. Extensive Ulceration of the Stomach of a Cancerous character . . 65 DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE STOMACH REFERRED TO UNDER THE PRECEDING HEADS . . . 67 Of Some modifications of Inflammatory Affections of the Mucous Membrane of the Stomach 72 Diphtherite ... 74 Of the Softening of the coats of the Stomach 77 CONTENTS. XI SECTION II. Page OF ORGANIC DISEASES OF THE STOMACH 80 § 1. Induration and thickening of the Coats of * the Stomach . -';. . . * 80 §2. Diseases of the Pylorus . . . 82 § 3. Diseases of the Cardia . . . 87 SECTION III. i PATHOLOGY OP DYSPEPSIA . . .88 Various Sources of Deranged Digestion 90 Outline of the treatment of Dyspepsia . 92 Observations on some of the more troublesome Symptoms connected with Derange- ments of the Stomach 96 I. Gastrodynia ... 97 II. Chronic Vomiting . . 99 III. Obstinate Pyrosis . . 100 IV. Haematemesis . . . 101 V. Sympathetic Affections of the heart 102 APPENDIX TO THE PATHOLOGY OF THE STOMACH . . Ill SECTION I. DERANGEMENT OF THE FUNCTIONS OF THE STO- MACH BY TUMORS ATTACHED TO IT EXTERNAL- LY, WITHOUT DISEASE OF ITS COATS . Hi xii CONTENTS. SECTION II. DISEASES OF THE ffiSOPHAGUS 1. Inflammation of the CEsophagus 2. Pathology of Dysphagia SECTION III. DISEASES OF THE DUODENUM • PATHOLOGY OF THE INTESTINAL CANAL 123 PART L OF ILEUS . 126 SECTION* I. OF SIMPLE ILEUS . • . • • 127 § 1. Ileus Fatal in the state of Distention without Inflammation . . . . 127 § 2. Ileus Fatal with Distention and a dark livid colour of the parts without Disorganization 129 § 3. Ileus fatal by Gangrene without Exudation 130 § 4. Ileus Fatal by Gangrene combined with Exu- dation . . .131 Page 113 113 114 119 • CONTENTS. xiii SECTION II. Page ILEUS FATAL WITH PREVIOUS DISEASE OF SUCH A NATURE THAT IT SEEMED TO ACT BY DERANG- ING THE MUSCULAR POWER OF THE CANAL, WITH- . OUT MECHANICAL OBSTRUCTION . . .133 § 1. Old Adhesion of the Intestine of small extent 133 § 2. Old Adhesion of the parts concerned in a Her- nia » .9 . . 135 § 3. A Slender band of adhesion betwixt two con- tiguous turns of Intestine . 1S6 § 4. Singular Twisting of the Sigmoid Flexure on itself . . . .137 § 5. Ligamentous band confining a portion of In- testine to the mouth of a Hernial Sac 139 SECTION III. ILEUS WITH MECHANICAL OBSTRUCTION, OR OTHER ORGANIC CHANGES IN THE STRUCTURE OF THE PARTS . . . . . • 140 § 1. Old Disease of the Intestine connected with Hernia and Artificial Anus . . 140 $2. Internal Hernia . . . 142 § 3. Intus-susceptio . . . 144 § 4. Fatal Ileus from a Gall Stone . 147 § 5. Contraction of the Calibre of the Intestine 148 \ 6. Remarkable Stricture of the Arch of the Colon . - 150 xiv CONTENTS. Pagie APPENDIX TO THE PATHOLOGY OF THE ILEUS . . . 152 $ 1. General Tympanites . . . 152 § 2. Effects of Galvanism on Distended Intestine 153 SECTION IV. PATHOLOGICAL AND PRACTICAL -INDUCTIONS FROM THE PRECEDING FACTS m . . . 154 SECTION V. TREATMENT OF ILEUS . . . . 164 PART II. OF THE INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CANAL, INCLUDING PERI- TONITIS AND ENTERITIS . . 170 SECTION I. SYMPTOMS OF INTESTINAL INFLAMMATION UNDER THESE FORMS ... . . . 173 I. Simple Peritonitis . . . 173 II. Enteritis.....177 CONTENTS. XV SECTION II. Page. EXAMPLES OF PERITONITIS AND ENTERITIS . 178 § 1. Simple Peritonitis . . . 178 § 2. Peritonitis confined nearly to the descending Colon and Rectum . . . 182 § 3. Local Peritonitis of very small extent 184 § 4. Peritonitis terminating by extensive Suppura- tion . . . . 184 § 5. Peritonitis passing into Enteritis . 188 § 6. Enteritis . . . . . 190 Practical Conclusions from the preceding facts 193 SECTION III. OUTLINE OF THE TREATMENT OF INTESTINAL IN- FLAMMATION . . . . 194 SECTION IV. ERYSIPELATOUS PERITONITIS . . . 203 SECTION V. CHRONIC PERITONITIS . . . . .213 § 1. Chronic Peritonitis in its more distinct form 216 XVI CONTENTS. Page § 2. Chronic Peritonitis in its more obscure form 219 § 3. Chronic Peritonitis supervening upon Measles 223 § 4. Chronic Peritonitis of the Colon supervening on an Injury ..... 224 § 5. Chronic Peritonitis complicated with disease of the Omentum ... . 225 § 6. Chronic Peritonitis with extensive Suppura- tion making its way outwards by the Ex- ternal Oblique .... 227 PART III. OF THE INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL . 229 Preliminary Observations on the Principal Morbid Appearances of the Mucous Membrane, and their influence on the Functions of the Bowels.....231 SECTION I. ACTIVE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL . . . . 241 Symptoms, &c. . . . 241 Terminations . . . .248 1. Fatal in the Inflammatory Stage } 2. Gangrene .... f 3. Ulceration ... f ^4B 4. By passing into Peritonitis or Enteritis 3 CONTENTS. XV11 Page § 1. Inflammation of the Mucous Membrane con- fined to the Rectum and part of the Ascen- ding Colon ..... 249 § 2. The Disease extending along the whole course of the Colon and Rectum,—Fatal in the Inflammatory Stage . . . 250 § 3. The Disease occupying the whole Colon and Rectum,—Fatal by Gangrene . .252 § 4. The Disease occupying the whole Colon and Rectum, and part of the Ileum . 254 § 5. The Disease in the Colon,—Fatal by Exten- sive Ulceration with Peritonitis . 257 § 6. The Disease confined to the Caput Coli, and part of the Ascending Colon,—the Patient dying of an Affection of the Brain 259 § 7. Fungous Ulceration of the Caput Coli, and recent Inflammation of the Ileum, with a Coating of false Membrane . . 260 § 8. The disease in the Ileum, with Deposition of False Membrane . . . . 261 § 9. The Disease in the Ileum,—Fatal in the state of Red Elevated Portions, with Incipient Ulceration......262 §10. The Disease in the Ileum,—Fatal by Gan- grene ... . . 263 § 11. The disease in the Ileum, with Ulceration,— Fatal by a perforating Ulcer and Peritoni- tis . • • 265 §12. The Disease occurring in Continued Fever, with Ulceration . • • 266 Pathological and Practical Conclusions from the Preceding Observations . 268 xvni CONTENTS. SECTION II. Page OF THE CHRONIC DISEASES OF THE MUCOUS MEM- BRANE . • • .273 General View of the Morbid Appearances in the Chronic Cases . . 27 3 General View of the Symptoms . 275 § 1. The Disease Fatal, with elevated Red Patch- es, without Ulceration . • 276 § 2. Numerous small detached Ulcers, the inter- vening Membrane healthy . 277 § 3. Extensive Continued Ulceration of the Mu- cous Membrane of the Colon . 279 § 4. Extensive Continued Ulceration in the small Intestines . . . 282 § 5. Ulceration of the Mucous Membrane, with Thickening and Induration of the Coats of the Intestine . . . . 284 SECTION III. ULCERS OF THE MUCOUS MEMBRANE WITHOUT PROM- INENT SYMPTOMS . . . . . .289 § 1. An Ulcer of this class Fatal by Haemorrhage without previous Symptoms in the Bowels 291 § 8. An Ulcer of this Class suddenly Fatal with Peritonitis . . . 292 § 3. Ulcers of this Class, without any previous ill- ness, suddenly Fatal by Perforation of the Intestine . . . . . 294 § 4. Ulcers of this Class found connected with Ob- scure Symptoms of long standing . 295 CONTENTS. XIX SECTION IV. OF THE TREATMENT OF THE AFFECTIONS OF THE MUCOUS MEMBRANE . . # £97 § 1. Treatment of the Acute Affections . 297 § 2--------of the Chronic Affections . 306 SECTION V. OF THE INFLAMMATION OF THE MUCOUS MEMBRANE IN INFANTS ..... 309 SECTION VI. CASES SHEWING THE STATE OF THE MUCOUS MEM- BRANE AFTER THE CESSATION OF THE SYMPTOMS. --THE PATIENTS DYING OF OTHER DISEASES 315 Concluding Observations on the Pathology of the Mucous Membrane, with Reference to the Investigations of Continental Writers on this Subject .' . . 321 APPENDIX TO THE PATHOLOGY OF THE INTESTINAL CANAL. SECTION I. DISEASES OF THE MESENTERIC GLANDS 325 XX CONTENTS. SECTION II. TYMPANITES . SECTION III. ARTERIAL HEMORRHAGE FROM THE RECTUM SECTION IV. OF A VERY OBSCURE AFFECTION, IN WHICH SYMPTOMS ARE CHIEFLY REFERABLE TO BOWELS • • • SECTION V. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI . . . • 336 SECTION VI. EXTENSIVE DISEASE OF THE RECTUM AND PROSTATE GLAND.--STRICTURE OF THE ARCH OF THE CO- LON, &C. . . . . . 3 38 Page 328 THE THE 334 CONTENTS. XXI PATHOLOGY OF THE LIVER 240 SECTION I. Page. OF THE MORBID CONDITIONS OF THE LIVER CON- NECTED WITH ACUTE DISEASE . . 343 § 1. Inflammation of the Liver . .343 § 2. The Mass of the Liver more or less Enlarged, especially on the right side ; externally of a very dark colour, or nearly black ; its substance, when cut into, also very dark coloured, and giving out much very dark blood. In other cases the black colour is only on the surface, the internal structure being tolerably healthy . . 345 § 3. Abscess of the Liver . . . 348 § 4. Simple Ramollissement of the Liver 355 § 5. The Black Ramollissement of the Liver 356 § 6. The White or Encephaloid Ramollissement of the Liver . . . 358 § 7. Copious Deposition of Gelatinous Matter of a soft consistence and a reddish colour 359 § 8. Remarkable Distention of the Biliary Vessels 360 SECTION II. OF THE CHRONIC AFFECTIONS OF THE LIVER . 360 § 1. Chronic Inflammation of the Liver . 361 § 2. Simple Enlargement, without Change of Tex- ture .....362 Xxii CONTENTS. Page. § 3. Tubera in the Liver, without other Disease in its Structure .... 364 § 4. The Pale Degeneration, consisting of change of Colour, without remarkable Alteration of Texture .... 365 § 5. Pale Colour, with Induration . . 366 A. Pale Indurated Liver, of the natural size .... 367 B.---------------------with Enlarge- ment .... 368 C.---------------------with Remarka- ble Diminution of Size . 370 § 6. Dark Induration of the Liver . . 371 § 7. Tuberculated Disease on the Surface of the Liver, without Disease of its Structure 372 § 8. Tubercles, or Tubera of various characters diffused through the Substance of the Liv- er, with Disease of the intervening Struc- ture . . . . 374 § 9. Hydatids . . . .377 §10. Large Cysts, containing a Watery Fluid, contained under the Peritoneal Coat of the Liver . . . . 377 Outline of the Treatment of Diseases of the Liver .... 379 APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. H-EMORKHAGE FROM THE LIVER . . . 383 contents. xxiii SECTION II, Page RUPTURE OF THE LIVER BY EXTERNAL VIOLENCE " 383 SECTION III. DISKASES OF THE GALL BLADDER. 1. Biliary Calculi.....384 2. Perforation or Rupture of the Gall Bladder, or one of its Ducts, and Escape of the Bile into the Peritoneal Cavity . . .385 SECTION IV. CHANGES IN THE QUALITY AND QUANTITY OF THE BILE .... . . 387 SECTION V. PATHOLOGY OF JAUNDICE . . . . 389 PATHOLOGY OF THE SPLEEN. § 1. Inflammation . . • 398 § 2. Suppuration of the Spleen . . 399 §3. Ramollissement or Black Degeneration of the Spleen . . ... 402 § 4. Simple Enlargement of the Spleen . 405 § 5. Tubercles . . . .408 § 6. Pale Induration of the Spleen . 408 § 7. Hydatids . . . .408 § 8. Haemorrhage from the Spleen, and Lacera- tion by External Violence . 409 Xxiv CONTENTS. PATHOLOGY OF THE PANCREAS. Page 1. Inflammation and its consequences . 411 2. Enlargement with a mixed state of Disease, partly consisting of Induration, and partly of a softened state, resembling the Medul- lary Sarcoma . . . .412 3. Scirrhous Induration, with little enlargement 414 4, Calculous Concretions . . .416 PATHOLOGY OF THE STOMACH AND INTESTINAL CANAL. VIEW OF THE STRUCTURES CONCERNED IN THIS INQUJ- RY, 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 gen- eral view of the various 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. 1. The Peritoneum is a serous membrane, which is constantly 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 chan- ges of structure, some of which are evidently the re- sult of inflammation, while others seem to have a dif- ferent 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 j 4 26 STRUCTURES OF THE STOMACH 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 in- creased quantity of fluid being afterwards absorbed, and the parts thus recovering their healthy relations. But, in different states of the disease, we find remarkable va- rieties in the characters of the fluid which is deposited : in one case, it is simply opaque and milky,—in another, it contains shreds of flocculent matter,—in a third, it has all the sensible properties of pus. All these vari- eties of the effused fluid are sometimes found without any remarkable change in the membrane itself; but, in general, it has undergone some considerable deviation from the healthy structure. These deviations are chiefly two. The first is a slightly softened and thickened state of the membrane, giving it somewhat the appear- ance of a part which has been boiled. This, I think is commonly connected with the opaque milky deposition. The second and the more common appearance consists in the surface being covered by a coating of false mem- brane. This may be connected with the milky floccu- lent fluid, or with fluid which has all the sensible qual- ities of pus, or with a fluid which is entirely limpid. In the latter case, the deposition on the surface 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 remarkably 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 reg- ulate these varieties in the deposition from inflamed serous membranes. Under the influence of inflamma- tion, also, whether acute or chronic, serous membranes are liable to form adhesions betwixt their opposite sur- fc- AND INTESTINAL CANAL. 27 faces, 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 of- ten 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 remarkable degree ; and it appears to be the result of inflammation which has gone on in a chronic form. 2. Tubercular disease,—the whole surface of the membrane being found studded with innumerable tuber- cles generally of a very small size, and of a firm con- sistence. They appear to be covered by .cysts, and pre- sent the same characters with tubercles in other parts of the body. 3. There is another affection, often met with in the peritoneum, which appears to be in its nature quite dis- tinct from tubercular disease. It consists in the surface of the membrane being covered by nodules of various shapes and sizes,—of a semi-pellucid character and smooth rounded surface. The masses of 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 opportunity of examining, it ap- peared to be of an entirely different nature. The nodules were of a uniform firm gelatinous consistence, or some- times more dense at the centre than at the circumfer- ence. They did not appear to be covered by any cyst, and they were entirely soluble in boiling water. II. The second structure is the Muscular Coat. It completely invests the whole extent of the canal ; and 28 STRUCTURES OF THE STOMACH 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 derange- ment 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 ir- ritation 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 sim- ilar 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 thi* case the same effect that the irritating causes do in the other. 2. A morbidly increased but partial and irregular ac- tion. This appears to arise chiefly from morbid irrita- bility of small portions of the internal surface ; the or- dinary stimuli producing, at these parts, a morbidly in- creased action, with which the other parts do not har- monize. 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 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 mus- cular covering investing a cavity, this appears to arise from two causes; namely, over distention and inflam- mation. The former we see distinctly take place in the bladder, and there is reason to believe that some- thing similar occurs in the bowels in certain states of AND INTESTINAL CANAL. 29 Ileus. Inflammation seems also to destroy the action of muscular fibre. Thus, intestine which has been high- ly inflamed is generally found in a state of great disten- tion, showing the complete loss of its healthy muscular action j and, if the disease has gone on until the intes- tine has either become ruptured, or has given way by ul- ceration, it is found to have fallen together like an empty bag, without any appearance of muscular 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 considerable obscurity ; but, one point may be consid- ered as known and established, which is of considerable importance for our future 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 inflammation has existed in the muscular coat; for we shall afterwards 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 structure and functions of this mem- brane, we have to keep in view the following circum- stances. 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 30 STRUCTURES OF THE STOMACH to be formed in large quantity ; according to Haller, to the extent of eight pounds in twenty-four hours. When an animal has fasted for a considerable 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 mu- cous surface, there is a distinct formation, from numer- ous follicles or simple glands, of a liquid which has been called the follicular fluid. These follicles exist in great numbers along the whole course of the intes- tinal membrane, though they are more numerous at some parts than at others. The peculiar properties of the follicular fluid have not been ascertained ; but, it is considered as certain, that it is distinct from the gene- ral mucous secretion,—because, in observations upon living animals, the latter may be seen to be produced from portions of the membrane, where no follicles ap- pear 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 absor- bents 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 mu- cous membranes 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 rath- AND INTESTINAL CANAL. 21 er various degrees, but we are ignorant of the causes which regulate these varieties. The effect of the first or lowest degree of inflammation on a mucous mem- brane, appears to be simply an increase of its proper se- cretion, 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 inflammation, we find the formation of aphthous crusts, and in a third the deposition of false membrane. This last we see most remarkably in the bronchial mem- brane ; it is also met with, though more rarely, in the mucous membrane of the intestine. In a more advanc- ed stage, inflammation of the mucous intestinal mem- brane terminates by ramollissement, or an ash-coloured pulpy degeneration of portions of the membrane ; these fall out and leave spaces, which are apt to pass into ulceration. A considerable extent of the membrane is also occasionally found in a state of uniform dark soften- ing, resembling gangrene. Adhesion of the opposite surfaces of the mucous membrane of the intestine is some- times met with, producing complete obliteration of the canal ; bilt 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 mem- branes exists in a.«nore chronic form, in which it goes on for a long period, and is chiefly distinguished by in- creased and morbid secretion from' the parts. In its progress in these cases, the membrane is apt to become thickened and even indurated, so as considerably to di- minish 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 sur- face in those cases is frequently found covered with fungous elevations ; and these frequently 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 32 STRUCTURES OF THE STOMACH membrane itself, or in the subjacent cellular texture. It is a point which it must be next to impossible to de- cide, and of no practical importance. 2. Diseases of the follicles, or simple glands of the membrane. This subject is involved in much obscuri- ty, but seems to promise some interesting results. The follicles appear to be liable to a vesicular or pustular disease, which passes into small defined distinct ulcers, quite unconnected with any disease of the mucous sur- face. 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 com- monly 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 cir- culation. The cause of this, most familiar to us, is dis- ease of the glands of the mesentery ; but the same eft- feet appears to result from certain conditions of the sur- face 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 j and the extent of it will farther appear, when we recol- lect, 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 extensive, it is but a very imperfect view that can be given in such an essay as the present; but I am anx- ious that what is given, may be correct and authentic, as far as it goes, and that it may be of some use in di- recting the researches of those who have opportunities of prosecuting the investigation. PATHOLOGY OF THE STOMACH. There are few points in medical science which have undergone more discussion than affections of the stom- ach : and yet, it must be confessed, that when we come to investigate the subject, according to the rules of pathological induction, we find little that is satisfactory. This has in part aiisen from numerous difficulties which attend the investigation. Many of the affections of the stomach, though productive of much and protracted discomfort, are not apt to be fatal; and thus few oppor- tunities 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 func- tional 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 ; 5 34 PATHOLOGY OF THE STOMACH. for the diseases are so much under the influence of moral and other adventitious causes, that the action of remedies is aided, modified, or counteracted, in a manner which entirely eludes our observation, and is often alto- gether 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 principles; and the whole subject is re- moved in some measure out of the usual limits of pathological inquiry. Amid this uncertainty we must endeavour to discover what is the pathological 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 ascertaining its extent, and tra- cing the course by which it may be enlarged. I shall consider affections of the stomach under three classes : I. Affections of an inflammatory kind, including ulcer- ation and its consequences. II. Affections which more properly come under the class of organic. III. Functional affections,—embracing a slight out- line of the subject of dyspepsia. In an appendix, I shall briefly allude to the affections of the oesophagus—and the duodenum—and to derange- ment of the functions of the stomach by tumours attach- ed to it externally. INFLAMMATORY AFFECTIONS, &C 35 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 diffi- cult 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 con- nected with it have been inflamed in the highest degree. In cases of very extensive peritonitis, the peritoneal coat of the stomach is sometimes affected ; but even this is rare, and a case of pure inflammation of the peritoneal coat of the stomach 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 inflam- matory deposition on the peritoneal coat of the stom- ach ; 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 idiopathic gastritis or whether the appearance occurred in connection with extensive peri- tonitis. The disease which we call gastritis is to be consider- ed, therefore, 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 mucous coat of the stomach, but we cannot consid- er these cases as necessarily exhibiting the same symp- 86 IMFLAMMATORY AFFECTIONS toms which would accompany the disease in its idio- pathic form. The symptoms which are usually describ- ed as those of gastritis are pain and tenderness in the region of the stomach, with urgent vomiting and fe- ver ; 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 sto- mach and fever, and died delirious in fifteen days,—no oth- er symptoms being mentioned. The stomach was found to contain a fetid ichorous matter ; and the fundus of it was inflamed with gangrenous spots and ulcerations. In an- other case, by the same writer, which was complicated 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 fulness in the sto- mach, with frequent vomiting of a brown matter, in which were floating shreds of the membranous appear- ance ; and these symptoms were followed by hiccup, de- lirium 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 vio- lent pain in the stomach, with urgent vomiting, disten- tion 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 de- scribed by Broussais appear to be equally unsatisfac- tory, OF THE STOMACH. 37 On the other hand, we find De Haen, Stohl and Frank describing 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 ad- mits, that symptoms, closely resembling those ascribed to gastritis, 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 ascertained by Dr. Yelloly and others. In numerous cases of persons who died of other diseases, without any symptoms in the stomach, and in the bodies of criminals who had been executed, they have pointed out appearances which might have been considered as distinctly indicating inflammation of the mucous membrane of the stomach. The older writers appear to have been very indefinite in regard to the use of the term inflammation ; and it will now probably be admitted, that it ought not to be applied to any appearances consisting of mere change of colour or increased vascularity, without some decided change in the structure of the part, or some of*the ac- tual 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 consider as being of this nature ; and I am disposed to regard as points not yet ascertained, what are the characters exhibited by the mucous mem- brane of the stomach in the earlier periods of acute gas- tritis, 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 tho bowels, I should be in- 38 INFLAMMATORY AFFECTIONS clined 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 membrane itself;—that, in the former case, it would consist, in its early stage, of detached and minute pus- tules 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 colour, and sensibly elevated above the level of the surrounding parts,—these portions afterwards ter- minating 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 found- ed 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 colour, without any decided change in the structure of the part. In a case mentioned by Mr. Annesley, 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, discharff- ing a thin sanious fluid. The symptoms were inces- sant 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 vo- miting. On the fourth day vomiting began, and he died on the seventh. The coats of the stomach in this case appeared to be thickened, but its internal surface was only deeply injected. I leave this part of the subject, merely pointing it out for farther investigation, and proceed to another of much OF THE STOMACH. 39 practical importance, in regard to which we have nu- merous interesting facts on which we can proceed with confidence. We have every reason to believe, that the mucous membrane of the stomach is liable to inflam- mation in a chronic form, which often advances so slow- ly 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 hope- less disease. Farther, we shall find, that even ulcera- tion 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 oppres- sion of the stomach after eating. 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, con- tinues in considerable severity while the process of di- gestion 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 unea- siness which is produced by it, and he is entirely free from complaint when the stomach is empty. A fre- quent 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 aggrava- ted by taking food ; and sometimes there is pain in the back at the part corresponding to the seat of the sto- mach. 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. Vomiting is apt to occur, but in the early stages is only occasional, and is ascrib- ed to some error in diet, or other accidental cause. 40 INFLAMMATORY AFFECTIONS Afterwards 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 manner the disease may go on for months without exciting alarm. The vom- iting then, perhaps, becomes more frequent, and the uneasiness in the stomach more permanent, until the patient 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 insidi- ous disease, there is great diversity in the symptoms. In some cases, there is little or no vomiting, the prom- inent 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 smallest possible quantity. In other cases, there is chiefly a constant and most painful feel- ing of pyrosis, with gradual emaciation ; 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 almost to the last period without vomit- ing, and with scarcely any symptom except the uneasi- ness which is produced by eating, and which subsides entirely in a few hours after a meal. This most inter- esting modification of the disease will be strikingly il- lustrated by Case IV. In some cases, again, the prominent symptom is a very copious discharge from the stomach of a clear glairy fluid like the white of eggs. In a woman, men- tioned by Andral, this discharge amounted to about four pints in twenty-four hours ; and she never vom- ited either food or drink. Sometimes this discharge is streaked with a black matter, or is entirely of the colour of chocolate, and not unfrequently is mixed with grumous blood. OF THE STOMACH. 41 The disease which is-going on during the course of symptoms now described, consists of chronic inflam- mation of the mucous membrane of the stomach, which in many cases appears to commence in a very small and circumscribed portion. Its progress seems to be very slow, and, it is probable that it may continue .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 stomach, adhesion to the neighbouring parts and ulceration. The result which we have oc- casion 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 ev- ident loss of 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 in the most healthy state ; or we may find that there has been a succession of them, some of them cicatrizing, and others appearing, while the health of the patient gradually sunk under the dis- ease, which after all may be found to have been of no great extent. In the cases of this first class, there is no general disease of the coats of the stomach, the ul- cer being confined entirely 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 ul- cer, all the rest of the stomach being perfectly healthy. 3. Extensive irregular ulceration of the inner sur- face of the stomach, generally complicated with thicken- ing and induration of the coats, and fungoid elevations. 6 42 INFLAMMATORY AFFECTIONS In some cases there is no actual ulceration,—the prominent morbid appearance being a thickened state of the mucous membrane to a greater or less extent. The thickened portion in this case may be of a pale ash colour, or of a brown colour, or of a dark colour with the characters of melanosis ; and these appearan- ces may be farther complicated with thickening and in- duration of all the coats of the stomach at the part af- fected, and perhaps adhesion to some of the neighbour- ing organs. In other cases again portions of the mucous membrane have been found softened or entirely de- stroyed. In the progress and terminations of this disease, there is considerable variety : the most important modifica- tions in a practical point of view may be thus stated. 1. The disease may be fatal by gradual exhaustion af- ter protracted suffering. In these cases we find either a succession of small ulcers which have been spreading from one place to another, or more extensive irregular ulceration with thickening of the coats, and probably adhesion to some of the neighbouring 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 in- duration of a defined portion of the parietes of the stomach without actual ulceration. 2. It may be fatal by haemorrhage from the ulcer, assuming at first the characters of the simple haemate- mesis, but resisting every attempt to check it, or to prevent its recurrence, until the patient sinks under it within various periods—from a few hours to several days. 3, It may be fatal by perforating the stomach,__the contents thus escaping into the peritoneal cavity, and OF THE STOMACH. 43 giving rise to extensive 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 modifica- tions 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 per- foration took place. In the other, there is much thicken- ing 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 perito- neal covering of the part. From the smooth appearance of the edges of the cavity which is formed 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 way. This remarkable modification of the dis- ease will be-illustrated by Cases IX. and X. The same symptoms arise from a similar affection occurring in the duodenum. A singular variety in the appearances is to be referred to before leaving this part of the subject. Though a complete perforation of the stomach by ulceration may have taken place, it is frequently found that an adhesion had been formed to some of the neighbouring 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 es- cape of the contents takes place. This remarkable cir- cumstance will be found exemplified in Case VIII. which was afterwards fatal by a small perforation immediately adjoining the portion where this adhesion had been form- ed. Another important modification arises from adhe- sion of the stomach to the arch of the colon, and a com- munication being formed between them by the ulcera- tion. This will be found illustrated, with very remarka- ble symptoms in Case XI. In these examples of adhe- 44 ULCERATION OF THE STOMACH sion of the stomach to the neighbouring parts, it will often be found that it has taken place to various organs, and perhaps also to the parietes of the abdomen,— showing that inflammatory action had existed in the coats of the stomach at various places and probably at differ- ent 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 be- twixt the adhering surfaces, as was very remarkable in Case XL The principal modifications of this important class of diseases will be illustrated by the following selection of cases. In the arrangement of them 1 shall not study minute pathological accuracy, which is in fact unattain- able ; but shall describe them in the manner which seems best calculated for practical utility. § I. Succession of small ulcers of the mucous MEMBRANE OF THE STOMACH, FATAL BY GRADUAL EX- HAUSTION. 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, whieh were generally ascribed to the 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 broken. He now complained of pain in the region of the stom- ach, which was not constant, but occurred at irregular intervals, and was sometimes dull and sometimes acute. FATAL BY GRADUAL EXHAUSTION. 45 He had vomiting, which generally occurred every day, and frequently several times in a day. Articles 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 functions were natural. In the beginning of the winter he suffered severely from the violence of the pain; towards the spring it became 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 begin- ning of June, 1824. He then complained chiefly of total want of appetite, and dull uneasiness across the region of the stomach ; but there was much less acute pain than he had formerly suffered; the vomiting also had much subsided. His look was dull and languid ; his countenance extremely pale, but not emaciated; strength very much reduced ; pulse a little frequent and weak; bowels natural. No other symptom could be discovered, and no organic disease could be detect- ed on the most careful examination. He died about a week after this, without any charige in the symptoms, except that for a day or two before death he was a lit- tle incoherent and slightly lethargic. Inspection.—The stomach was .large and distended with air, but externally healthy. On laying it open, there were observed about the middle of the small cur- vature two or three small round ulcers, not more than an eighth of an inch in diameter, with inflamed margins, but without any appearance of thickening of the parts. Higher up towards the. cardia, there were numerous white or ash-coloured spots, of various sizes, like the marks of small-pox. They were much smoother than the surrounding membrane, and of a much lighter col- our ; and there was every reason for considering them as the cicatrices of small ulcers. They were numerous 46 ULCERATION OF THE STOMACH all along the cardiac portion of the stomach, but were all smooth and cicatrized, except the two or three spots with inflamed edges already mentioned, which were in a state of actual ulceration. The disease seemed to be entirely seated in the inner membrane, without any tokening of the coats, and there was no other ap- pearance of disease in any part of the stomach. The liver seemed smaller than natural, but was quite heal- thy. The pancreas appeared 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 interesting 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. § II. Circumscribed ulceration with thickening, fa- tal BY GRADUAL EXHAUSTION. Case II.—A woman, aged 4 5, had long complained of her stomach, but without any uniformity in the symptoms. She had occasional pain, with sense of op- pression at the stomach ; her appetite was variable, and FATAL BY GRADUAL EXHAUSTION. 47 she sometimes vomited, but at long and irregular inter- vals. 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, and constant uneasiness in the abdo- men. She was first seen by Dr. Begbie, about a fort- night after the commencement of these symptoms, when she complained of 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 symptons, 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 pre- sented a uniform white structure of almost cartilagin- ous 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 mucous membrane of the intestines presented many spots, which were of a dark red colour and highly vas- cular, but without any change of structure. Case III.—A lady aged 50, had been for many years affected with dyspeptic complaints, and about eight years before her death, was first attacked with copious discharge of dark grumous blood both from the sto- mach and bowels. She soon recovered from this, and enjoyed tolerable health,, though with constant dyspep- tic symptoms, until 1826 ; she then had much pain in the stomach, constant feeling of acidity, and frequent vomiting of tough ropy mucous of a brown colour. She recovered from this attack after three or four months, but the stomach continued to be easily disor- 48 ULCERATION OF THE STOMACH dered- 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 began to have pain on pressure in the region of the stomach, and a broad flat tumour was felt in the left side of the epigastric region. Repeated topical bleeding was now employed, and the tumour subsided in a most re- markable degree; but, from this time, she continued liable to pain and distention of the stomach and bow- els, and vomiting of acid matter; and occasionally she vomited considerable quantities of the tough brown mucous; 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 epigastric re- gion, even on very firm pressure, and scarcely any re- mains of the tumour couki be perceived. Her food was relished and retained, and the bowels were natural ; but she became progressively more and more emacia- ted, without suffering, and died in April, 1828. Inspection.—The stomach was drawn up into the left hypochondriac region, and adhered in several places by loose membranous bands to the parietes of the abdo- men, 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 contiguous to the pancreas. The surface of the ulcer was rough, with several induratioHS like small glands. The pancreas was enlarged, and felt through- out of scirrhous hardness. Opposite to, and connec- ted 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 tumour had been felt in the course of the disease. The coats of the stomach were considerably thickened at the place of the ulce- FATAL BY GRADUAL EXHAUSTION. 49 ration, and for a small space around it ; the other parts of it were healthy. These cases will serve to illustrate some of the vari- eties 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 dyspeptic. Other remarkable varieties occur both in the symptoms and in the morbid appearances, of which it is impossible to give any gen- eral statement. A woman mentioned by Chardel had dyspeptic complaints, with pain in the stomach and back, and occasional vomiting. Solids only were vom- ited, 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 com- mencement 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 consid- erably 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 examination. After death, the stomach was found ad- hering intimately to the concave surface of the liver; and an ulcer at this place had perforated the stomach, and penetrated a considerable way into the substance of the liver ; there was also ulceration in the neigh- bourhood of the cardia. A man mentioned by Pinel had great acidity of the stomach, and other dyspeptic symptoms, with occasional attacks of acute pain ;—af- terwards vomiting and gradual wasting ; and a tumour . 7 50 ULCERATION OF THE STOMACH was felt in the epigastric region. The pain became more acute, the smallest quantity of food producing great uneasiness, and he died exhausted after six months. The omentum was found hard, red and fleshy, and gath- ered up into a mass under the great arch of the sto- mach. 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 re- lated by Frank. A man aged 50, was seized, after vio- lent exertion, with copious vomiting of blood, followed by discharge of blood by stool: these symptoms con- tinued several weeks, and then ceased. He then had dyspeptic symptoms, with debility and emaciation ; his appetite was good ; but he had great uneasiness after eating ; and some tenderness was felt in the right hy- pochondrium, with difficulty of lying on the right side. He became gradually more and more emaciated, and had «ome vomiting and dropsical symptoms before death,—his 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 Avas a very large ulcer which perfo- rated the stomach, and penetrated into the substance of the liver. § III.—Extensive ulceration, with thickening, com- plicated WITH REMARKABLE DISEASE OF THE OMEN- TUM AND PERITONEUM ;--FATAL BY GRADUAL EXHAUS- TION. Case IV.—A gentleman, aged 53, consulted me in autumn 1825, on account of pain in the region of the FATAL BY GRADUAL EXHAUSTION. 51 Btomach, which attacked him only after dinner. It usu- ally continued an hour or two, and frequently extended considerably upwards along the thorax on both sides. He was cupped in the epigastric region, 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 sto- mach, without any regularity in the symptoms ; but, in the following winter, the affection returned with the same violence as before. He was quite well during the earlier part of the day, no uneasiness 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. Some- times 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 taking a regular dinner, and confine himself to small quantities of arrow root. After a variety of treatment in the country, he came to Edinburgh in the beginning of June, I827. 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, with- out severe suffering for some time after. No organic disease could be discovered, and no particular tender- ness in the epigastric region. He had never had any vom- iting ; 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 bu- siness, with the promise of returning in a very few days ; but he did not return for a fortnight, when it was found that ascites had taken place to a considerable extent, with some anasarca of the limbs. He now began to decline rapidly in flesh and strength, and refused almost every kind, of nourishment. He did not complain so much 52 ULCERATION OF THE STOMACH as formerly of acute pain, but had a feeling of intoler- able distention 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 quan- tity 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 vom- ited a few times, but to no extent, and his bowels were easily regulated through the whole course of the dis- ease. 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 stomach was remarkably contracted, and its coats were much thickened 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 irregular fungous disease of a tubercular character. The omen- tum presented a large mass of a tubercular structure, of nearly cartilaginous hardness, about four inches in ex- tent, 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 inti- mately to the contracted and thickened stomach, that they seemed to be blended into one mass. It also ad- hered to the arch of the colon, but this was not other- wise diseased. The duodenum from its very commence- ment was entirely healthy ; but among the other small FATAL BY GRADUAL EXHAUSTION. 53 intestines there were some slight adhesions. The liver was rather pale, and seemed diminished in size, but up- on 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 ad- vanced period, might have been considered merely indi- cating a high degree of dyspepsia. The important char- acters of the case in this respect are, the intermitting nature of the pain,—the absence of vomiting,—and the general appearance of health continuing unimpaired un- til a very few weeks before death. This very interesting variety of the disease is farther illustrated by many cases which are on record. A man mentioned by Chardel had dyspepsia and acute pain af- ter 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 were found thickening of the coats of the stomach at the upper pait, without ul- ceration, and enlargement of the lymphatic glands in the neighbourhood of the stomach. A man mentioned by the same writer had pain in the right hypochondrium and loss of appetite, with great acidity and gradual wasting. He had no vomiting, but a good deal of diar- rhoea, the stools at last having become black and bloody, and he died gradually exhausted after a year. The sto- mach was found adhering both to the diaphragm and the colon. At the place of adhesion to the diaphragm, 54 ULCERATION OF THE STOMACH a portion of the stomach was entirely destroyed by ul- ceration, and, by means of the adhesion, a portion of the diaphragm supplied the place of the part that was de- stroyed. 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 sto- mach adhered to the liver and the pancreas ; the mu- cous membrane was irregularly destroyed and ulcerated ; and at the place of adhesion to the liver the parietes were perforated by the ulceration. The pyloric extre- mity was considerably thickened, and the omentum was thickened and indurated. § IV.—Ulcer of the stomach fatal by hemorrhage. Case V.—A gentleman, aged about 40, had been long dyspeptic, and liable to pain in his stomach, which had not assumed any fixed or regular character ; but he required great care in respect of his diet, and many ar- ticles were apt to disagree with him. He was other- wise in good health, and applying himself actively to business till Saturday, 5th November, 1825, when he was suddenly seized in his counting-house with a feel- ing of extreme faintness. He was assisted with difficul- ty to his dwelling-house, which was in the neighbour- hood, and soon after vomited a large quantity of black fluid resembling ink. On Sunday he continued 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 Tues- day 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 followed by ex- FATAL BY HEMORRHAGE. 55 treme 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 some time before his death with violent pain in the stomach. Inspection.—The stomach was of immense size, but showed no appearance of disease in its structure, ex- cept at a part in the small arch about half way be- tween the cardia and pylorus. Here a round defined portion about the size of a half-crown piece was much indurated a*hd 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 col- our. No other disease could be detected in any organ. Case VL—A woman, aged 45, had been for several years liable 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 particular spot of very small extent; it was much increased by eating, 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 56 ULCERATION OF THE STOMACH. 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 com- plained 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 examina-. lion. 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 occurred 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 adhe- sion of small extent to the left lobe of the liver, and anoth- er of greater extent, and very firm, to the pancreas. At both these places, the coats of the stomach were dis- eased, but in the greatest degree at the adhesion to the pancreas. Here they were much thickened and indura- ted, for a space about three inches long, and two inches broad ; and the internal surface of this portion was en- tirely 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 reason to believe that they had been the source of the haemorrhage. The other parts of the stomach were in a natural state, and all the other vis- cera were healthy. I consider this case as one of very great interest, on account of the periodical nature of the pain, and the long intervals of perfect health. There seems every reason to believe that the paroxysms had been connect- ed with inflammatory action, confined to a circumscrib- ed 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 sue- FATAL BY PERFORATION. 57 Cessive 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 af* Fected for about six months with variable appetite, and occasional pain in the stomach, which made her frequent- ly 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 improved, On the 26th November, 1824, while in a room by her- self late in the evening, she was heard to scream vio- lently ; 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 em- ployed without relief. She continued with every'ap- pearance of extreme suffering, and unable to speak, till 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 extending downwards over the abdomen. The abdomen was now becoming distended, and when I saw her about three 8 5 8 SIMPLE ULCERATION OF THE STOMACH o'clock in the afternoon, it was distended to the great- est degree and very tense. The pulse was extremely feeble ; she was scarcely able to speak, but her counte- nance was expressive of extreme 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 dis- tended with air, and likewise contained upwards of eight pounds of fluid of a whitish colour, and fetid smell. There was slight but extensive inflammatory deposition on the surface of the intestines, producing adhesions to each other, and to the parietes of the ab- domen. On the upper part of the small curvature of tho stomach near the cardia, there was a small perfora- tion of a size which admitted the point of the little fin- ger. 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 sub- stance. 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 vom- iting. He was often obliged to leave the table sudden- ly 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 ev- ery appearance of extensive organic disease, though none could be discovered on examination. He requir- ed 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 FATAL BY PERFORATION. 59 recovered its healthy functions. He had at various times, however, slight threatenings of his former symp- toms, and, required to live with great caution ; but he was full in flesh, and his general health 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 oc- casional vomiting. On account of these symptoms he was keeping the house, though able to attend to the affairs of an extensive business, until Saturday evening, 3d February, 1827, when he was suddenly seized with excruciating pain in the pit of the stomach, accompa- nied by some vomiting, coldness of the body, and a small frequent pulse. From the moment of this attack, nothing that was done afforded the least relief. He continued in the most violent and unceasing pain through the night and through the following day ; th« whole abdomen became distended 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 stom- ach was entirely destroyed ; 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 usu- al marks of extensive but recent peritonitis. Except the two spots now referred to, the stomaeh was per- fectly healthy. 60 SIMPLE ULCERATION OF THE STOMACH These examples will be sufficient to illustrate this most formidable modification of the disease. Many oth- ers are on record, in some of which the previous symp- toms were very slight and obscure. 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 vi- olent pain and vomiting, and died in 24 hours, with symptoms of peritoneal inflammation. In the ante- rior part of the stomach there was a round ulcer no larger than a sixpence, with hard callous edges, and some thickening of the coats 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 seventeen examples of this affection, in a memoir, " Des Perforations Sponta- nees de l'Estomac." In some of these there had been previously chronic vomiting, and other symptoms indi- cating disease in the stomach ; but in others the pre- vious symptoms were slight and obscure ; and some had enjoyed tolerably good health. The fatal attack and the morbid appearances corresponded with the cases now described ; and death took place in a period of from 12 to 24 hours. Several cases of the same kind are described by Dr. Crampton and Mr. Travers, in the Medico-Chirurgical Transactions. In a lady mentioned in the Journ. Gen. de Medicine for August, 1821, the attack commenced with severe pain in the epigastric region, extending towards the left kidney, and accompanied by cold shivering, dyspnoea, and pros- tration of strength. These symptoms subsided, but re- turned 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 FATAL BY PERFORATION. 61 not subside, and was fatal in 20 hours. In the ante- rior part of the stomach there was a perforating ulcer nine lines in diameter, and surrounded by a margin of slight inflammation. There was peritoneal inflam- mation, with effusion of a brown fluid, mixed with portions of food. The kidneys were healthy. To these observations, may be added, the remarka- ble case of Admiral Wassenaer, mentioned by Boer- haave, who died suddenly in the act of vomiting, or rather of attempting to vomit, soon after he had dined. The lower part o€ 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 vol- ume of the Arch. Gen. de Medicine. A man who had for six months suffered severely from his stomach, especially after eating, was seized with violent vomit- ing, which continued three days. He was then seized with palsy, and in four days more died coma- tose. Effusion was found in the brain. The oesopha- gus had given way a little above the cardia, by a rent an inch and a half long, and much fluid had been dis- charged 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 CAVITY 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 fifty, had been for several years in bad health; her principal complaints were re- ferred to the region of the uterus, and the os uteri was 62 OLD ULCERATION WITH THICKENING, felt to be hardened. She was also liable to pain in the stomach, capricious appetite, and occasional vomit- ing ; but these complaints had not been so severe or regular as to attract much attention, until she was sud- denly seized with most violent pain, referred to a small spot in the epigastric region, accompanied by vomiting, and followed by pain and tension of the whole abdo- men, 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 inch in thickness at the centre. In the middle of this portion, there was a round excavation about one-third of an inch in diam- eter, and entirely penetrating the part. Internally this opening 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 re- spects was healthy. The neck of the uterus was scirr- hous. 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 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 twenty-one, while engaged at her work be- tween 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 belly, sickness, and vom- iting. About ten, she was bled ad deliquium, and twice afterwards in the course of the day. The bowels were freely moved by an enema, and she took purgative me- SUDDENLY FATAL. 63 dicine which did not operate ; but there was no allevi- ation of the symptoms. The belly became tense, ten- der, and tympanitic, the pulse feeble and rapid ; every thing 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 swal- lowed. 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 of 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 thickness, and the thickening extended in a greater or less degree over a portion five or six inch- es in extent. The inner surface, at the place of the rupture, presented a deep excavation with rounded and smooth edges, like a deep eroding ulcer which had cic- atrized. It was fully half an inch in diameter, and a third of an inch or more in depth, having penetrated the thickened substance 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 com- plain of her stomach, or to show the smallest deviation from most robust health ; and the only farther informa- tion 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 com- munication WITH THE ARCH OF THE COLON. Case XL—A gentleman, aged fifty-six, who had pre- viously enjoyed good health, except occasional dyspep- tic complaints, began to feel languid with impaired ap- 64 PERFORATING ULCER OF THE STOMACH, ANC petite, some loss of flesh, and occasional pain in the ab- domen ; hut 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 seiz- ed with vomiting, and the matter vomited had the odour and appearance of feces. He felt no farther inconve- nience till about a week after, when he was again seiz- ed in the same manner. After this attack he was seen by Dr. Combe of Leith, who found him with a look of impaired health, but with a natural pulse and a good ap- petite. His bowels were easily regulated, and no ap- pearance of organic disease could be detected. Dr. Combe was 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 distinguished from that which he had passed from his bowels the same day. After this, the vomiting re- turned at various intervals, sometimes three or four times a day; and sometimes he was free from it a week at a time. The matter vomited always 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 bowels continued regular or easily regulated ; the feces varied considerably in their appearance ; but that which was vomited always resembled what was passed from the bowels so closely, that it was impossible to distinguish them. He never was observed to vomit food, or other matters which had been taken into 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, with- out any particular change in the symptoms, except that a week before his death he vomited a considerable quantity of blood. There was occasional pain in the COMMUNICATION WITH ARCH OF THE COLON. 65 abdomen, but not distinctly referred to any particular part. Inspection.—The stomach was found contracted and adhering to the parietes of the abdomen on the left side, and to the arch of the colon. At the place of the adhesion, a soft tubercular 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 occupied the whole of its great curvature, and covered about one half of the inner surface of the stomach. The pylo- rus and whole pyloric extremity were healthy. In the centre of the ulcerated part there was a ragged irregu- lar 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 intestines were empty ; the caput coli was distended with fecu- lent 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 follow- ing remarkable 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 described. Case XII.—A lady, aged 49, had been in bad health through the winter 1811-12, complaining chiefly of 9 66 extensive ulceration of the stomach weakness and a constant uneasiness across the region of the stomach, with occasional attacks of acute pain towards the left side. In May, 1812, she began to have vomiting, which continued from that time, and be- came more and more urgent. I saw her in July, and found her much emaciated ; she complained of a dull pain in the epigastric region, where considerable hard- ness was felt; and she vomited a portion of every thing she took, sometimes immediately after taking it, and sometimes a considerable time after. She contin- ued with little change till the beginning of September, when the vomiting subsided, and she was free from it for more than a fortnight. But during this time she was affected 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 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 ano- ther ; in the substance of it there was a cyst full of very fetid matter. This mass was attached to the car- dia by a narrow portion, which remained 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 remarkable. When stretched out in this manner, about one-half of the stomach at the pyloric extremity OF A CANCEROUS CHARACTER. 67 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 lower part of the great arch of the stomach was entirely wanting to such an extent, that, when the parts were extended in the manner now mentioned, it seemed as if nearly one half of the stomach had been entirely destroyed. There was reason to believe 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 separa- tion had taken 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. DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE' STOMACH REFERRED TO UNDER THE PRECEDING HEADS. From the facts which have been related, we have every reason 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 membrane of the stomach, or the mucous follicles,—and the termination of this by ulce- ration. In both these conditions, it may probably be the subject of medical treatment; for we have reason to believe, that the inflammation may be arrested and prevented from passing into ulceration, and that the ulceration may heal before it has become connected with any permanent change in the organization of the 68 DIAGNOSIS AND TREATMENT 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 suc- cess. The difficulty here is in the diagnosis,—the dis- ease 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 re- spects very different from that adapted to dyspepsia. The disease may be suspected, when there is pain in the stomach occurring with considerable regularity immediately after 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 pressure. 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 vomiting, and, on the other hand, that it is some- times indicated by vomiting occurring occasionally, without any regular periods, and with very little pain. In the cases will be seen other important varieties in the symptoms, which are of great interest in a practical point of view, particularly the intense and peculiar feel- ing of pyrosis mentioned in Case VIII. When this feel- ing occurs with great intensity after food of all sorts, ta- ken even in the most moderate quantities, we have reason to suspect disease of the mucous membrane of the sto- mach. The feeling appears to be in some cases con- nected with the formation of an acrid fluid, which we often see brought up in considerable quantities ; and in others, seems to depend merely upon the morbid con- dition of the mucous membrane itself, in consequence of which, ordinary articles produce that peculiar feelincr of irritatio^ which in the sound state of the parts is produced by matters of an acrid quality. It is com- mon to hear such patients say, that attention to diet OF CHRONIC GASTRITIS. 69 makes little difference in their feelings, but that every thing turns immediately to intense acidity, even a bit of meat or a glass of cold water. The disease may be al- so suspected, when, along with any of the above men- tioned 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 ac- companied and characterized by a raw and tender state of the tongue and throat ; in some cases, with minute ulcers ; and in others, with the formation of slight aph- thous 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 gradual- ly along the oesophagus, and at last into the stomach. Amid such a diversity of symptoms as occur in con- nection with this disease, our chief reliance in the di- agnosis must probably be on a careful examination of the region of the stomach itself, with the view of disco- vering the existence of tenderness referred to a parti- cular 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 discovered, the character of the case will be obvi- ous ; but we have seen, that most extensive ulceration may exist without any induration ; 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 describ- ed. In particular, we should not be deceived, either by the pain having remarkable remissions and the pa- tient enjoying long intervals of perfect health, or by re- markable alleviation of the symptoms taking place un- der a careful regulation of diet; for these circumstan- ces we have found occurring in a very striking manner, 7 0 DIAGNOSIS AND TREATMENT while the disease was making progress to its fatal ter- mination. When the disease is detected at an early period, the treatment must consist chiefly of free and repeated top- ical bleeding, followed by blistering, issues, or the tar- tar emetic ointment. The food must be in very small quantity, and of the mildest 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 pos- sibly be avoided even by the mildest articles. The pa- tient should abstain in a great measure from bodily ex- ertions, and hence the importance of endeavouring to distinguish the disease from mere dyspepsia, as the re- gimen and exercise which are proper and necessary in a dyspeptic case, would in this case be highly injurious. In the early stages, little probably is gained by med- icine 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 dis- ease has passed into ulceration, the same observations will apply in regard to external applications and regi- men ; 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 mucilaginous nature, appear frequent- ly to be beneficial,—likewise articles of an astringent nature, such as kino, alum, and the Rhatany root. The arsenical solution has also been recommended, and small doses of the nitrate of silver ; and in several in- stances in which I have suspected this disease to be going on, I have found remarkable benefit from the sulphate of iron. Whether the disease can be cured, after it has advanced to ulceration, must indeed remain OF CHRONIC GASTRITIS. 7 1 in some degree a matter of doubt; because in a case which has terminated favourably, we have no means of ascertaining with certainty that ulceration had existed. In some of the cases, however, which have been describ- ed, we have seen every reason to believe that some of the ulcers had cicatrized, though the disease had after- wards 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 cic- atrices of such ulcers when the patient has died of another disease, after having been for a considerable time free from any symptom in the bowels, I insert here the following case, without deciding whether it is referrable to the affection which has been the subject of the preceding observations. In a prac- tical point of view it is of some importance. Case XIII.—A lady, aged about 30, came to Edin- burgh from a distant part of the kingdom in summer, 1818. She was affected with violent pain in the sto- mach, which seized her every day immediately after din- ner, continued with great violence through the whole evening, and gradually subsided about midnight; it sometimes seized her after breakfast, but more rarely. The complaint was of two years' standing, during which time a great variety of practice and every varie- ty of diet had been tried, but with very slight and tran- sient benefit. The paroxysms occurred 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 discovered, but there was considerable tender- ness on pressure at a particular spot. Various remedies were employed during the summer with little advan- 72 DIAGNOSIS AND TREATMENT tage ; at last, however, she appeared to derive some benefit from lime water, and returned home in the au- tumn rather better. But the affection soon recurred, and she returned to Edinburgh in 1819, as bad as ever. After another trial of various remedies, this severe and intractable affection 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 pow- der 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 far- inaceous articles and milk are those which seem in ge- neral to agree best; and some cases have been found to make most satisfactory recoveries under 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 a considerable time laboured under symptoms which were supposed to indicate scirrhus of the pylorus, and her case had been regarded as entirely hopeless. She suffered severe pain in the stomach when the small- est 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, CHRONIC GASTRITIS. * 73 when Dr. Barlow determined,upon trusting entirely to regimen, by restricting her to a d.iet consisting wholly of fresh-made uncompressed OAifd, of which she was to take but a table-spoonful ^B.t a time, and to repeat it as often as she : found ^t advlsajde. On this article she subsisted for several months, and recovered perfect health. • fe An inflammatory affection W 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 mem- brane from the pharynx downwards. I think it some- times occurs as an idiopathic disease, but I have gen- erally observed it taking place at an advanced period of other diseases,—as simple fever, or any of the inflammatory affections, as pneumonia. There is a pe- culiar rawness and tenderness 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 aph- thous 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 ex- treme 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 10 74 diphJPherite. required, with very mild articles of food; and, when there is much /inking, wine or brandy, mixed with ar- root. The following case will^ilhistrate the affec- row tion. Case XV.—A woman aged 20, Etod previously healthy, after some continuance of a febrile disorder, with very mild symptomlpbecame affected with pain and tenderness in the epTgastric region, extending over the abdomen. The mildest articles of food produced great pain ; there was diarrhoea, with much griping, and frequent vomiting. The affection was accompa- nied by a feeble' rapid pulse, great debility, and collapse of the features ; 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 under 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 ul- cers of the mucous membrane of the intestine. A sim- ilar 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, ac- companied by tenderness along the oesophagus and in the stomach, when there is no affection in the bowels. Another modification of disease in the mucous mem- brane 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 child- ren. The first symptom is a deep redness of the ton- DIPHTHERITE. 75 sils or velum, without swelling or ulceration ; but with the formation of aphthous crusts, which are generally of a pure white colour. When these crusts either are removed, or drop off spontaneously, the membrane be- neath is seen to be deeply red without breach of sur- face, and the crust is reproduced in a few hours. We find usually excoriation, or very minute Ulcers along the inner membrane of the cheeks and lips, and a painful excoriation of the membrane of the nose,—often spon- giness and bleeding of the gums ; and, in some cases, the whole mouth becomes inflamed in a manner re- sembling the effects of mercury. There is in general 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 vesica- tion, and inflammation of the neighbouring lymphatics. The disease is in some cases a slight affection, confin- ed to the fauces ; but in others, it evidently extends along the oesophagus and to the stomach, producing tenderness of the epigastrium and vomiting ; and in a few cases there was diarrhoea, with excoriation about the anus. 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 1 826, I saw no case, fatal except when the disease extended to the larynx; but of those patients in whom the larynx was distinctly affected, very few recovered. The disease 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 ;. 76 D1PIITHERITE. and benefit seemed to be obtained from the ftee use of the vegetable and mineral acids ; careful regulation of the bowels, without strong purging ; very free ventila- tion, 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 gargles were in some cases beneficial. Dr. Ham- ilton recommends the acetate of lead, both internally and in gargles. M. Bretonneau 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 af- fected, the danger is extreme, for the disease does not in general bear bleeding, 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 occurred 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 diminished 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 Inflammations Speciales du Tissu Mu- queux." The error of the French writers consists in having, from their zeal for generalizing, considered 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 distin- guished 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, to which DIPHTHERITE. 77 we commonly apply the name of croup. The distinc- tion is of much practical importance ; for when, either in this disease or in the cynanche maligna, the inflam- mation extends to the larynx, the cases do not bear any active treatment, and a very large proportion of them are hopeless. But the idiopathic croup is a pure ac- tive inflammation, in which, by early and decided treat- ment, we have the fairest prospect of being able to ar- rest 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, ten- derness of the epigastrium, and untractable vomiting of a fluid the colour of verdigris. The body was examin- ed in one of the cases only. The veins on the inter- nal surface of the stomach were remarkably turgid: the mucous membrane, particularly at the great extrem- ity, was of a dark mahogany colour, which appeared to be owing to vascular distention and general extravasa- tion into the submucous tissue. The mucous mem- brane of the oesophagus was of a deep red colour, 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 existed, indicating extensive dis- ease of the stomach ; or even when the patient had died of another disease, without any symptoms referrable to the stomach. This appearance has been ascribed by Hunter and others to solution of the substance of the stomach by the gastric juice ; but it must be confessed that this doctrine seems extremely questionable, for, were the gastric juice capable of producing such an ef- ♦ Dublin Hospital Reports, Vol. IV. 78 RAMOLLISSEMENT feet, the appearance ought to be of much more fre- quent occurrence. This curious subject has been care- fully and ably investigated by Dr. Gairdner, in the first volume of the Med. Chirurgical Transactions of Edin- burgh. In his cases, the appearance occurred in chil- dren, and was preceded by obscure symptoms indicating general febrile disturbance, usually accompanied by some symptoms referable to the stomach and bowels, as vomiting or diarrhoea. On the other hand, the appear- ance has been observed in the bodies of persons 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 'examination of a body at the usual period after death ; but, upon a second inspection, two days after, this peculiar destruction of parts was found to a considerable extent ; and, in the experiments of Dr. Wilson Philip, upon rabbits, he found in many instan- ces the great arch of the stomach dissolved to a great extent 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 degene- ration 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 ap- pearance of increasing vascularity. The perforation is, in some cases very large ; in others, there are four or five perforations, separated by narrow portions in a par- tially softened state ; and, frequently, there is no actual perforation, but merely a considerable extent of the OF THE STOMACH. 79 stomach much softened, which tears upon the slightest touch. Upon the whole, the conclusion, in regard to this singular affection, seems to be, that it takes place after death ; that it has been in some cases preceded by dis- ease of the stomach ; but that, in others, there has been no ground for believing the existence of any such dis- ease. It is certainly not an appearance on which any pathological principle can be founded, in regard to pre- vious disease ; and this is a point of the utmost conse- quence, especially in reference to the judicial examina- tion of bodies in cases of suspected poisoning. For various interesting details in regard to it, I refer to Dr. Gairdner's essay. Nearly the same observations seem to apply to the ra- mollissement of the mucous membrane of the stomach, on which much attention has been bestowed by some of the French writers, 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 mucous, in general 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 complain- ed for some time before death of pain and heat in the epigastric region, with loss of appetite, nausea, and oc- casional vomiting. It is, however, 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 mem- brane existing where there had been no symptom refer- * Louis' Memoires et Recherches Anatomico-pathologiques. SO OF ORGANIC DISEASES OF THE STOMACH. red to the stomach. Upon the whole, there seems rea- son to doubt whether this is to be considered as an ap- pearance on which can be founded any principle in pa- thology. 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 stom- ach, and other permanent 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 ob- jects of medical treatment, I shall mention them very briefly under the following heads : I. Induration and thickening of the Coats of the Stomach. II. Diseases of the Pylorus. III. Disease of the Cardia. § 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 stom- ach, consisting chiefly of distention, acidity, and occa- INDURATION AND THICKENING, &C 8l sional attacks of acute pain. After several months from the commencement of these symptoms, she began to be affected with vomiting ; and, for the three or four last months, had vomited daily, generally in the after- noon or evening, at irregular periods after dinner. Sometimes she escaped it till she went to bed ; but then it always came on early in the night. A hard tu- mour of considerable extent could be felt in the epi- gastrium. She died in September, in a state of ex- treme emaciation, having, before death, dischai^ed much blood, both by vomiting and by stool. Inspection.—The stomach adhered to all the neigh- bouring 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 tumours, the one the size of a pigeon's egg, and the other of a hazel nut. Externally they were of a dark purple colour, internally white. The large eurvature and the anterior part of the stomach were extensively ulcerated, dark coloured, and of very irregular thickness ; and at one place, there was a per- foration 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 characters of scirrhus, or almost of cartilage ; in others, it has more the ap- pearance of a mass of tubercular disease, and, frequent- ly, a considerable part, or a mass of tumours projecting from it internally, is of a soft texture resembling the 11 82 DISEASES OF THE PYLORUS. substance of the brain. In a case by Pinel, a large ab- scess had formed in the substance of the diseased mass, and had burst into the cavity of the stomach. A large tumour in this case had been felt in the epigastric re- gion, had been gradually increasing, and suddenly dis- appeared during a fit of coughing, a considerable time before the death of the patient. § II.—Diseases of the pylorus. In a pathological point of view, there are some facts relating to the diseases of the pylorus, which are wor- thy of being recorded, though they can seldom become the objects of medical treatment. Disease of the pylorus may begin in a slight and insidi- ous manner, like a mere dyspeptic affection, and gradu- ally 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 vomit- ing, occurring at certain regular intervals after meals, generally with fixed uneasiness in the region of the stomach; and we can commonly discover, on examina- tion, more or less induration in the region of the pylo- rus. But we find remarkable deviations from these, which we are apt to consider as the established charac- ters of the disease. ' The cases which I shall here in- troduce are intended to illustrate some of these devia- tions, by showing extensive disease of the pylorus, ex- isting 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. diseases of the pylorus. 85 Case XVII.—A gentleman, aged 30, had been for several years liable to- paroxysms of pain in the .sto- mach, 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, until about a year before his death, when he was sud- denly seized with copious vomiting of blood. From this time, his attacks of pain in the stomach became more frequent, and he had repeated attacks 0*1 the vomiting of blood ; but still he had considerable inter- vals of health ; no hardness could be discovered by examination ; and that uniformity of symptoms was entirely wanting 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 ema- ciated ; 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 scirrhas, the size of an orange, very firm, or nearly j cartilaginous. The stomach in other respects was en- ■ tirely healthy, as were also the liver, the spleen, and the pancreas. There were considerable adhesions among the intestines ; and there was slight ossification of the vftves on the right side of the heart. Case XVIIL—A man, aged 40, came under my care in December, 1817. He was weakened and emaciated to the last degree, with a weak pulse at 120, but with- out any other complaint ; 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 cartilage and the urn- 84 diseases of the pylorus. bilicus, a hardness was felkw^ich could be traced for several inches, and was painful upon pressure. He had been ill eighteen months," and the affection had com- menced with vomijjng, which occuired generally five or six times a day. This continued for five or six months, when the vomitf% ceased entirely; and, for the. last twelve months, he had no complaint, except pro- gressive debility and emaciation. He died completely exhausted in the beginning of February, having con- tinued without any other symptom than repeated at- tacks of violent pain in the abdomen. Inspection.—A mass of scirrhus, four or five inches in diameter, surrounded'the pylorus; and the pyloric orifice was so narrowed, as scarcely to admit the point x>f 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 cancerous look- ing tubercles. The other parts of the stomach were tolerably sound, and the other viscera were healthy. Case XIX.—A gentleman, aged 66, came under my care only a few weeks before his death. He was then emaciated in an extreme degree, with an exhausted I withered look. He had been long in bad health, but 'particularly for the last four months, during which pe- riod he had been affected with frequent vomiting, which however did not occur at any regular periods. When questioned about it, he said, that he seemed to vomit by a voluntary effort to relieve an extrefhe unea- siness which took place in his stomach ; and accord- ingly, by putting him upon a regulated diet, it appear- ed that he could in a great measure prevent it. His debility and emaciation, however, continued to increase, 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» DISEASES OF THE PYLORUS. 85 Inspection.—The pylorus was surrounded by a mass of scirrhus, the size of a small apple ; and the inter- nal part of it projected into the cavity^of, the stomach, in the form of numerous hard papillae; The principal projection of the mass was backwards, where it had formed adhesions, by means of which the pylorus was firmly bound down to the pancreas. The pyloric ori- fice 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 remarkable deviations from the more common cha- racters of the affection ; but they are not in these re- spects singular exceptions to the general history of the disease.- A man mentioned by Chardel was affected with* a strong pulsation in the epigastric region, in which a pulsating tumour 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 exhausted, and died without any other symptom, except diarrhoea and oedema of the legs. The tumour was found to be an enormous mass of scir- rhus, occupying the posterior part of the pylorus, 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 as- cites. On dissection, there was found scirrhus of the pylorus.and of the pancreas; and the latter compres- sed the ductus communis. In another case, complicat- ed 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 r 86 DISEASES OF THE PYLORUS. length occupied the pylorus, and extended along the small curvature of the stomach. It does not appear that these varieties in the symp- toms depend upon the degree of contraction of the py- loric orifice ; for, in Case XIX. there was little con- traction ; and in a case by Chardel, there did not ap- pear any contraction at all, though a large mass of scir- rhus surrounded the pylorus. In this case, there had been frequent vomiting, with violent attacks of pain. In Case XVIII. 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 py- loric 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 patient. This may result from the mass being bound down by adhesion to the parts behind, as in Case XIX. But besides this, the disease may be of so small extentas not possibly to be detected in this manner, while it is capable of producing the usual symptoms in their most violent form. In a case by Dr. Morrison,* the pylorus was almost totally obstructed by small tu- bercles arising from its internal surface, without any ex- ternal disease. The patient died, after several years' illness, with pain of the stomach and vomiting ; and in a case by Chardel with the same symptoms, the py- loric 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 verv much emaciated. * Med. Ob. and Enq. vol. vi. DISEASE OF THE CARDIA. 87 § III.—Disease of the cardia. Case XX.—A man, aged 38, consulted me in sum- mer, 1815, on account of difficulty in swallowing. The artieles swallowed seemed to lodge at a spot to which he pointed, (corresponding to the seat of the cardia,) and were almost immediately brought up again. He had been for many years liable to this affection in a greater or less degree, but at first it attacked 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 swallow 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 No- vember. Inspection.—A mass of scirrhus 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 stomach was healthy. Case XXI.—A man, aged 60, had been liable for many months to difficulty in swallowing, which had at different times been better and worse, and sometimes entirely removed for a week at a time ; but he was now emaciated to a great degree. By the probang an ob- struction was felt about the middle of the oesophagus; and under treatment directed to this in the usual man- ner, he seemed to improve considerably in swallowing. 8S DYSPEPSIA. 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 ori- fice was compressed by a tumour the size of a walnut, situated on the outside of the oesophagus, or rather con- fined 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 changed, in the course of from three to five hours, into a homogeneous pultaceoUs matter called the chyme. The observations of Majendie have rendered it probable, that, sometime after the process of diges- tion 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 quantity 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 chyme is at last gradually propelled into the duodenum, and thence very gradually through the in- testinal canal, by a certain consecutive muscular action, which is called its vermicular or peristaltic motion. In DYSPEPSIA. 89 this course, the alimentary matter is mixed with the bile, pancreatic juice, and the fluids of the intestinal canal; and it undergoes farther important changes, by which it is converted into chyle fit for absorption, and the ex- crementitious matters are separated and expelled. The fluid called the gastric juice appears to be merely a mixture of the mucous and follicular fluids of the sto- mach. 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 therefore of digestion is, that it is the result of the combined action of this fluid, and of the peculiar muscular motion of the stomaeh now referred to. In healthy digestion, it appears that no gas is ge- nerated 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 tiie regular manner into healthy chyme ; but, remain- ing 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 imperfectly 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 gas- eous fluids, there are produced painful distention, op- pression, and anxiety, or in other words, a paroxysm of dyspepsia. 90 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 in- testinal membrane. 5. A healthy state of the mucous membrane itself, both in the stomach and intestines. The dependence of the function of digestion upon the influence of the eighth pair of nerves, is among the most beautiful discoveries of modern physiology ; but nothing of a practical nature has hitherto been deduc- ed 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 functional nature, or not connected with any change of structure either of the stomach itself, or of any of the neighbouring 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 mus- cular action of the stomach may be deficient, so that the alimentary matters remain in it too long, are imper- fectly changed, and pass into chemical decompositions. DYSPEPSIA. 91 We know the state of the urinary 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 emp- tied 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 healthy contraction. 2. There may be a deficiency of the corresponding and harmonious intestinal action, interfering with the second stage of digestion, and giving rise to imperfect chylification and various morbid actions in the upper intestines. 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 quanti- ties, 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 diges- tion, particularly the bile. If the mucous membrane be morbidly irritable, the muscular coat will probably be too easily excited to ac- tion, 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-digested state into the intestine, there to prove a source of new irritation. This is probably the state to be afterwards more particularly referred to, in which animal food pro- duces much uneasiness in the stomach, often followed 92 DYSPEPSIA.--CAUSES. 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 in- testine, the articles may undergo their proper change in the stomach, but will be propelled too rapidly through the intestinal canal, without time being afford- ed for the complete 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 en- tirely unchanged. I have no intention of entering at any length upon the treatment of indigestion ; but there are a few ob- vious and important rules, which, upon the strict grounds of pathology, may be deduced from the points which have been briefly referred to. I. It appears that the muscular action of the sto- mach is both more vigorous and more extensive when its contents are in small quantity, than when it is much distended ; and if we suppose the fluids of the stomach to be secreted in nearly a uniform quantity, their action must also be greatly regulated by the quantity of mat- ter which they have to act upon ; hence, the indispen- sable importance in dyspeptic cases of restricting the food to such a quantity as the stomach shall be" found capable of digesting in a healthy manner. This is unquestionably the first and great principle in the treat- ment of indigestion ; and without invariable attention to it, no other means will be of the smallest avail. II. It appears that various articles of food are of va- rious degrees of solubility in the stomach. When, therefore, digestion is apt to be easily impaired, it will be of the greatest importance, not only to avoid arti- cles 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 fa- DYSPEPSIA.--TREATMENT. 93 vour in a great measure the process of chymification going on in a regular and healthy manner, by avoiding a state in which the solution of one article may be more advanced than that of another. 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 experiments of Sir Astley Cooper, it is sup- posed, that the solubility of animal food is in the order of pork, mutton, veal, beef. Articles 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 mastica- tion. III. If digestion go on more slowly and more imper- fectly than in the healthy state, another important rule will be, not to take in additional food until full time has been given for the solution of the former. If the healthy period be four or five hours, the dyspeptic should probably allow six or seven. The injurious in- fringement of this rule by a breakfast, a meat lunch, and a dinner, all within the space of seven or eight hours, is too obvious 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 whatever. I believe that every stomach, not actually impaired by organic disease, will perform its functions if it receive reasonable attention ; and when we consider the manner in which diet is general- ly conducted, both in regard to quantity, and to the va- riety of articles of food and drink which are mixed up into one heterogeneous mass, instead of being aston- ished at the prevalence of indigestion, our wonder must 94 DYSPEPSIA.—TREATMENT. 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 dyspeptic 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 regard to quantity. It is often, indeed, remarkable, how articles which cannot be borne as a part of mixed diet, agree perfectly when taken alone; how a person, for example, who fancies that milk disagrees with him, will enjoy sound digestion upon a milk diet; and how another, who cannot taste vegetables 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 com- fortable 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 sto- mach, 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 severe- ly. He liad 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 moder- ate 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 know to complain of his stomach. DYSPEPSIA.--TREATMENT. 95 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 digestible, but there are -many cases which depend upon an irritable state of the mucous m 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 membrane, have already been refened to ; but there ap- pear to be modifications of it, which, without assuming this formidable character, have a similar effect on the func- tions of the stomach, and require similar treatment, es- pecially in regard to diet. The subject is one of great interest, and opens a most important field of observation to him who, renouncing a mere empirical 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 im- provement which is made in certain cases, under a diet restricted entirely to rice, arrow-root, or bread and milk, with total abstinence from all stimulating liquors, after the patient had spent years of wretchedness upon ani- mal 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, and the moderate use of stimulating liquors. The diagnosis is often difficult, and must be guided more by the judg- ment and attention of the practitioner, than by any gen- eral 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 impossible to advance any thing new. One thing, however, has always appeared to me to be of the ut- most importance in regard to the regulation of the 96 DYSPEPSIA.--TREATMENT. bowels, which in general are habitually slow. It con- sists in regulating them by the daily use of very small doses of laxatives combined with tonics, so as, without ev- er purging, to imitate at all times that moderate but reg- ular 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 potash and a few grains of rhubarb, taken once or twice a day ; sulphate of iron with aloes ; sul- phate of quinine with aloes ; oxide of bismuth with rhubarb or aloes, &c. Lime water is often useful, and the mineral acids. The nitric acid, in particular, is often found 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 stimu- lants, and by active purging ; and I must also express my apprehension that no small injury is done by the in- discriminate use of mercury. There are indeed some affections of the stomach, probably connected with de- rangements of the liver, in which a very cautious use of mercury appears to be beneficial ; but in many others, it is decidedly hurtful; and I conceive that in all dis- orders 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 a case to be afterwards described. In concluding this siight outline of the pathology of the stomach, it may be right to add a few observations on some points which frequently become objects of at- tention in the treatment of diseases of this organ. GASTRODYNIA. 97 I. Gastrodynia or pain in the stomach. This occurs to us in practice under four different forms, which seem to imply important differences in the nature of the af- fection. 1. Pain occurring when the stomach is empty, and rather relieved by taking food. This probably depends upon some degree of acrimony of the fluids of the sto- mach itself, and is generally relieved by absorbent and alkaline remedies. 2. Pain occurring immediately after taking food, and continuing either during the whole process of di- gestion, or till the stomach is relieved by vomiting. This is probably connected with chronic inflammation or increased 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 proba- bly seated in the duodenum, and connected with in- flammatory action or morbid sensibility of its mucous membrane. This form of the affection is often accom- panied by pain and tenderness on pressure in the right hypochondrium, and, on that account, is apt to be mis- taken for disease of the liver. In the course of the paroxysm, the pain is apt to extend obliquely down- wards and backwards in the direction of the right kid- ney, and thence again inwards towards the umbilicus. The duodenum evidently bears an important part in the function of digestion, and is probably the seat of some affections which are apt to be mistaken for dis- eases of the stomach and liver. Facts are wanting up- on this subject, but the investigation promises impor- tant results. All that we can say at present is, that, if the disease be chiefly or entirely seated in the duo- denum, 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 13 98 GASTRODYNIA. 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. When the af- fection proves more obstinate, it must be treated by top- ical bleeding and blistering, with farinaceous diet. 4. Pain in the stomach takes place in a fourth form occurring at uncertain intervals, in most violent parox- ysms ; accompanied generally by a feeling of disten- tion, much anxiety, and extreme restlessness ; and, in females, it is frequently combined with hysterical symp- toms. 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 injec- tion. From the facility with which such affections of- ten yield to this remedy, it is probable that the uneasi- ness is sometimes seated in the arch of the colon. Ex- ternal 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 to- gether. 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 treated CHRONIC VOMITING AND PYROSIS. 9§ by topical bleeding and blistering, if it do not soon give way. There is also a violent affection of the sto- mach, occurring chiefly in females of an irritable habit, and assuming a spasmodic or neuralgic 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 several remarkable examples have been given which show that they are often connected with chronic inflam- mation or ulceration, and that they may be very rapidly fatal, without having assumed any formidable character till the fatal attack. ''.-—* In all these painful affections of the stomach, atten- tion to regimen is, of course, of the utmost conse- quence. On this head it is impossible to lay down any general rules, as the diet must be regulated by atten- tion to the nature and characters of the case. One rule is applicable to all of them, namely, that the food shall be always in the smallest quantity. In regard to quality, there is a great, diversity. Some of the cases agree best with farinaceous diet and milk, while in oth- ers, 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 vaiiety of interesting facts on this subject, I refer to a work by M. Barras, " Sur les Gastralgies et les Enter- algies." 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 indiscriminate application of this system, and the practice founded upon it. II. Chronic vomiting, occurring at various irregular intervals, and without suspicion of organic disease. This seems in general to be connected with a morbid irritability of the mucous membrane of the stomach, 10* ^OBSTINATE AND UNTRACTABLE PYROSIS 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, the py- lorus 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 cas- es yield to the use of a strong tincture of garlic ; and others,to small doses of calomel. Much depends up- on regimen, and some of the most severe and protract- ed cases have got well under a diet restricted entirely to milk. External applications are also frequently use- ful, 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 liv- er, the spleen, the pancreas, and sometimes the brain. III. Obstinate and untractable pyrosis, often accom- panied with discharge of quantities of thin acrid mucifs by eructation, or with a feeling of constant and intense acidity, produced by articles which are not likely to be- come acid. These symptoms are probably connected with a diseased condition of the mucous membrane of the stomach. In some of the cases formerly described, we have seen them connected with actual ulceration ; 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 Jike the white of eggs ; and she never vomited either food or drink. On dissec- tion, no other morbid appearance could be discovered than a general thickened state of the mucous membrane of the stomach, which was of a brownish colour, and the follicles were remarkably developed. When the ftjEMATEMESIS. 101 fluid discharged is tinged of a brown or chocolate col- our, 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 propor- tion of albumen, and the colour appears to arise from the colouring matter of the blood. The affec- tion is very untractable ; it is often benefited by lime water, bismuth, the stimulants, as garlic and benzoin, and frequently by the acids, particularly the nitric; likewise by blistering and mild farinaceous diet. IV. Haematemesis. 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 dis- ease 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 re- duced 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 at- tacks of it, sometimes in connection with retention of the menses. When the patient is much exhausted, it is necessary to give smalr quantities of brandy at short intervals. 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, repeat- ed every three or four hours, for thirty-six or forty-eight hours, if necessary ; also the acids, the muriated tinc- ture of iron, bismuth, alum, and kino in powder 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 supported by farinaceous nourishment in small quantities, or by milk, or fresh-made soft curd. 102 SYMPATHETIC AFFECTIONS Of THE HEART. V. Sympathetic affections of the heart. These are often among the most troublesome symptoms that ac- company affections of the stomach, and are always the most alarming to the patient. They appear under va- rious forms, and frequently assume, in a very great de- gree, 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 ac- companied by an intermission of the pulse. This feel- ing may be repeated only once or twice at a time, and occur at long intervals ; or it may return in rapid suc- cession, for half an hour or an hour together ; or it may be felt occasionally, at irregular intervals, for se- veral days or weeks, or for a still longer period. It is sometimes accompanied 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 con- tinue 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 palpita- tion 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 frequent- ly there is no irregularity in the action,—the affection merely consisting of a strong pulsation, which the pa- tient 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 for an hour or two at a time, without any irregularity. I shall mention in the sequel a remarka- SYMPATHETIC AFFECTIONS OF THE HEART. 1 03 ble case, in which an affection of this kind continued with little remission for a year. Betwixt the various forms of this affection and dis- ease 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 re- lieved by it,—and not being excited by such bodily ex- ertion as we should naturally expect immediately to in- • fluence a disease of the heart. The affection is al- ways very alarming to a patient, and sometimes per- plexing 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 stethoscopic signs, particularly the bruit di 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 per- haps be acceptable to practical men. Between three and four years ago, a gentleman aged 52, consulted, 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 exer- cise, and he did not complain of his stomach. His pulse in the intervals was quite natural ; his bowels were rather confined, but very easily regulated. The affection had been going on for about three years, and 104 SYMPATHETIC AFFECTIONS OF THE HEART. a great variety of treatment had been employed with- out benefit. I confess I did not expect to do any good in this case, and, rather by way of doing some- thing, 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. Cautions were given him with regard to his regimen ; but I believe they were not at- tended to, for, under the simple remedy now mention- ed, this severe affection very soon disappeared. After a short time, he left off the regular use of the medi- cine ; but afterwards recurred to it occasionally for a few days, and in this manner he enjoyed very good health for upward of two years. He then went to the conti- nent, and I lost sight of him for about a year. I saw him on his return, as he passed through Edinburgh, on his way to his seat in the north, and found him very unwell. His pulse was frequent and extremely irregu- lar ; the action of the he'art was diffused, irregular, and tumultuous ; he had attacks of dyspnoea, amount- ing at times to a feeling of suffocation ; 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, express- ing great apprehension, and requesting him to watch the case very narrowly. In a short time I received no- tice, that the patient had been attacked with gout, and that all his other symptoms had disappeared. I have heard little of him since that time, but I believe he has enjoyed good health. A gentleman, aged 48, in November, 1825, began to be affected with paroxysms of palpitation of the heart, and intermission of the pulse. They attacked him daily, sometimes twice or three times a-day, and gen- erally continued about an hour at each time ; and they were occasionally accompanied with a considerable de- SYMPATHETIC AFFECTIONS OF THE HEART. 105 gree of dyspnoea. During the intervals, the pulse was calm and regular, and the action of the heart quite nat- ural. The period of the attack was generally soon af- ter meals • but it likewise occurred at various other times ; sometimes on first getting up in the morning, and sometimes during the night. During the parox- ysm, 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 di- et, were employed with very little benefit. He went to London, and then to Cheltenham, where much treat- ment was again had recourse to with little effect. He sometimes lost greatly in flesh and strength, and some- times improved again ; his digestion was sometimes bet- ter and sometimes 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 sub- sided under the use of the colchicum wine, in very moder- ate doses. I do not attempt to account for the action of the remedy in this singular case ; it acted at first strongly as a purgative, so that he was only able to take ten drops of the wine twice a-day. The patient's own ac- count of the effect of it is in these words : " At the time of commencing the use of the colchicum, I had once at least every day a severe fit of palpitation of an hour's dura- tion ; 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 begin- ning 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 14 106 SYMPATHETIC AFFECTIONS OF THE HEART. the quantity did not in general exceed from fifteen to twenty drops in a day. About three years ago, a gentleman, aged 65, began to be affected with some uneasy feelings in his chest, accompanied by an occasional sense of dyspnoea. On examination, his pulse was found to be very rapid, sel- dom under 120 often 130 or more, with some irregular- ity, and it was uniformly thus frequent at all hours of the day. The action of the heart was frequently slight- ly irregular; his digestion was impaired ; his nights were often very disturbed ; and during the night he had frequently a feeling of dyspnoea, which obliged him to sit up in bed. A variety of treatment was employ- ed for months, with 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 anxiety, 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 two 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 af- fected 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 his uneasi- SYMPATHETIC AFFECTIONS OF THE HEART. 107 ness by frequent and very deep inspirations, which are performed without difficulty. While the lungs are in the 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 inspiration. The attack generally continues from 15 minnies'to half an hour, and then passes off in an instant, with a feel- ing of some obstruction suddenly giving way ; every uneasy sensation is then instantly removed, and the pulse becomes full, soft, regular, and of the natural frequency. This affection was originally brought on by intense anxiety of mind nearly 30 years ago ; it has continued to recur since that time, but at very un- certain intervals, often of weeks or months, and has never produced any injurious effects upon his general health, It is unnecessary to enter into any general detail of the various sympathetic affections, which, in connection with disorders 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 occurrence. A gentleman, aged about 50, liable to delicate health and impaired digestion, about four 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, accom- panied by a violent and very loud sound, as if from the belching of wind. At the same instant that 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 accom- 108 SYMPATHETIC AFFECTIONS. panied 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 parox- ysms occurred many times in the day, and, in the night, he had frequent starting of his limbs. His digestion was bad ; the bowels were confined, and the motions were dark and unhealthy. At one time during the con- tinuance of the complaint, his limbs became considera- bly weakened, so as to assume the appearance of a slight degree of paraplegia; but nothing could be discovered about the spine, and the limbs after some- time 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 attempting a more correct diagnosis of this class of diseases. Some of them ap- pear 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 for- midable 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 connect- ed with corresponding diseases of the mucous membrane PATHOLOGY OF THE STOMACH. 109 of the bowels, or the affections of the neighbouring or- gans. It appears 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 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 terminates by ulcera- tion, or various organic affections of the parts concern- ed, I cannot avoid considering them as using a phrase- ology which is at variance with the principles of sound investigation, and calculated to obscure a subject of the utmost practical importance. APPENDIX TO THE PATHOLOGY OF THE STOMACH. In this appendix I mean to introduce a few observa- tions on the following subjects, closely allied to the pa- thology of the stomach, though not connected with dis- ease of that organ itself. 1. Derangement of the functions of the stomach by tumours 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 TUMOURS ATTACHED TO IT EXTERNALLY, WITHOUT DISEASE OF ITS COATS. Of the singular phenomena connected with some of the affections of this class, I shall only give the follow- ing example : 112 TUMOURS ATTACHED TO THE STOMACH. Case XXII.—A lady, aged about 70, had been affect- ed 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 nau- sea, 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 suddenly, and died after a short illness with diarrhoea and rapid failure of strength. Inspection.—The only morbid appearance that could be discovered, was a tumour 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 disease in the stomach it- self. 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 scirrhous hardness of the pancreas, without enlarge- ment ; 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 neighbouring parts, as the liver, the spleen, and the omentum. Many years ago, I examined the body of a woman who died gradually exhausted by daily vomiting, which had continued more than a year, and I could dis- cover no morbid appearance except the gall bladder dis- tended by a large number of biliary calculi, which completely filled it. In the Philadelphia Journal of Medical Science, a case is mentioned, in which the symptoms of deep-seated disease in the stomach were DISEASES OF THE (ESOPHAGUS. 113 connected with a tumour attached to the oesophagus at the third, fourth, and fifth dorsal vertebras. The patient had gnawing 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 (ESOPHAGUS. § I-—Inflammation of the (esophagus. Case. XXIII.—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 glandular swelling on the right side of his neck. His voice was hoarse, with a peculiar husky sound. The fauces were of a bright red colour without much swell- ing, 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 fever- ish, the other symptoms continuing 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 15 114 DYSPHAGIA. • recurrence of fever which now assumed a typhoid type, with considerable appearance of exhaustion. He had some dyspnoea, with considerable difficulty of swallow- ing. The attempts to swallow excited sometimes cough, and sometimes vomiting ; and by both were brought up considerable quantities of a soft membranous substance. He became more and more exhausted, without any re- markable 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-his death, he swallowed pretty freely. Inspection.—The whole of the pharynx was covered by a loose soft adventitious membrane, which also ex- tended over the epiglottis; and portions of it were found lying in small irregular masses, within the larynx, at the upper part. A similar membrane 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 oeso- phagus closely contracted 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 introduce more than a slight outline of it in connexion 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. These affections are generally distinguished DYSPHAGIA. 115 by cough and difficult breathing, but these are often slight or scarcely observed; and I have seen several cases in which the dysphagia was the prominent symp- tom, so as to lead to the supposition of disease of the oesophagus rather than of the trachea. In one of these cases, the epiglottis was thickened and much elongat- ed ; the patient had no "constant difficulty of swallow- ing, but was liable to sudden attacks of it during his meals, which threatened instant suffocation. In anoth- er case, the dysphagia was permanent, and was combin- ed with a hoarse husky cough and slight dyspnoea. The whole body of the larynx was much enlarged and thick- ened ; and it was in some degree ulcerated both inter- nally and towards the oesophagus. In both cases, the oesophagus was entirely healthy. 2. Paralysis of the oesophagus, generally connected with disease 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 intro- duced through an elastic gum tube, for five weeks be- fore his death. Dr. Monro has described several remark- able cases, in which complete loss of the power of the oesophagus seemed to take place without any other dis- ease. The peculiar character of the affection was a sudden and complete 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 remarka- ble 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 stricture of the oesophagus, which consists of a contraction of small extent at a particular spot, generally connected with thickening of the mu- cous membrane at the part, without disease of the other coats. 116 DYSPHAGIA. 4. Contraction with more extensive disease, as thick- ening and induration of the coats of the oesophagus, of- ten of great extent, and frequently combined with ul- ceration 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' they 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 oblitera- tion of a considerable extent of the oesophagus follow- ed an injury produced by swallowing a preparation of potass. 5. Tumours external to the oesophagus, formed by enlargement of the bronchial glands, or the glands in the posterior mediastinum. 6. Polypous tumours, growing from the inner surface of the oesophagus 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 tumour 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 in- strument. 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 affecte^ in this case, and swallowing was almost impossible. A remarkable 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 oeso- phagus, and a probang was introduced. When this reached the part which was very low down, it luptured DYSPHAGIA. 117 the abscess, and an immense discharge of matter took place, with immediate and permanent relief. 8. Aneurism of the aorta. I have seen several ex- amples 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 oeso- phagus. I have describee! one remarkable case in which the fatal attack was complicated with ramollisse- ment of the spinal cord. In another, a gentleman, in the vigour of life, had been complaining for a few weeks of difficulty of swallowing, 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 morning 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 occasioned rupture of the aneurism, and almost immediate death. 9. Disease of the Cardia. This has been already briefly referred to. 1 0. Dysphagia appears to exist, assuming all the cha- racters 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 indefi- nite 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 con- sidered a stricture of the oesophagus, accompanied by all its usual symptoms. Various courses of medicine and the frequent use of bougies had been employed without benefit. I scarcely know what induced me to 118 DYSPHAGIA. 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 pharynx. To my astonishment, the affection was completely re- moved, 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 remov- ed in the same manner; and she had afterwards several slight returns 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 rawness and tenderness a short way down the oesophagus. I have no doubt that they depended upon a superficial disease of the mu- cous 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. For numerous interesting facts relating to what has been called the spasmodic stricture of the oesophagus, as well as to the whole subject of dyspha- gia, I refer to the learned work of Dr. Monro.* * Morbid Anatomy of the Guild, Stomach, and Intestines. DISEASES OF THE DUODENUM. 119 SECTION III. DISEASES OF THE DUODENUM. Facts are wanting on this interesting subject, but it is probable the duodenum is the seat of several affec- tions, which are apt to be mistaken for affections of the stomach or the liver. The leading peculiarity of dis- ease of the duodenum, as far as we are at present ac- quainted 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 di- rection of the right kidney. In some cases, it gradu- ally subsides after several hours, and, in others, is re- lieved by vomiting. The peculiar characters of disease of the duodenum are well illustrated by a case related by Dr. Irvine, in the Medical Journal 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 occurred regularly every day. His appetite was good, and the functions of his stomach were unimpaired for two, three, or four hours after a meal. He was then seized with violent pain, followed by vomiting, and the pain did not cease till the stomach was completely emptied. He died gradually exhausted, in about six months from the tima 120 DISEASES OF THE Dl'ODKNLM. when the attacks began to occur daily. About three weeks before his death, a tumour 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 ex- tensive surface of ragged ulceration. It was also stud- ded with tubercles, varying in size from that of a hick- ory nut to a hazel nut. In the largest there was a soft white matter, and the cavity of the duodenum contain- ed 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 dyspep- tic 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 pul- sation- On the tenth day after the operation, he was seized with coldness, paleness, and convulsive move- ments, 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.* Ulceration of the duodenum may also be fatal by perforation and rapid peritonitis, in the same manner as we have seen in regard to the corresponding affec- tion of the stomach. There is a preparation of this kind in the Museum of the Royal College of Surgeons of Ed- inburgh, 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 de- scribed by M. Roberts.f A man, aged twenty-seven, had complained for some months of wandering pains in the epigastric region. For the last six weeks there had * Broussais sur la Duodenite Chronique. f Nouvelle Bibl. Medicale, Juin. 1828. DISEASES OF THE DUODENUM. 121 been diarrhoea, and for six days preceding the follow- ing attack, he had complained of nausea and loss of appetite. On 10th December, 1 827, three hours after dinner, he was suddenly seized with excruciating 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 peri- tonitis, 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 concluding this imperfect outline of the patholo- gy of the stomach, and the parts immediately connect- ed with it, I add the following observations as posses- sing considerable interest in a practical point of view. A gentleman from the country consulted Dr. Kellie and myself, in regard to a tumour in the epigastric re- gion, of about a year's standing ; and the commence- ment of it was dated from a violent exertion in lifting some heavy body. The tumour was large, flat, and firm, and free from pain or tenderness. On first inspec- tion it had the appearance of a^ mass of organic dis- ease of great extent; but, when we considered that his health was good, and the functions of the stomach lit- tle impaired, we departed from this opinion, and were disposed to believe that it might be formed in the par- ietes. After repeated examinations, we were prepared 16 122 DISEASES OF THE DUODENUM. to send him home with general instructions, when, on making a final examination, Dr. Kellie perceived in the tumour an obscure feeling of crepitus. Following this indication, persevering pressure was now employed, and the tumour gradually disappeared. It was distinctly a hernia, but what the contents of it were, we cannot de? cide. A lady from the country consulted me respecting pa- roxysms of pain in the epigastric region, accompanied by vomiting, to which she was liable at short but un- certain 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 ab- dominal 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 cover- ed 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 struc- tures 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 dis- tinct 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 trac- ing, in other parts of the body, in which the three structures are more distinct from one another, the lead- ing phenomena connected with the diseases of each. Thus, from ample observation, we have reason to be- lieve, that the most frequent result of inflammation, in a serous membrane, is deposition of false membrane,— in a mucous membrane, ulceration,—and in a muscular part, gangrene. There are various modifications of these terminations, but these now mentioned are the •> 124 PATHOLOGY OF^THE INTESTINAL (ANAL. most prominent, and the most peculiar to the diflerent structures. When, therefore, in a fatal disease of the intestinal canal, we find ulceration of the internal sur- face, 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 peri- toneum ; when we find gangrene, that the muscular coat had been affected ; and when we find both gan- grene and false membrane, that both the muscular and peritoneal coats were involved in the disease. In tracing the symptoms connected with inflammato- ry affections of the abdomen, we find them resolving themselves into three most important modifications. Thus, we meet with inflammation existing in the intes- tinal canal, with a perfectly natural state of the bow- elSj—with a loose state of them,—and with a state of insuperable obstruction. In the progress of this inves- tigation, we shall see reason to believe, that these three states of disease, so different from each other, are con- nected 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 as- suming the characters of untractable diarrhoea or dysen- tery ; 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 termination, while the functions of the bowels con- tinue in a perfectly natural state, through the whole course of the disease. It is necessary to anticipate these results, in connection with the arrangement 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, that which affects it simply as a muscular organ. This includes the various modifications of Ileus, which, though it very often'tci mi nates by inflammation FATHOLOGY OF THE INTESTINAL CANAL. 125 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 canarmight, therefore, divide itself in- to diseases affecting it as a muscular organ, including the varieties of Ileus,—and the inflammatory 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 subject, but I think it will answer the purposes of practical utility to consider peritonitis and enteritis to- gether, and the diseases of the mucous membrane sep- arately. On this plan, the actual division of the sub- ject 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. 126 ILBUS. 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 se- verity round the umbilicus, obstinate costiveness, and generally vomiting ; but without fever, and commonly at first without tenderness,—the pain, on the contrary, being rather relieved by pressure. As the disease ad- vances, and if no relief be obtained, the abdomen be- comes tense, tender, and tympanitic ; the vomiting very often becomes stercoracious, with severe tormina, in- tense suffering and rapid failure of strength. In this manner, the disease may be fatal without inflammation, or, at an advanced period, it may pass into inflamma- tion, and be fatal by extensive gangrene. The first part of our inquiry is to investigate the con- ditions of the affected parts in the various degrees and stages of this disease. In a pathological point of view, it resolves itself into three leading modifications, 1. Simple Ileus without any previous disease. ILEUS. 127 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. § I.—Ileus fatal in the state of distention with- out INFLAMMATION. Case XXIV.—A man, aged 40, 20th August 1814, had violent pain of the abdomen, urgent vomiting, and costiveness. The pain was at times increased by pres- sure, but not uniformly so ; his pulse was generally about 96, but at last rose to 120. The attack had commenced with symptoms resembling cholera, which had speedily passed into those of ileus. Repeated bloodletting 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 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. 128 ILEUS. 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 symptoms 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 dis- ease. *• Case XXV.—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 pressure ; frequent and violent vomiting, and obstinate costiveness. The belly was distended and tense; the tongue white ; pulse 76, and small. On the IGth, she had got wet during the flow of the cata- menia, which ceased, but returned at night; pain about the umbilicus began on the 17 th, and increased grad- ually ; vomiting began on the 2 1st, 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 ; frequent hiccup ; no stool ; pulse 88, and small ; frequent vomiting ; belly distended and tender ; every medicine was instantly vomited. • (25th.) No stool; every thing vomited ; pain almost gone ; pulse very feeble. (26th.) No stool; free from pain ; vomiting contin- ued with hiccup. Died in the night. Inspection.—The whole of the colon, and about twelve inches of the lower extremity of the ileum were empty, contracted, of a white colour, and seemed per- fectly healthy. The remainder of the small intestine was distended to the greatest degree, so as to appear FATAL WITHOUT DISORGANIZATION. 129 thin and transparent; its contents were chiefly watery matter and air. On the surface of the distended intes- tine, there was on several places, especially at the low- er part near the contracted portion, a superficial blush of vivid redness, but without any appearance of exuda- tion. 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 termination, 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 in- creased 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 appearance of inflammation. § II.—Ileus fatal with distention, and a dare li- vid COLOUR OF THE PARTS WITHOUT DISORGANIZA- TION. Case XXVI.—A lady, aged 7 0, after her bowels had been confined for several days, was seized on the 5th January, 1820, with violent pain of the abdomen and vomiting; pulse natural. The usual means were em- ployed by Mr. White without relief. On the 6th, the pain was considerably abated, but there was severe sickness, with frequent vomiting, and obstinate costive- ness ; 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 17 130 ILEUS, any flatulent distention. The lower extremity of the ileum, to the extent of 18 inches, was empty, contract- ed, and of a white colour, like the intestine of an in- fant; immediately above this, a portion from 18 to 24 inches in extent was throughout of a dark livid brown colour, 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 colour, with here and there portions of a dark livid brown. It con- tained only thin fluid feces and air. There was con- siderable disease of the internal surface of the abdomi- nal 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 obser- vation, that it was without any appearance of inflamma- tory exudation. § III.—Ileus fatal by gangrene without exuda- tion. Case XXVIL—A boy, aged 12, (26th Oct. 1813) was affected with violent pain of the belly, chiefly round the umbilicus, urgent vomiting, and costiveness for two days ; abdomen distended, pulse 50. Various remedies were employed without benefit. On the 27th the pulse rose to 120, with increase of the pain, ten- sion and tenderness of the abdomen. Bloodletting was used in the mor ning, and again at three p. m., after which the' pulse fell to 112. The other usual means were employed without procuring any evacuation from FATAL BY GANGRENE. 131 the bowels; the pain continued unabated ; sinking took place, with coldness of the body ; and he died between 7 & 8 o'clock in the evening, having continu- ed 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 in- testine was a little distended and slightly inflamed, es- pecially 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 perito- neum 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 imflammatory exudation ; and, at the upper part of the ascending colon, this dis- eased 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, which, with the rectum, contained much con- sistent feces* § IV.—Ileus fatal by gangrene combined with EXUDATION. Case XXVIII.—A young man, aged 19, (17th Oct. 1813) was affected with violent pain round the umbili- cus ; incessant vomiting ; abdomen hard, tense, and tu- mid ; bowels obstinately costive ; pulse S4 ; counte- nance depressed and anxious. He had been ill six days, during which a variety of remedies had been em- ployed without relief. He was now treated by repeat- ed general and topical bleeding, blistering, various pur- 132 ileus, gatives, purgative and tobacco injections, and all the other usual remedies, but without any permanent relief. On the 18th, the pulse was 120, and the belly tympa- nitic ; the vomiting was urgent, but not feculent, and there was some slight feculent discharge by the injec- tions. On the 19th, the symptoms were somewhat abated; but, on the 20th, they again increased ; the pain violent, the vomiting incessant, the belly much dis- tended ; the pulse from 92 to 96 ; slight discharge of watery matter by stool. He died on the 21st. Inspection. The stomach was healthy. Almost im- mediately below it, the intestine was distended to the greatest degree. It was in some places thin and trans- parent ; in others, highly inflamed and gangrenous, and bursting when handled ; and in others firm though per- fectly 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, inflamed, gangrenous, and adhering by exten- sive exudation, until three inches from the extremity of the ileum, where it became again contracted, empty, and of a healthy colour. These contracted 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 con- tained some consistent feces. The distended portions of intestine were chiefly filled by air ; there was in some places thin feculent matter, but in small quantity ; and no consistent feces could be found in any part of it. WITH OLD ADHESIONS. 133 SECTION II. ILEUS FATAL WITH PREVIOUS DISEASE OF SUCH A NA- TURE, THAT IT SEEMED TO ACT BY DERANGING THE MUSCULAR POWER WITHOUT MECHANICAL OBSTRUC- TION. § I.—Old adhesion of the intestine of small EXTENT. Case XXIX.—A gentleman, aged 17, had been for a considerable time liable to attacks of vomiting, ac- companied by a very constipated state of the bowels; but, in the intervals, he enjoyed good health. On the 26th July 1822, he had vomiting, 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 bow- els 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 every thing that was taken ; occa- sional 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 exhausted,— 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 dis- tended, and had a blush of redness. From the caput coli, the extremity of the ileum took a turn downwards into the pelvis, and adhered to the parietes of the pelvis by an attachment of old standing for several inches. 134 ILEUS, 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 adhesions. Case XXX.—A gentleman, aged 24, had been for several years liable to attacks of pain in the abdomen, affecting chiefly the right side. They usually con- tinued for several hours ; sometimes they returned ev- ery 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 13ht, 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. Inspection. The small intestine was greatly distend- ed, and, on many places, especially on the ileum, there were inflamed portions with exudation of false mem- brane, and other parts of a dark colour, approaching to gangrene. The right side of the colon was singu- larly 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 adhe- sion of old standing. The parts concerned in it did not WITH OLD ADHESIONS. 135 appear to be thickened, and the colon and caput ccecum were in other respects quite healthy. § II.—Old adhesion of the parts concerned in a HERNIA. Case XXXI.—A man, aged 63, had been for 40 years affected with double inguinal hernia, easily reduc- ible ; and he was liable to violent paroxysms of pain in the abdomen, during which he said the herniae were ge- nerally forced out. In November 1812, he suffered one of these attacks, more severe and longer continued than usual. During this attack the herniae had protrud- ed frequently, but he always reduced them with ease, till the morning of the 29 th, when he failed. They were easily reduced by a gentleman who then saw him, but, at night, when I saw him, they had again protrud- ed ; 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, fee- ble, 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 surface of that on the left side was inflam- ed and sloughy. The small intestine, down to the mid- dle 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 at- tached to each other, by an old adhesion about three 136 ILEUS, inches in exte nt. The coats of the intestine at this place appeared slightly thickened, but scarcely produc- ed any sensible diminution of its area. K HI,__A SLENDER BAND OF ADHESION BETWIXT TWO CONTIGUOUS PORTIONS OF INTESTINE. Case XXXII.—A boy, aged 8, had frequent vomiting and obstinate costiveness ; belly swelled and tympanit- ic ; countenance exhausted ; pulse frequent and feeble. He had been ill 10 or 12 days, during which the com- plaint had resisted every remedy ; and he died in two days more. Inspection. The small intestine was distended to the greatest degree, down to a point on the ileum, where the following cause of the disease was discovered. Be- twixt two turns of intestine, 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 re- mained 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, Ihe band of ad- hesion being thus put upon the stretch, so that the pe- ristaltic motion had been interrupted ; 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 ob- struction, and the coats of the intestine were perfectly healthy, except a circumscribed redness on its inner surface, at the point corresponding to the attachment of the band of adhesion. On the distended portion of WITH TWISTING OF SIGMOID FLEXURE. 137 intestine, there was a slight appearance of superficial inflammation, but it was of small extent and appeared to be quite recent. §- IV.—Singular twisting of the sigmoid flexure UPON ITSELF. Case XXXIII.—A man, aged 60, (23d 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 exhausted ; and his belly was enlarged and tympanitic, with frequent vomiting. He lived in great distress till the 28th, and the swelling of the ab- domen progressively increased, until it resembled the abdomen of a woman at the most advanced period of pregnancy ; yet to the last he could bear pressure up- on 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 en- larged to three or four times its natural size. On more accurate examination, 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 sto- mach, 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 colour ; 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 colour ; it contained only air and thin feces. The rectum was collapsed and healthy. The following appeared to be 18 136 ILEUS, the cause of this remarkable state of disease. The sigmoid flexure was found to have taken a singular turn upon itself, so that what is naturally its right side lay to the left, in contact with the descending colon ; and the left or ascending portion of it passed in front of this portion, and lay on the right. In consequence of this transposition, the rectum, as it descended from the former, namely, what was now on the left side, 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 colour of the diseased intestine terminated abruptly, and the remainder of the gut became white and collapsed. At this point, how- ever, there was no mechanical obstruction, for the part was quite pervious, and, excepting the slight twist, per- fectly healthy. In this singular case also, I had an opportunity of ascertaining 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 exam- ine 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 instrument, 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 inject- ing water into it. This was retained for some time in the distended state, and then slowly withdrawn ; but no discharge followed, though, as I have already stated, the distended intestine contained only air and fluid feces. WITH A LIGAMENTOUS BAND. 139 § V.—Ligamentous band confining a portion of INTESTINE TO THE MOUTH OF A HERNIAL SAC. Case XXXIV.—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 feeling of commotion, or, as he term- ed it, « a working," which began at the lower part of the belly, towards the left side ; it moved gradually up- wards, till it reached the stomach, and then he vomited almost every thing he had taken since the last attack. 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 affect- ed 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 hernea had never appeared, but very soon after he applied the truss the above mentioned com- plaint 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 af- ter 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 abdo- men. The other symptoms continued as before. His hernia never appeared ; the pulse was natural; evacu- ation from the bowels was procured by medicine. He died of gradual exhaustion, about ten weeks from the. commencement of the vomiting. Inspection.—The hernia was found to have been fe- moral ; a portion of the sigmoid flexure of the colon adhered to the mouth of the sac, and a fine ligamentous 140 ILEUS, 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- susceptio in two places of the small intestine ; and the lower part of the ileum was inflamed. The colon was collapsed ; the pylorus was hard, and a little thicken- ed ; and the inner surface of the stomach at the pylo- ric extremity was considerably eroded. SECTION III. ILEUS WITH MECHANIOAL OBSTRUCTION, OR OTHER OR- GANIC CHANGES IN THE STRUCTURE OF THE PARTS. § I.—Old disease of the intestine connected with HERNIA AND ARTIFICIAL ANUS. Case.XXXV.*—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 a very considerable time, and then gradually closed. Ten years after this, she had another attack, which was reduced without opera- tion ; but, from this time, she had been liable to at- tacks of pain in the abdomen, accompanied by obstruc- tion 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, urgent vomit- ing and obstinate costiveness ; the pulse little affected. WITH OLD DISEASES FROM HERNIA. 141 In the right groin the cicatrix left by the artificial anus was very obvious ; a small puffy tumour protruded from beneath the crural arch, which could be reduced with- out any difficulty; and the aperture felt quite free. This severe case having resisted every remedy for four days, and the patient's strength beginning to give way, it was determined, in consultation with Dr. Bal- lingall, to attempt her relief by an incision in the seat of the cicatrix. This was accordingly made by Dr. Ballingall in the evening of the 15th. The incision 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 diameter, 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 examination, was found to be a small finger-like pro- cess of the intestine, 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 obstruction. No relief followed the op- eration ; the symptoms continued unabated, with ster- coraceous vomiting ; and the patient died on the 16th — 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 operation was found to be in the lower part of the ileum; and a small process, or appendix, went off from one side of the intestine at the part, and descended in- to the hernial sac. The coats of the intestine were 142 ILEUS. somewhat thickened, both above and below 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 colour or structure. It contained only air and liquid feces ; and no obstacle appeared to the free discharge of these by the orifice in the groin, for the feculent matter began to flow freely during the dissection. § II.—Internal hernia. Case XXXVI.—A gentleman, aged 25, on 8th Au- gust, 1821, was seized with pain in the abdomen, and other symptoms of ileus, for which he was treated by Dr. Macauly in the most judicious and active manner, but without relief. I saw him on the 1 Oth ; his pulse was then C-6 and weak, and his countenance exhausted. The pain had subsided ; there was no tumefaction 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 re- turned with great violence in the abdomen, with vomit- ing and rapid failure of strength, and he died in the night. Inspection.—The whole tract of the small intestine was greatly 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 gangrenous ; and the strangulation was produced by a firm ligamentous band, which came down from the omentum, and was firmly attached to the parts about the brim of the pelvis. INTERNAL HERNIA. 143 Case XXXVII.—A girl, aged 17, was seized, on the 5th of July 1818, with violent pain and tenderness of the abdomen, vomiting and obstinate costiveness. Va- rious remedies were employed for four days without re- lief. I saw her on the 9 th ; the abdomen was then enormously enlarged, tense and tender; there had been no evacuation of the bowels ; the pulse was feeble and rapid ; and she died at night. Inspection.—The small intestine was much distended and inflamed ; 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 tumour and the caput coli, it left beneath it a space which admitted three fingers. In this space, a turn of intestine, six inches in length, was strangulated and gan- grenous. Case XXXVIII.—A man, aged 2 8, was seized with the symptoms of ileus in the usual form, on the 15th of August 1815, and died on the 18th. Inspection.—There was a hard glandular mass of con- siderable 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 adhered to the mass by two con- tiguous points, leaving betwixt them a space which ad- mitted 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 suf- fered much, for some months, from deep-seated pain in the abdomen ; but he had got well, and from that time had enjoyed tolerable health, except two attacks of 144 ILEUS. 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. § III.—Intus-susceptio. Case XXXIX.—A woman, aged 32, (9th November 1818) while sitting dressing her child, was suddenly seized with vomiting, and pain at the stomach, which soon after moved downwards, 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 produced 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 loth. Inspection.—The small intestine was greatly distend- ed. 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 in- verted parts were inflamed, and extensively gangrenous, —some portions being reduced to the state of a soft pulp. The colon was healthy. Case XL.—A young man, aged 19, awoke in the night of 23d October, 1819, complaining of violent pain in the abdomen, with urgent vomiting. Pulse at first natural, but in the course of the day became fre- quent—pain little increased by pressure. All the usu- al remedies were employed without relief. I saw him SNTUS-SUSCEi'Tlu ] 45 on the 25th; pulse then 120, and feeble; urgent vom- iting ; belly not tumid, and little or no pain on pres- sure ; no stool ; features collapsed. He died in the night. Inspection.—The small intestine was considerably distended, with inflamed poitions and spots of gan- grene. 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 con- siderable quantity of coagulated blood. Case XLI.—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 quanta . ties of bloody mucous, 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 tumour of a dark bloody colour protruded from the anus, to the bulk of an egg. It was easily reduced, but, on exam- ination, was distinctly ascertained to b.e inverted intes- tine ; and a probang, being introduced, passed to a great depth by its side, without reaching the commence- ment of the inversion. The child died on the follow- ing morning. Inspection.—A most remarkable inversion of the in- testine 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 a correspond- ing portion of the ileum, measured thirty-eight inches. The part that had protruded at the anus was the invert- ed caput coli. The inverted portion of the colon was of a dark livid colour, very soft, and, at some places, thickened. The portion of the ileum included within this was tolerably healthy. Besides the mesentery con- 19 146 ILEUS, nected with the inverted intestine, a portion of omen- tum was included. I have seen another case exactly resembling this, ex- cept 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 XLII.—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 tenderness; but no stool except small quantities of bloody mucus. Ill three days ; con- tinued through the day without any change in the Symp- toms, and died in the night. Inspection.—A portion of the ileum, more than twelve inches in extent, was inverted, and firmly impacted with the caput coli; some inflammation had com- menced in the parts above. Case XLIII.—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 fre- quent vomiting. (29th.) Some vomiting, but hot ur- gent; febrile oppression and scanty discharges of bloody mucus from the bowels. (30th.) Much oppression ; abdomen soft, but a deep-seated,, defined fulness was felt in the left side; no vomiting ; a few scanty stools of reddish mucus, without feces. Various purgatives had been given without effect, and injections could not be made to pass up. (31st.) No vomiting; no dis- tention of the abdomen ; increasing exhaustion ; evac- uations 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 FROM GALL STONB. 147 the remainder of the colon and the corresponding ex- tent of the ileum, were included in the inversion, and extended as low as the sigmoid flexure of the colon. The included parts were very dark coloured, turgid, and in some places ulcerated. § IV.—Ileus from a gall stone. Case XLIV.—A' man, aged 45, had been repeatedly affected with violent paroxysms of pain, followed by jaundice, which had been supposed to indicate the passage of gall stones. On 3d June, 1822, he was seized with one of those paroxysms in the usual man- ner, and the pain continued in great violence through the whole day, accompanied by vomiting. On the fourth, the violent 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 fre- quent, and his bowels had not been moved. On the fifth, the symptoms were those of complete ileus, and he died in the night. I had seen him only late in the evening. Inspection.—The upper half of the small intestine was distended and inflamed, with considerable exuda- tion. The lower half was collapsed, empty, and of a healthy appearance. At the place where the disten- tion 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. 148 ILEUS, § V.—Contraction of the calibre of the intestine. Case XLV. A man, aged 7 0, had complained foi several weeks of a deep seated pain referable to a de- fined spot at the lower part of the abdomen ; but it was not so severe as to prevent him from following his usual employments. On the 27th of July, 1815, he was seized with symptoms of ileus, and died on the 3 Ist. • Inspection.—The whole of the small intestine and the colon were in a state of great and uniform disten- tion, and of a dark colour. The distenton stopped at the second turn of the sigmoid 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 scarce- ly to admit the point of the little finger. The inner surface of this portion was covered with red fungous excrescences, like granulations. Much feculent matter was accumulated in the parts above. Case XLVI. A woman, aged 60, had complained for some time of frequent uneasiness in her bowels, with much flatulent distention. (27th August, 1817.) Uneasiness in the bowels was increased ; no stool for four days. From this time she resisted every remedy, but the symptoms were not violent; there was occa- sional griping, but no fixed pain ; no fever; no tender- ness ; 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 prodigiously distended, and there was in several contraction of the intestine. 149 places recent inflammation, with exudation of false membrane. The disease extended to the rectum, about four inches from the anus, where the canal was so con- tracted as scarcely to admit the point of a very small finger. Behind this spot, there was a large mass of dis- eased glands, and the contraction was* occasioned by a firm flat substance, which crossed the intestine in front, and was connected on both sides with this mass. When this substance was cut through, the intestine was set at liberty, and its coats were healthy. Case XLVII.—A woman, aged 63, had enjoyed tole- rable health till within three months of her death. She then had vomiting and costiveness for a week, and was relieved by purgatives. After this, she complained of nausea, without vomiting, and without pain ; the abdo- men 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 exhausted, about three months from the commencement of the disease. Inspection.—There was great thickening and indu- ration 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 coloured. Case XLVIII.—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 judi- cious manner by Dr. Ross, but without relief, and I saw her along with him on the 3d.' The pulse was then rapid and feeble ; countenance anxious and ex* 150 lLEl'S, hausted ; abdomen distended, tympanitic, and tender ; 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 colour, with some exudation of false membrane. This state terminated abruptly at about ten inches from the lower extremity of the ileum, and the remain- der of the ileum was of a healthy colour, but ap- peared unusually thick, firm, fleshy, and of a tor- tuous figure. The canal of the intestine, through this portion, was found to be narrow, 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 turns of the*intestine ad- hering 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 membrane was removed, and the adhesions were separated, which was done with dif- ficulty, 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 XLIX.—A man, aged 24, had an attack of cho- lera about a year before his death, and from that time was liable to uneasiness 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, progressive loss of stricture of the colon. 15 1 strength and most obstinate costiveness. When I saw him, a few weeks before his death, he was much wast- ed, 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 ex- hausted, without much suffering ; his abdomen had been tense, but not remarkably distended. Inspection.—In the centre 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 composed of fibres from the mucous membrane, which were attached 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 stric- ture, the right side became immediately distended to upwards of twelve inches in circumference ; it continu- ed of this size to the caput coecum, and the whole was completely impacted with firm consistent feces. A great part of the small intestine was also distended with consistent feces. 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 of appendix, as they seem to illus- trate points in the pathology of ileus. § I.—General tympanites. Case L.—A man, aged 40, had undergone an opera- tion for fistula of small extent, which healed favourably ; and he was preparing to return to the country, when in the night preceding 1st September 1825^ he was seized with vomiting. He vomited 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 occa- sional vomiting, but not urgent. He took laxative me- dicine, which produced several dark watery evacuations, without relief; and in the evening he was becoming ex- hausted, with a rapid pulse. I saw him on the morn- ing of the 2d. He was then extremely exhausted ; perspiration standing in drops on his forehead ; extrem- TYMPANITES.--EFFECTS OF GALVANISM. 153 Hies cold ; pulse 160, and feeble; abdomen much dis- tended and tympanitic ; it was somewhat pained when pressed, but not acutely tender ; some vomiting contin- ued ; bowels moved several times ; stools dark, watery, and scanty ; every attempt was made to rally him with- out effect; he died early in the afternoon. Inspection.—The whole tract of the bowels, to the very extremity of the rectum, presented one continued state of great tympanitic distention ; in some places they were tinged of a deep red colour; in others, of a livid or leaden colour, but without any change in their struc- ture. 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 sani- ous fluid, slightly puriform. § II.—Effects of galvanism on distended intestine. Case LI.—A gentleman, aged 50, for whose case I am indebted to Mr. Clarkson of Selkirk, was affected with vomiting and pain in the right side of the abdo- men^ which was hard, distended, and acutely tender to the touch. His bowels were obstinately costive, and resisted the action of the strongest purgatives, except when assisted by repeated and strong injections. Treat- ment upon this plan had been continued for a fortnight, with very slight effect, when Mr. Clarkson determined upon trying the application of galvanism to the part of the abdomen which was hard and tense. The applica- tion was almost immediately followed by copious evac- uation 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 20 154 ILEUS. rumbling noise ; and this was soon followed by a copi- ous evacuation. 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 al- low 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 discharged much black hardened feces, but they became gradually more natural, and at the end of ten days the galvanism was discontinued. SECTION IV. PATHOLOGICAL AND PRACTICAL INDUCTIONS FROM THE PRECEDING FACTS. From the cases now detailed, illustrative of the vari- ous modifications of ileus, some principles appear to be deducible, of much pathological interest and practical importance. At the earliest period at which we have an opportu- nity of seeing the condition of the parts in a fatal case of ileus, it seems to consist in a state of simple disten- tion without any visible change in the structure of the part.—(Case XXIV.) At a period a little more advan- ced, we find on the distended part a tinge of vivid red- ness.—(Case XXV.) In another state of the disease, the distended part presents a leaden or livid colour, without any sensible change of texture,—(Case XXVI ;) and, at a period still more advanced,this seems to pass in- GENERAL CONCLUSIONS. 155 to gangrene, (Case XXVII.) It is probable that these appearances are chiefly seated in the muscular coat, for we see them, in the cases referred to, pass through all these stages without any appearance indicating perito- nitis. But it also appears that the affection, in its more advanced stage, may be combined with peritonitis, as in Case XXVIII, in which we find the gangrene combi- ned with exudation of false membrane. The next interesting point in this investigation is to mark the condition of the muscular action of the bow- els, during the progress of these morbid changes. At the more advanced period of them, it is evident that the muscular action is entirely destroyed ; for we find the part which has been distended fallen flat when it is emptied, and presenting a broad surface like an empty bag, without any tendency to contraction, (Case XXVII.) This case, indeed, presents the disease in a state of perfect gangrene ; 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 remarka- ble case, (Case XXXV.) in which the patient lived for eighteen hours, with a free external opening directly communicating with the distended intestine, but with- out any discharge taking place, though the part con- tained only air and fluid feces. In this case the intes- tine, for a considerable space above the opening, must have been entirely deprived of its muscular action, and yet, upon examination after deaths the part presented only a uniform distention, without any remarkable change either in colour or texture. A similar condi- tion of the parts must have existed in Case XXXIII, in which the obstruction was within reach by the rectum, and was repeatedly dilated by various mechanical means, without any discharge following. A remarkable illustration of these principles is derived from Case LI, in which an obstruction, which had resisted the most 156 ILEUS. active purgatives, and was accompanied by an evident and painful distention of a part of the bowels, was re- moved by the repeated application of galvanism to the pait; 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 conse- quence 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, pre- senting nearly the form of a cord ; and there has been supposed to be a difficulty in determining which of these is the primary seat of disease,—some having con- tended that the collapsed part is contracted by spasm, and thus proves a source of obstruction, which leads to the distention 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 endeavour to throw any light upon this important pathological question. The following considerations seem to bear upon the inquiry :— 1. The collapsed state of intestine, in which it as- sumes 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 in a very open state up to the period of death. We cannot doubt that a similar state of uni- form contraction is the healthy condition of other mus- cular organs when they are empty, such as the bladder. We have then no sufficient ground for assuming that GENERAL CONCLUSIONS. 157 the state of uniform contraction of intestine is a state of disease ; on the contrary, the facts favour the sup- position of this being its healthy condition*when it is entirely empty. 2. On the other hand, we learn from various cases, particularly from the remarkable case, (Case L.) that a state of uniform 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 invariably found in a healthy condition at all periods of the disease ; the morbid appearances, whether inflam- mation, lividity, exudation, or gangrene, being almost entirely confined to the distended parts. 4. In Case XXXV, every obstruction below was en- tirely removed, while the parts above were, to external appearance, in a healthy state,— and yet the action was entirely suspended. 5. In Case LI, the cause, which uniformly acted in so singular a manner, must be supposed to have acted upon a part only whose action was impaired, not upon one which was spasmodically contracted. 6. In Cases XXIX, XXX, and XXXI, we see the state of distention arising from causes entirely of a dif- ferent nature, without the peculiar contraction here re- ferred to; and on the other hand, in Cases XXXII, XXXIII, and XLIV, in which the disease was distinct- ly traced to a mechanical cause, this peculiar contrac- tion existed below the seat of the obstruction, but could not be considered as having had any influ- ence in producing the disease. In Case. XXXIII also it is to be remarked, that the contracted part was re- peatedly and freely dilated during the course of the disease, without any effect in relieving the parts above. On these grounds, I submit the probability of the opinion, that, in a case of ileus, the distended part ib 158 ILEUS. the real seat of the disease ; and that the contracted part is not contracted by spasm, but is merely collaps- ed, because it is empty, its muscular action being un- impaired. m On a subject of this nature, it is dangerous to spec- ulate beyond 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 ali- mentary 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 con- tents into a portion No. 2, the force exerted must be such, as both to propel these contents, and also to over- come the tonic contraction of No. 2. The portion No. 2. then contracts in its turn, and propells the mat- ter into No. 3 ; this into No. 4, and so on. Now, for this process going on in a healthy manner, it is neces- sary, 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 in- terrupted ; (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 inanimate 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 GENERAL CONCLUSIONS. 159 formidable nature takes place in the function of the canal. (2d.) If, in the series of actions now referred to, No. 4. contracts in its turn, while some obstacle exists to the free dilatation of No. 5. it is probable the motion may be so inverted, that the contraction of No. 4. may dilate No. 3. and that this inverted action may be communicated backwards to the other portions. Something of this kind seems to have occurred in a striking manner in Case XXXIV. In the state of parts here referred to, varieties may occur, which ap- pear to give rise to important differences in the phe- nomena. The obstruction to the dilatation of No. 5. 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 dilatation is required ; but, when there is an increased distention of the parts above, ei- ther from increase of solid contents, or from some ac- cidental accumulation' of flatus, then a greater degree of expansion may be required than No. 5. 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 af- fections of the canal, we find the patient liable to at- tacks of pain and other concomitant symptoms, which at first occur only at long and uncertain intervals, but at length terminate in fatal ileus. This important mod- ification of the disease is strikingly illustrated by Cases XXIX, XXX, and XXXV ; in the two former of which, it is particularly to be remarked, that there was no me- chanical obstruction. • In such cases, it is also to be observed, that, though the healthy action is interrupted, a portion of the contents may pass through. This ev- idently occurred in the very interesting case, (Case XXXIV.) in which evacuation from the bowels was re- gularly procured, though the action of the canal was 160 ILEUS. uniformly inverted, whenever it reached the seat of the disease. The* principles now slightly referred to, seem to bear upon many affections of the intestinal canal, which wc in vain endeavour to reconcile with the vague and in- definite.doctrine of spasm. But I forbear from specu- lating upon them farther at present, and shall conclude this part of the subject by certain inductions of a prac- tical nature, which appear to arise out of the cases which have been described. 1. The most uniform morbid appearance, in fatal cases of ileus, is a greater or less extent of the intes- tinal 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 va- rious stages of its progress, from a recent tinge of red- ness to extensive gangrene. 4. There seems to be great variety in the period at which the inflammation takes place. It appeared to be quite recent in Case XXV. which was fatal on the 9th day, and in Case XXXIII. which was fatal about the 13th, while in Case XXVII. it had passed into exten- sive gangrene as early as the 3d day. 5. Pain increased upon pressure'does not appear to be a certain mark of inflammation in the bowels ; for it occurred in Case XXIV. in which there was no in- flammation ; 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 at- GENERAL CONCLUSIONS. 161 tention, can generally be distinguished from the acute tenderness of peritonitis. 6. Sudden cessation of the pain, and sinking of the vital powers, are not necessarily indications of in- ternal gangrene ; for we have seen these symptoms existing with recent inflammation ; and, in a subse- quent 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 ex- tensive gangrene, in which the pain continued violent to the last. 8. The pulse appears to be a very uncertain index of the condition of the parts in ileus. In Case XXV. in which there was considerable inflammation, it was less affected than Case XXIV. in which there was none. In Case XLVI. again, there was neither fre- quency of pulse, nor tenderness of the abdomen, though there was inflammation with exudation to a very consi- derable extent. Many other important circumstances, with regard to the state of the pulse, may be remark- ed in the cases ; one of the most important is in Cases XXVII. and XXX. which were fatal, with ex- tensive inflammation and gangrene, within eight or ten hours from the time when the pulse was first observed above the natural standard. In others, in which the disease was equally extensive, we find the pulse but slightly affected through the whole course of the disease. 9. Ileus does not appear to be necessarily con- nected with feculent accumulation, or with any con- dition 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. 1 0. Ileus does not appear to be necessarily connect- ed with obstruction in any part of the canal; for we 21 162 ILEUS, have seen it fatal without obstruction, and we have seen every thing like obstruction entirely removed without relieving the symptoms. 11. We must be cautious in forming a favourable prognosis in ileus, from the appearance of feculent eva- cuations. For these, we have reason to believe, may oc- cur while the disease is nevertheless going on to a fatal termination ; and much feculent matter 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 intestinal canal, without sensibly interrupting its func- tions, until at length, from some cause which eludes our observation, it suddenly produces fatal ileus. (Cas- es XXXVIII. XLV. and XLVI.) 13. On the other hand, such organic disease may be fatal by gradual exhaustion, without ileus. (Cases XXXIV. XLVII. and XLIX.) 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, and we have seen extensive in- flammation 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 assume the characters of ileus, there is great di- versity in the primary state of the affected parts ; that, in some, it consists of simple loss of muscular power, though it may pass into inflammation at an advanced GENERAL CONCLUSIONS. 163 period ; while in others, it is at an early period con- nected with inflammation as a part of the primary dis- ease. 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 gan- grene, uncombined with the flocculent or pseudo-mem- branous deposition, which is so prominent a character of enteritis. Now, gangrene in the intestinal canal appears to be chiefly a disease of the muscular 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 pe- culiar symptoms, and they do not affect this part of the inquiry. When, in the cases now under consideration, therefore, we find gangrene uncombined with any other morbid appearance, we are perhaps warranted to con- jecture that the muscular coat has been the principal seat of the inflammation. It seems to constitute a modification 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 rapidly fatal. We shall afterwards see reason to believe, that inflammation may be seated in the peritoneal coat alone, producing a dis- ease which may be fatal without any interruption of the action of the canal ; or that it may affect the perito- neal and muscular coats at once, giving rise to the dis- ease which we commonly call enteritis. 164 IliF.LS. 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 accu- rate examination in regard to the existence of hernia ; and here two circumstances 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 por- tion from one side of the intestine, and yet be the cause of fatal ileus. In the medical management of cases which are re- ferable' to the general head of ileus, there are impor- tant distinctions to be kept in mind as to the state of the symptoms, which seem to require important diver- sities in the 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 fol- lowing. 1. Obstinate costiveness with distention of the ab- domen, and considerable general uneasiness, but with- out tenderness, and without much acute suffering. 2. The same symptoms, combined with fixed pain and tenderness, referred to a defined space on some part of the abdomen, frequently about the head of the colon. 8. Violent attacks of tormina, occurring in parox- ysms, like the strong impulse downwards from the ac- tion of a drastic purgative,—the action proceeding to a TREATMENT. 165 certain point,—there stopping and becoming inverted, —followed by vomiting,—the vomiting often feculent. These forms of disease will be recognised by the practical physician, as constituting affections distinct from each other. In a practical view, the importance of the distinction consists in pointing at two modifica- tions of the disease which seem to lead to differences in treatment ; namely, a state in which there is a defi- cient action of the canal,—and one in which there is a violent action limited to a certain part of it, though in- effectual for overcoming a derangement which exists below. The practical application of the distinction re- fers chiefly to the use of purgatives in ileus; and to the question, whether, in every case of ileus, the ac- tion of the canal requires to be excited by purgatives,— or whether there are not modifications of the disease in which its action rather requires to be moderated. The adaptation of the remedies to the individual cases in fact demands the utmost discretion ; and it is impossi- ble to lay down any general rules for it. There are some cases which yield at first to a powerful purgative, and there are others in which anything like 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 inter- vals, of moderate doses of mild medicine, 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, that there are cases which yield to a full dose of opium, after the most active purgatives have been tried in vain. In re- gard 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, re- quires to be used with the utmost discretion. The 166 ILEUS. 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 muscular coat, and therefore not exhibiting the characters of enteritis, but simply of ileus, though in a very violent and rapidly fa- tal form. On both these views, therefore, blood-letting is a most important remedy in every case of ileus, ex- cept 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 first with much caution,—perhaps not more than fifteen grains infused for ten minutes 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 produc- ed, in slight giddiness and muscular relaxation, as show that its peculiar 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 a free use of this powerful remedy. If, while the tobacco injection is used in this man- ner, 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 TREATMENT. 167 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 application ol cold to the abdomen by cloths wet in vinegar and water. In tympanitic states of the abdomen, when not accompanied by coldness of the surface, and in cases attended with local circumscribed pain and ten- derness, this remedy is often followed by the most beneficial results. Cold injections have »also 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 9 th volume of the Edinburgh Medical Journal. (4.) Opiates. I have already alluded to a modifica- tion of the disease which yields to a full opiate, more readily than to any other mode of treatment. The case to which this practice is particularly applicable, is perhaps chiefly characterized by the paroxysms of vi- olent tormina. If these are accompanied by frequency of pulse, and fixed pain or tenderness, a full bleeding, followed by an opiate, seems in general to be the best mode of treatment ; 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. (5.) In the advanced stages of the disease, when tke system begins to become exhausted, stimulants must be given freely ; and, under the use of these, a case vrill often give way which had previously resisted the most active treatment. The aloetic wine is a convenient re- 168 ILEUS. medy in this stage of the disease, combining the stimu- lating 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 man- ner ; and it is a remarkable fact, that, in this state of the system, and even with a tympanitic state of the ab- domen, the tobacco injection, if given with sufficient caution, may still be employed with much advantage, along with the use of stimulants. Of a recovery 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 LII.—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 afternoon, the pain nearly ceased ; there was collapse of the features, 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 snail quantity, and was repeated several times. It did not increase the sinking, but seemed rather to abate both it and the vomiting. On the following day, there w£.s a decided improvement, and some scanty evacua- tion had taken place from the bowels ; wine was con- tinued in smaller quantities, and the tobacco injection TREATMENT. 169 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 continu- ed convalescent. The remedies which I have now mentioned are those of which 1 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 symp- toms. 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 (mantity 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 tur- pentine applied externally or by injection. When the vomiting is very urgent, so as to prevent medicines from remaining on the stomach, large doses of calomel, of from fifteen to twenty grains, 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, repeated at short intervals in combination with the oxide of bismuth. Whatever practice is employed ought to be zealouslv persevered in, notwithstanding the most unfavourable ap- pearances ; for the disease has been known to resist the most active remedies, and yet terminate favourably, as late as the 17th day. 22 PART II. INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CANAL, INCLUDING PERI- TONITIS AND ENTERITIS. In tracing the phenomena connected with inflamma- tion in the intestinal canal, we cannot fail to take notice of three remarkable varieties in the symptoms. We find inflammation existing in the canal, and going on to a fa- tal termination, with a natural or easily regulated state of the bowels,—with insuperable obstruction of the bowels,—and with severe and uncontrollable diar- rhoea 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 fre- quently some puriform fluid; in the second, we gen- erally observe this appearance combined with gangrene ; in the third, we find ulceration, 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 INFLAMMATORY AFFECTIONS. 171 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 perito- neal 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 up- on which these distinctions are made, will appear more particularly in the sequel ; but it is necessary simply to state them here, with a view to an arrangement 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 in- testinal inflammation may be confined to the peritoneal coat, and that, in this case, it may run its course with- out 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 symptoms 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 mucous membrane, produc- ing a train of symptoms altogether different 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 be- lieve, that these forms of disease may pass into each other, by spreading of the inflammation from one struc- ture to another ; that a case, for example, may begin as simple peritonitis, and may afterwards pass into en- teritis ; and that another may begin with severe diar- rhoea, or dysentery, and afterwards terminate by inflam- mation of the other coats. In treating of ileus, I have alluded to the important fact, that cases of ileus which have not shown any in- flammatory symptoms, or not till a very advanced peri- 172 INFLAMMATORY AFFECTIONS. od, are sometimes fatal by extensive gangrene, without any inflammatory exudation ; and, as gangrene, in such cases, must probably be considered as an affection ol the muscular coat, I have proposed a conjecture, that the worst forms of ileus may sometimes depend upon inflammation confined to that coat. On the other hand, it will be found, that the cases which exhibit the cha- racters commonly assigned to enteritis, are fatal either by extensive inflammatory exudation and adhesion, or by these combined with gangrene, never by gangrene alone. This is the result of my observation, as it stands at present ; if it shall be verified by farther ob- servation, it will give probability to the following con- jectures : \. That inflammation may exist in the intes- tinal canal, confined to the muscular coat, and marked by symptoms of ileus, without exhibiting the symptoms usually considered as 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 cha- racterized by symptoms of ileus, without exhibiting those of enteritis. 2. That in the more acute affections of the bowels, assuming those characters which are usu- ally considered as indicating inflammation, the disease is primarily seated either in the peritoneal coat alone, or in both the peritoneal and muscular coats at once. In the practical consideration of this important class of diseases, I shall consider peritonitis and enteritis in connection, because they are very generally combined, or pass into each other ; and I shall then treat sepa- rately of the inflammation of the mucous membrane. PERITONITIS. i -o J / u SECTION I. SYMPTOMS OF INTESTINAL INFLAMMATION UNDER THE FORMS OF PERITONITIS AND ENTERITIS. I. 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 fre- quently, the lower part, immediately above the pubis. It is increased by pressure, and frequently is little com- plained of except when pressure is applied ; being an acute tenderness of the parts, rather than 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 mistaken 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 distending the inflamed part; and the action of a purgative is often followed by a violent aggravation of all the syptoms. The pain is also aggra- vated by various exertions, such as coughing, sneez- ing,—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 position, or even of the.action of the ab- dominal muscles or of the diaphragm. In some case? 174 PERITONITIS. the pain is apt suddenly to shift its place from one part of the abdomen to another. According to the seat of the inflammation, various neighbouring 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 extend- ing along the urethra ; when it is in the neighbourhood of the kidneys, the secretion of urine is often greatly diminished, or nearly suspended ; when it is in the up- per part of the canal, there is frequently vomiting, and sometimes a particuliar spasmodic action like the belch- ing 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 extend- ing to the diaphragm. The pulse is often little affect- ed, especially in the early stages; it is perhaps from 80 to 90 or 96, but is often scarcely above the natural standard ; 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 appear s to have been subdued, the operation of a purgative is immediately followed by a renewal of the symptoms in all their original violence. This affection differs from enteritis in the bowels being natural or easily regulated,—in the pulse being often little affected,—in the pain frequently occurring in par- oxysms,—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 permanent, the pulse rises, the belly becomes tympanitic, and, at PERITONITIS. 175 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 con- tinuing 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 pro- gress of the inflammation, destroying the action of the parts ; or it may arise merely from the loss of tone, af- ter the inflammation has been subdued. In the former case, it is generally a fatal symptom, but, in the latter, it may often b# recovered from. Simple peritonitis may be fatal in three days, but fre- quently 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 se- veral weeks or months. On dissection, we generally find extensive deposition of flocculent matter and false membrane, producing extensive adhesions, and frequent- ly copious**effusion of a limpid or milky fluid, and some- times of a fluid with ail the characters of pus. Gan- grene 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 accom- panied with extensive deposition of false membrane. I have already stated my conjectures in regard to the nature of this disease. I conceive that the inflamma- tion is confined to the peritoneal coat ; that in this state it may be fatal without interrupting the muscular action of the bowels; or that the inflammation may ex- tend to the muscular coat, and then assume the charac- ters of enteritis. Inflammation of the peritoneum may occur in a more limited form than that which I have now described, and, 176 PERITONITIS. 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 seated in the membrane lining the diaphragm, may simulate disease 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, with- out 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 having terminated favourably. 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 originally of this nature ; and this form of the affection will also be illustrated by Case LVII. in which it was ascertained at an early pe- riod in consequence of the patient dying of another disease. A remarkable circumstance in the history of perito- nitis 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 con- dition, while most extensive disease remains, which may go on for some time without its presence being suspect- ed, until it assumes a fatal character, either suddenly, or by gradually undermining the health of the patient. This remarkable point in the history of the disease will be strikingly illu»trated by Case LVIII. KNTER1TIS. 17T 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 perma- nently 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 tenderness of the abdomen, but without much com- plaint of pain. This variety seems to occur chiefly in young persons, as is exemplified in Cases LXIII. and LXIV. The pulse in enteritis is generally small and rapid, but not uniformly so, for we may find the dis- ease with a full pulse and little increased in frequency, as in Case LX. Enteritis is generally fatal with a tympanitic state of the abdomen and rapid sinking, and we commonly find on dissection extensive deposition of false membrane, with adhesion, often combined with deposition of floc- culent or puriform fluid, and generally lividity, or some degree of gangrene. The disease, we have reason to believe, consists in inflammation affecting both the pe- ritoneal and muscular coats at once ; and it is proba- ble that it may supervene either upon ileus or perito- nitis, or may take place at first in its complete form. We shall afterwards see cause to conclude that it may likewise supervene upon inflammation beginning in the mucous membrane. 23 178 ► tailTONITiS. SECTION II. EXAMPLES OF PERITONITIS AND ENTERITIS. § I.—Simple peritonitis. Case LIII.—A girl, aged 15, on Sunday, 2d March, 1817, was at church in her usual health ; in the even- ing she complained of some pain of the abdomen; (3d.) had pain of the belly and some vomiting ; took castor oil, which operated copiously ; (4th.) pain con- tinued 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. (5th.) 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 examination of the body. Inspection.—The whole tract of the small intestines presented one smooth uniform surface, being firmly glued together, and the interstices filled up by an im- mense deposition of coagulable lymph, which was quite soft and recent; and the mass likewise adhered to the parietes of the abdomen. There was a similar depo- sition, though in smaller quantity, on the surface of the great intestine ; and it was traced nearly to the extrem- ity of the rectum ; it also appeared on the surface of the liver. The omentum was inflamed and dark col- oured ; and there were considerable marks of inflam- PERITONITIS. 179 mation on the peritoneum lining the parietes of the abdomen. Case LIV.—A girl, aged 15, (12th May, 1818) had fever, with pneumonic symptoms ; was bled with relief; the fever subsided gradually, and on the 19th she was considered as well. On the 20th, at night, she com- plained of some pain of the belly, which soon went off, and through the night she felt no uneasiness. 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 also was much alle- viated, and was only complained of upon pressure. The purgative did not operate during the day, but op- erated 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, especially on the ileum, there was peritonitis with deposition of false membrane. On the inner sur- face of the ileum, near the caput coli, there was an in- flamed 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 transmit- ted 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 perforating the intestine, and allowing the es- cape of its contents into the peritoneal cavity; the same form of the disease has already been exemplified 180 PERITONITIS. in connection with perforating ulcer of the gtomach ; and we shall have occasion to refer to it again, when we come to the consideration of ulcers of the mucous membrane. These cases may be sufficient to establish the exis- tence of the disease alluded to under this section, name- ly, fatal abdominal inflammation, with an open state of the bowels ; but, as the disease is not of very common occurrence, I shall introduce here the following case described by Dr. Marshall Hall, which illustrates in a very striking manner the peculiar characters of this in- teresting affection.* A man, aged 50, had acute pain in the hypogastric region, with frequent desire and difficulty of voiding h\s urine. After some relief during the night, his com- plaint 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 contin- ued, and the pain extended more generally over the ab- domen ; the bladder was found empty by the catheter ; pulse nearly natural. (4th day.) There had been co- pious evacuations by stool ; some high coloured 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 attend- ed 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 even- ing 84, soft, and regular. (6th day.) The chief pain had shifted to the right iliac region,—the former pain * 1-V.in. Mod. J.-iir. Vol. XII. TEItlTONITIS. 181 in the left having now ceased ; pulse 124, and small ; features collapsed ; body cold ; died at 4 p. >r. Inspection.—Much exudation and adhesion over the surface of the bowels ; the ileum, caecum, and colon, were injected with numerous vessels in some places, so as to acquire a dark colour ; but the texture was firm and entire. The appendiculae pinguedinosae were in- jected and covered with a viscid effusion, communicat- ing the appearance of a mass of disease. The external and posterior portion of the bladder appeared also a lit- tle injected ; the other viscera were natural. The following case bears a remarkable similarity in its symptoms to the very important case of Dr. Hall. Case LV.—A gentleman, aged 25, (18th Sept. 1816,) was affected with pain in the bowels, accompa- nied 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 continued unabat- ed, accompanied with tenderness of the abdomen, and aggravated by motion ; the more violent pain was not constant, but occurred in paroxysms ; pulse in the evening 80. He was bled to 16 ounces, and took a moderate opiate. (J 9th.) Easy in the night, .but, in the morning, the pain returned with such violence as to occasion screaming, and extreme distress ; it was chief- ly about the umbilicus, but sometimes 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 vom - iting ; pulse from 90 to 100; several feculent consist- ent stools after a mild enema. Was bled to 16 ounces, and took a dose of aloes. After the bleeding, the vio- lent pain subsided, but the tenderness continued, with occasional short paroxysms of pain, and repeated vomit- ing. The dysuria continued, and at one time amount- 182 TERITONlTIS. ed 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 epigastri- um. He lay on his back, but could not bear the pres- sure of the bed clothes ; countenance anxious ; voice feeble; 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 ; tympanitic feeling gone ; discharged much fl^us, and the bowels were moved 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 con- tinued well, but discharged much hardened feces for several days. In this very important case, I believe the bleeding ought to have been pushed more actively in the early stages ;. and particularly that it ought to have been re- peated on the evening of the 19th. <§> II.—Peritonitis confined nearly to the descend- ing COLON AND RECTUM. Case LVI.—A gentleman, aged about 60, (17th May, 1817,) complained of pain about the umbilicus, without fever. Took castor oil, aided by injections, and discharged much scybalous matter with relief; but PERITONITIS. 183 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 fulness, tension, and a 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 motions were feculent and healthy. (19th) Seemed much relieved ; pulse natural ; but. the same feeling of tympanitic distention continued in the lower part of the abdomen, though without tenderness ; he took some small doses of laxatives, and had repeated feculent motions through the day. In the evening, he complained of more pain, and the tympanitic, feeling was increased. Through the night he was restless. In the morning of the 20th, he began to sink, and died at three in the afternoon. Inspection.—The bowels were generally distended, and in many places of a dull leaden colour, 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 descending 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. 1£4 PEIUTONITli WITH SI PPL HA TION. ( HI.—Local peritonitis of very small extent. Case LVII.—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 complained 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 employed, 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 em- ployed without any relief. He died in two days more. By the medicines which were given him during this pe- riod, his. bowels* were moved readily and freely. Inspection.—There was high vascularity of the mem- branes 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 in- testine, through a space about six inches in extent ; and the inner surface of one of the portions was extensive- ly ulcerated. The other parts were healthy. ( IV.—Peritonitis terminating by extensive suppu- ration. The following remarkable case shows, in a striking manner, what extensive disease may remain after an at- tack of peritonitis though every symptom has been re- moved. peritonitis with suppuration. 185 CaseLVIII.—A young lady, aged 20, (9th Julv, 1 822,) 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 convales- cent. At night she took some pills of aloes and colo- cynth, which operated frequently with much irritation. 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 removed 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 med- icine ; and her strength improved daily. About the 25th, she began to be troubled with a pa- rotid swelling, which gave her a good deal of uneasi- ness ; 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 24 186 PERITONITIS WITH SUPPURATION. 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 in the drawing-room through the day, and without any complaint except the parotid swelling. Early in the morning of the 3d, she awoke in great dis- tress, 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 fetid. She died about twelve. Inspection.—Betwixt the diaphragm and the upper surface of the liver, there was formed a distinctly de- fined cavity, lined by a cyst of coagulable lymph, and containing at least a pound of thin puriform matter of intolerable foetor. The left 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 was traced as far as the trunk of the trachea. The liver was sound in its internal structure, but on its peterito- neal 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 intestine could be traced without, tearing these adhesions, which were soft. Throughout this mass of disease there were in sev- eral places cavities of various sizes, containing purulent matter ; one of these on the right side seemed to com- municate by a small canal with the great abscess above the liver. In the posterior part of the pelvis, behind the uterus, another great abscess was discovered, con- taining nearly a pound of thin fetid pus. It was form- ed by adhesions betwixt the intestine, the uterus, and PERITONITIS WITH SUPPURATION. 187 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 discharge their functions in the most healthy manner for a fortnight, is perhaps one of the most striking facts that can be presented 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 peritoneal coat. Case LIX.—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 remit- ting, but afterwards more constant, though without confining her to bed. This had continued for nearly a month, when I saw her in the beginning of December, with symptoms of more active peritonitis, from which she was relieved by repeated blood-letting, and the oth- er usual means. The bowels were at first obstinate, but soon yielded to the usual remedies, and the immediate urgency of the symptoms was thus soon removed ; but from this time she continued liable to transient attacks of pain in the belly, which were usually 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 constitu- tional irritation, until the second week of February, when it broke and discharged a large quantity of very fetid pus. During this time her bowels were quite easy 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 ema 188 PERITONITIS PASSING INTO ENTERITIS. ciated 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 intes- tines 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 contracted, and at this spot the intestine was bound down by adhesions to the spine ; above the contraction, the canal was dilated into a large sac. No trace remained of the abscess except the cicatrix in the integuments, which nearly corres- ponded in situation with the place where the intestine was so much contracted. § V.—Peritonitis passing into enteritis. Case LX.—A gentleman, aged 20, (3d September, 1812,) had pain and tenderness in the lower part of the abdomen; pulse from 84 to 90, and full; bowels natural. Was bled and took laxative medicine which operated fully. The bleeding was repeated on the 4th, and on the 5th and 6th, he was much better, complain- ing 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 colour. (7th.) Free from complaint in the morning, and the bowels open. In the afternoon, he peritonitis passing into enteritis. 189 complained that some laxative medicine had produced most unusual pain ; and at night he had fixed pain in the upper part of the abdomen, with shivering follow- ed by heat; pulse S4. Through the night had copious feculent evacuations, without relief of the pain, and repeated vomiting. (8th.) Pulse 96 ; fixed pain in the abdomen, which was hard, tender, and tympanitic ; re- peated vomiting ; the bowels obstructed ; repeated blood-letting and all the other usual remedies were em- ployed 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 look place ; and he died at nine in the morning of the 10th. Inspection.—All the intestines much distended and glued together by most extensive adhesions ; omentum highly inflamed and adhering to the intestines. At the lower part of the small intestine, an extensive por- tion was gangrenous, and another at the lower part of the descending colon. The appendix vermiformis was gangrenous, and an opening had taken place in it through which liquid feces had escaped into the cavity of the abdomen. Case LXI.—A gentleman, aged 20, 10th December, 1817, late at night, was found writhing and scream- ing from intense pain in the abdomen, every part of which was extremely tender to the touch ; frequent vomiting ; much pain and difficulty in making water ; pulse 96 and soft. He felt pain for several days, but it had increased on the evening of the 9th, with vom- iting ; took laxative medicine on the morning of the 10th, which operated freely three or four times; but after these evacuations the pain was much increased. 190 ENTERITIS. He was largely bled ; and on the 11 th 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 vomit- ed 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. (J2th.) Pulse 90 ; no stool; less pain but much tenderness ; very little vomiting. Two small bleedings, no more being borne; large blister, &c. (13th.) Pulse very fre- quent ; abdomen enlarged at the lower part and ten- der ; no stool; urine scanty and passed with much pain. (14th.) Pulse 120; no stool ; no urine; belly tympa- nitic ; rapid exhaustion with much vomiting ; died at night. Inspection.—Extensive inflammation of the ileum; the inflamed parts were extensively glued together, and pressed down into the cavity of the pelvis, by the dis- tention of the parts above, which were also inflamed but with less exudation. Bladder inflamed and col- lapsed ; omentum inflamed ; about a pound of puri- form matter in the cavity of the peritoneum. § VI.—Enteritis. Case LXII.—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 applications, tobacco injections, vari- ous laxatives, &c. continued through the 4th, 5th, and 6th, the inflammatory symptoms subsided ; but the bowels continued very unmanageable, and were not moved in a satisfactory manner till the 12th. From ENTERITIS. 191 the beginning of the attack she had complained of pain in the ear, which at first attracted little notice, but af- terwards became more severe ; and on the 22d she died of abscess of the cerebellum, as I have fully described in another place.* From the 12th 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 lower extremity of the ileum were of a very dark livid colour, without any change in their structure. Case LXIII.—A child, aged 3 years and 3 months, (12th February, 1812) had urgent vomiting and great thirst; all the liquids taken being vomited almost imme- diately, mixed with large quantities of a light green fluid ; pulse frequent; countenance 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 of pain in her bowels, but had not mentioned it again. The vomiting began on the even- ing of the I Oth, and was very urgent through the whole of the 1 1th ; and the bowels had not been moved since the vomiting began. The usual remedies were employ- ed without benefit; the vomiting continued urgent, and the bowels obstinately obstructed. (13th.) Vomiting abated ; medicines were retained but produced no ef^ feet. 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 coloured fluid. About a fourth part of the small intes- tine, at the upper part, was highly inflamed,—in some * Researches on the Pathology of the Crain, Case XL. 192 ENTEUITIS. places black and gangrenous, in others adhering and covered with false membrane. The diseased portion was greatly distended and contained much dark colour- ed fluid, but no feces. Immediately below this part the intestine became at once narrow and contracted, empty, and of a white colour, except a few streaks of superfi- cial redness. Case LXIV— A boy, aged 10, (10th May, 1823,) was out at play, in the morning before breakfast in per- fect health ; returned 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. (1 1th.) Pain continued in the early part of the day, but subsided in the afternoon ; was seen by a surgeon, who ordered a succession of purga- tives, 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 appa- rent 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 complaint 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 disten- tion of the upper portion, a great part of the ileum was crammed 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 sides of the pelvis ; much force being required either PRACTICAL CONCLUSIONS. 193 to separate them from each other, or to raise them out of the pelvis. The inflammation extended over a great part of the small intestines, but the principal seat of it was the ileum ; and the bladder also seemed to be af- fected. In the cavity of the pelvis, there was a con- siderable quantity of puriform fluid. The high importance of the subject must be my apology for detailing so many cases, calculated to illus- trate the pathology of this interesting and dangerous class of diseases. They seem to warrant the following practical conclusions. CONCLUSIONS FROM THE PRECEDING FACTS. I. 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 natural state, or easily regulated by mild medicines, through the whole course of the dis- ease. 2. No diagnosis can be founded in such cases on the appearance of the evacuations. These may be slimy, and in small quantity ; they may be copious, watery, and dark coloured ; 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 course of the disease. 4. Extensive inflammation may go on without vomit- ing and without constant pain ; the pain often occur- ring in paroxysms, and leaving long intervals of com- parative 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. 25 194 TREATMENT OF INTESTINAL INFLAMMATION. 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 de- fined space of no great extent; for, we have seen, that with every variety in these respects, a disease may ex- ist of a very formidable character, and be advancing to a fatal termination. 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 atten- tive practitioner can in general have no difficulty in making the distinction. When the tenderness exists without distention, as is frequently the case in the ear- ly stages of peritonitis, there can be no difficulty in the diagnosis. SECTION III. OUTLINE OF THE TREATMENT OF INTESTINAL IN- FLAMMATION. In the treatment of this most important class of diseas- es, the great principle to be kept in view is, that the affection which we have to contend with is simply in- flammation. 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 obstruction had existed, we have found it give way, and free evacuation take place, without in any de- gree improving the situation of the patient. Our first TREATMENT OF INTESTINAL INFLAMMATION. 195 great object, then, is simply to combat the inflamma- tion ; and the remedies for this purpose are few and simple. The most important is general blood-letting, repeated according to the urgency of the symptoms and the strength of the patient, aided by large topical bleeding, blistering, &c. In a considerable number of cases, I have used with evident advantage the applica- tion of cold, by covering the abdomen with cloths wet with vinegar and water, or even iced water. Injections of iced water have been proposed, and I think it prob- able, 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, paleness, 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 repetition of it to the extent of 20 ounces may be required for producing that effect upon the disease, which, by the former method, might be pro- duced by five ; and, besides the disease has in the inter- val been gaining ground, its duration is protracted, and the result consequently rendered more uncertain. The inflammation of a vital organ should not be lost sight of .i.bove an hour or two at a time, until the force of it be 196 TREATMENT 01 INTESTINAL INFLAMMATION. decidedly broken, and, unless this take place within 24 hours, the termination must be considered as doubt- ful. The means now alluded to are those calculated for subduing the inflammation, which is our first and great object in the treatment 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 diversi- ty ; we have seen the bowels obstinately obstructed, and we have seen them spontaneously open or easily regulated ; and, in both cases, ihe disease has run its course with equal rapidity to a fatal termination. We have found no reason 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 imme- diately followed by a renewal of the symptoms. Along with these considerations, we must keep in mind the fact, that, in the ordinary cases of enteritis, the action of purgatives is in general entirely fruitless ; they are usually vomited as often as they are given, and consequently can only prove additional sources of irri- tation. 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 of 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 injections will often be found to have the effect, after the most active purga- tives had previously been given in vain. In the general TREATMENT OF INTESTINAL INFLAMMATION. 197 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 in- jections, or by the tobacco 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 subdu- ing the inflammation. # Before concluding these general remarks, I would briefly allude to some circumstances which often occur during the treatment of enteritis, and which are apt to embarrass the young practitioner :— I., The pulse continuing very frequent after the in- flammation appears to be subdued. In this state, digi- talis 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 symptoms are generally considered as indicating gangrene, and consequently 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 LXV.—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 practition- er. On the 5th day, the pain ceased ; the pulse was 140, and extremely feeble and irregular; his face was pale, the features were collapsed, and his whole body was covered with cold perspiration ; his bowels had 198 TREATMENT OF INTESTINAL INFLAMMATION. been moved. In this condition, I saw him for the first time. Wine was then given him, at first in large quan- tities, and, upon the whole, to the extent of from two to three bottles during the next 24 hours. On the follow- ing day, his appearance was improved; his pulse 120 and regular ; the wine was continued in diminish- ed 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 cadts in which, at a particular period of the disease, wine is given with much advantage, though the symp- toms are much more ambiguous, and it is difficult to de- cide upon the practice which ought to be followed. This is strikingly illustrated by the following case :— Case LXVI.—A lady, aged 35, on the 7th day af- ter delivery, was seized with symptoms of peritonitis, with much tenderness 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 laxa- tive medicine, which operated freely. After the bleed- ing, 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 following 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 pow- der and laudanum ; and these were repeated as often as they were discharged, 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 TREATMENT OF INTESTINAL INFLAMMATION. 199 112 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 degree of enlargement, occurring at an advanced period of the disease. This is a very formidable symp- tom, 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 LXVII.—A young man, aged 17, was affected with enteritis in a severe form, which required mueh ac- tive treatment ; but the case yieldly favourably, and about the 7th day he was free from complaint. On the 9th day, his pulse began to rise again, and the abdo- men 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 oc- curs in connection with several forms of the disease, and in every form of intestinal inflammation is a symp- tom to be watched with the most anxious attention. The most unfavourable is the true tympanites abdomi- nalis, which arises from perforation of the intestine, and the escape of flatus into the cavity of the perito- neum. Some examples of this have been already men- tioned, and others will be referred to when we come to 200 TREATMENT OF INTESTINAL INFLAMMATION. treat of ulcers of the mucous membrane perforating the intestine. In the early stages of enteritis, a tym- panitic state may occur from a temporary derangement of the muscular action, and may subside as the inflam- mation is subdued. At a more advanced period of the disease, it must be looked upon with much anxiety. If it occur at this period before the inflammation has been subdued, it is generally a fatal symptom, depending up- on a complete loss of the tone of the bowels ; and it is commonly found to be connected with very extensive adhesions. Tympanites, however, may occur from mere loss of tone of the parts, after the inflammation has been subdued ; and, in this case, it may be recovered 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 de- pends ; but under these circumstances, the safe rule always is, to act upon the supposition of it being in the more favourable form, from which it may be recov- ered. This is to be treated by small quantities of wine or brandy given at short intervals ; gentle compression and friction of the abdomen ; and injections of beef tea, to which may be added considerable quantities 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 re- quire to be given with the utmost caution. The affec- tion is one of very great interest in a practical point of view, because the patient has very often the appearance of being almost moribund, and yet by attention may be speedily recovered. On this account, I think it will not be out of place to conclude with the following ex- amples. TREATMENT OF INTESTINAL INFLAMMATION. 201 Case LXVIII.—A lady, aged about 36, a few days after her accouchment, was seized with symptoms of peritonitis, which was treated in the usual manner, by a judicious practitioner. The activity of the symp- toms was subdued by two bleedings ; the bowels yield- ed to laxative medicine, which, in fact, operated rather fully and with irritation. This was followed by a state of exhaustion, in consequence of winch I saw her. I found her with a haggard and exhausted look ; the skin clammy ; the pulse feeble and rapid ; the whole abdomen tympanitic 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 treat- ment she improved rapidly, and in a few days was in her usual health. Case LXIX.—A boy, aged 6, had acute pain in the abdomen, much increased by pressure and by inspira- tion ; short anxious breathing; pulse extrehnely fre- quent. He was bled from the arm, and took some lax- ative medicine, which operated, and he was very much re- lieved. He then did well for two days, when, on visit- ing him at night, I found him oppressed and restless ; countenance anxious; pulse above 140; the belly en- larged and tympanitic, and painful on pressure. Injec- tions, containing bark in powder with tincture of assa- foetida, were given every three hours, aided by friction, &,c. with great relief. Under this treatment the affec- tion 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 26 202 TREATMENT OF INTESTINAL INFLAMMATION. muscular power, yet assumed characters which might have been considered as indicating mesenteric disease ; and I believe it is an affection of frequent occurrence, especially in children, in whom it often assumes cha- racters resembling those of fixed and serious disease. It is treated by air and exercise, tepid bath, friction of the abdomen, and vegetable bitters, as the columbo powder combined with small doses of rhubarb or aloes, or small doses of the sulphate of iron combined with rhubarb. A tympanitic state of the abdomen, such as occurred in the above-mentiond cases, occurs also from other causes, though putting on the same alarming charac- ters. Case LXX.—A lady, aged about 35, had suffered for some days from a loose state of the bowels, accom- panied by a good deal of pain and irritation; but the complaint was considered as a common diarrhoea, and at- tracted little attention. After she had allowed it to go on for several days, her abdomen began 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 cadaverous; skin cold and clammy ; abdomen very much enlarged and tympanitic; pulse 160, and ex- tremely 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 usu- al health. ERYSIPELATOUS PERITONITIS 203 SECTION IV. ERYSIPELATOUS PERITONITL*. In the preceding remarks on inflammation of the peritoneum, I have confined my observations to that which may be considered as the genuine form of sim- ple acute peritonitis. But there is another form of the disease of very great interest, and, in several respects, remarkably, distinct from the former. The reasons 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 arrangement of the subject. In a pathological point of view, the principal charac- ter of this affection is, that it terminates chiefly by effu- sion 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 mixed 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-coloured, or contains shreds of .flaky matter ; and sometimes 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 colour ; in 204 ERYSIPELATOUS PERITONITIS/. others, there is only a slight increase of vascularity ; and frequently little or no deviation can be discovered from the healthy structure. In some cases again, the perito- neal coat, or a portion of it, has a slightly thickened and softened appearance, like a part that has been boil- ed ; 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 insidious, but sometimes very severe ; and they arc chiefly distinguished by the rapidity with which they run their course, and by a remarkable sinking of the vi- tal powers, which occurs from an early period, and often prevents the adoption of any active treatment. A re- markable circumstance in the history of the affection is its connection with erysipelas, or with other diseases of an erysipelatous character. This will appear from the following examples, by which I am anxious to illustrate this affection, as it seems to present a very interesting subject of investigation. Case LXXI.—A lady, aged 50, in June, 1S23, was seized with extensive erysipelas of the left leg, ac- companied by acute pain, and considerable swelling of the upper part of the foot. After six or seven days the erysipelas of the leg subsided gradually,—the swel- ling and pain of the foot continuing undiminished. 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, mov- ed downwards, and settled with great severity in the lower part of the abdomen, and around the umbili- cus. This took place in the night, and 1 saw her in the afternoon of the following day. She was then moan- ing 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, ecc, but the former. I afterwards found, was ERYSIPELATOUS PERITONITIS. 205 not done at the time. At night the pain continuing- unabated, she was bled without relief. The other usu- al 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 colour, but without any exudation ; the upper half was of a dull leaden colour ; and the whole was considerably distended. In the cavity of the peritoneum there was a considerable quan- tity of bloody sanious fluid. No other morbid appear- ance could be discovered. Case LXXII.—A woman, aged 30, had been ill for several days with the erysipelatous inflammation of the throat, accompanied with considerable fever. She felt better and was able to be out of bed, when, having ta- ken some laxative medicine, she was severely pained during its operation ; and in the evening was seized with most violent pain over the whole abdomen, ac- companied 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 ; coun- tenance expressive of exhaustion ; severe pain and acute tenderness of the whole abdomen ; some vomiting ; no stool. A bleeding was attempted, but she bore very little ; and it gave no relief. Blistering, opiates, to- bacco and other injections, &c. were then employed without benefit. She continued in the same condition, and 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 considera- bly distended, and of a dark livid colour without exuda- tion. In the cavity of the peritoneum, there was a con- 206 F.RYHIPEHTOL'S rERITONlTI* siderable quantity of puriform fluid. There was much appearance of inflammation upon the omentum, espe- cially at the lower part, where it was for several inch- es highly inflamed and thickened, and had formed an adhesion to the sigmoid flexure of the colon. In the Merchant's Hospital of Edinburgh (a charita- ble institution for the education of girls,) an epidemic appeared in the beginning of March, 1824. Its princi- pal character was a slight erysipelatous affection of the throat, generally beginning with vomiting, and accom- panied by slight fever ; and in many of the cases, there was swelling of the glands of the neck. It spread with great rapidity, 1 5 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 I 5th she complained only of slight headache, on account of which she was still kept in bed. About two o'clock in the afternoon, she suddenly got out of bed in a state of in- coherence, and was soon after affected with repeated vomiting and diarrhoea, by which she discharged a green and watery matter. When asked if she felt pain, she laid her hand on the right side of the abdomen about the seat of the caput coli. After vomiting repeatedly, she sunk into a state of great lowness, or almost of in- sensibility. When seen by Mr. Wm. Wood between four and five, she was unable to answer any question ; pulse scarcely to be felt ; body cold ; face cadaverous ; occasional vomiting continued. Stimulants were or- dered, and I saw her along with Mr. Wood between nine and ten at night ; she was then lying with her eyes open, and seemed to observe those about her but made no attempt to speak ; pulse scarcely to be felt ; ERYSIPELATOUS PERITONITIS. 207 action of the heart tumultuous and irregular ; body cold ; occasional vomiting ; no return of diarrhoea; she died about eleven at night. Inspection.—Extensive marks of peritoneal inflamma- tion with slight deposition of lymph in flakes on various parts of the intestines ; in the cavity of the peritoneum there was a considerable quantity of milky puriform flu- id. The appendix vermiformis was large, turgid, and of a very dark colour approaching to gangrene ; the brain, and viscera of the thorax were sound ; and no- thing 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 rawness and redness with little or no swelling; in some there were aphthous crusts, and in others a considerable tur- gescence of the uvula; and in a ^considerable number there were small angry ulcerations about the lips, with spunginess of the gums. It was still, however, in gen- eral a slight affection, requiring little treatment except confinement to bed for a few days, and gentle laxa- tives ; 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 symp- toms, 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 operated. 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, wiien Mr. Wood found her complaining of severe pain, with tenderness over the whole abdomen, and the pulse 20S ERYSIPELATOUS PERITONITIS. 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 ; abdomen 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 ; abdomen still tense and tender when touched, but not much complained of at other times ; no vomit- ing; 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 inflam- mation on the surface of the intestines, with deposition of lymph in flakes in many places, and some slight ad- hesions ; there was^pxtensivc deposition of puriform fluid in the cavity of the peritoneum ; the upper sur- face of the liver was covered by a thin deposition of false membrane. The remarkable epidemic referred to in the preceding observations seems to have been very analagous to the Diphtherite formerly described, though in its progress and terminations it differed considerably from the epi- demic of 1826,—in which, as I have already mention- ed, the disease often extended to the larynx. This ter- mination 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 exam- ple of the larynx being affected, and there was no fa- tal case, except the two now described from this pecu- liar affection of the peritoneum. About the time ERYSIPELATOUS PERITONITIS. 209 when this epidemic was prevailing in the Hospital I saw in private a good many cases of the erysipelatous inflammation of the throat, 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 mem- brane of the nose, accompanied with a copious mor- bid 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 man- ner the identity of the inflammation which had appear- ed in the three situations with different characters; namely, in the membrane of the throat with extensive aphthous crusts ; in the membrane of the nose, with a copious discharge of morbid mucus ; in the integu- ments 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 con- siderably from the cases now described. Case LXXIII.—A gentleman, aged about 50, of a feeble and broken down constitution, about four weeks before his death suffered for some days intense pain in the rectum, which terminated in an abscess ; and, in connection with it, sinuses were formed along the but- tocks. These were opened, and appeared to be going on favourably ; and though he was a good deal confin- ed to bed by them, he made no particular complaint 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 27 210 ERYSIPELATOUS PERITONITIS. griping pain in the bowels. On Wednesday the vo- miting had subsided, the bowels were moderately open, and the stools were healthy ; but there was much gen- eral uneasiness over the abdomen, with some hiccup, and his look was depressed and anxious. His pulse was natural 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 stomach ; his pulse was still natural, and the bowels moderately open. The abdo- men was not distended, but he complained of conside- rable uneasiness upon pressure across the epigastric re- gion. His look was depressed, anxious and exhausted ; and, without -any change in symptoms, he died in the night. Inspection.—The cavity of the peritoneum contained a large quantity of purulent matter of intolerable foe- tor ; three pounds and upwards, were collected besides much that was lost. The surface of the intestines was in general of a dark livid colour, but without any ap- pearance 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 oth- er organ. The most diligent search was made for any abscess or cavity which might have been the source of the matter, but none was discovered. The affection illustrated by these examples differs from the usual forms of peritonitis ; and, without spec- ulating farther upon the nature of it, we may merely add, that its alliance to erysipelas seems to be an obvi- ous and remarkable character of the disease. We have every reason to believe that inflammation of an erysipelatous character may affect the same parts which are liable to the ordinary acute inflammation, but giv- ing rise to symptoms remarkably different. We see this strikingly exemplified in the erysipelatous inflam- mation of the throat; compared with the ordinary cy- ERYSIPELATOUS PERITONITIS. 211 nanche tonsillaris; and there are many other facts which tend to show that erysipelatous inflammation, when transferred to internal organs, produces diseases decidedly different from the common acute inflamma- tion of the same parts. The subject has not been much investigated, but promises some interesting results ; and there is one class of diseases to which it seems to point In a peculiar manner, namely, the peritonitis of puer- peral women. I have not seen so much of this disease as can enti- tle me to offer a decided opinion from personal obser- vation ; 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 puerperal state are lia- ble to two distinct forms of peritonitis, which, in the discussions on this subject, have probably not been suf- ficiently distinguished from each other. They are lia- ble to the common acute peritonitis,—presenting the usual symptoms,—yielding, in a large proportion of cases, to the usual treatment,—and exhibiting, in the fatal cases, the usual morbid appearances of extensive pseudo-membranous deposition and adhesion. But they are likewise liable to another form of diseasex in which the symptoms are more insidious, and 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 treatment; 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 without 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 affected with it, to another who is in the puerperal state. It appears as an epidemic at par- ticular times, being very frequent and very fatal while 212 ERYSIPELATOUS PERITONITIS. it prevails ; and erysipelas, or other affections of an erysipelatous character, have often been observed to be prevalent at the same time. Some of the cases which I have described under this section bear an evident re- semblance to this formidable disease. This modification of peritonitis we have seen may be fatal without any remarkable change in the organiza- tion 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 inflammation 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 tap- ping, and the patients recovered. I have even observ- ed some facts which induce me to believe that, in some modifications of this affection, a certain degree of pe- ritonitis is resolved by effusion ; that the effusion is af- terwards absorbed, 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 peritonitic symptoms, leave a tume- faction of the abdomen with much suspicion of effu- sion, which after some time entirely disappeared. CHRONIC PERITONITIS. 21^ SECTION V. CHRONIC PERITONITIS. This, insidious affection is more common than per- sons not familiar with pathological investigations are generally aware of. It is a disease ef the utmost dan- ger, yet often extremely obscure in its symptoms, and can only be treated with any prospect of success by the utmost attention to its very earliest indications. The symptoms of chronic peritonitis vary considera- bly in activity 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 defined 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 shrink- ing from pressure on any part of .the abdomen. There is occasional vomiting, which in some cases becomes urgent in the more advanced stages. There is gener- ally more or less distention of the abdomen, 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 ten der to the touch. In a very important modification of the disease, there is no complaint of pain ; the patient 214 CHRONIC PERITONITIS. merely speaks of a feeling of distention, with variable appetite and irregular bowels, and, with these com- plaints, becomes progressively emaciated. In many cases, indeed, the early symptoms are so slight, that no attention is paid to them until the emaciated ap- pearance of the patient excites alarm. The abdomen on examination is then probably found tumid, and in some degree tender at various parts ; and, upon ques- tioning the patient, it is found that there has 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 disease 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, laxative medicine is very uncertain in its opera- tion, being apt either 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 its advanced stages; in other cases again, as the disease advances, great obstinacy of the bowels takes place. The appearance of the motions varies consid- erably ; in general, I think they are of a pale colour and of a peculiar foetor, but sometimes they are dark coloured, and sometimes pretty natural. The disease may come on gradually and insidiously, without" any cause to which it can be ascribed. In other cases, it supervenes upon slight attacks of more acute affections of the bowels, or upon other febrile diseases, as measles and scarlatina ; it may also super- vene upon injuries, as in Case LXXXI. 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 gener- CHRONIC PERITONITIS. 215 erally combined with disease of the mesenteric glands. In persons rather more advanced in life, it is often com- plicated with disease of the lungs ; and in another place I have described a remarkable case, in which it was complicated with extensive tubercular disease, both in the lungs and in the brain. The progress of the dis- ease is generally by increasing emaciation, with small frequent pulse and hectic symptoms, sometimes with di- arrhoea. In some cases matter forms and may find its way outwards, either through the parietes of the abdo- men, or by the ring of the external oblique, as in Case LXXXIII. On dissection, the bowels are generally found more or less extensively glued to each other and to the pari- etes of the abdomen, and the omentum is often involved in the disease. There is sometimes ulceration of the mucous membrane, and not unfrequently 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. Tn many cases there are left, amid the adhering portions of the intestine, cavities full of purulent mat- ter, which is generally of an unhealthy or scrofulous character. There is frequently disease of the mesen- teric glands and of the liver or the lungs. In the treatment of this insidious and dangerous af- fection, every thing depends upon endeavouring to ar- rest it at its very earliest period ; for after it has advan- ced but a little way in its progress, it is probably ir- remediable. 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, blis- tering, confinement, rest, antiphlogistic regimen, and the mildest possible diet. When, under such treat- ment, the case terminates favourably, we cannot indeed decide with confidence that this formidable disease had 216 CHRONTC PERITONITU- existed ; but we have always good reason to suppose its existence, when, in a young person, there is derang- ed health, with tenderness over the abdomen. All that I can say farther on this subject is, that I have seen cas- es terminate favourably in families, which had formerly suffered from this affection ; and that their symptoms corresponded with 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 dan- gerous character, and the frequency of its occurrence. § I.—Chronic peritonitis in its more distinct form. Case LXXIV.—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, IS 14. I saw her on the 4th of May, and found her affected with great pain over the whole abdomen, accompanied by some diarrhoea ; pulse about 90. Two days after this, she was sudden- ly seized with severe pain and tenderness over the whole abdomen, accompanied with great tympanitic dis- tention, repeated vomiting, and such a degree of sink- ing of the vital powers, 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 manner for three days. Under this treatment, she gradually improved ; the tympanitic swelling subsided ; the pulse came down to 84 ; the vomiting became less frequent, IN ITS MORE DISTINCT FORM. 217 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 it was acutely painful on pressure. Under the usual treatment, she seemed now for some time to im- prove, but soon began to fall back again ; the pulse became more frequent with hectic symptoms, loss of ap- petite, some cough, and increasing debility and emaci- ation. 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 trou- ble except when it was pressed. The bowels were ea- sily regulated, but the stools were always thin. She died, gradually exhausted, in the end of June. Inspection.—The cavity of the abdomen presented one uniform mass, produced by universal adhesion of the bowels to each other, in which it was impossible to trace any part of the intestine. 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 parietes of the abdomen, produced a large cavity, internally pre- senting 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 extensive abscess in the left ovarium, and another smaller in the right. The stomach, the liver, and the viscera of the thorax, were tolerably healthy. 28 218 CHRONIC PERITONITIS Case LXXV.—A boy, aged 10, (16th June, 1816,) complained of pain in the abdomen, which was tense and tympanitic, and, in several places, tender to the touch ; bowels open ; tongue clean ; little appetite ; pulse about 100 ; for a year had been delicate, and li- able to swelled glands; had complained of his abdomen for several weeks. (5th July,) Little change, except 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 ] 08 to 112. (1st August,) Progressive emacia- tion and hectic fever ; occasional attacks of diarrhoea and of vomiting. (10th.) Almost constant vomiting im- mediately after taking any thing ; occasional diarrhoea. Died on the 16th. Inspection.—All the viscera of the abdomen were glu- ed together into one mass, except where their union was interrupted by cavities containing purulent matter of a scrofulous character, and presenting a surface of unheal- thy 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. Case LXXVI.—A girl, aged 10. In this case, the disease went on for a year or more, and was chiefly dis- tinguished 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 com- plaint 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 IN ITS OBSCURE FORM. 219 the winter and spring of 1823-4. During the summer, she began to fall off more rapidly, with cough and an- asarca, which at last became very extensive ; and she died in August. Inspection.—The omentum adhered intimately to the parietes 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 ab- domen, so as not to allow of the different parts being separated or traced. The left lung was hard and ex- tensively tubercular ; the right was healthy. § II.—Chronic peritonitis in its more obscure form. Case LXXVII.—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 hec- tic 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 insidi- ous 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 * 220 CHRONIC PERITONITIS any uneasiness. In the middle of April, she seemed to improve 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 contin- ued frequent, being generally from 100 to 120, and the abdomen retained a considerable degree of tympanitic fulness. 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 symptoms, 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 became more and more frequent, until at last she could retain no- thing; 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 pre- sented one solid mass of adhesion, in which it was im- possible to distinguish one intestine from another. The mass likewise adhered extensively to the parietes of the abdomen ; and, in various parts of it, there were cavi- ties containing purulent matter, and presenting, on their internal surface, unhealthy scrofulous ulceration. There was also much purulent matter in the cavity of the pelvis. There was much disease of the mesenteric glands, and the liver was considerably enlarged. The lungs were sound. Case LXXVIII.—A lady, aged 24, had been in deli- cate 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 be- gan to complain of pain in the abdomen, which affect- ed her chiefly in walking ; it was sometimes a sharp stinging pain, and sometimes a dull uneasiness. She IN ITS OBSCURE FORM. 221 continued to go about, but her health was somewhat impaired. She had dyspeptic symptoms, occasional vomiting, irregular bowels, hysterical affections, and a long train of symptoms, which were often considered as in a great measure imaginary. 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 tender- ness over the whole abdomen, accompanied with vomit- ing, costiveness, and frequent pulse. This attack con- tinued two days, and then subsided, having been reliev- ed by topical bleeding and laxatives; and she then re- turned to nearly her former state, except that she was more reduced in flesh and strength, and her pulse con- tinued frequent. Her bowels were now easily kept open ; but the stools were thin and very offensive ; she was considerably emaciated, 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 ten- derness. 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 puru- lent 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 blad- der, were firmly agglutinated to each other, and to the parietes of the abdomen, except where they left irregu- 222 CHRONIC PERITONITIS, &C. lar 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 adhesions, but of a different character, being pale and membranous, 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 LXXIX.—A child, aged 5 years, had been ob- served 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 ab- domen. 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 at- tack. 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. CHRONIC PERITONITIS 223 § III.—Chronic peritonitis supervening upon measles. Case LXXX.—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 irreg- ular, 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 ema- ciated, with constant pain in the belly, and occa- sional 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 impos- sible 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 perito- neum, 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 tu- bercles, but they were .all in a solid state ; and there was considerable effusion in the cavity of the pleura. 224 chronic peritonitis ^ IV.—Chronic peritonitis of the colon super- vening UPON AN INJURY. Case LXXXI.—A man, aged 21, a carter, (July 18 18,) was emaciated to a great degree, with effusion in the abdomen, and anasarca of the legs; some diffi- culty of breathing ; pulse small and frequent; bowels quite open, sometimes rather loose ; complained of pain extending across the upper part of the abdomen ; some time 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 as he was unloading a cart; and from that time he had complained of uneasiness in the abdomen, but not so severe as to confine him from his work, until some weeks after, when he receiv- ed another injury by being squeezed between his cart and a wall. After this, the pain in his bowels increased, and had frequent attacks of nausea and some vomit- ing ; but these symptoms ceased after a short time, and the complaint went on in a gradual but obscure man- ner, till the time when 1 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 deposition of coagulable lymph, and had formed most intimate adhesions to the parietes of the abdomen, and to all the neighbouring 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 in- testine. The coats of the colon were much thickened, especially on the left side, where they were in some WITH DISEASE OF THE OMENTUM. 225 eases 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-coloured fluid. The lungs were healthy. § V.—Chronic peritonitis complicated with disease OF THE OMENTUM. Case LXXXII,—A gentleman, aged 54, of a full habit, and previously enjoying good health, about Christ- mas, 1823, complained 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 with- out any defined uneasiness, except some obscure and Wandering pains extending along both sides of the ab- domen, 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 fluctuation. Imme- diately 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. Pres- sure occasioned little uneasiness. The bowels were 29 226 CHRONIC PERlTONlTtS easily moved, and the motions were natural, but scanty. He had a constant feeling of nausea, which, in fact, was the principal uneasiness that he complained of. Various remedies were employed with little benefit, and, for some time, there was little or no change in the symptoms. He then began to have occasional vomit- ing ; his nights became very disturbed; and he fre- quently laid his hand across the upper part of the abdo- men, as being the seat of much undefined uneasiness ; his bowels continued to be easily regulated. The vom- iting increased 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 tumour in the epigastrium was form- ed by the omentum drawn up into an oblong mass, near- ly two inches in thickness, and internally of a pale colour and firm tubercular consistence. The intestines Were of a very dark colour, and adhered extensively to each other, and to the parietes of the abdomen. The hard spot which had been felt below the umbilicus, was produced by one of these adhesions of a part of the ileum to the parietes. The peritoneum lining the pa- rietes of the abdomen was diseased through its whole extent; in many places much thickened, and in some al- most cartilaginous. Its internal surface presented a variegated appearance of dark red portions, 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. WITH SUPPURATION. 227 § VI.—Chronic peritonitis with extensive suppura- tion MAKING ITS WAY OUTWARDS BY THE RING OF THE EXTERNAL OBLIQUE. Case LXXXIII.—A man, aged 40, (August, 1814,) had severe pain of the abdomen, which was hard and tense, with occasional vomiting ; much wasting ; bow- els irregular; had been ill four or five months. A short time after I first saw him, he was suddenly seize*d with a swelling, which appeared at the ring of the external oblique of the left side, and extended rapidly along the scrotum. After watching the progress of this swelling for some days, the scrotum was punctured, and discharged very fetid purulent mat- ter, in such quantity as immediately shewed a commu- nication betwixt the swelling and the cavity of the ab- domen ; 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 mat- ter ; he became more and more exhausted, and died in the middle of September. Inspection.—The omentum was much diseased, being thickened, ulcerated, and studded with numerous tuber- cles ; and it adhered intimately both to the intestines, and to the parietes of the abdomen. The intestines likewise adhered most extensively to each other, and to the parietes ; the peritoneum also was in general much thickened. On the right side of the abdomen, there was an extensive collection of purulent matter, which extended 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 228 CHRONIC PERITONITIS, &C. 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 abdominal muscles, PART III. INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL. The inflammatory affections of the mucous membrane of the intestinal canal present a subject of great in- terest and considerable difficulty. In the diagnosis of them, much attention is required in their early 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 con- founded with diseases of a much less dangerous charac- ter. This arises from the circumstance, that symptoms, very similar to those which proceed from extensive dis- ease of the mucous membrane, may be produced by va- rious irritations applied to the membrane in a healthy state, constituting two classes of disorders, very differ- ent in their nature, and implying very different degrees of danger. Thus, we may have the symptoms of di- arrhoea 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- 230 MUCOUS MEMBRANE OF THE INTESTINE. 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 af- fections ; 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 vis- ited. 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 ascertained, that many of the appearances in mucous membranes, which have often been con- sidered as marks of disease, are merely changes of colour, 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 dieases, without any symptoms referable to the bowels ; and of those who have died from violent deaths, as execution or drown- ing, without any suspicion of previous disease. Among the appearances referable to this head, may be reckon- ed the following ; suffusion or increased 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 colours, as red, blue, green, livid, brown, or black, without any change of texture of the part; and ecchymosis or slight extra- vasation of blood into the cellular texture connected with the membrane. These and some similar appear- ances, not connected with any change of texture, and not shewing any of the actual results of inflammation, are not worthy of any confidence in the pathological inquiry. In entering upon this subject, therefore, I shall sim- ply describe the principal changes, observed in the mil- MUCOUS MEMBRANE OF THE INTESTINE. 231 cous membrane of the intestinal canal, which we are warranted to consider as morbid. I. Portions of the membrane of greater or less ex- tent, shewing a uniform and high degree of redness, with slight flakes of coagulable lymph, or a more con- tinued coating of false membrane, attached to its sur- face in various places. This appearance is seldom ob- served 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 the Case LXXXIX 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 mem- brane, as exemplified in Case LXXXV. In a modifica- tion of the disease, which seems to be different from the former, the effected portion is covered by a thin uni- form coating, like the crust of aphthae ; the membrane beneath shewing a high degree of redness when the crust is removed. This uncommon appearance is shewn in Case XC.; but the phenomena connected with it have not been sufficiently investigated. II. The mucous membrane covered to a greater or less extent with irregular patches, of a bright red col- our, and sensibly elevated above the level of the sur- rounding parts. These portions vary in size, being, in general, one or two inches in diameter, with sound por- tions of considerable extent interposed between them. They are, in some cases, covered by a brownish tena- cious mucus ; in others, by flakes of false membrane ; and frequently the surface of them is studded with mi- nute 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 and the rectum ; when seated in the small intestine, and the colon 2 32 INFLAMMATORY AFFECTIONS. 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 XCV. III. An extensive portion of the mucous membrane exhibiting a soft consistence, of a uniform black colour, or what may be properly termed gangrene of the mu- cous membrane. This appearance is illustrated by Cases LXXXV, and XCII. The result of it has some- times been the separation of considerable portions 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 different periods of the same affection, or are distinct forms or degrees of the disease. The latter seems to be the more probable supposition ; and there is every reason to believe, that the disease differs in its nature, by being, in some cases seated in the mu* cous membrane itself, in others, in the mucous fo.llicles ; and in others, by involving both these structures at once. Another form has likewise been supposed to exist, in which it is primarily seated in the cellular tex* ture betwixt the mucous and muscular coats ; but this must be considered as in great measure conjectural. The most common form which the disease exhibits in this country, when it is fatal at an early period, consists of the irregular elevated patches of inflammation, as in Case LXXXIV; and this, at a more advanced period, seems to pass into the irregular continued ulcer- ation 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. INFLAMMATORY AFFECTIONS. 2-33 as in Case LXXXIX, or by the actual gangrene, as in Cases LXXXV. and XCII. IV. Minute dark coloured spots spread extentively over a portion of the membrane, and each surrounded by a small but distinct 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 diarrhoea. It is exemplified in Case XCVII. It is probably a dis- ease of the mucous follicles, and the earliest period of an affection, which would have terminated in the forma- tion of small detached ulcers, such as occured in Case XCVI. V. Small round or oval portions of the mucous mem- brane, of a dark gray colour and soft pultaceous con- sistence. These are easily separated, and leave ulcers, or rather excavations, corresponding to their size. This appearance seems to be the termination of inflam- mation confined to small defined portions of the mem- brane ; or, perhaps, is primarily situated in the mucous follicles, and involves a small portion of the membrane immediately surrounding them. VI. The surface of the mucous membrane covered by numerous small spots of an opaque white colour which are found upon examination to be vesicles, very slightly elevated, but containing a small quantity of clear fluid. This uncommon appearance is exemplified in Case CXIV. VIK Ulcers of various appearance and extent. The principal varieties of these seem to be referable to the following heads : (I.) 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 referred to under the fifth head. 30 234 MUCOUS MEMBRANE OF THE INTESTINE. (2.) Portions of various extent in a state of more de- cided ulceration ; covered at the bottom with yellowish or dark coloured 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 exten- sive 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 accurs in chronic cases, and is exemplified in Cases XCVIII, and XCIX ; but is al- so met with in connection with recent and acute dis- ease in the very remarkable case (Case LXXXVI.) In other examples, the elevated inflamed patches de- scribed under the second head are found covered with small ulcers, sometimes not more than a line in diam- eter. (3.) Small round well defined ulcers like the deep pits of small pox, or sometimes very much resembling chancres ; deeply excavated with round and elevated edges. They are generally at a considerable distance from each other, and the intervening membrane is heal- thy. The casesin which these occur are generally chronic, as in Case XCVI ; but they are found in con- nection with acute disease in Case LXXXVI. The primary seat of them is probably in the mucous follicles ; and the appearance 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. (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 considerable extent of intes- tine 'f but perhaps, only one or two of them may be INFLAMMATORY AFFECTIONS. 235 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 history of these is obscure. There is reason to believe that they may exist for a considerable time with very slight symptoms, or without any symp- toms which lead to a suspicion of their existence. They may be fatal by haemorrhage, as in Case CVI.; or by perforating the intestine and leading to rapid pe- ritonitis. They are also met with in acute diseases very rapidly fatal, as in Case CVII.; 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 ter- mination. ^ Ulceration of the mucous membrane, under all its forms, frequently goes to such a depth as entirely to. perforate the intestine ; and the case 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 portion, so as to shew the affection in its different stages. We may find, for ex- ample, a small deep ulcer, which has perforated the in- testine by an aperture, which would admit a quill ; this surrounded by a circle in a state of superficial ul- ceration, and this by a ring of inflammation. VIII. Portions of the mucous membrane are some- times 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 con- tinues entirely healthy, so that, on first opening the abdomen, even in very protracted cases, there is no ex- ternal appearance of disease. In others, there are patches of a deep red or livid colour, as if shining through the peritoneal coat, or the uniform black tinge 236 Ml COLS MEMBRANE Of THE INTESTINE. of actual gangrene, as in Case LXXXV,—the perito- neum itself however still continuing entirely healthy. The affection sometimes passes into extensive peritoni- tis a short time before death, and this happens in two ways. In the one, a 6inall ulcer perforates the intes- tine, and the inflammation spreads rapidly in all direc- tions, probably produced by the escape of the contents of the intestine into the peritoneal cavity, as is exem- plified in Cases LIV, and XCIII. In the other, the pe- ritonitis seems to take place more directly from the in- flammation extending through all the coats, without any appearance of perforation. This probably occur- red in Case LXXXVII. In many of the acute cases, the diseased intestine dquires a soft and thickened appearance, which has been compared to that of boiled tripe : in the chronic, thickening is still more common,—the affected acquir- ing a great degree of thickness, and an almost carti- laginous hardness, which seems to involve the whole structure of the intestine. In some of these the intestine becomes contracted at the thickened por- tion ; in others, it becomes distended into large defined cysts, with an internal surface of dark rag- ged ulceration; and the parietes of these cysts sometimes acquire such a degree of thickness and hard- ness, as to exhibit, during the patient's life, the charac- ters of a mass of organic disease. This affection is strikingly illustrated by Cases CIII, and CV. Exten- sive 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 apearances now described may probably be con- sidered as the principal morbid conditions of the mu- cous membrane of the intestine ; and the enumeration seems to include all those which, in the present state of our knowledge, can be considered as essential in this investigation. The inquiry has been involved in much INFLAMMATORY AFFECTIONS. 237 obscurity by a practice prevalent among continental writers, of giving a place in the pathology of mucous membranes, to mere changes of colour, 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 utmost consequence to have it dis- tinctly admitted, that in our researches on the patholo- gy of mucous membranes, they are entirely unworthy of confidence. Among the symptoms which chiefly engage our at- tention in reference to the diseases of the mucous mem- brane, 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 serious disease ex- ists, when they are feculent and of a healthy appear- ance. We shall see reason in the sequel to be satis- fied of the fallaey of this conclusion ; and to be convinced that most extensive and deep seated dis- ease may be going on, with feculent and healthy evac- uations. The effects upon the functions of the bowels in con- nection with these diseases, are chiefly referable to the following heads: (1st,) A simply irritable state of the bowels, with thin feculent discharges. (2d.) Mor- bid discharges from the diseased surfaces of various kinds, as watery, mucous, bloody, puriform. (3d.) Va- rious mixtures of these matters with the feculent evacuations. (4th.) Various changes in the appear- ance of the feculent evacuations themselves, in conse- quence of articles passing through in a partially digest- ed state, or frequently almost entirely unchanged ; also from the mixture of bile or other matters from the up- per part of the bowels. In this general outline it is impossible to give a full account of the different ap- pearances which the evacuations assume, in connection 238 MUCOUS MEMBRANE OF THE INTESTINE. with the various forms of the disease ; but the follow- ing brief statement may be given, with reference to the morbid conditions 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 peculiar discharges from the diseased surfaces are only to be distinctly recognised 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 nourish- ment partially changed. II. The appearances described under the second head produce, when seated in the lower part of the in- testine, the dysenteric stools commonly so called ; name- ly, frequent scanty discharges 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 frequent occurrence, and probably constitutes the dysentery of systematic writers. When the whole tract of the colon is affected, there are no scybalae, but oc- casional discharges of thin feculent matter from the healthy parts above; while the more frequent evacua- tions consist of the bloody mucus, dark watery matters, or muco-purulent discharges from the diseased surface, coming off sometimes alone, and sometimes mixed with the feculent 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 surface are then seldom seen uncombined, and their characters are dis- INFLAMMATORY AFFECTIONS. 239 guised by being mixed, either with thin feculent matter, or with articles of food or drink partially changed. The chronic form of the disease referred to under this v head, I think in general produces merely an irritable state of the bowels, without any thing particularly mor- bid in the character of the evacuations. 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 any thing particularly unhealthy in the evacuations. V. The same observations will probably apply to the appearance described under the fifth head, except that it may occasionally be possible to recognise in the evac- uations the softened and separated portions of the mu- cous membrane, which however is not probable. VI. The discharges connected with the case more particularly referred to under the sixth head, consisted of large quantities of very firm tenacious mucus, as- suming 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 quan- tities of semi-transparent gelatinous matter. These dis- charges, however, had entirely ceased for a considera- ble time before the death of the patient. VII. The appearances connected with ulceration of the membrane 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 gradual wasting, without any peculiar discharge. (2.) The ulceration described under the second head 240 INFLAMMATION OF THE MUCOUS MEMBRANE. produces 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 rec- tum 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 fecu- lent matter is thin, and comes off more mixed with the morbid discharge. On the other hand, when the dis- ease is in the small intestine, and the colon healthy, the peculiar discharge will seldom be seen uncombined, as it will generally come off mixed with thin feculent mat- ter. Portions of flaky matter may occasionally be seen in such cases floating in the evacuations ; but in other cases, they have merely a thin feculent appearance, ge- nerally of a pale colour, and of a remarkable and pecu- liar foetor. (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 CVIII. and CIX. 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 consider- ed as tedious 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 varies considerably in its characters, according SYMPTOMS. 241 to the extent and the seat of the disease. It may be fatal in the inflammatory stage,—by gangrene,—by ul- ceration,—and by passing into peritonitis. II. Chronic disease of the membrane. This may su- pervene upon an acute attack, or may come on in a gradual and insidious manner without any acute symp- toms. It generally goes on for a length of time, and is fatal by gradual exhaustion ; and shews upon dissection fungoid disease of the membrane,—ulcera- tion of various characters,—or thickening and indura- tion of all the coats of the intestine. It may be fatal more suddenly by peiforation of the intestine and rapid peritonitis. III. An interesting modification of the disease may be considered separately, as a matter of practical in- terest, though there is no real distinction in its patho- logical 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 unexpectedly fatal in the manner to be hereafter men- tioned. The phenomena connected with these various states of disease present a subject of much interest, of which I cannot hope to give more than a slight and imperfect outline. SECTION I. ACTIVE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE INTESTINE. The symptoms accompanying active inflammation of the mucous membrane vary considerably according to 31 242 INFLAMMATION OF THE MUCOUS MEMBRANE. the seat and extent 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 tenderness when rather severe pressure is made, but distinct from the acute sen- sibility which accompanies inflammation of the perito- neum. 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 occasionally the pulse is little af- fected through the whole course of the disease. There is frequently vomiting, but not urgent; sometimes hic- cup ; and sometimes a peculiar irritability of the sto- mach and bowels,—articles taken exciting a burning uneasiness, succeeded by irritation, and a sensation as if they almost immediately passed through the bowels. The calls to stool are sometimes very frequent, oc- curring, perhaps, every ten or fifteen minutes, with much painful tenesmus ; 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 times 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 mem- branous crusts are discharged like coagulable lymph in irregular portions; but in some instances, the evacua- tions are more abundant and consist of a watery mat- ter of a dark brown colour, and remarkable 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 SYMPTOMS. 243 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 the early stage of the disease, and that the morbid dis- charges may not Uegin to appear until it has gone on for several days. In certain states of the disease, again, the evacuations are farther varied bf a mixture with bile, either in a healthy or a morbid state, and by articles of food or drink which pass through nearly un- changed. I have endeavoured to state the principles which appear to regulate these important varieties. The dis- ease seems to exist 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 colon, the discharge from the diseased sur- face comes off uncombined, while the healthy feces are apt to be retained, or discharged only in small scybalee, 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 con- tents ; after which, the evacuations will consist, at one time, of the morbid discharges from the diseased sur- face, 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 seated in the small intestine, while the colon is healthy, the morbid discharges will be less apparent, because they will sel- 244 INFLAMMATION OF THE MUCOUS MEMBRANE. dom come off uncombined. The effect in this case will probably be, a general increased action of the whole canal ; and the matter evacuated will be either fluid feces, moie or less mixed with the morbid dis- charge, articles of food or drink partially changed, or various combinations of these three substances, produc- ing frequent changes in the appearance of the evacu- ations. 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 evacuations may at first be healthy, like those of a simple diarrhoea, and after- wards consist of the morbid discharges from the diseas- ed 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 re- tained above the seat of the disease ; and in case XCIV. there was fluid feces of a perfectly healthy appearance in immediate contact with the diseased surface. On the other hand, in Case LXXXIV., 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 affec- tion running its course to a fatal termination, with fecu- lent evacuations of a healthy appearance, when the dis- ease 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 excru- ciating pain, and required constant fomentation to allay SYMPTOMS. 245 the tormina which it excited in its passage through the diseased portion of intestine. The principles now referred to indicate the sources of important varieties in the phenomena of this class of diseases; but there are other circumstances worthy of much attention. Inflammation of mucous membranes i • exists in different states or degrees ; in some of which it has a tendency to a spontaneous cure,—the dis- charge from the membrane gradually undergoing cer- tain changes, during, the progress of which the in- flammation subsides." This is most remarkably exempli- fied 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 Lacnnec has well remarked, that a simple catarrh affecting the whole bronchial membrane, or a very large proportion of it, is one of the most formida- ble diseases that we can have to contend with. On the other hand, in the proper bronchitis, or laryngitis, we have examples of the disease existing in a different form ; in which the danger is not regulated by the extent of the surface affected, but by the degree or the intensity of the inflammation. A corresponding variety appears to exist in the inflammation of the intestinal membrane. In one form, it seems to be a highly dan- gerous disease whatever may be its extent; while in another, it is, when of small extent, a disease of little danger, and admitting of a spontaneous cure, though it may become highly dangerous when of great extent, from the constitutional irritation by which it is atten- ded. These two forms of the disease are well illustra- ted by Cases LXXXIV, and LXXXV. The affection, as it occurred in the former, would probably have been free from danger, had it been of small extent; while, as it occurred in the latter, it would have been, of what- ever extent, a disease of the utmost danger. • 246 INFLAMMATION OF THE MUCOUS MEMBRANE. With these varieties in the symptoms, the affection may go on for sometime before its real nature is sus- pected, as, under some of its modifications, it may be mistaken for a common diarrhoea, and thus may excite little attention and no alarm. When the disease is in the lower part of the bowels, it is more readily distin- guished by the peculiar morbid discharges, or what have commonly*been called dysenteric stools; but when the inflammation is seated in the small intestine, the diag- nosis is often difficult. The disease should be suspect- ed when there is diarrhoea with much pain, and when the pain is increased by pressure.* If these symptoms are accompanied by fever, the case is still more suspi- cious ; but fever, as I have already stated, is frequently wanting. The disease occurs both in an idiopathic form, and as a symptomatic affection. In the latter case, it appears as an attendant on continued fever, and may either exist from the commencement of the fever, or may take place at an advanced period of it. It seems occasionally to accompany or follow other febrile diseases, especially measles ; and there is rea- son to believe, that it may supervene upon affections of the bowels which were at first free from any danger- ous character,—a case beginning like a simple diarrhoea, and, after several days, exhibiting symptoms which mark the presence of this dangerous affection. In a less ac- tive 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 the 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 abun- dant reason to believe, that its characters vary in a re- markable 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 sys- SYMPTOMS. 247 tematic writers, ought to receive the name of diarrhoea, not of dysentery. The dysentery of this country is, in many cases, a mild disease, 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 fe- ces ; there is generally some degree of fever, with more or less of constitutional disturbance, and frequently vomiting. Whenever such" symptoms, however, occur, a disease is present which requires to be watched with much attention. While it is limited to a defined por- tion of the lower part of the intestine, it may be a dis- ease of little danger ; but it is to be kept in mind, that its danger is generally in proportion to its extent. If it be attended 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 extreme. 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 va- ry in the manner which has been already referred to ; being either mucous, watery, or feculent, or consisting of various combinations of these matters with each other. 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 symptoms, or it may not have 248 INFLAMMATION OF THE MUCOUS MEMBRANE. been discovered until it proves rapidly fatal. In cither case the affection may be fatal by exhaustion, by peri- tonitis, or by haemorrhage. There is also a modification of the disease of very great importance, which affects infants. Though the phenomena accompanying this form accord with the general history of the affection, yet in a practical point of view it will be worthy of a separate consideration. Inflammation of the mucous membrane of the intes- tine, 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 nu- merous patches of redness, which are in general sensi- bly elevated above the level 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 ulcers. II. By gangrene, a portion of the mucous membrane appearing of a uniform black colour, 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, generally 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 perfo- rates the intestine, its contents escape into the perito- neal cavity, and very rapid peritonitis immediately fol- lows. CONFINED TO THE RECTUM, &C 249 The leading phenomena connected with the various forms of this important class of diseases will be illus- trated 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 occa- sional appearance of scybalae. I have not seen it as a fatal disease ; but it is evidently 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 details of individual cases ; but his account of the appearan- ces on dissection, even in the older cases, is, " in all of them the rectum 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 affec- tion, he says, "the stools 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 continued for sometime, the sick complained for a day or two of severe gripes, and then discharged along .32 250 COLON--FATAL IN INFLAMMATORY STAGE. with the stools little pieces of hardened excrement." At other times, though more rarely, little pieces of white stuff like tallow or suet were discharged ; 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 tu- mid. The tenesmus, in cases of this class, goes on with scanty morbid discharges from the diseased surface, while the colon above may contain much hardened fe- ces, 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 INFLAM- MATORY STAGE. Case LXXXIV.—A gentleman, aged 60, had been for some years liable to an irritable state of bowels which affected him chiefly after exposure to cold, and was generally accompanied by mucus discharges ting- ed with blood. He was seized with one of these at- tacks, while he was at a distance from home, in Sep- tember, 1827, which seems to have been more pro- tracted than usual, and on his return home, in the end * Monro on the Diseases of the British Military Hospitals in Germany. —Pages 61 and 63. INFLAMMATION OF THE MUCOUS MEMBRANE. 251 of September, he was again seized in a still more violent degree. When I saw him along with Mr. Gillespie, a- bout 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 frequent and rather small. He complained of much general uneasiness of the abdomen, especially across the epigastric region, where 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 sometimes almost entirely of blood. He had occasional hiccup and some vomiting. All the usual remedies were employed without benefit; the symp- toms continued unabated ; the vomiting became more urgent; his strength sunk rapidly ; and he died in four days more, being about the eighth from the commence- ment of the disease. The evacuations retained through- out the same character, without the least appearance of feculent matter, even when laxative medicine was given. Inspection.—The whole tract of the colon appeared moderately and uniformly distended. Externally, it pre- sented no morbid appearance, except some degree of that softened and slightly thickened state which has been compared to boiled tripe. Internally, it shewed most extensive disease of the mucous membrane. This consisted of portions of the membrane, of various forms and degrees of extent, being of a fungous appearance and bright red colour, 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 con- sidered as ulceration or even abrasion of the membrane. The small intestine and all the other parts were entirely 252 COLON, &C.--FATAL BY GANGRENE. healthy ; and there was no appearance of feculent mat- ter in any part of the canal. § III.—The disease occupying the whole colon AND RECTUM, FATAL BY GANGRENE. Case LXXXV.—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 numerous 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 ehtirely of blood. His tongue was parched, but his pulse was little affected. (10th.) The pulse was still nearly natural, but there was much pain and tenderness of the lower part of the abdomen with some dysuria. The evacuations were now more abundant in quantity, and were remarkably changed in their charac- ter, being watery, dark coloured, and with a remarka- ble and peculiar foetor; they are compared by Mr. White to the washings of putrid flesh. For several days from this time there was little change. The evac- uations continued watery, of a dark brownish colour, and remarkable foetor, and without any appearance of feculent matter. They varied much in frequency, some- times occurring every ten minutes, and sometimes leav- ing him quiet for several hour's. 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 feu times, but it was not urgent, 1 saw him for the first COLON, &C.--FATAL BY GANGRENE. 253 time on the 1 5th. 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 rec- tum to nearly the middle of the arch of the colon, the intestine was of a uniform black colour, as if com- pletely gangrenous. From the middle of the arch to the caput coli, the appearance was more healthy, but was variegated by numerous patches of a deep red or livid colour. These seemed to be deep seated, and were seen shining through the peritoneal coat, which appeared to be healthy. The large intestine being laid open, the mucous membrane at the black parts was throughout of a deep uniform black colour, 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 assumed an appear- ance more resembling that described in the former case,—being elevated into irregular patches of a dark red colour, with interspersed portions in a more heal- thy state. Towards 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 defined ulcers. The ileum, for a few inches from its junction with the caput coli, was slightly distended, and its mucous membrane was reddened ; the other parts of the cana 254 INFLAMMATION OF THE MUCOUS MEMBRANE. were healthy. The inner surface of the urinary blad- der, at its posterior part, shewed 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 shew the disease running its course in about the same peri- od ; affecting the same extent of intestine, and shew- ing similar constitutional symptoms,—while the actual morbid condition of the parts was remarkably different. The following case shews the affection fatal in neaily the same period, and with a remarkable extent of dis- ease ; but with a very important difference in the char- acter of the evacuations. § IV.—The disease occupying the whole colon and RECTUM AND PART OF THE ILEUM. Case LXXXVI.—A lady aged 35, on Monday 7th July, 1828, was suddenly seized with vomiting and purg- ing, accompanied by considerable uneasiness in the abdomen ; various remedies were employed without relief. On the 8th, the symptoms continuing and the pain being very severe, a bleeding was attempted, but only a very small quantity was obtained. I saw her "ii the afternoon of the 9th ; she had then occasion- COLON, RECTUM AND PART OF ILEUM. 255 al but not frequent 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 full 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 time they resist- ed 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 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 disturbance ; but, how- ever she might be in this respect, her aspect never im- proved from a febrile and anxious expression, charac- teristic 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 pe- riod 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 sepa- rated on standing, and deposited at the bottom of the vessel, a quantity of a thin puriform fluid of remarka- ble foetor, and variegated with small round spots of blood; on the two last days of her life, they became of a dark brown colour, 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 256 INFLAMMATION OF THE MUCOUS MEMBRANE. frequent pulse and some delirium, and she died on Tuesday the 1 5th, 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 jplaces, of a dark red colour, which seemed deep seated as if shining through the peritoneal coat ; about the sigmoid flexure and the up- per part of the rectum, there was slight deposition of false membrane. The mucous membrane was healthy in the stomach, and in the upper part of the small in- testine. In the ileum there began to appear spots of increased vascularity, which were at first at consider- able distances from each other, but afterwards became more numerous ; and, for about twenty-four inches at the lower end of the ileum, the whole mucous membrane was of a uniform deep red colour, without any remarka- ble 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 co- lon, there was a more irregular state of disease, consist- ing of wandering undefined ulceration, variegated with dark fungoid elevations of portions of the mucous mem- brane. In the arch of the colon, the disease assumed a different character; for it there consisted of small well defined ulcers, the size of split peas or smaller ; they were quite distinct from each other, and the mu- cous membrane betwixt them was of a pale colour and quite healthy. In the descending colon, the whole of the mucous membrane shewed one continued surface of disease,—being of a dark brown colour, fungoid and spongy, without any defined ulceration. It is difficult to describe the appearance at this place ; it might per- haps be compared to the surface of very coarse cloth of a loose fabric, and of a dull brown colour ; and the mucous membrane, along the part so affected, was uni- COLON, RECTUM AND PART OF ILEUM. 257 formly and gjpatly thickened. Along this portion, al- so, all the coats of the intestine were considerably thickened, and in some places were almost of cartilagi- nous hardness. This state of disease extended from near the commencement of the descending colon to within two inches of the extremity of the rectum ; here it ceased abruptly, and the small portion that remained shewed only marks of recent inflammation or increased vascularity. This very remarkable case shews nearly all the mod- ifications of disease of the mucous membrane ; and I confess that I found it difficult to believe that it had been the result of a disorder of only nine days' dura- tion. But the body was full in flesh, and shewed 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 sim- ilar 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 per- fect health, and able for a great deal of exercise. I likewise ascertained, that her bowels were habitually rather costive, requiring the frequent use of gentle lax- atives. •§ V.—The disease in the colon fatal by exten- sive ULCERATION WITH PERITONITIS. Case LXXXV1L—-A girl, aged 8. I saw her for the first time on the 9th of January, 1826, and obtained but an imperfect account 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 33 258 INFLAMMATION OF THE MUCOUS MEMBRANE. bowels had been loose, but not very troublesome ; the motions had been sometimes mucous, but not remark- ably morbid ; and some that I saw were quite healthy. The belly had been for some days tense and tympanitic, with much tenderness upon pressure, but no actual complaint of 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 moderately 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 mod- erately 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 farther 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 par- ty on the 2d of January, two days before the com- mencement of the fatal attack. Inspection.—The left lung was a mass of tubercular disease; the right was tolerably healthy. In the cav- ity 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 cover- ing of false membrane ; the liver was completely cov- ered 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 red colour; 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 CAPUT COLI, AND ASCENDING COLON. 259 the colon and the caput caecum ; and the meso-colon was also of a bright red colour, 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 com- mencement of the ileum, but the rest of the small in- testine was healthy. § VI.—The disease confined to the caput coli and PART OF THE ASCENDING COLON,--THE PATIENT DYING OF AN AFFECION OF THE BRAIN. Case LXXXVIII.—A girl, aged 6, was affected with severe and obstinate diarrhoea, which reduced her to great weakness and emaciation. It subsided after three or four weeks, and was succeeded, after a short inter- val, by severe pain in the belly, headach, and vomiting, the bowels being then rather bound ; the pulse was from 30 to 40 in a minute ; the urine was high-col- oured, and diminished in quantity.—The headach con- tinued, 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 con- tinued from 30 to 40, till a few days before her 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 ventricles of the brain, with ramollissement of the sep- tum and of the cerebral substance surrounding the ven- tricles. The inner surface of the caput coli, and of a great part of the ascending colon, was of a dark red 260 INFLAMMATION OF THE MUCOUS MEMBRANE. colour, and covered with numerous patches, also of a dark red colour and fungous appearance, which wcie considerably elevated above the level of the surrounding parts. § VII.—Fungous ulceration of the caput coli and RECENT INFLAMMATION OF THE ILEUM, WITH A COAT- ING OF FALSE MEMBRANE. Case LXXXIX.—A seaman, for whose case I am indebted to the late Dr. Oudney, was affected with dys- entery, accompanied with the usual symptoms. The stools were in general copious, and varied very much in appearance, being sometimes slimy, sometimes wate- ry, and sometimes consisting of mucus mixed with green matters of various shades. There was fever with rap- id emaciation ; at first, he had acute pain, and after- wards a dull uneasiness over the lower part of the abdo- men ; 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 6ide. He died in about five weeks. Inspection.—There were some superficial ulcerations of the mucous membrane towards the lower extremity of the colon ; but the principal seat of the disease ap- peared to be the caput coli, in which there were nu- merous fungous projections ulcerated upon the surface. In the ileum four inches from its lower extremity, there was a portion in a state of recent inflammation and cov- ered with false membrane. There were small abscesses in the liver, and the mesenteric glands were enlarged. ILEUM--WITH FALSE MEMBRANE. 261 § VIII.—The disease in the ileum with deposition OF FALSE MEMBKANE. Case XC.—A woman, aged about 30, in November, 1827, was received into the clinical ward of the Roy- al 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 al- lowed to remain in the hospital ; and she went on for ten days without any symptoms except weakness. She then seemed to relapse, complaining chiefly of headach and pain of the back. After this, she had sickness and a good deal of vomiting, and complained of pain, with some tenderness, referred to the region of the liv- er, which was relieved by topical bleeding. She still had sickness, with occasional vomiting ; the pulse con- tinued frequent and weak ; her strength sunk rapidly ; and she died in four days from the commencement of this relapse. 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 aphtha? ; beneath it the membrane shewed a high de- gree of redness. The peritoneum covering this portion of intestine shewed some minute- flakes of coagulable lymph for three or four inches. AU the other parts were healthy. For this important case I am indebted to Dr. Alison. The appearance described in it, and which also occur- red in the ileum, in the preceding case, is rather un common. It differs entirely from th^ -.appearance of 262 INFLAMMATION OF THE MUCOUS MEMBRANE. the disease as it occurred in the colon in the formei cases, and which also will be found occurring in the ileum in the cases to be next described. In the pre- sent 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 inflammation altogether distinct. The deposition of false membrane on the surface of the mucous 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 seems to have been most * frequent and most remarkable in the colon and rectum. He describes it in some cases as occurring in patches ; but in others, the mucous membrane was covered by a uniform layer of white lymph, which was in greatest quantity in the neighbourhood 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 intestine, in his able account of the Dysentery of Dublin of 18I8.f The appearances to be described as occurring in the ileum in the following cases, correspond with the ap- pearances described in regard to the colon in cases LXXXIV, and LXXXV. § IX.—The disease in the ileum fatal in the STATE OF RED ELEVATED PORTIONS WITH INCIPIENT ULCERATION. Case XCI.—A girl, aged 3 years, about three weeks before her death, was attacked with vomiting, frequent * Trails, of King's and Queen's Colleges, vol. V. \ Dublin Hospital Reuoits, vol. 1:1. m ILEUM--FATAL BY GANGRENE. 263 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 frequent irregular febrile paroxysms ; she had vomiting and frequent stools, which were of a clay colour, 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 coma- tose, with frequent screaming and great unwillingness to be moved. The pulse varied from 130 to 150, and she had frequent stools, which were now of a dull green colour, 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 Feb- ruary, 1820. Inspection.—The ileum, from its termination in the colon to near the jejunum, was highly vascular, its mi- nute vessels appearing as if injected. Its mucous mem- brane was covered with numerous irregular inflamed patches, which had a fungous appearance ; 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 other, and the membrane in the intervals was healthy. The mesenteric glands were greatly en- larged and very vascular. § X.—The disease in the ileum fatal by gangrene. Case XCII.—A woman, aged 25, was admitted into the Infirmary of Edinburgh, affected with pain over 26 1 INFLAMMATION OF THE MUCOUS MEMBKANS* the abdomen, tenesmus and diarrhoea. The pain inter- mitted occasionally, and was most severe on going to stool and on passing urine. The evacuations were free from scybalas or blood. She had headach, thirst, some cough, nausea, occasional vomiting, and a pale ema- ciated 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 reports shews a state of the functions of the bowels, which, when com- pared with the morbid appearance to be described, pre- sents 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 seemed to consist of broth which she had recently ta- ken, little changed. (4th day) Two scanty evacuations without griping ; abdomen hard and painful ; vomited once ; a mild ene- ma produced a copious discharge and relieved the pain. (5th day) Less pain; vomited several times; one stool thin and feculent; pulse 7 8 ; took six grains of calomel. (6th day) Two stools ; one of them thin and fecu- lent, the other much tinged with blood ; much pain be- fore the evacuations ; abdomen tense and painful ; pulse 80 ; vomited a considerable quantity of slimy matter tinged with blood, and having some purulent matter mixed with it. She took gr. viii. of calomel. (7th day) Two stools, thin, feculent, and of a natu- ral appearance, but preceded by much pain ; vomited re- peatedly some greenish slimy matter, mixed with bloody pus ; less tension of the abdomen ; pulse from 60 to 70 ; took some calomel with opium. ILEUM--WITH PERFORATING ULCER, &,C. 265 (8th day) No stool and no vomiting ; died in the night. Inspection.—The vessels on the stomach, duodenum and jejunum were unusually distended with blood. The ileum was livid, with some adhesions ; its inter- nal surface was quite black ; and it contained dark coloured 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 colour ; and be- tween these parts there was much fetid pus. § XI.—The disease in the ileum, with ulcera- tion, FATAL BY A PERFORATING ULCER AND PERI- TONITIS. Case XCIII.—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 most violent pain of the abdomen, which began at the lower part, but 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 coldness of the body ; there was some dis- charge 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 afternoon. Inspection.—Extensive inflammation on the outer sur- face of the small intestine, especially at the lower part, where there were considerable exudation and gangrene. There was extensive inflammation of the mucous mem- 34 266 THE DISEASE OCCURRING braneofthe small intestines, in various places ; and the inflamed portions were covered with minute ulcers. At one place, at the lower part of the ileum, there was a more extensive ulcer about the size of a shilling ; this was surrounded by a ring of inflammation, which was cov- ered by minute ulcers ; and in the centre of the large ulcer, there was a small opening which perforated the in- testine ; the outer surface at this place was of a dark livid colour. § XII.—The disease occurring in continued fever, WITH ULCERATION. Case XCIV.—A girl, aged 9, was seen by Dr. Alison in December, 1819, affected with the usual symptoms of contagious fever, which was very prevalent in a nar- row and crowded lane where she resided, and had affected a person in an adjoining room. From the commencement of the disease, she had diarrhoea, with griping, and considerable tenderness of the abdomen ; and the evacuations were thin, feculent, and of a heal- thy 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 inflam- mation. 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 present at the examination of the body. Inspection.—There was considerable peritoneal in- flammation, especially on the ileum, where there was extensive adhesion, with considerable deposition of floc- culent matter. The intestine was also seen to be in sev- IN CONTINUED FEVER, WITH ULCERATION. 267 era! 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 surface, the mucous membrane being extensively eroded, and in many places completely destroyed, by round well defined ul- cers, many t>f them as large as a shilling. This state of disease extended over the greater part of the ileum, and, in several places, its coats were considerably thick- ened. It contained a considerable quantity of fluid fe- culent matter, which was quite healthy in its appear- ance. 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 col- lapsed, and externally healthy; internally, there were in several 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 bowels may perhaps be considered as symptom- atic. This occurred still more distinctly in a case men- tioned by Dr. Duncan, junior, in his clinical reports. The patient (a woman aged 60) seemed to be convales- cent from fever with petechia?, when, about the 23d day of the disease, she was attacked with diarrhoea, without any complaint of pain ; the stools fetid and dark-coloured ; the pulse varying from 80 to 100. About the 7 th day from the commencement of these symptoms, she began to have pain and bloody evacua- tions, and died on the 9th day. On inspection, the disease was found nearly in the state of simple inflam- mation. At various parts of the mucous membrane, from the jejunum to the rectum, there were purple patches, occurring, at first, at intervals of one or two 268 INFLAMMATION OF THE MUCOUS MEMBRANE. inches, and then running gradually more and more into each other. There was the same appearance in the caput coli, but the arch was entirely free from it. It occurred again at the sigmoid flexure ; and, in the rectum, in addition to this appearance, there were nu- merous fungous looking patches, from a quarter to half an inch broad, and elevated fully an eighth of an inch above the surface of the intestine; they had a very vascular appearance, and their surface was covered with a thin yellowish crust. The various observations which have been detailed in this section, appear to illustrate the principal phe- nomena connected with inflammation of the mucous membrane of the intestine ; and they lead to some con- clusions of much practical importance 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 disturbance with which the more extensive degrees of it are attended. 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 illustrated by Cases LXXXIV, and LXXXV. II. It appears that the more intense forms of the dis- ease may be fatal, though of small extent, by gangrene or by ulceration ; and that the ulceration may perforate the intestine, and terminate speedily by extensive pe- ritonitis. III. We see some evidence of the contagious, or at least the epidemic character of the disease ; as, in the family in which Case LXXXV occurred, five individu- als were affected in quick succession, and two of them died. GENERAL CONCLUSIONS. 269 IV. It is probable that the symptoms vary consider- erably, according to the extent of the disease, and the part of the canal which is the primary seat of it. This appears most remarkably in the character of the evac- uations. 1. When the disease is confined to the rectum or the lower part of the colon, the evacuations appear to be scanty, and mucus 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, 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 extent, affecting at once a great part of the bowels, especially of the small intestine, and constitut- ing 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 accord- ance with the statements of the best practical writers. It will now perhaps be generally admitted, that in talk- ing 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 tenes- mus and scanty discharges of bloody mucus. We have seen that such a modification of the disease does exist, but practical writers, of the first authority, des- cribe another form of the affection, in which the evac- uations are copious, and vary exceedingly in appear- ance, at different periods of the disease,—being some- 270 INFLAMMATION OF. THE MUCOUS MEMBRANE. times dark, watery and sanious, and sometimes quite natural. Sir James M'Grigor has particularly remarked, that the tropical dysentery which was fatal to the troops under his inspection, differs remarkably from the dysen- tery of Cullen, and ought rather to belong to the form of disease which he has classed with diarrhoea. " 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. Ballingall is strong- ly in favour of the same important fact. In his des- cription of that formidable modification of the disease, which he has termed colonitis, he distinctly describes the evacuations as being in the early stage of the dis- ease generally copious, of a fluid consistence, and without any particular foetor. In a private communica- tion, in reply to certain queries which I addressed to him on this subject, he farther states, that " at this pe- riod of the disease, the evacuations differ only in con- sistence from healthy feces; as the disease advances, important changes take place in this respect, the evac- uations becoming more scanty, and of a morbid appear- ance," 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 is probably the state of the disease referred to by another intelli- gent practical writer, when he says, " I had been taught to believe that the proper dysentery, or that which is most distinct from diarrhoea, is the most for- midable disease, but I found, contrary to expectation, that the dysenteries which began with diarrhoea, often proved the most violent."* Now, in the dysentery of Cullen, as described by Dr. Donald Munro, the primary seat of the disease appears to have been the rectum and * Dcwar on the Diarrhoea and Dysentery as they appeared in the British army in Egypt. DYSENTERY. 271 the lower part of the colon,—often the rectum alone ; while, in the colonitis of Dr. Ballingall 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 intestine. If we are asked, therefore, what is the difference betwixt diarrhoea and dysentery, we must reply, that it consists in the na- ture 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 ir- ritating causes applied to the mucous membrane in a healthy state,—the highest degree of it is the cholera of this country, which may be dangerous hv 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 thesG are often entirely wanting, or are so mixed up with the feculent evacuations as not to be recognised ; 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 danger- ous. Dysentery is often accompanied by diseases of neighbouring organs, especially the liver, in which are found in some cases abscesses, and in the protracted cases, chronic induration. These 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 accumulation of blood in its more minute vessels; but 272 INFLAMMATION OF THE MUCOUS MEMBRANE. this must be considered as in a great measure conjec- tural. Dysentery was formerly supposed to have an intimate dependence upon the liver, and a modification of it has been described under the name of hepatic dysentery. By such a distinction I can understand nothing more than the fact, that a patient may be affected at the same time with dysentery and disease of the liver. Dysentery is a disease of the mucous membrane of the intestine ; and that in patients affected with it, the liver is frequently diseased, is a fact of much practical im- portance ; but this does not seem sufficient to establish any connection betwixt the two diseases, and it seems to be now ascertained that the connection is incidental. I have never seen the liver affected in the dysentery of this country, except in one or two chronic cases to be afterwards mentioned. It seems to be of more frequent occurrence in Ireland, and still more in India; but in the dysentery which was so fatal to the troops at Ran- goon in the Burmese war, Mr. Waddel states, that he did not find disease of the liver in any one of his dis- sections.* I am also informed by Dr. Knox of this city, that he had opportunities of examining the bodies in sixty-four cases of chronic dysentery from India, Ceylon, and the coast of Africa, and that he found the liver diseased in two only of all this number. We hear, indeed, a great deal about functional disease of the liver, which leaves no morbid appearance to be dis- covered on dissection ; but this is a mere hypothesis to which no importance can be attached in a pathological inquiry. The urinary bladder is often affected in dysenteric cases, with pain, dysuria, or retention ; and in old cases of chronic dysentery, we may find almost all the viscera more or less diseased, and perhaps extensively agglu- tinated together by chronic peritonitis. * Transactions of the Medical and Physical Society of Calcutta, vol. iii. CHRONIC DISEASES OF MUCOUS MEMBRANE. 273 SECTION II. OF THE CHRONIC DISEASES OF THE MUCOUS MEMBRANE. The chronic diseases of the mucous membrane may be left as the effect of an acute attack," or they may come on gradually in a chronic form. They present to us chiefly the following varieties of morbid appearan- ces. I. A greater or less extent of the membrane covered with irregular patches of a dark red colour, and fun- gous appearance, sensibly elevated above the level of the surrounding parts. II. Small well defined ulcers, more or less numerous ; often at considerable distances from each other, and not larger than the diameter of a split pea, the intervening membrane being entirely healthy. These two modificatipns of the disease I think are generally characterized by long continued diarrhoea, without any thing particularly morbid in the appearance of the evacuations, except that they are always fluid, and have often a peculiar foetor. There seems to be little discharge from the diseased surface, or not suffi- cient to impart a character to the evacuations. III. An extensive tract of the membrane, shewing one continued surface of disease, in which ragged ir- regular ulceration alternates with fungous elevations, and with other parts from which portions of the mem- brane appear to he removed. When this form of the disease occurs in the colon, there are copious evacua- tions of morbid matter from the diseased surface, which are sometimes puriform, and sometimes consist of a mix- ture of a tenacious puriform fluid, with mucus, or semi- gelatinous matter ; and the whole is often deeply tinged 35 274 CHRONIC DISEASES OF MUCOUS MEMBRANE. with blood. According to the extent of the disease, this discharge may come off uncombined and in considera- ble quantities ; or it may be mixed with healthy feces. When the disease is confined to the lower part of the colon or rectum, we may have the feces coming off in a solid, or even a hardened state, but generally mixed with more or less of the morbid discharge ; and, at other times, yve may have the discharge coming off in considerable quantities without any appearance of fe- culent matter. When the disease extends along the whole course of the colon, the feces generally come off in a liquid state, and, in this case, we may have the evacuations consisting sometimes of thin healthy feces, more or less combined with the morbid discharge ; and, at other times, we may find the morbid discharge com- ing off without any appearance of feculent matter. When the disease is in the small intestine, we seldom see the peculiar discharge uncbmbined ; it seems either to be in smaller quantity, or to come off so mixed with fluid feces as not to be easily distinguished. This form of the disease, in which the ulceration is confined to the small intestines, seems to be of frequent occurrence in phthisical cases ; and indeed it appears probable, that, in some of these, it is the primary disease, and that the affection of the lungs takes place at a subse- quent period. This probably occurred in cases C. and CI. IV. The other coats partaking of the disease, and a portion of the intestine of greater or less extent, be- coming thickened and indurated, often with adhesion to the neighbouring organs, or to the parietes. In some cases, the part so affected becomes- contracted, with great diminution of its area; in other cases, it is dis- tended into a large cyst, with firm and hardened parietes, giving externally the feeling of a mass of organic dis- ease. CHRONIC DISEASES OF MUCOUS MEMBRANE. 27 5 The symptoms connected with these various states of disease vary considerably in different cases. After the affection has continued for some time, we general- ly find the patient considerably emaciated, often with a peculiar withered look. There is generally an un- tractable diarrhoea, which in some cases is permanent, and, in others, occurs at short intervals,—continuing for a few days at a time, and alternating with costiveness. In some cases the appetite is good, or even voracious ; but, in general, it is variable and capricious, with indi- gestion and great uneasiness after eating ; and sometimes every thing that is taken into the stomach produces a peculiar uneasiness, which passes downwards into the bowels, and is not relieved until after repeated evacua- tions. If by opiates or astringents the diarrhoea be restrai- ned, the uneasiness in the stomach is generally increased, and in some cases vomiting is excited. In other cases, vomiting regularly alternates with the diarrhoea,—the patient perhaps being for a few days at a time affected with frequent vomiting, and then for a few days with diarrhoea without vomiting. The remedies given in such cases to alleviate one symptom generally lead to the other ; or these may alternate without any interfe- rence. There is commonly pain in the abdomen, but it varies much both in degree and duration ; in some cases, it only appears in the form of tormina, preced- ing the evacuations, and in others, it is more permanent and is increased by pressure. Some of the chronic cases appear to go on for a considerable time without much disturbance of the ge'neral health; but in others, there is much weakness and emaciation, frequently with hectic paroxysms ; and sometimes there is a peculiar rawness and tenderness of the mouth and fauces, with aphthae or minute ulcers, often accompanied by a tenderness of the whole oesoph- agus, and a painful burning sensation in the stomach, produced by almost every thing that is swallowed.. 276 CHRONIC DISEASE* OF MUCOUS MEMBRANE. The appearance of the evacuations varies in the man- ner which has been already stated ; so that no diagno- sis can be founded upon them. They sometimes con- sist, in a great measure, of bloody puriform matter, and of various combinations of this discharge with thin fe- ces', or with articles of food or drink partially chang- ed ; but in many cases, they will be found to consist, through the whole course of the disease, of fluid feces without any mixture of morbid discharge. In some cases, again, there are discharges of venous blood, which may come off either in the form of coagula, or of a dark pitchy matter, giving a black or dark brown colour to the whole of the matter that is evacuated. In the cases, again, in which there occur thicken- ing and induration of the coats of the intestine, there is frequently a complete loss of the muscular power, so that they pass into perfect ileus. These various modifications of this very interesting class of diseases will be illustrated by the following ex- amples. § I.—The disease fatal, with elevated red patches WITHOUT ULCERATION. Case XCV.—A gentleman, aged about 50, had been for several years liable to a loose state of his bowels ; it attacked him most frequently in the night time, and often obliged him to get up several times in the night. His general health, however, was not much affected, until a few months before his death, when the diarrhoea became more severe, and resisted every remedy. He now became pale and emaciated, with bad appetite and bad digestion, and died gradually exhausted. • MALL DETACHED ULCERS. 27 7 Inspection.—The liver was enlarged, pale, and tu- bercular. The intestines were externally healthy ; in- ternally, the mucous membrane was in many places ele- vated into irregular portions of a dark red and fungous appearance. These portions were observed through the whole tract of the canal, but were most numerous in the small intestine ; the intervening mucous mem- brane was of a healthy appearance, and there was no ulceration observed in any part of the canal. $ II.—Numerous small detached ulcers, the inter VENING MEMBRANE HEALTHY. Case XCVI.—A lady, aged 35, died in April, 1818, after having suffered for nearly four years from a diar- rhoea, which had resisted every remedy. I saw her on- ly a few weeks before death, and found her pale, with- ered, and emaciated, with frequent pulse, slight cough, and considerable uneasiness in the abdomen. The di- arrhoea occurred several times every day ; and the evac- uations were thin, feculent, and of a healthy appear- ance. The abdomen was to the feel soft and natural ; she had no vomiting ; the cough was not severe, and had commenced only within the last year. At the commencement of the complaint, she had suffered much from pain in the bowels, and occasionally through the whole course of it; but it wras not constant, and not confined to any particular part. For some time before death she had aphthae of the throat. Inspection.—The bowels were externally healthy, ex- cept in several places of the small intestine, where there were large spots-of a dark red colour, which seemed to be deep seated as if shining through the pe- ritoneal coat. At the places corresponding with these 27 8 CHRONIC DISEASES OF MUCOUS MEMBRANE. spots, the mucous membrane was elevated into patches of a fungous appearance, and deep red colour ; and on these portions, there were numerous small oval ul- cers, the bottoms of which were smooth and pale, vvjiile the parts around were of a dark red. At these ulcers, the intestines, when held up to the light, were semi- transparent; they were found wherever the dark fun- gous appearance existed, and this was over a considera- ble part of the small intestine, in irregular portions, some of them six or eight inches in length, the inter- vening membrane being healthy. The colon was ex- ternally healthy ; internally there were many small ul- cers which had a different character from those in the small intestine. They were more distinctly ulcerated at the bottom; few of them were larger than the diam- eter of a split pea, but each of them was surrounded by a firm elevated margin, without any discoloration of the surrounding parts. They were chiefly observed in the ascending colon and in the arch. On the inner surface of the stomach, near the pylorus, and of the oeso- phagus through its whole extent, there were numerous very minute superficial ulcers, of an oval shape, and scarcely larger than the diameter of a pin's head. The lungs were tubercular, and in the left there were several small abscesses. The other viscera were healthy. .Perhaps we may have some grounds for supposing that, in this form of the disease, the ulceration may be primarily seated in the mucous follicjes ; and that, in the form in which it appeared in the .small intestine in the preceding case, it was accompanied by disease of the surrounding mucous membrane, while in the colon the membrane surrounding the ulcers was healthy. This is mere conjecture, and it is a point of no practical importance. The appearances described in the follow- ing case probably indicate the earliest stage of this form of the ulceration, and, had the patient not died CONTINUED ULCERATION OF COLON. 279 of another affection, would probably have passed into a state of disease similar to that which has now been re- ferred to. Case XCVII. A girl, aged 7, about the 22d of July, 1826, complained of pain in the bowels, with diarrhoea, and some vomiting. These symptoms were relieved by the usual remedies, but she still complained of pain in the bowels, and had some cough. After these symp- toms had gone on for a few days, she began to be- af- fected with disease of the brain, of which she died on the 1 Oth of August.* Inspection.—In the mucous membrane of the intes- tine, especially at the lower extremity of the ileum, there were observed numerous minute black spots, at some distance from one another, each of which, when viewed by a lens, was found to be surrounded by a mi- nute circle of inflammation. ^ III.—Extensive continued ulceration of the mu- cous MEMBRANE OF THE COLON. Case XCVIII.—A young lady, aged 17, had been liable, from an early period of her life, to an irritable state of her bowels, but the affection had assumed a more fixed and alarming character about the beginning of the year J 827. She at that time became affected with more constant uneasiness in the abdomen, and a tendency to diarrhoea, with considerable irritation ; and after sometime, the motions began to exhibit a very un- healthy character. She became feeble and exhausted, with a quick pulse and hectic paroxysms ; and a great * Sec the -tntlior's Researches on Disease* ef the Brain, Ca?e XXVI. 2 80 CHRONIC DISEASES OF MUCOUS MEMBRANE. variety of treatment was employed through the spring and summer without benefit. I saw her, along with Mr. Alexander, in September. She was then much exhausted ; had a feeble and rapid pulse, little appetite, and disturbed feverish nights, with considerable perspi- ration. She had much uneasiness extending over the whole abdomen, with some tenderness, and frequent calls to stool, accompanied by much pain and irritation. The motions sometimes consisted almost entirely of a tenacious puriform matter streaked with blood ; at other times, of thin feculent matter with much of this puriform discharge mixed in it, and occasionally, there was healthy feculent matter of considerable consistency. After using some remedies without benefit, she began to take a strong decoction of cusparia combined with nitric acid and small doses of laudanum ; under the use of this the puriform discharge entirely ceased ; but she continued to have much uneasiness in the abdomen, with frequent stools, which were thin, feculent, and healthy. Her strength sunk gradually, and she died in October. Inspection.—The colon externally had a soft and slightly thickened appearance, and there were patches of a deep seated redness shining through its peritoneal coat. On laying it open, its inner membrane presented one continued diseased surface through its whole extent. There were deep abrasions in some places, from which portions of the mucous membrane appeared to have been entirely removed ; at others, more super- ficial irregular ulcerations of various extent; and, in many places, round well-defined ulcers; and the whole was interspersed with portions of a dark reddish brown colour in a state of fungous elevation. Through the whole extent of the colon and rectum, there was no spot that presented a healthy appearance; but the small intestine and all the other viscera were entirely healthy. In the sigmoid flexure of the colon, there CONTINUED ULCERATION OF COLON. 281 was a small portion where the intestine was considera- bly thickened in its coats, and of almost cartilaginous hardness. Case XCIX.—A gentleman, aged 70, had been for nearly twenty years liable to an irritable state of his bowels, with sudden calls to stool, which often obliged him to retire suddenly from company, or, when walking out, to retire behind a hedge. He had several times recovered good health for a short time, especially after the use of some of the saline mineral waters. He had also suffered from calculus, but his general health was so little impaired, that, three years before his death, he underwent the operation of lithotomy, and had a rapid recovery. When I saw him a few weeks before his death, he was feeble and confined to bed, with frequent calls to stool. The motions were sometimes thin, feculent, and natural ; and sometimes consisted of a whitish muco-purulent matter of a peculiar foetor, about an ounce of which was generally discharged at each evacuation. He died gradually exhausted. Inspection.—The small intestine was entirely healthy. The whole tract of the colon was diseased ; its coats were much thickened, and its mucous membrane pre- sented one continued surface of ulceration through its whole extent. This, in some places, consisted of a continued irregular surface of ulceration; in others, of a thickened and dark coloured state of the membrane, which was studded with small round defined ulcers. See also another very remarkable example of exten- sive ulceration of the colon, in Case CXXII, in which it was complicated with extensive disease of the liver. The peculiarity of this case was, that there had been no symptoms in the bowels until three weeks before death. 36 282 CHRONIC DISEASES OF MUCOUS MEMBRANE. § IV.—Extensive continued ulceration in the SMALL INTESTINE. Case C—A lady, aged 27, had suffered for a consid- erable time from a chronic affection of the ankle joint, which never assumed any alarming character, and ulti- mately got well. It had, however, prevented her from taking exercise, and, during the course of it, she be- gan to be affected with diarrhoea, for which she took a variety of medicines without permanent advantage. This had gone on, in a greater or less degree, for about two months, when she was first seen by Dr. Beilby. The stools were^ then frequent, scanty, light colour- ed, and very offensive, but without any thing peculiar in their character ; they had at one time been occasion- ally bloody, but this had disappeared. There was con- siderable emaciation; the pulse was rapid and fee- ble ; the abdomen was full and tense, but not tender; there was some cough, which was quite recent and without expectoration. Various remedies were given with temporary benefit; the diarrhoea was restrained for a time, but returned with severity, and the pectoral symptoms increased; her breathing was easily hur- ried ; she became more and more weakened and ema- ciated ; and died about two months from the time when Dr. Beilby saw her, or four months from the commence- ment of the diarrhoea. When I saw her, a few weeks before her death, she was much emaciated, and the pulse was small and very rapid ; there was nothing un- healthy in the character of the evacuations, and they were easily restrained within a very moderate degree of frequency. The abdomen felt rather tense, but with- out tenderness. The cough was but trifling, and there was to the last very little expectoration, and of no un- healthy character. ULCERATION OF SMALL INTESTINES. 283 Inspection.—In the right lung there was a large ab- scess in the upper part, and in the other parts there were numerous smaller abscesses, with tubercles in various stages of their progress. The left lung was in a sim- ilar state, except that the abscesses were fewer in num- ber, and there was one cyst of a large abscess empty. The small intestines adhered extensively to each other, and to the parietes of the abdomen ; and their inner sur- face presented one continued series of ulcers of vari- ous extent, many of them of considerable depth, with defined and elevated edges, others more superficial and irregular. The intervening portions of the mucous membrane were of a dark red colour. The Fallopian tubes were greatly enlarged, and filled with cheesy mat- ter. Case CI.—A gentleman, aged 19, about four months before his death, began to be affected with slight fe- brile paroxysms, and an unhealthy state of his bowels. His stools were in general not above two in the day, but were always thin, light coloured, and remarkably fetid. This went on for two or three weeks, when, under some treatment which was adopted, his stools became formed and more natural, but they were often slightly tinged with blood. Soon after this, he was exposed to cold, and was seized with much griping and frequent watery stools, which continued for two days. This attack left him weak, and he had feverish paroxysms in the even- ing. He had still generally no more than two stools daily, but they were always thin, and remarkably fetid. He took a good deal of food, but wasted progressively. He had slight cough, which was chiefly observed during the night, and seldom in the day ; his pulse was con- stantly quick and small, with flushings in the evening, and perspiration in the night, but the latter afterwards ceased. I saw him about a month before his death ; he was then weak and much emaciated, with a small 284 CHRONIC DISEASES OF MUCOUS MEMBRANE. rapid pulse, slight cough, and very little expectoration. There was some distention of the abdomen, with con- siderable tenderness ; he had regularly about two stools daily, which were sometimes thin and feculent, with- out any thing unnatural in their appearance, except a very remarkable foetor ; at other times, there were mix- ed with them flakes of a yellow curdy matter. He died gradually exhausted, without any change in the symp- toms, except considerable oppression of his breathing. His cough was never severe, and there was very little expectoration to the last. Inspection.—The lungs were most extensively tuber- cular, with numerous vomicae. In the upper part of the left lung, there was an abscess larger than an or- ange, full of a sanious fluid mixed with broken down tubercular matter. The bowels were externally heal- thy ; internally, nearly the whole tract of the small in«- testine was covered by a series of ulcers. They were in some places small and distinct, being scarcely larger than the diameter of split peas ; in other places, many of these had run together, forming considerable spaces of continued ulceration. The colon was healthy. § V.—Ulceration of the mucous membrane, with THICKENING AND INDURATION OF THE COATS OF THE INTESTINE. Case C1I.—A girl, aged 1 3, about a year before her death, began to be affected with pain of the abdomen and frequent vomiting. The bowels were at first nat- ural, but soon became loose ; and from this time she was almost constantly affected either with diarrhoea or vomiting, and sometimes with both at once. She be- came gradually emaciated, but was not confined to bed ULCERATION AND THICKENING. 285 until a month before her death, which happened in June, 1814. When I saw her about a week before she died, she was emaciated to the last degree, with some cough and a small frequent pulse. She had still fre- quent diarrhoea and vomiting, and complained of con- stant pain in the bowels, which was increased by pres- sure, but the abdomen was soft and collapsed. Inspection.—The caput coli was dark coloured, hard and much thickened in its coats; internally, it was much eroded by ulceration; the disease extended, in the form of numerous smaller ulcers, about three inches along the ascending colon ; and the valve of the colon was destroyed by the ulceration. The lower end of the ileum, to the extent of about eighteen inches, was distended, thickened in its coats, externally of a red- dish colour, and internally covered by numerous well- defined ulcers, varying in size from the diameter of a split pea to that of a sixpence. The lungs and all the other viscera were healthy. This case shews the disease in a form analogous to that which has been illustrated by the preceding exam- ples, and differs from them only in being complicated with the thickened and hardened state of the parietes of the intestine at the part affected. It is by this thickening of the intestine at length destroying muscular action, that the disease sometimes passes into obstinate costiveness or ileus. A gentle- man, whose case was communicated to Dr. Munro by Dr. Sanders, had been liable for twenty years to heart- burn and occasional vomiting, and generally had five or six liquid stools every day, which were sometimes slimy and streaked with blood. He was afterwards affected with such obstinate costiveness, that he had no stool for nine days. After this, the diarrhoea returned with vom- iting, and he died at last with great distention of the abdomen and obstinate costiveness. The intestines 286 CHRONIC DISEASES OF MUCOUS MEMBRANE. were found extensively adhering to each other; and a large portion of the ileum was distended, very much thickened in its coats, and internally covered with va- rious tumours, indurations, and ulcers. But the disease exists in another form, in which the symptoms are remarkably different, and often very ob- scure. The peculiarity of these cases seems to depend upon the disease being very limited in extent, so a*s not to interfere materially with the general action of the canal. The phenomena connected with some of these cases are very remarkable ; the principal modifica- tions of them will be illustrated by the following exam- ples. Case CIII.—A naval officer, aged 53, in the begin- ning of the year 1821, fell in walking down some steps, and struck his left side against the corner of one of them, about half-way betwixt the ribs and the spine of the ileum. No violent symptoms followed at the time, but he continued to feel some uneasiness at the part, which varied very much in degree at different times, but was never entirely gone. After some time, he began to have various dyspeptic complaints, with loss of flesh, and his general health was considerably impaired. He then went to Cheltenham, where he got considerably better, but returned home, and, having lived rather freely, be- came worse again. After a considerable time had pass- ed in this manner, a swelling was perceived in the left side of the abdomen, which was by some considered as an enlargement of the spleen, and by others, as a dis- ease of the liver. He now went through several cours- es of mercury, by which his strength was considerably reduced, but without any improvement in his complaints. His bowels had hitherto been in general pretty natural, but sometimes rather loose, and occasinally he had passed by stool considerable quantities of coagulated ULCERATION AND THICKENING. 287 blood. These discharges had generally been preceded by a good deal of pain in the left side. The disease had gone on in this manner for about eighteen months, when he came to Edinburgh in the beginning of Sep- tember, 1823, and I saw him for the first time. He was then much emaciated, with a sallow complexion, a small frequent pulse, great weakness, and considerable anasarca of his legs. His belly was tumid, and there was considerable but not severe uneasiness in the left side, immediately above the crest of the ileum. At this place a firm defined deep-seated swelling was perceptible, which did not extend into the region of the spleen, and was evidently too low down to be considered as a dis- ease of that organ ; and, on repeated examination, it was distinctly perceived to vary sensibly in size on dif- ferent days. It was, however, so firm as to convey the impression of a mass of organic disease. His bowels were moderately open ; the stools were thin and very dark coloured, with an occasional mixture of blood. After he had been in Edinburgh for ten or twelve days, he was seized with vomiting, which had never occurred before ; his bowels became confined, with great pain in the left side, and much uneasiness extending over the whole abdomen. His strength now sunk rapidly, and he died in three days. Inspection.—The swelling in the left side was found to be a disease of the descending colon, a portion of which was dilated so as to form a large irregular cyst, and the parietes of the cyst were thick and very hard, so as to be at some places almost cartilaginous. Ex- ternally, the cyst adhered extensively to the parietes of the abdomen ; internally, it presented a continued sur- face of dark coloured fungous ulceration, with many elevations and depressions. The disease was entirely limited to the part forming the cyst, which was between four and five inches in diameter. The intestine, both immediately above and immediately below, was entirely 288 CHRONIC DISEASES OF MUCOUS MEMBRANE. healthy, and communicated freely with the diseased cav- ity. The spleen was quite healthy ; the liver was tu- bercular but not enlarged. Case CIV.—A lady, aged about 35, was affected with frequent attacks of vomiting and severe pain in the epi- gastric region. A variety of treatment was employed with little or no benefit; and at length she could retain nothing upon her stomach except liquids in very small quantities. A succession of blisters upon the epigas- tric region seemed now to give considerable relief, and the vomiting ceased after the complaint had gone on for several months. She continued however to complain of violent pain, which was always referred to the epi- gastric region ; but nothing could be discovered on ex- amination, either in the seat of the pain, or in any part of the abdomen. The bowels were natural or easily regulated ; the pulse was little affected; but she could take almost no nourishment. In this manner her strength sunk gradually, and she died in a state of extreme ema- ciation, about a year from the commencement of the complaint, and about three months from the time when the vomiting ceased. Inspection.—No disease could be discovered in the epigastric region, except some enlarged glands lying behind the stomach. The bowels also were healthy except the caput coli, which was throughout much thickened in its coats, in some places cartilaginous, and internally presented one continued surface of dark fun- gous ulceration. Case CV.—A lady, aged 45, was affected with a hard and painful tumour, which was felt arising out of the hollow of the os ilium of the right side. When I saw her in June, 1816, she was much exhausted, with extensive anasarca of both the lower extremities, but in the greatest degree in the right; pulse small and ULCERATION AND THICKENING. 289 frequent; no appetite. The bowels were natural or easily regulated, sometimes rather inclined to be loose ; but in no considerable degree. She had been in bad health about three years, having been first affected with a fixed pain in the right side ; and the tumor had been observed for about two years. It had been con- sidered as a disease of the ovarium, and a variety of treatment had been adopted without relief. She suf- fered constant pain in the tumor, Jlthout any other de- fined symptom, except the anasarca of the lower ex- tremities ; and died gradually exhausted in August. Inspection.—The tumor was found to be a disease of the caput coli, which was converted into a large cyst, the parietes of which were hard and thickened,—in some places almost cartilaginous. It adhered extensively to the parietes of the abdomen, and internally present- ed a surface of dark fungous ulceration. The ileum entering the cyst, and the ascending colon arising from it, were both perfectly healthy. On the convex surface of the liver there was a cyst lined by a firm white membrane, invested externally by the peritoneal cov- ering of the liver, and containing about a pound of clear serous fluid. The uterus, the ovaria, and all the other viscera were entirely healthy. SECTION III. OF ULCERS OF THE MUCOUS MEMBRANE WITHOUT PROM INENT SYMPTOMS. The .distinction on which this section is founded is entirely of a practical nature. In its pathological 37 290 CHRONIC DISEASES OF MUCOUS MEMBRANE. characters, the affection is the same with that which occurred in the preceding cases, and differs from it on- ly in the extent of the disease, and in the symptoms with which it is accompanied. It consists of ulcers of various extent, but few in number ; perhaps only one or two of them occurring in the whole course of the canal ; or a few of them in succession occupying a small space, most commonly about the lower end of the ileum, while e^ry other part of the canal is in a perfectly healthy stote. The ulcers in these cases are generally about the size of a sixpence—sometimes larg- er, with deep excavations, and round elevated edges ; and the remarkable circumstance connected with their history is, that they often seem to exist without produc- ing any symptoms which indicate their existence, un- til the case proves suddenly fatal. The termination in such cases may take place by haemorrhage or by peri- toneal inflammation. The latter seems in general to be connected with perforation of the intestine by one of the ulcers, and the escape of its contents into the peritoneal cavity. Ulcers of this class are chiefly met with under the following circumstances. 1. In acute diseases, as the common continued fever. In this case there may have been some diarrhoea or slight symptoms in the bowels ; or there may have been no symptoms indicating any such disease, until the fatal event takes place in an unexpected manner by haemor- rhage or peritoneal inflammation. 2. Ulcers of this class seem to exist in a more chro- nic form, in which the symptoms may be so obscure that their presence is not suspected during the life of the pa- tient. The fatal event, in such cases, may occur sud- denly, by perforation of the intestine, or by gradual ex- haustion after long continued bad health ; or the affec- ULCERATION--FATAL BY HiEMORRHAGE. 291 tion may be discovered only when the patient has died of some other disease. § !•—An ulcer of this*class fatal by hemorrhage without previous symptoms in the bowels. Case CVL—A gentleman, aged 35, (1st January, 1826) had been affected for a few days with symptoms in- dicating the mildest form of continued fever, which was at that time very prevalent in Edinburgh. He had foul tongue ; bad appetite ; andidisturbed sleep ; pulse from 96 to 100; had kept his bed only two days, and had not done so until desired by his medical attendant, Mr. Law. His bowels were easily moved, and the stools were quite natural; and for two days more this case seemed to be going on in the mildest possible form, without any local uneasiness, and without the slightest appearance of danger. On the 3d, about mid-day, he got up to go to stool, and discharged from his bowels a quantity of fluid blood, which nearly half filled the night table. He fell in a state of syncope on the floor, where a mat- tress was put under him, after he had recovered a little, as it was found impossible to get him into bed. After some time blood began to flow again from his bowels, in such quantities as to penetrate entirely through both the-mattress and the carpet. A variety of means were employed without benefit; he rallied slightly from time to time, but always sunk back again into a state of ex- treme exhaustion ; and died in about four hours after the first appearance of blood. Inspection.—The bowels were found externally heal- thy, till we came to the lower end of the ileum, where a small portion was of a very dark colour, and appear- ed to be considerably thickened. In the inner surface 292 CHRONIC DISEASES OF MUCOUS MEMBRANE. of this portion, there was a deep defined ulcer about the size of a shilling, with elevated edges ; it was par- tially filled up by a dark red fungous and by portions of coagulated blood. There was a similar ulcer in the caput coli, but the former appeared to have been the source of the haemorrhage. No other disease could be discovered in any organ. § II.—An ulcer of this class suddenly fatal by pe- ritonitis- Case CVII.—A girl, aged 14, about the 29th Octo- ber, 1825, was seized with symptoms of continued fever, which went on in a mild and favourable form for a week. I saw her for the first time on the ninth day ; her tongue was then clean ; pulse 96 ; there was no com- plaint of any pain; the bowels were easily moved, and the motions were natural; the abdomen was soft and natural to the feel, and no pain was complained of on pressure in any part of it. The same evening she be- gan to complain of a burning pain in the right side of the abdomen, and passed a very restless night. Being out of town, I did not see her till the afternoon of the following day, when I found the pulse 1 40 and small ; the abdomen tense, distended and very painful upon pressure, especially in the right side, in the region of the caput coli. Her strength was sinking, and sho died in two hours after the visit. Inspection.—On the small intestine, there was a bright redness with some distention. The caput coli and ascending colon were distended, and of a dark livid colour. On cutting into the caput coli, the open- ing into the ileum appeared very turgid, with rounded projecting edges ; and the lower extremity of the ileum, ulceration—fatal by peritonitis. 293 immediately adjoining the aperture, was completely surrounded by a series of ulcers. Other ulcers of the same kind appeared in a more detached form, along the lower extremity of the ileum in several places. The mesenteric glands were diseased in a very singular man- ner ; many of them formed semi-transparent vesicles, which, when touched with the knife, burst with a sharp explosion, throwing out air only. When they were emptied of this, the vesicles were found to contain cal- careous or cheesy matter of the usual appearance. No perforation of the intestine was observed in this case, but it had very much the appearance of the cases that terminate in this manner. An interesting collec- tion of these has been published by M. Louis, an ab- stract of which I inserted in the Edinburgh Medical Journal for January, 1824. These cases had in gen- eral at first the caracters of continued fever, with pec- toral symptoms in a few of them. In some, there had been]pain and tenderness of the abdomen with diarrhoea ; but in others, there had been no symptom referred to the belly until the fatal event took place. This occur- red at various periods of the disease, generally from the 10th to the 15th day ; in one, it was so early as the 4th day ; in another as late as three weeks ; and in sev- eral, it occurred after the patients were considered as convalescent. The fatal attack consisted of a sudden accession of most violent pain in the abdomen, with tenderness and tension, in some with vomiting; and it was fatal in periods of from twenty to fifty hours. On inspection, ulcers of various extent were found in the small intestine, generally towards the lower end of the ileum ; and in all of them, there was found a per- foration of the intestine by one of the ulcers, with extensive peritonitis, adhesions and turbid effusion in the peritoneal cavity. In some cases of the same kind mentioned by Cloquet, the preceding symptoms marked 294 CHRONIC diseases of mucous membrane. more distinctly intestinal disease. There was in gener- al obstinate diarrhoea, with pain of the abdomen ; and after a certain period, varying from *eight or ten days to two months, there was a sudden and violent aggrava- tion of the pain, with tension and extreme tenderness of the abdomen, and this attack was speedily fatal. Ul- ceration of greater or less extent was found in the mu- cous membrane, with perforation of the intestine by one of the ulcers, and the usual appearances of recent peritonitis.* § III.—Uloers of this class, without any pre- vious illness, suddenly fatal by perforation. Case CVIII.—A stout man, aged 36, who had pre- viously enjoyed good health, was suddenly seized, while engaged at his usual employment, with violent pain in the abdomen and vomiting ; 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 without benefit. The symptoms continued, the pain extending over the whole 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 cav- ity 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 duodenum, capable of transmit- ting a large quill; it had its origin in an ulcer of the mucous membrane, which was considerably larger than the perforation. * Nouveau Jour, de Med., Tom. i. ULCERATION--WITH old obscure symptoms. 295 Case CIX.—A gentleman, aged 60, had enjoyed ex- cellent 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 judi- eious 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 escap- ed through a perforation of the colon at its lower part, a little above its junction with the rectum. The open- ing 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 ex- tensively ulcerated. At the lower part of the diseased portion, about two or three inches below the rupture, the intestine was contracted by a hard ring, so as scarcely to transmit a finger. § IV.—Ulcers of this class found connected with obscure symptoms of long standing. There is reason to believe that ulceration of the mu- cous 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. 296 chronic diseases of mucous membrane. A gentleman, aged 34, who had formerly suffered from dysentery, 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 fre- quently confined. After several months had passed in this manner, he had frequent vomiting and a distressing sensation of heat in the stomach and oesophagus. He sometimes took food with eagerness, and sometimes re- fused it. His pulse continued natural, until three days before his death ; he then had convulsive affections and delirium, with frequent pulse, and died in a 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 ex- tremity 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 fungus which was 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 colic pains, which were slight and transient; and she had some discharge of blood by stool, which was considered as haemorrhoidal. 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 * Mem. of the Med. Soc. London, vol. vi. p. 128. DYSENTERY—treatment. 297 of it, and the left side of the colon, were red and pur- ple, as if sphacelated,—the other viscera were souhd.* By a minute examination in cases of this kind, the seat of the disease may sometimes be detected by ten- derness upon pressure, limited to a circumscribed space. It is also a good rule in all obscure affections of the bowels to make a careful examination of the rectum. I have in several cases discovered cancerous ulceration there, in connection with derangements of the bowels of a slight and obscure character. SECTION IV. OF THE TREATMENT OF THE AFFECTIONS OF THE MU- COUS MEMBRANE. § I.—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 intestine, we can be at little loss in fixing upon the first and great principle to be followed in the treat- ment ; while, if we use the term dysentery, we in vain endeavour 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 dys- entery is primarily an inflammation of the mucous mem- brane of the intestine ; and that the first principle in * Pincl Med. Cinique, p. 257. 38 298 INFLAMMATION OF MUCOUS MEMBRANE. the treatment is precisely the same as that which ap- plies 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 diversity of opinion in regard to the na- ture and treatment of dysentery ; namely, that inflam- mations of all mucous membranes exist in a state in which they admit of a spontaneous cure,—certain chan- ges 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 process 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 not- withstanding go on 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 pro- gress, 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 prin- ciple, we cannot doubt that dysentery, in all its forme 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 following :— . 1. To subdue the inflammation. DYSENTERY--TREATMENT. 299 2. To quiet the general irritation of the canal. 3. To correct the morbid secretions from the diseased surface. * 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 them, are general and topical blood-letting, blistering, diaphoretics, and anti- phlogistic 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 va- rious parts of the world, particularly Dr. Ballingall, Dr. Bampfield, and many others ; and the practice has also received the high sanction of Sir James M'Grigor, un- der whose instructions it has become the established treatment of dysentery by the medical department of the army. Dysentery, indeed, may exist in a degree 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 circumstances only introduce new difficulties in regard to individual cases, and do not af- fect the general principles which regulate the treatment of the disease. The use of general bleeding must of course be reg- ulated 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 free 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 recommend- ed, and James' powder, given in the same manner; but 300 INFLAMMATION OF MUCOUS MEMBRANE. in all inflammatory affectidhs 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 gen- eral irritation of the canal, will be chiefly answered by mucilaginous articles and opiates, particularly Dover's powder, perhaps combined with chalk, with the mildest kinds of farinaceous food in very small quantity ; and I 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 pos- sible of either food or drink; as from the morbid irri- tability of the parts, the mildest articles often produce great irritation. Suet, dissolved in milk, has been much recommended; and a favourite 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 flannel, 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 mem- brane, after the force of the inflammatory symptoms has been subdued by the necessary means, various rem- edies appear to be useful, in different states and differ- ent stages of the disease. In the earlier stages, bene- fit is frequently obtained from doses of Dover's powder, of from 5 to 10 grains, combined with 1 grain of calomel, repeated, at first, every four or five hours, and afterwards at longer intervals. This applies to the dysentery of this country ; in the more severe cases, which occur in warmer climates, Dr. Ferguson has * Sec Dewar en Dysentery, DYSENTERY--TREATMENT. 301 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 dysente- ric 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 opin- ion, 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 injurious; and when mercury is given, it appears that the small doses 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 appear to be useful,—such as, cusparia, lime water, oxide of bismuth, 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 pow- der, it appeared to Mr. Gillespie and myself to be decidedly useful. Nitric acid, combined 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 302 INFLAMMATION OF MUCOUS MEMBRANE. 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 subdu- ed, I have seen decided benefit in relieving the tenes- mus by 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 re- gard to the use of purgatives, and what are the cases to which they are adapted. It is clear that a modification of the disease exists, in which it is confined to the lower part of the bowels, and is accompanied 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 at- tention, because, in a febrile * and irritable state of the system, it must prove an additional source of irritation, 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 obviat- ing 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 disease. The spontaneous improvement of the evacuations, in connec- tion with the resolution of the disease, is to be consid- ered, I imagine, as an effect and a sign, rather thai? a cause of that resolution, and as a stale which cannot be DYSENTERY--TREATMENT. 303 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 accu- mulation of feculent matter ; but we have seen in the most satisfactory manner, that the bowels may be entire- ly 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 pur- gatives must be unnecessary ; and, when the inflamma- tion 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 unnatural 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 extensive 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 expe- rience of this eminent physician, the remedy " least equivocal in its effects, and the most uniformly useful," was blood-letting. The mercurial treatment was tried 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 affec- ted ; 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 sup- posed 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 * Dublin Hospital Reports, vol. ill. 304 INFLAMMATION OF MUCOUS MEMBRANE. saline purgative, followed by two or three doses of Do- ver's powder ; and even of the more severe cases, at- tended with fever and tenderness of the abdomen, 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 appear- ance of the stools ; 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 observation seems to be, that the mode of treatment most generally useful was, —bloodletting, 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 ag- ony, 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. Anncsley'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 dysentery. The point on which I am chiefly disposed to differ from this eminent writer, or I ought rather to say, in which I am disposed to think that his treatment is not entirely adapt- ed to the dysentery of this country, is in the frequent or almost cbiily use of purgatives. I have already stat- ed my opinion on this subject, and the grounds which 'DYSENTERY—TREATMENT. 305 induce me to believe that the use of purgatives in dys- entery is a practice requiring the utmost discretion, be- ing in some cases proper, in others unnecessary, and in not a few decidedly injurious. I have also stated the experience of Dr. Cheyne, that purgatives in many cas- es produced no beneficial result, and in others greatly aggravated all the sufferings of the patient. The sub- ject is one of the highest practical importance, and de- serving to be investigated with the utmost 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 debilitated habits, topical bleeding is employed. These are followed at the distance of a few hours by a purgative of castor oil, or jalap and cream of tartar, and a purgative injection. The cal- omel and opium are also repeated after a few hours in- terval ; and this treatment is assisted by warm fomenta- tions, warm bath, and anodyne injections in very small bulk. These remedies are afterwards repeated accord- ing 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 powder with camphor and catechu, nitric acid, and the external application to the abdomen of the ni- tro muriatic solution. Mr. Annesley gives no countenance to the empirical and indiscriminate use of mercury, which has become so much in fashion with some writers in all stages and all conditions of dysentery. He gives calomel with opium in the early stages, along with the necessary evacuations, but chiefly as a purgative. " When given late in the dis- ease with the intention of affecting the system, or when its exhibition is continued with this intention for too long a period, it often seems to precipitate the malady to an un- 39 806 INFLAMMATION OF MUCOUS MEMBRANE. favourable termination, by inducing or keeping up irrita- tive 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 occa- sioned by the existence of active inflammation, and that the appearance of mercurial action in these cases is of- ten 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 dis- ease 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 unfavourable termination. And even in the milder cases which got well under the constitution- al effects of mercury, there was often a protracted re- covery from the diminished energy of the powers of life, occasioned more by the mercurial action than by the disease. § II.—Treatment of the chronic cases. In the chronic form of the disease, the morbid con- ditions which we have chiefly to contend with, are either the chronic fungoid inflammation, or ulceration. The treatment is extremely precarious, and but few of the cases comparatively do well. The remedies which ap- pear 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 ipecacuan; the resins, as turpentine, bal- sam of copaiva or tolu, with small opiates ; sulphur with opium ; nitric acid ; various combinations of these TREATMENT. 307 remedies with each other, as a strong decoction of cus- paria with nitric acid and laudanum. Repeated blis- tering on the abdomen is often very beneficial, also bandaging with a broad flannel roller, and tepid salt water bath. Sulphate of copper has lately been recom- mended by Dr. Grenville in various protracted affec- tions of the bowels; and in any trials of it which I have had an opportunity of making in this class of dis- eases, it appears to be a remedy deserving of much at- tention. It is given in doses, at first, of half a grain, combined with an equal quantity of opium, and is grad- ually 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 depends 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. A modification of the disease appears to exist, affec- ting the whole course of the mucous membranes, and going on for a length of time with characters of an alarming kind, while it is still under the control of me- dical treatment. The following case will illustrate this modification of the disease, which in practice, is one of considerable interest. Case CX.—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 sa- liva ; 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 immedi- ately through the bowels. There was some cough, 308 chronic diseases of the mucous membrane. with frequent pulse, great debility, and increasing emaciation. The throat appeared raw, and a little in- flamed ; the edges of the tongue and the inside of the under lip were excoriated, and covered with small ul- cers, having inflamed margins ; there was also a pain- ful excoriation about the anus and the labia. The com- plaint was of about three months standing, and had be- gun while she was in the puerperal state in England. A variety of treatment was employed 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 hope- less, she began to take a decoction of logwood (1 S. to 1 lb.) a wine glassful 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 protracted bad health, with obscure and undefined symptoms, such as a superficial observer is apt to consider as hypochondriacal. There is varia- ble appetite, with impaired digestion, and a variety of uneasy feelings about the bowels, sometimes described as a rawness and tenderness, and sometimes as a feel- ing 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 appearance of the tongue and throat; and sometimes the tongue has a peculiar red, dry, and glazed appearance. Alon<* with these feelings, there is occasionally a slight and IN infants. 309 protracted feverishness, but, in some cases, the pulse is not at all affected. The bowels are often tolerably na- tural, or easily regulated ; but laxative medicine is in general uncertain in its effects, and is apt to operate too violently. The motions are sometimes natural, 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 round- ed or tubular 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 treat- ment is most beneficial. The remedies deserving of attention are chiefly those already referred to, in re- gard to the diseases of the membrane, especially bis- muth, lime water, cusparia, balsam of copaiva. Mer- cury in any form appears in general to be hurtful. Much depends upon diet; and the greatest benefit is often obtained from a regimen restricted entirely to fa- rinaceous articles and milk. Stimulating friction of the abdomen is often useful ; also warm clothing and the tepid salt water bath. SECTION V. OF THE INFLAMMATION OF THE MUCOUS MEMBRANE IN INFANTS. Acute inflammation of the mucous membrane of the intestine is a frequent disease of infants, about the age of 6 or 8 months; and though the general 310 INFLAMMATION OF THE MUCOUS MEMBRANE. principles, which are applicable to it, do not differ from those already referred to in regard to adults, it is an affection of so much practical importance, as to be de- serving of separate description. The most important point in the investigation refers to the means of dis- tinguishing the disease, in its early stages, from the or- dinary bowel complaints of children about the period of dentition ; and this is often a. matter of considerable difficulty. The principal circumstance to be kept in view in the diagnosis is, that it is a febrile disease. The infant is usually hot and restless in the early stag- es, with thirst; and the tongue is dry, or covered with a brownish crust; there is in general a good deal of screaming and fretfulness, disturbed sleep, frequently vomiting ; and, in many instances, pressure on the ab- domen appears to give uneasiness. The bowels are loose, but this is not in every case a prominent symp- tom ; 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 ter- mination. In other cases, however, this symptom is more urgent,—the evacuations being very frequent, and preceded by much restlessness 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 evacuations vary ex- ceedingly in appearance, and I have never been able to satisfy myself that any reliance is to be placed up- on them in ascertaining the disease. They sometimes consist chiefly of a reddish brown mucus, sometimes of a pale clay-coloured matter, and sometimes of a dark watery fluid ; but in many cases they shew little devia- tion from the healthy state, while, in others, their ap- pearance is evidently disguised or modified by articles of nourishment, which pass through nearly unchang- ed. The disease often goes on for some time without exciting alarm, or being distinguished from an ordina- IN INFANTS. 311 ry diarrhoea, until attention is strongly and suddenly directed to the dangerous nature of it, by the occur- rence of constitutional symptoms. These consist in some cases, of a great degree of febrile oppression, with dry crusted tongue, thirst and vomiting; in others, of a very sudden and rapid exhaustion of the vital powers, which is unexpected, and is not accounted for by the frequency of the evacuations ; and sometimes the first appearance of unfavourable symptoms consists in the sudden occurrence of coma, with a peculiar hollow lan- guid look of the eye, and a pale waxen aspect of the whole body, while the pulse perhaps continues of tole- rable 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 affection, in short, had not been distinguished from the ordinary bowel complaints of infants, which often go on for a long time without producing any in- convenience. The causes of this affection are not well ascertained. It frequently 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 pe- culiar sinking of the vital powers or by coma. The appearances on dissection are nearly uniform. In vari- ous parts of the inner surface of the intestine, especially the ileum, we find irregular patches of inflammation, sensibly 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 ulceration, or terminate by peritonitis. In the cases which termi- nate by coma, effusion in the brain is met with, and this termination is often preceded by a remarkable dim- inution of the secretion of urine, amounting, in many cases, nearly to suppression. This termination seems 312 INFLAMMATION OF THE MUCOUS MEMBRANE. to bear a considerable analogy to the Ischuria Rcnalis, which usually terminates by coma, after the suppression 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 favourably, 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 abdomen, tepid bath, and small doses of calomel com- bined with Dover's powder. In some cases the free use of digitalis seems to be extremely useful, also blis- tering on the abdomen ; and, when the disease exhib- its 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 free- ly ; when there are threatenings of coma, blistering on the neck must be employed. From both these condi- tions infants often make most unexpected recoveries. When there is urgent vomiting, blistering on the epi- gastrium appears to be the most effectual remedy ; con- siderable benefit in settling the stomach is often ob- tained from small doses of the vegetable bitters and the oxide of bismuth. The state of the teeth is to be at- tended to, and the gums are to be divided wherever they appear to be producing irritation. In the protrac- ted 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. IN INFANTS. 313 Case CXI.—An infant, aged 6 months, (13th May, 181 7) had. been affected for about a week with loose- ness of the bjOwels and occasional r vomiting. The af- fection had been considered as the common bowel complaint of dentition, but the stools were scanty, offensive, and dark coloured^; and though they were by no means frequent, there was observed a considerable tendency 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 favourable appearances wem^f short continuance. On the even- ing of the 18th the diarrhoea suddenly increased ; it was excited by every*" thing that was taken into the stomach, and the articles that' we*f taken seemed to pass through the bowelPwith great rapidity. On the morning of the 19th, she wis 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 re- sembling-coma. < ** Inspection.—The bowels were externally healthy;, except some spots of superficial redness. „On the in-' ner surface of the small intestines there were, in many places, irregular patches of inflammation ; in othef^ places there were circumscribed spots of a dulxfash colour, which were sensibly elevated above the let^ of the surrounding parts* and were coipred by minute ulcers, so as"to give therh a peculiar honeycomb ap- pearance. 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 CXII.—An infant, aged 7 months, soon after weaning was suddenly seized with vomiting and diar- 40 314 INFLAMMATION OF THE MUCOUS MEMBRANE. rhoea ; was oppressed, 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 ceased ; the diarrhoea continued, not severe nor frequent, but accompanied 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 rem- edies 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 calo- mel. The motions then became green, but were gene- rally scanty and watery ; the febrilej^state continued, with the fur on the tongue ; the 'child sunk gradually, with oppressed breathirfg,* and died on the ninth day. Inspection.—The bowels were externally healthy, ex- cept spots of redness on various parts of the small in- intestine, which appeared deep seated, as if shining through the peritoneal coat. At the parts correspond- ing with these spots, the mucous membrane was elevated into irregular patches of inflammation, and the inflam- ed surfaces were covered by very minute ulcers ; in the neighbourhood of these portions the mesentery was un- usually vascular. The colon was collapsed and exter- nally healthy ; its inner surface was covered in many places by very small vesicles, which were scarcely ele- vated above the surface of the membrane, but appear- ed as if shining through it, clear, transparent, and wate- ry ; 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 inflammation or ulceration. DEATH FROM OTHER CAUSES. 315 SECTION VI. CASES SHEWING THE STATE OF THE MUCOUS MEMBRANE AFTER THE CESSATION OF THE SYMPTOMS, THE PATIENTS DYING OF OTHER DISEASES. To the facts which have been related in connection with this interesting inquiry, I shall only add the follow- ing examples, calculated to shew the state of the parts, when the symptoms had ceased, after long continuance, and the patients died of other diseases. The second shewed a very remarkable and rather uncommon variety of the matter evacuated^from the bowels. Case CXIII.—A lady, aged 24, had been of a feeble and delicate habit from her early years, but from the age of sixteen, had been almost constantly in a more de- cided state of bad health. She was generally confined during the whole winter, with cough, pain of the bow- els, and diarrhoea; she got a little better during the sum- mer, but was constantly more pr less jjffected with diar- rhoea, 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 emaciated, with a constant loose state of the bowels ; the evacuations were fluid, and of a whit- ish colour, and usually occurVed four or five times eve- ry day; when at any time they were less frequent, she became much oppressed about the stomach, and extreme- ly uneasy. She had frequently pain in the bowels ; her appetite was bad, but the^pulse was natural. In the 316 CHRONIC DISEASES OF MUCOUS MEMBRANE. winter, the same state of her bowels continued, and she had loud noisy cough without expectoration. In sum- mer 1816, she began to improve considerably, having appeared to derive much benefit from large doses of the muriated tincture of iron, combined with tincture of hy- osciamus. The bowels got into a^jiatural state, the stools being consistent and healthy, and from- this time there was no return of diarrhoea : bul her appetite and digestion continued very bad, and sh&made little im- provement either in flesh or strength.^In the following winter her cough returned, at first without expectora- tion ; but afterwards she had pain in the breast, puru- lent expectoration, and hectic fever ; and died of phthi- sis in May, 1817, without any return of the complaint in the bowels. *fa'- Inspection.—The lungs were extensively tubercular, with numerous vomicae. Thedower half of the stomach was contracted! and considerably tnrckened, and the pylorous was a little thickened, butonot indurated. On the internal surface of the intestine there were many portions, several inches in extent, of a dark red colour, and more vascular thar^the other parts; and on many places there'were, on the mucous membrane, small "cir- cumscribed smooth spots, which had every appearance of the cicatrices of ulcers wMch*had healed. The oth- er viscera were healthy. 7 <*£ f f Case^ CXIV.—A lady, aged 1 8, liad suffered for a year or more from a disordered ^state* of the*bowels, ac- companied by a most remarkable and unmanageable de*- gree of tympanitic distention. When I saw her, along with Dr. Combe|jjn the summer of 1826, she was affect- ed with a variety of hysterical symptoms, with much weakness, impaired appetite, and a very disordered state . of the^ bowels. Ufltder a course of mild laxatives, com- bined with tonics, these symptoms gradually subsided; and when she returned' to &e country in August, she DEATH FROM OTHER CAUSES. 317 was in very, good health, except that the bowels requir- ed the frequent use of medicine and that she occasion- ally complained of headach, and of a feeling of heat in the epigastric region. In November the bowels again became more obsti- . nate, and she was considerably annoyed with acidity. In the beginning of December, her throat was covered with aphthae, 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 white substance. She now had thirst, was feverish in the evenings, 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 numerous variations, for six or seven months, dur- ing the greater part of which period she was entirely confined to bed, and was reduced to a state of the greatest weakness. The prominent symptom now was frequent discharge from the bowels of immense quanti- ties 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, uniform, tenacious membrane. These last were occasionally discharged in flat portions several inches in extent, and frequently formed distinct tubes ; some- times they were in masses resembling hydatids, and sometimes in membranous bags which enclosed healthy feces. The membranous crusts or tubes now mention- ed were frequently four or five inches in extent, and sometimes portions of white matter resembling cream were observed in the evacuations. 318 CHRONIC DISEASES OF MUCOUS MEMBRANE. The discharges of these various matters frequently ceased for several days together, the motions then becom- ing quite natural. The re-appearance of the morbid discharges was generally preceded by a feeling of con- stipation, and a sense of heat along the intestinal ca- nal, with a sensation of craving at the stomach, thirst and headach. The pulse generally continued from 70 to 80. The feculent matter, which came off mixed with the morbid discharges, was of a natural appear- ance, but hard and lumpy. Her appetite was gener- ally variable, and her digestion bad. Towards 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 mem- branous 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 improvement 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 prominent 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 emaciation, but a pale unhealthy aspect ; there was slight cough without expectoration, and occasional un- easiness in the left side of the thorax, where the respi- ration was very imperfect. The febrile paroxysms con- tinued to increase in severity, with rapid failure of strength. In the beginning of September she began suddenly to expectorate large quantities of matter, which had a decidedly tubercular character ; and she died on the 9 th. DEATH FROM OTHER CAUSES. 319 Inspection.—The left cavity of the pleura contained air and much sero-purulent fluid, in which was a large floating mass of flocculent matter. The left lung was a mass of disease, presenting various morbid conditions, from hepatization to total disorganization, with much infiltration of puriform matter, and numerous small tu- bercles. In the middle lobe, a small aperture made a communication betwixt the cavity of the pleura and an irregular 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, except a small cavity at the upper part; the bronchial glands at the root of the lungs were much enlarged and tubercular. The vis- cera of the abdomen presented no appearance of dis- ease, except the mucous membrane of the colon. Through its whole extent, it was thickly covered with small spots of a clear white colour, which were re- markably distinguished by their colour from the mucous membrane surrounding them. Few of them were larger than the diameter of large pin heads, and, on minute examination, they were distinctly ascertained to be vesicles, very little elevated, but, when punctured, dis- charging a small quantity of clear fluid. The whole surface of the membrane presented a very peculiar ap- pearance, 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 endeavoured to give an outline of the pathology of the mucous mem- brane of the intestinal canal, in as far as, in the present state of our knowledge, the facts appear to be worthy 320 DISEASES OF MUCOUS MEMBRANE. 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 the writ- ers whom I now refer to, inflammation of the gastroin- testinal membrane, in an acute, sub-acute, or chronic form, is considered as being the origin of a great varie- ty of diseases, particularly of almost every modification of dyspeptic affections, 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 sup- ported are chiefly three, namely, in regard to the facts, —their generalization,—and their causation. I. We do not recognise the facts upon which this system is founded ; because, according to it, many ap- pearances are considered as indicating inflammation of the gastro-intestinal membrane, which we believe to take place after death or immediately before it, and consequently are not to be considered as indicating dis- ease. The nature of these appearances has already been mentioned, as well as the grounds on which we con- clude that they are not worthy of confidence in this pa- thological inquiry. They consist of livid, red, or brown spots on the membrane, portions shewing a violet or rose colour, enlarged vessels, varicose veins, slight extrava- sations of blood under the membrane, and various other appearances, consisting of mere change of colour with- out any change in the organization of the part. Such appearances we now consider as fully ascertained to oc- cur 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 considered as indicating a morbid condition of the mucous membrane. II. While we set aside, as foreign to the inquiry, a large proportion of the appearances described by these CONCLUDING OBSERVATIONS. 321 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 re- fer. In a pathological point of view, for example, it is an important fact, that, in a considerable proportion 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 appear* ancgs were met with in all the fatal cases of fever, the question still remains, whether they'are the cause of fe- ver or the effects of it; and upon this head, a very slight view of the facts will shew that they are decided- ly in favour of the supposition of these appearances be- ing the effects rather than the cause of fever. This conclusion we must consider as resulting, in the first place, from the fact already mentioned, that these ap- pearances 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 earliest stage, in cases which have proved fatal at a very advanced peri- od, and with symptoms of the utmost malignity ; while, on the other hand, they exist in a very high degree, and are apparently the immediate cause of death, in cases which have proved fatal at an early period, and in which the proper symptoms 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 gas- tro-intestinal membrane which are met with in connec- tion with continued fever, are to be considered either as incidental concomitants, or as effects of the fever,— and cannot be regarded as its cause. 41 322 DISEASES OF THE MUCOUS MEMBRANE. These observations apply to the general appearances of the mucous membrane, to which so much impor- tance has been attached by the pathologists of the continent; but some of the later writers have taken rather a new vi«w of the subject. Under 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 atten- tion as far as 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 wri- ters ; in short, that every variety of fever, continued, intermittent, and remittent, arises from the inflamma- tion of these follicles. As the symptons of the dothinenterite, they of course describe all the phenomena of continued and malig- nant fever, accompanied by a loose state of the bow- els and some degree of tenderness of the abdomen. The morbid conditions which they describe in these cases are, that, in the early stages, the crypts or folli- cles appear rather more' prominent than natural, and slightly injected, especially in the upper part of the canal ; that, as the disease advances, they become more prominent, with softening of the mucous membrane which covers and surrounds them; and that, at a peri- od still more advanced, this passes into ulceration. These observations are worthy of attention as facts ; but when, in describing the symptoms of the dothi- nenterite, all the usual symptoms of fever are detail- ed, 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 CONCLUDING OBSERVATIONS. 325 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 modifi- cations depends upon the inflammation of these follicles* we hesitate alike about the doctrine and the gener- alization 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 second- ly, 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 intensity of its symptoms. This will appear from a slight examination 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 ty- phus, the only morbid appearances found in the mucous membrane were,—in some places a grey colour; 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 al- most all in their natural state, except a few which shew- ed ulcerations, and a very small number which offered traces of melanism; the mucous membrane of the great intestine was of a pale rose colour, and appear 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 appearances 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 mem- brane or its follicles become inflamed, pustular, or ulce- rated ; and that, as facts in the history of fever, these 324 DISEASES OF THE MUCOUS MEMBRANE. 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 Dothinenterite—Revue Modicale, 182G. 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 pathology of the abdomen, but not requiring a de- tailed consideration. 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 observations on it. There are, however, some points relating to the affection, which present an interest- 326 PATHOLOGY of intestinal oanal.--APPENDIX. ing subject of investigation. * 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 me- sentery most contiguous to the seat of the ulcers. To what extent this connection exists has not been inves- tigated, 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 examining the diseased glands, they present, when cut into, a pale flesh colour, and a soft fleshy texture ; and we sometimes find them of very considerable size, though presenting merely this tex- ture. As the disease advances, they seem to become firmer, and to loose the flesh colour, assuming first a kind of semi-transparency, and afterwards a firm opake white structure, resembling the white tubercle oigthe lungs. In a mass of considerable size, we often ob- serve these various structures in alternate layers ; but in the more advanced stages, the opake white tubercu- lar matter is the most abundant; and this afterwards appears to be gradually softened, degenerating into a soft cheesy matter, or ill-conditioned suppuration, so familiar to us in diseases of this nature. When a gland in the first state of soft fleshy enlargement is plunged into boiling water, its colour instantly changes to an opake white or ash colour ; its texture becomes much firmer ; it contracts very much in its dimensions ; and by a short boiling, it loses a great part of its weight, leaving a residuum of an opake white colour and great firmness, having the appearance of concrete albumen. In the more advanced stages of the disease, the glands lose less and less by boiling ; and the opake white tuber- cular matter, when it can be obtained pure, scarcely loses any thing. In the first volume of the Medico- chirurgical Transactions of Edinburgh, I have mention- ed some experiments which render it probable, that, DISEASE OF MESENTERIC GLANDS. 327 during these changes in the structure of the glands, there is a gradual deposition of albumen, at first in a soft, afterwards in a concrete state ; and that the pecu- liar character of glands, in a state of tubercular dis- ease, 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 occa- sionally occur in the state of the diseased mesenteric glands. I have mentioned a case in which they con- tained calcarious matter, and their cysts were so disten- ded with a gaseous fluid, that they burst with a very sharp explosion, when slightly touched with the 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 considered as a scrofulous affection, occurring chiefly in children, and frequently combined with other affec- tions of a scrofulous character, or with chronic perito- nitis. 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 oc- currence. Case CXV.—A lady, aged about 40, mother of a large family, and previously enjoying excellent health, was affected with a deep-seated painful tumor in the left side of the abdomen, which was at first considered as an affection of the kidney. After some time a simi- lar 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 pain- ful 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 328 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. glands were traced from them under 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 trachea, fits of dyspnoea, hectic paroxysms, and pro- gressive 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 glarlds, 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 trachea, and along the posterior mediastinum, .there were large masses of diseased glands ; and there were some tubercles in the lungs, but of no great extent. SECTION II. TYMPANITES. Tympanites has been usually distinguished into ab- dominalis and intestinalis. I have never seen such a disease as the tympanites abdominalis, except when air has escaped into the peritoneal cavity, in consequence of perforation of the intestine. Several examples of this have been given. It often requires a great dpal of time and attention to discover the perforation, which may very often have escaped notice ; and in this man- TYMPANITES. 329 ner, 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 con- nection with acute disease, we have seen taking place in various forms. In its relation to active abdominal inflammation, we have seen reason 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 period in connection with extensive adhesion, or disor- ganization of the parts, marking a hopeless state of the disease ; or that it may be left as an effect of the dis- ease, from derangement of the muscular power, after the inflammation has been removed, and may, by at- tention, *be entirely recovered from. In Case LXX, again, we have seen tympanites supervening upon diar- rhoea, and assuming a very alarming aspect ; and in Case L, we have seen it very rapidly fatal, and affecting the whqle course of the canal, apparently connected with a general loss of its muscular power. The treat- ment adapted to this form of the disease has been men- tioned in treating of the cases now referred to. It al- so takes place in connection with continued fever, and is in general rather an unfavourable 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 ap- parently 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 42 330 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. connection with chronic disease of the mucous mem- brane, as we have seen in Case CXIV ; and it may be left as the effect of an acute attack, as in Case LXIX. When it does not arise from such causes as these, the treatment must consist chiefly of attention to the gen- eral health, with regular exercise, cold bath, and care- ful regulation of the bowels ; especially by small doses of aloes or rhubarb, combined with tonics and stimu- lants, as sulphate of iron, quinine, and the stimulating gums. Small doses of turpentine may often be useful ; also friction of the abdomen; 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 tympa- nites, though assuming characters different from the or- dinary cases. The abdomen becomes gradually and uniformly enlarged, and is throughout firm and tense, and without the usual feeling of tympanites. It some- times assumes the character of a mass of OLganic dis- ease ; and has not unfrequently been mistaken for preg- nancy, especially in females who have been married late in life. It is often in such cases accompanied;by sup- pression 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 ap- proaching accouchement, before the nature of the af- fection 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 appearing to have any very considerable effect upon the health of the patient, though it often assumes in a great measure 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 peculiar ; and it is TYMPANITES. 331 probable, that in the advanced stages, some change takes place in the parts, which has not yet been inves- tigated. A remarkable circumstance in the history of some of these affections is, that, after continuing in a most ex- traordinary degree for a length of time, and resisting every remedy, they sometimes disappear spontaneously. In the Edinburgh Medical Essays, Dr. Monro has de- scribed the case of a young woman, whose abdomen be- came 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 cir- cumscribed portions of the intestines, forming defined enlargements, with such a degree of firmness, as gives them*very much the characters of solid tumors ; and I have seen several cases in which, on a superficial exam- ination, such affections were mistaken for masses of or- ganic disease. I have described several cases in which this occurred from remarkable thickening of the coats of the intestine at particular parts : but, in the cases which I now,.refer to, the coats appear to be healthy, and the affection seems to depend upon a very singular state of distention confined<.to a small* part of the canaL Several years ago, a £entlefhan from England consulted me 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 and unyielding; but, on laying him in the hori- zontal posture, and making pressure upon it, the whole swelling disappeared suddenly with a gurgling noise. It appeared to be the caput coli in a singular state of distention. The affection had existed for a considera- ble time, and though he was subject to flatulence and indigestion, his» general health was little impaired. In my treatise on the Affections of the Brain, I have de- 332 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. scribed the case of a woman, who had swelling and hardness occupying the whole right side of the abdo- men, 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 bo discovered in the abdomen. SECTION III. ARTERIAL HEMORRHAGE FROM THE RECTUM. I have seen a good many cases of arterial haemor- rhage from the rectum, and they presented some -facts worthy of being recorded. The discharge is usually at first considered as hemorrhoidal, and does not ex- cite 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 ; palpitation and breathlessness are excited, by any exer- tion, frequently 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 fre- quency by very moderate exertionsfperhaps by walk- ing across a room. He becomes more and more Ex- hausted, till he acquires all the appearance of a per- son sinking under the advanced. stage of some deep- seated disease. During this time, he probably com- plains 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 Ije has been at stool, or on making the extremity of the rectum pro- PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. 333 trude by means of a stipulating injection, a small fun- gous mass is discovered within the verge of the anus, on the apex of which a minute artery is seen bleeding per saltum. The remedy is simple and effectual, and consists in taking up the bleeding point with a tena- culum and tying it, so as to include a part of the fun- gus. 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 rapidi- ty every appearance of disease vanishes. It is diffi- cult to say what is the source of the alarming character of the symptoms 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 haemor- rhoids for a length of time, without any effect upon the general health. When the ligature does not en- tirely command the haemorrhage, the free application of the nitrate of silver 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 blood coming off in coagulated masses ; and it would appear, that in these cases the minute vessel is nearly at all times bleeding a little, and that the blood coagu- lates in the rectum, and accumulates, till such a quantity is collected as excites the patient to go to stool. This I think does not take place with the discharge of hae- morrhoids. The'affection is also distinguished by the arterial colour of the blood,—that which is haemorrhoi- dal being probably always venous. 334* PATHOLOGY OF INTESTINAL CANAL.—APPENDIX. SECTION IV. 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 pre- cise nature of which eludes our observation. The pa- tient is found thin, pale, and weak, with a withered look, a peculiar dry state of skin, and a small weak pulse. His appetite is" variable and capricious, and he feels uncomfortable after eating. The bowels are slow, though easily regulated ; and the evacuations are always of a remarkably dark colour, like dark mahoga- ny, or almost black. The obscure nature of the affec- tion will appear most strikingly from the following case, which was fatal. Case CXVI.—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 stage of phthisis. She had a small frequent pulse and bad ap- petite, but complained of nothing except some undefin- ed uneasiness in the abdomen. The bowels were slow, requiring the constant use of medicine ; the motions were consistent and formed, but always of a deep brown colour of dark mahogony or rose wood, and no treat- ment had any effect in correcting that colour. The ab- domen was collapsed, and nothing could be discovered by examination. Sometime after I saw her, she began to have uneasiness in her chest, with slight cough ; she ftien became liable to fits of coma, in which she lay OBSCURE AFFECTIONS. 335 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 adhesions of the pleura. The intestinal canal was throughout so thin, as to be transparent like gold- beater's leaf. On the mucous membrane there was in many places a tenacious mucus of a dark brown colour, but no disease could be discovered in the membrane it- self, 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 preventing the nourishment of the body. I have seen some other cases which shewed similar characters, and proved very tedious and unman- ageable, but I am not aware that any of them have been fatal. The peculiar character in all of them was the remarkably dark colour of the evacuations, which no- thing 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 colour. 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. 336 ABSCESS COMMUNICATING WITH CAPUT COLI. SECTION V. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI. Case CXVII.—A young man, aged 19, on the evening of 16th September, 1827, was seized, after eating freely of pears, with pain of the bowels, accom- panied with much vomiting and purging. These symp- toms»were relieved by the usual means, but were im- mediately followed by fixed pain in the right iliac re- gion, a little below and inwards of the superior spi- nous process of the ilium. At first nothing unu- sual 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 now carefully administered by Dr. Begbie, failed in giving any relief. Fever continued with high deli- rium ; 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 fluc- tuation was discovered in it. On the 3d, he was seized with severe diarrhoea, accompanied by a tympanitic state of the abdomon ; the local affection then became less urgent, but the constitutional symptoms continu- ed and assumed the characters of the advanced stage DISEASES OF RECTUM—STRICTURE OF COLON. 337 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, hounded by this portion of omentum, the posterior surface of the caput coli and the portion of peritone- um lining the parietes at the part. This cavity con- tained 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 commu- nicated with the caput coli by a small irregular open- ing,'' and the mucous membrane around the opening was thickened and highly vascular. The cavity of the abscess was also found to extend behind the peritone- um covering the iliac muscles, and upwards, along the whole extent of the lumbar vertebrae. There is an obscurity in the pathology of this sin- gular case ; and it seems difficult to say, whether the abscess had been originally 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 exis- tence of the seeds of fruit, covered by an earthy in- crustation, in the cavity of the abscess, would appear to favour the latter supposition. 43 338 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. SECTION VI. EXTENSIVE DISEASE OF THE RECTUM AND PROSTATE GLAND.--STRICTURE OF THE ARCH OF THE COLON, &Q. Case CXVIII.—A gentleman, aged 72, had been li- able for fifteen years to 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. This at last increased to such a degree, that for several years before his death he scarcely ever made water without having his bowels moved. His general health, however, continued good, until about a year before his death, when he began to fall off greatly in flesh and strength. Soon after his legs became oedematous, and his pulse feeble, and he was greatly distressed with flatulence. The frequent desire to pass urine continued, but it was passed with- out 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 regulated, 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 neighbouring parts. The sigmoid flexure of the colon adhered to the brim of the pelvis. The bladder was DISEASES OF RECTUM--STRICTURE OF COLON. 339 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 thickened 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 he discharged regularly and freely, and apparently 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. PATHOLOGY OF 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 symp- toms or the treatment. My reason for doing so is, that acute affections of the liver are conpparatively rather rare in this country, so that 1 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 general beyond the reach of medi- cal aid. I must at the same time confess my suspicion, that it has become a kind of fashion to refer symptoms to mor- bid 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 phrase- ology of medicine, that it seems a very delicate task to sfart a doubt in regard to a doctrine so generally re- PATHOLOGY OF THE LIVER. 341 ceived. 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 fre- quently see such complaints get well under very mild treatment, as regulation of the bowels, and a little at- tention to diet; 2. That I have seen such patients put JKt. through long and ruinous courses of mercury, without any benefit, and afterwards found the complaint remov- ^ ed by a course of mild laxatives ; and 3. That I have " * known patients die of other diseases, while these alleg- ed affections of the liver were going on, without being able to discover in the liver, upon dissection, the small- est deviation from the healthy structure. I am ready to admit, that in such an organ as the liver there may be morbid actions which do not leave any appearance that can be discovered 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 considerable 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 symp- toms were of such a kind as might with equal plausibil- ity be referred to other sources, such as disordered con- ditions of the stomach or bowels, especially the duode- num 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 net- work, which appears to be of a yellowish white or ash colour, and to possess comparatively little* vascularity. The other is a substance of a red or reMdish-brown 342 PATHOLOGY OF THE LIVER. colour, contained in the cells of the former ; it is high- ly vascular, and is supposed to be capable of very rap- id increase or diminution of its volume, in a manner al- most resembling the erectile tissues. This, however, is probably in some measure hypothetical, and it is prob- able, that the rapid changes in volume to which the liver appears to be liable, may be rather referred to the ■ great vascularity of its structure, arising from the two ,jjA 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 bil- iary vessels. In endeavouring to trace a slight outline of the actu- al 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, be- cause the two classes run so much into each other, that cases which begin with very acute symptoms, often be- come in their progress protracted and chronic. In using the terms, then, as a mere arbitrary division of the sub- ject, 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 affec- tion steals on in an obscure and insidious manner, per- haps only with dyspeptic symptoms,—or in which the affection of the liver is not ascertained till after pro- tracted illness, or when the patient has died of another disease. This distinction is sufficiently correct for practical purposes; and an attempt at minute patho- logical arrangement on such a subject is often made at the expense of utility. In the following outline I mean to describe dhiefly the liver diseases of this country as they have occurred to myself, though with occasional ACUTE DISEASES OF THE LIVER. 343 reference to those of India, as they are described by the best practical writers. SECTION I. OF THE MORBID CONDITIONS OF THE LIVER, WHICH AP- PEAR TO BE CONNECTED WITH ACUTE DISEASE. § I.—Inflammation of the liver. The symptoms of inflammation of the liver seem to ^. vary exceedingly, according to the activity of the dis- ease, and the part which is the primary seat of it. There is generally pain in the right hypochondrium, in- creased by pressure, and frequently by inspiration, with tension, considerable disturbance of the functions of the stomach, and often urgent vomiting. There is gener- ally fever, but this is often in a very slight degree ; there is sometimes jaundice, but this is often entirely wanting; and frequently there is pain extending to the right shoulder, but this also is by no means a uni- form symptom. When the inflammation 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 paren- chymatous 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 situation, jaundice is more likely to take place, which may not appear at all if the disease be chiefly in the convex surface. When the inflammation is seated in the substance of the liver, the 344 INFLAMMATION. 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 symp- toms, however, attending inflammation of the substance of the liver are by no means uniformly obscure, for, in some of the following cases, terminating by abscess, it will appear that they were of a very acute character. I have not seen inflammation confined to the peritoneal covering of the liver, except when combined with ex- tensive and general peritonitis. 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. Ramollissement or softening of the substance of the liver, which appears under various forms, to be afterwards more particularly 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 liv- er, I shall not describe them under this arrangement; but, following the course which I have already propos- ed, I shall simply refer to them in the general investi- gation of the actual morbid conditions which we find in the liver after death. acute diseases of the liver. 345 ■§ II.—The mass of the liver more or less enlarg- ed, ESPECIALLY ON THE RIGHT SIDE ; EXTERNALLY OF A VERY DARK COLOUR, OR NEARLY BLACK J ITS SUBSTANCE, WHEN CUT INTO, ALSO VERY DARK CO- LOURED, AND GIVING OUT A LARGE QUANTITY OF VE- RY DARK BLOOD. In OTHER CASES, THE BLACK CO- LOUR IS ONLY ON THE SURFACE, THE INTERNAL 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 described as connected with it are chief- ly a febrile state, with anxious expression of the coun- tenance, nausea, impaired appetite, and very bad diges- tion, pain, or a sense of weight and fulness in the re- gion of the liver, and great oppression across the prae- cordia, often oppressed breathing, headach, disturbed sleep, turbid urine, and a sallow colour of the complex- ion. The disease has been called congestion, but this is merely a name accommodated to the appearance, and explains nothing. It appears to be nearly allied to inflammation, and there seems much reason to believe that it is to be considered as inflammation of the sub- stance 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 the appearance referred to under this section, and the morbid condition appeared to have been very super- ficial. Case CXIX.—A gentleman, aged 28, (6th Septem- ber, 1822) was seized with vomiting, and for three days vomited every thing which he took into his stomach. There was an obscure uneasiness across the epigastric 44 346 ACUTE DISEASES OF THE LIVER. 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 re- turned 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 attack, without any other symptom. He was then seized with very deep jaundice, and I saw him for the first time on the following day, 1 3th September. The jaundice was then very deep ; pulse 120 and strong ; no vomiting ; no complaint of pain, even upon pres- sure ; tongue white ; bowels open ; stools very dark. 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 bow- els open ; the stools dark ; the urine deeply tinged with bile. On the 1 6th and 17th, the pulse came down, but very deep jaundice continued, with a look of much fe- brile oppression, but no cdmplaint of pain; the bowels were freely moved by repeated purgatives, and the mo- tions shewed 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 colour, almost black, without any sensible increase of size. When cut into, it appeared that the black colour 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. BLACK CONDITION OF ITS SUBSTANCE. 347 That this black condition of the substance of the liver is a state connected with inflammation, is rendered probable by an interesting case mentioned by Portal, in which it was combined with abscess. A gentleman, aged 50, was seized with shivering, 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. In the peritoneal cavity, there was much bloody fluid, with flocculent filaments floating in it. The liver was enormously enlarged ; externally, it was of a deep red colour, with pseudo-membranous de- position on its upper surface, and adhesion to the dia- phragm ; internally, it was of a deep black colour, and discharged, when cut into, much black blood; and there were in various places vomicae, full of purulent matter.* The combination of this black condition of the substance of the liver with suppuration will also be found in Case CXX. The earliest stage perhaps at which the morbid ap- pearances of the liver can possibly be seen, occurred in a remarkable case also mentioned by Portal. A la- dy, 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, hic- cup, and very difficult breathing ; and she died on the following day. The liver appeared much enlarged, and when cut into, seemed to be infiltrated with a bloody serous fluid. Its upper surface was covered with false membrane, and the right side of the dia- phragm was inflamed. The lungs were much gorged with blood. The other viscera were healthy. * Portal,—Maladies du Foic. 348 ACUTE DISEASES OF THE LIVER. «| III.—Abscess of the liver. This must be considered as the result of inflamma- tion of the substance of the liver, but the symptoms appear to vary exceedingly in activity,—in some cases being such as distinctly indicate active disease ; in others, stealing on insiduously with little more than a feeling of weight and fulness ; and in many cases, most extensive abscesses have been met with, when the symptoms had been merely dyspeptic, or perhaps had been considered as hypochondriacal. The following cases will exhibit the principal varie- ties of this affection as it occurs in this country. Case CXX.—A gentleman, aged 22, (15th June 1817) was affected with pain across the epigastric re- gion, increased by pressure, and accompanied by vom- iting and frequent pulse. 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 symptoms, he was seized with very deep jaundice. 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 ehange 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 re- ABSCESS. 349 gion of the left lobe of the liver. The usual remedies were persevered in without any effect in controling 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 sev- eral 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 soften- ed and broken down, and of a very dark or nearly black colour. Both the hepatic duct and the ductus commu- nis 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 CXXL—A lady, aged 51, (23d October, 1816) was affected with incessent vomiting, and severe pain in the region of the stomach, much increased by pres- sure, and extending downwards towards the umbilicus; bowels open ; pulse 84 ; the symptoms had continued 20 hours. She was treated by repeated blood-letting, blistering, full doses of calomel, &c. In the even- ing 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 inspiration ; 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 was free from vomiting; pulse 108. On the 26th, the pain returned with much severity, and continued with little abatement on the 27th and 28th. It was chiefly referred to a spot immediately below the ensi- form cartilage, and extended into the region of the left 350 ACUTE DISEASES OF THE LIVER. lobe of the liver, where there were some tension and tenderness on pressure. She was now free from vomit- ing ; the bowels were quite open, and the motions dark coloured; the pulse varying from 100 to 120. She was now chiefly treated with calomel, digitalis and blistering. On the 29th, the symptoms began to sub- side, and in a short time, she was able to be out of bed, and seemed to be convalescent. But it soon appeared that she was not. free from the effects of the attack. She had occasional uneasiness in the region of the stomach and liver, with severe nausea, occasional vom- iting, and oedema of the legs; pulse sometimes natural, and sometimes rather frequent. 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 com- plaint 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 February. Inspection.—On the upper surface of the liver, to- wards 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 contained a great number of biliary calculi of various sizes. There were some small abscesses in both kidneys. All the other viscera were healthy. Case CXXII.—A gentleman, aged 67, and enjoying good health, except frequent dyspepsia, had occasion- ABSCESS. 351 ally complained for some time of a pain in his right side, which affected him chiefly when he walked quick- ly. But he made little complaint, and was not con- fined 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 confin- ed to bed, his chief complaint being the frequent irri- tation of his bowels ; the stools were scanty, and com- posed chiefly of bloody mucus. I saw him only a few days before his death ; he was then considerably ex- hausted ; the pulse feeble, but little increased in fre- quency ; the bowels still troublesome, but kept in check by opiates. There was obscure uneasiness across the epigastric region, but without tenderness ; and no.fulness 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 now no room for active treatment; he died gradually exhausted, a fortnight from the time when he was first eonfined to bed. Inspection.—The liver appeared to be considerably enlarged, and the right lobe was found to have almost entirely degenerated into a large abscess, containing fully three pounds of thick purulent matter, the proper substance of the liver merely forming a very thin cyst around the cavity. At the cardiac orifice of the sto- mach there was evident inflammation of the mucous coat, with deposition of flocculent matter ; and this appearance extended along the whole course of the oesophagus, with much deposition of flocculent matter in thin layers in different 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, mix- 352 ACUTE DISEASES OF THE LIVER. ed 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 ab- scess is sometimes found of a most extraordinary size, occupying nearly the whole substance of the liver. A man, mentioned by Hasenoehrl, had hepatitis, 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 remained seemed to be little more than the empty cyst of the ab- scess. In a similar case by Bonetus, there was found, in place of the liver, a great cyst, formed by its invest- ing membrane in a thickened state, and full of a fluid like the washings of flesh. This man also livid 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 contain- ed in the cyst. I have the report of a case that occur- red in Edinburgh, in which an abscess occupying the greater part of the liver, was found in the body of a ABSCESS. .. 653 man who died gradually worn out by complaints, which, almost to the time of his death, had been considered as hypochondriacal. In a case by Annesly, an abscess of the liver contained 90 ounces of matter, and the paren- chymatous substance of the right lobe was entirely destroyed. In other cases again the disease appears in the form of numerous small abscesses, having no communication with each other. In a case by Andral, which was fatal in thirteen days, the liver was beset with numer- ous small abscesses no larger than nuts, but each lined by a firm cyst of false membrane, the intervening sub- stance being of a bright red colour and softened. The symptoms were pain and tenderness in the region of the liver, with-'tever and jaundice. He found, how- ever, the same appearances in a man who died with symptoms of peripneumony without jaundice, and with- out any symptom referrable to the liver. There were ten small abscesses in various parts of the liver, with a red and softened state of the intervening substance ; the right lung was* hepatized,s with deposition of false membrane. Small cysts containing a thick puriform matter are sometimes found in chronic cases, and ap- pear to be softened tubercles. When the parts which cover an abscess of the liver form adhesions to the parietes of the abdomen, the ab- scess 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, es- pecially the colon. In a case by Malpighi the biliary duct was found to communicate with the cavity of an ab- scess. But the most remarkable course by which it some- times finds an outlet, is through the lungs, by means of ad- hesions 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 ; 45 S54 ACUTE DISEASES OF THE LIVER. and not a few, in which there was every reason to be- lieve, that it had taken place though the cases termi- nated favourably. The following is the most remarka- ble example of this kind which has occurred to me ; and which, there seems every reason to consider, as be- ing of the nature now referred to, from the total ab- sence 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 CXXIII.—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 violent pain in that situation, accompa- nied with vomiting. By the usual remedies she was much relieved, but some degree of uneasiness continu- ed 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 viotent that for many nights together she was unable to lie down in bed ; these paroxysms alternated with intervals of compara- tive ease, but, by the frequent repetition of them for nearly three months, her strength was very much reduc- ed. The whole region of the liver was tense and ten- der 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 coughing, and expectorated purulent matter to the amount of at least two pounds. On the 15th she ex- pectorated in the course of the day at least one pound, and about the same quantity on each of the two follow- SIMPLE RAMOLLISSEMENT. 355 ing 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 characters 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 coagulable 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 colour. It is in general most remarkable on the convex surface, extending to a greater or less depth ; it is accompanied by a separation 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, leav- ing 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 356 BLACK RAMOLLISSEMENT. with sanious or puriform fluid, not collected in- to abscesses, but mixed irregularly through the substance of the softened part. This appearance we have every reason to consider as the result of in- flammation. It is found in combination with abscess or other marks of inflammation, and I have very often ob- served it on the upper surface of the liver, in connec- tion with extensive inflammation of the right lung. In these cases there was not in general any symptom indi- cating that the liver was affected. Mr. Annesley states that this appearance is frequently met with in India in persons who have died rapidly from cholera or dysen- tery. § V.—The black ramollissement of the liver. I use this term simply to express the appearance, without implying 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, sometimes resembling a soft coagulum of venous blood, and occasionally accompani- ed 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 complicat- ed with abscess, and, in some observations by Andral, it was met with in cases in which fatal diseases of the liv- er supervened upon external injuries. • It appears, how- ever, to occur without any acute symptoms, for in a case by Boisment* the symptoms were chiefly vomiting, with a slight yellow tinge of the skin. The following + Bnismenf.—Obs. sur quelques Maladies du Foic.—Archives Generalcs, torn. xvi. acute diseases of the liver. 357 is the best marked example of the affection which has occurred to me. Case CXXIV.—A lady, aged about 50, of a full ha- bit 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 fulness in the region of the liv- er ; 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 mo- tions 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 frequent com- plaint of nausea, and a feeling of languor ; the tongue was white, but the pulse was natural. No other symp- tom was complained of, and nothing could be discover- ed in the region of the liver. On the 1 6th 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 vom- iting now became more and more urgent, with increase of the quantity of this black matter, and she died grad- ually exhausted on the morning of the 21st. Inspection.—The liver was reduced to a little more than a third of its natural size ; it was of a very dark, almost black, colour, and internally soft and disorganiz- ed, like a mass of coagulated blood. The gall bladder was empty and collapsed. The stomach and bowels contained a considerable quantity of black matter, sim- ilar to that" which had been vomited, but were in other respects quite healthy. The appearance described under this head is probably a sequel to the condition described under $ II. ; and it 358 white ramollissement. appears to admit of various modifications. In a case by Boisment the tissue of the liver was infiltrated with dark blood, the substance, in other respects, was dark and friable, and beset with small friable tumops of a reddish brown colour ; in other places there were small cavities, containing a soft semi-liquid fluid like grumous blood. Little account is given of the symptoms ; but the case seems to have been protracted, and to have been ac- companied, towards the conclusion, by haematemesis. § VI.—The white or engephaloid ramollissement OF THE LIVER. The nature of this affection has been little investi- gated. I have placed it among the acute diseases on account of the degree of pain which occurred in the following case, which is the best example of it that I have met with. Case CXXV.—A gentleman, aged 05, in September, 1820, was seized, during a journey on horseback, with diarrhoea, the motions being black and pitchy. He then had pain in the region of the liver, which for several days was so severe that he could not bear the motion of his horse. It then subsided considerably, 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 increase of the pain, with fever, and the pain ex- tended 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 mercury with apparent relief, and for a short time was better; but in the end of November he began to lose flesh, and acute diseases of the liver. 359 the pain in tho right side continued. I saw him for the first time on the I 1 th of December ; he was then much emaciated, with some anasarca of the limbs; there was still fixed pain in the region of the right lobe of the liver, but nothing could be discovered by pressure, and there was no appearance of jaundice ; the pulse was frequent and weak. The debility and dropsical symptoms increased progressively, and he di- ed, gradually exhausted, 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 covered 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 colour, very much resem- bling the substance of the brain, and in many places almost of pulpy consistence ; scarcely the smallest por- tion could be discovered that retained any thing like the healthy appearance. There was considerable ef- fusion in the abdomen; the other viscera were heal- thy. § VII.—Copious deposition of gelatinous matter OF A SOFT CONSISTENCE AND A REDDISH COLOUR. 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 tumours, accompanied with great enlargement of the liver. The case was of several months standing, and was distinguished by pain in the epigastric region and 3'60 DISEASES OF THE BILLIARY VESSELS. vomiting, at first occasional, but becoming gradually more frequent; there was progressive wasting, and at last, dyspnoea and anasarca. § VIH.-^-ReMARKABLE DISTENTION OF THE BILIARY VESSELS. This occurred in a case by Boisment to such an ex- tent as to give the liver the appearance of a large undulating cyst. The appearance was found to de- pend upon a remarkable distention of all the biliary vessels, with dark coloured bile, and was accompanied 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 pas- sed 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 ad- vanced period of the disease, when perhaps the liver is felt to be enlarged, or symptoms occur which point out the seat of the affection. In other cases the morbid CHRONIC DISEASES OF THE LIVER. 361 condition of the liver is discovered only when the pa- tient has died of some other disease. The distinction, I have already admitted, 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 :— § I.—Chronic inflammation of the liver* This term is applied to a morbid.condition of the liv- er which often remains after an acute attack, and a cor- responding condition 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 se- vere and untractable dyspeptic symptoms, wasting, and sometimes jaundice ; in other cases, pale evacuations without jaundice. There is generally a feeling of dis- tention and oppression in the epigastrium and right hy- pochondrium ; 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 burning sensation in the hands and feet. On exam Lnatibn, 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 discov- ered by examination. The morbid appearances in thes« cases usually consist of some degree of enlargement of 46 362 CHRONIC DISEASES OF THE LIVER. the liver, especially of the right lobe ; the substance is generally dark coloured or variegated in various ways, with streaks of a lighter colour, its consistence is fre- quently more dense than natural, but in other cases it is soft and friable ; abscesses are me t with in some cases, and in others tubercles. § II.—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 de- scending as low as the umbilicus, without any remarka- ble change of its texture. It appears in some cases to be connected with a low and protracted inflammato- ry action; and in others, to depend upon causes im- peding the return of the blood from the liver towards the heart. In this manner the liver is frequently found to be enlarged in connection with diseases of the heart. In a case by Andral, in which the patient was liable to severe paroxysms of the symptoms arisirfg from the disease of the heart, the liver was distinctly felt to be- come 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 derange- ments of the stomach, arising probably from the in- creased bulk of the liver ; in some cases there is jaun- dice, and in others dropsy ; but upon the whole, simple enlargement of the liver, without any considerable change of its texture, must perhaps be considered as a rare affection in adults. The following case will illus- TUBERA OF THE LIVER. 363 trate the appearance, as it occurs in young persons of a scrofulous habit. Case CXXVI.—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 considerably 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 um- bilicus, and so much into the left side as to fill the up- per half of the abdomen. It was a little paler than natural in its colour, but in other respects was scarcely altered from the healthy structure. There was exten- sive disease of the mesenteric glands. The lungs were slightly tubercular, and there was a chain of en- larged glands, some of them as large as walnuts, ex- tending behind the lungs from the bifurcation of the trachea to the diaphragm ; some of these were of carti- laginous hardness, others contained thick purulent mat- ter, and in others there were hard calcerous particles. There was considerable effusion in the abdomen. 564 CHRONIC DISEASES OF THE LIVER. § HI.—Tubera of the liver without other dis- ease OF ITS structure. These tubera present externally a surface elevated into numerous irregular knobs, of a yellowish or ash colour, and perhaps from two to three inches in diameter. Inter- nally, 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 I shall only add the following exam- ple. • Case CXXVII.—A gentleman, aged 80, had enjoyed uninterrupted 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 shewn any other symptom of disease, when one morning he was found dead in bed. Inspection.—No morbid appearance could be discov- ered 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 sur- face of the liver, there was a tumor about three inches in diameter, elevated into numerous irregular knobs ; on cutting into it, a cavity was exposed capable of holding about § 8, and full of an opake ash-coloured fluid, which could be drawn out into strings. The liv- er in other respects was perfectly healthy. PALE DEGENERATION. 265 For a more particular account of these tubera, I re- fer to the description and engravings of Dr. Farre. £ IV.—The pale degeneration of the liver, con- sisting OF CHANGE OF COLOUR WITHOUT REMARKABLE ALTERATION OF TEXTURE. Under this head I mean to include a class of morbid changes of the liver of frequent occurrence, though pre- senting considerable varieties. The liver so affected has lost, in a greater or less degree, the healthy ap- pearance, and has become of a paler colour, without any considerable alteration from the healthy texture. This change, in some cases, consists merely of a much paler shade of the natural colour; in others, it is a dull white or £ti colour, and frequently a uniform dull yellow, closely resembling the colour of impure bees wax. The liver thus affected may be of the natural size, or it may be increased in size, or it may be di- minished. The symptoms accompanying these changes have not been well investigated ; they are chiefly ob- served when the patient has died of some other affec- tion, and are scarcely themselves to be considered as fatal diseases, though there may have been symptoms indicating some derangement of the functions of the liver or the stomach. The most remarkable of these changes is the yellow degeneration of the liver, which, from its resemblance to wax, has received from the French writers the name of Cirrhose. It is sometimes found in irregular portions, mixed with the healthy structure, and sometimes in small nodules like peas dis- persed 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 366 CHRONIC DISEASES OF THE LIVER. mass of impure wax, and it seems to possess very little vascularity. A case is 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 1 5, who had immense ascites. In a case by Boisment, these no- dules were as large as peas, and the liver was diminish- ed 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 liv- er in its healthy state. No good can arise from such discussions, as it is impossible to decide them. § V.—Pale colour of the liver with induration. The degree and aspect of the pale induration of the liver varies in different cases, from an appearance re- sembling a mass of tubercular lung, to that of true scirrhus, or to a texture in some places almost cartilag- inous ; and, in some cases, there is a firm fibrous tex- ture with a softer matter in the interstices. These mor- bid appearances may be confined to portions of the liver, or the whole organ may be entirely changed from the healthy structure. The colour of the diseased parts varies considerably ; the most common is a dull ash colour, sometimes with a considerable tinge of yellow. The disease may be complicated with hard tubercles of various sizes, embedded in the substance of the liver, or spread over its surface under the peri- toneal coat; or there may be thickening or tubercu- lar disease of the peritoneal covering itself. * Clossy.—Observations on some of the Diseases of the Parts of the Hu- man Body. CHRONIC DISEASES OF THE LIVER. 367 A liver in this state of disease may be not at all al- tered in its size, or it may be much increased, or it may be very much diminished. The symptoms, of course, will differ in some respects in connection with these varieties. The following cases will illustrate the prin- cipal modifications. (A) Pale Indurated Liver almost Cartilaginous, of the Natural Size. Case CXXVIII.—A man, aged 45, in the beginning of May, 1813, was affected with severe pain in the re- gion of the stomach, which soon shifted into the right hypochondriac region among the lower false ribs; it was much increased by respiration ; there was some cough ; pulse 120. Tn the course of two days and a half, he was bled to the extent of § 145 ; the symp- toms then yielded, and soon after he went to the coun- try. But he did not recover .sound health : he had some cough and dyspnoea, with much debility ; after some time he became dropsical ; the dropsical symp- toms increased with pain in the right side, and he died in the beginning of August. Inspection.—There was extensive effusion in the ab- domen. The liver was completely changed in its tex- ture, being, through its w.hole structure, of a dull white colour, and very hard, in many places almost cartilag- inous. There was not the smallest portion of it that retained the healthy structure or colour, but it was en- tirely of the natural size. The lungs and all the other viscear were healthy. There is every reason to believe, that in this impor- tant case the remarkable disease of the liver superven- ed upon the acute attack, which occurred three months before the patient's death ; and therefore, according to 368 PALE INDURATION, WITH ENLARGEMENT. the division upon which I have proceeded, it ought to have been included among the acute affections. 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 for it. (B.) Pale Indurated Liver with Enlargement. Case CXXIX___A lady, aged 4 5, had long been li- able 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. Slie also frequently com- plained of pains in the back, neck, -and shoulders, which had merely a rheumatic character. In autumn, 1818, she went'to Harrowgate, and seemed to derive much benefit from the use of the water. In the follow- ing winter, she was again a good deal confined, com- plaining chiefly of wandering rheumatic pains, with bad appetite, and very bad digestion, and a feeling of oppression across the region of the stomach. On ex- amination, the liver was now found to be much enlarg- ed and very hard, but without pain or tenderness. In January, 1*819, she began to lose flesh and strength ; the pulse became small and frequent, with difficulty of breathing, and effusion in the abdomen ; and she died, gradually exhausted, in the end of February. Inspection.—The liver was very much enlarged, so as to extend quite into the left side of the abdomen, and to descend three or four inches beyond the line of the ribs ; in the epigastric region, its margin formed an adhesion to the parietes of the abdomen. Internal- PALE INDURATION, WITH ENLARGEMENT. 369 ly, it was entirely changed from the healthy structure, being of a pale or ash colour, and very firm in its texture, 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 CXXX.—A lady, aged 50, had for some time complained 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 af- fection of the liver was then ascertained only by acci- dent ; it filled the upper part of the abdomen, extend- ing from side to side, and on the right side descended 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 baqk, the margin of the ribs could not be traced ; but the hones of the thorax and the surface of the tumor felt like one continued bony sub- stance as low as the umbilicus. At this time her gen- eral health was little affected : but after a short 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 colour, and partly of a dark reddish brown; internally it was uni- formly pale and harden its texture. 47 »■*.-. 370 CHRONIC DISEASES OF THE LIVER. (C.) Pale Indurated Liver, with great Diminution of Size. Case CXXXL—A man, aged 40, was first affected with pain in the right side, not increased by pressure, and not impeding 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 paroxysms with progressive emaciation, and at last 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 liv- er was so remarkably 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 studded with numerous tubercles ; internally it was of a pale colour, and very hard in its texture. Many cases are on record, in which the indurated liver was much diminilhed in size, but in few perhaps to the extent which occurred in this case. A man mentioned by Andral, had weakness, 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 scirrhous hardness ; its surface was covered with a kind of sandy matter. A man men- tioned by Boulland,* had pain in the region of the liver, and very deep jaundice ; he died^the day after * Mem. de la Soc. Med. D'Emulation. Tom. ix. - "* DARK INDUAATfON. 371 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 dimin- ished in size and indurated ; internally it presented a va- riegated surface of gray and yellow, with numerous small portions of an orange colour. In other cases, this state of disease has been marked merely by wasting, with obscure dyspeptic symptoms, and at last dropsy, with- out any thing calculated to point out the liver as the seat of the disease. A remarkable peculiarity in Case CXXXI, was the violence of the pectoral symptoms. This effect of cer- tain diseases of the liver will be afterwards more par- ticularly referred to ; it seems to be occasioned by the irregular tuberculated state of the convex surface of the liver, keeping up a constant irritation of the dia- phragm. § VI.—Dark induration of the liver. The following case will illustrate this modification of the disease, which differs from the pale induration only in its pathological characters, the symptoms be- ing the same. Case CXXXII.—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 com- plaint till the middle of June, when he became dropsi- cal 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 diur> 372 CHRONIC DISEASES OF THE LIVER. etics with a little mercury, for some time with very little effect; on the contrary, the distention of the abdomen seemed gradually to increase, with an evident fluctuation. 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 favourable 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 tol- erable 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 his 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 effusion in the abdomen to the amount of about lOlbs. The liver was entirely of the natural size, but very dark in the colour, nearly black, and covered on the surface with small hard black tubercles. Internally, it was much indurated throughout, and of a very dark brown colour, inter- spersed with streaks of deep yellow. The heart was remarkably 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 WITHOUT DISEASE OF ITS STRUCTURE. The symptoms arising from this affection vary ac- cording to the part of the liver which is the principal seat of the disease, as they consist chiefly of irritation of neighbouring organs, particularly the sjlomach and DARK INpURATION. 373 the diaphragm. The disease may assume any of the forms whicru,.already have been *e>fjerred to, as .the black or the.pale tubqjcle, and in_some cases appears to consist of\a simple elevatj&n of the surface of the liver into' irregular tumors, without any remarkable change in the structure ofJ;h*e.fiart. When the disease is'so situated as to irritate the stomach, we find pro- tracted vumitjng, 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 pul- monary*.eomplaints, without any symptom referable to the liver. ". The following case will illustrate this modi- fication of the disease. Case CXXXIIL—A lady, aged 35, had severe cough with dyspnoea, wjpch was sometimes severe, especially in the night. TWiere was occasional pain of the chest > and sides, with frequent pulse, restless nights, with "*^ fgbrile paroxysms and perspirations in the morning. There was considerable expectoration, which consisted 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 eomplained 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 the third year^he became gradually exhausted. She then had diarrhoea, anasarca, and gradual emacia- tion, 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»»sev,ere paroxysms of cough, with cogious. expectoration and fits of dyspnoea 374 CHRONIC DISEASES OF THE LIY1E$. Inspection.—No morbid appearance «xould be de- tected in any part of the thorax. The spleen was en- larged and hard. ,0n the convex surface of the liver there was a remarkable .tumefaction pressing against the diaphragm, and pushing it upwards ; and the sur- face of the tumefied part was studded with small hard tubercles. The liver was not in other respects dis- eased, and the other viscera we're healthy. *r ✓ Another case has been formerly described, sKtiwing the production of severe pectoral symptoms by disease on the surface of the liver; and various cases are on record, shewing the same result from diseases of other .organs, situated in the neighbourhood of the diaphragm. In a case by Portal, similar symptoms appeared to arise from scirrhus of the pancreas, and in one by Bo- netus, from disease of the spleerur In a case 4)y Morgagni, there was a tumor, which weighed a jjound, attached to the posterior part of the stomach. A young- woman, mentioned by Laennec, had cough, dyspnoea, •'» copious expectoration, hectic fever, and great wasting. After these symptoms had gone on for some time, arid 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 hyda- tids ; from that day she recovered rapidly, and was, soon well. § VIII. Tubercles and tubEra of various charac- ters DIFFUSED THROUGH XH» SUBSTANCE OF THE LIVER, WITH DISEASE OF THE INTERVENING STRUC- TURE. „■ ■ The mixed masses of disease which I include under this head, seem to derive their character, in some instan- TUBERA, J&C. 375 ces, from new formations imbedded in the substance of the liver, in others from morbid degeneration of por- tions of the liyer itself. The appearances vary in dif- ferent cases ; in some there are portions or nodules of a true scirrhous character, in others tubercular or cheesy, in others of the consistence of the brain; some por- tions are of a yellow colour resembling the cirrhose, oilers of a dark brown or nearly black appearance. Tjjjjese various states of disease may sometimes be trac- ed 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 hyda- tids. Th§f 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 enlarged. A remarkable cir- cumstance in thev history of the affection is the slight and obscure symptoms with which the disease may ad- vance even to a prodigious degree of enlargement. I shall only add the following example. Case CXXXIV.—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 be- gajj. to decline considerably in flesh and strength, and complained chiefly of a feeling of oppression about his che% He went to the country and improved consider- ably, but in May he became worse. His chief com- plaint was then of a fixed pain in the lower part of his back, with restless nights ; he was able to take a gojxl 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 fallenjoff in flesh and strength, and his pulse was a lit- tle frequent ; but his appetite was good, and he made no comprint of his digestion ; his chief complaint was still of a feed pain in the lower part of the back. On 376 CHRONIC diseases of the liver. examination nothing wwfdiscovered in his back; but a mass of* disease was felt in the abdorfien, extcndlnjr from the ribs to near the spine of the if urn chiefly on the left side. It was- not at all painful on pressure/'and he could give no account of the origin or progress of it, having never taken notice of it until it was pointed out to him. There was now a gradual failure of strftrffth without any urgent symptom. His appetite and diges- tion continued tolerable until eight or ten days beftUte his death, when he began to have nausea with thirst, foul tongue and impaired appetite ; and he died gradu- ally 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 enormously enlarg- ed, especially the left lobe, which descended nearly to the spine of the ilium. Externally it was of a very dark colour, variegated with light ash-coloured spots. In- ternally it was composed chiefly of numerous found tubera, of the size of small oranges ; they were gen- erally of a white or ash colour, some of them ap- proaching to a scirrhous hardness, others of a softer consistence, and some of them contained a fluid of a puriform character. In the interstices -betwixt these tubera there were portions which retained the a'&jflfai;- ance of the proper structure of the liver, butCthey were of very small extent, dark coloured, and* of a soft consistence. It appears that the form of disease which' occurred in this case is sometimes much more rapid fn Its pro- gress. A man mentioned by Andral, died with fever, vomiting, and pain in the right hypochondriufh,>havin'g begun only about a month before to coniplain of some uneasiness in the region of the liver. Trae-liver Was HYDATIDS. 377 much enlarged, and presented a mixed mass of disease, scirrhous, encephaloid and tubercular. <$> IX.—Hydatids. * :a 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 containe4 are sometimes lined with a thick coating of false membrane, and not unfrequently there are found in them portions of bone. A liver which con- tains hydatids may be enlarged and otherwise diseased, or it maybe quite healthy except with respect to the cyst whicft is iybedded in it. There are no symptoms which mark'the presence of hydatids "in the liver, dis- tinct from mose of the other chronic affections, and they have been f$und where patients died of other dis- eases without any symptoms referable to the liver. § X.—Large cysts containing watery matter con- fined 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 CXXXV. A man, aged 32, was affected with an immense tumour of the abdomen, which filled the greater part of it, extending from the region of the liver considerably below the umbilicus, and into the left side. At the upper part, near the ribs on the 48 378 chronic diseases of the liver. right side, there was an evident fluctuation ; this was most remarkable when he was in the erect posture ; in the horizontal posture it seemed as if the fluid re- tired under the ribs ; no fluctuation was perceivgcLin any other part of the mass. His breathing was much oppressed and laborious, especially when he attempt; ed to turn on the left side ; he then seemed in dan- ger of instant suffocation, for several minutes gasping in the utmost agony before he recovered his breath; similar attacks were produced by other causes, espe- cially any bodily exertion. He" was much'emaciated ; and the complaint was of about a year's standing. A puncture was made on the spot where the fluctuation was felt, and clear serous fluid was drawn off to the amount of nine or ten pounds ; and the opening con- tinued to discharge freely for a good many days. By s this evacuation, he was very much rtrfieved, but his strength continued to sink, and he died about ten days after the operation. A * -. Inspection.—The liver was very litUe enlarged. The tumor was found to c6nsist 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 tjfce umbilicus, and on the other, had pressed'the diaphragm upwards as hggh as the se- cond rib. 'file, right Tung was consequently compressed 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 yea*n This immense cyst adhered firmly to the posjg^j 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 opfriBH in the operation ; but the great cyst was entire, and contained lb. 18 of transparent colourless fluid. Its parietes were firm and dense, like the peritoneum very much thicken- ed. In the bottom of this cyst there were found two cysts full of watery fluid. 379 singular bodies, consisting of flat cakes of a soft gelat- inous matter rolled up into solid cylinders; when un- rolled, they were about ten inches in diameter, and about one-eighth of an inch in thickness, and had the appear- ance of a deposition which had been separated from the juiner surface of the cyst. The liver was not diseased in its structure, and the other viscera of the abdomen were healthy,' ^ut remarkably displaced, the stomach being on the lelt side and the pylorus towards the left os ilium. •*■' . 0 A remarkable circumstance in this case was the un- common 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 in the Infirmary of Edinburgh many ^ears ago, under the care of the late Dr. Gregory. It was supposed to be an immense en- largement of the liver ; but one day the whole hardness suddenly disappeared, with a feeling to the patient of something bursting^internally. Fluctuation then be- came 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. Annesley men- tions a case in which there was attached to the concave surface of the liver a cyst containing a quart of watery fluid, with a hydatid floating in it. The above outline, which was intended to be merely an enumeration of the principal morbid conditions of the liver, has extended to a greater length than I ex- pected ; and I shall therefore allude but very briefly to what remains of the subject, namely, the treatment of 380 diseases of the liver. these affections. I have already referred to a fact which I conceive to be of the utmost ."importance, and deserv- ing the most serious attention of practical men. I al- lude to a prevailing doctrine, or rather prevailing phra- seology, 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 atten- tion would show, that the affection is seated entirely in the stomach or bowels, especially in the arch of the co- lon. The prevalence of this doctrine, and the indiscri- minate 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 be- fore 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 scientific practitioner will find himself con- strained to use greater circumspection. The real diseases of the liver resolve themselves into two great classes, the acute and the chronic. The acute affections a*e to be combated by the means adapt- ed to other inflammatory diseases, namely, general and topical blood-letting, blistering and saline purgatives. In the less active cases, indicated by local 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 mercury ; and it seems in general to be most advantageously applied by friction. In regard to the chronic affections of the liver, under the various forms which have been detailed in the pre- ceding observations, it will probably be admitted that & TREATMENT. 38 1 large proportion of them are beyond the reach of any human means. The treatment of these ought to be en- tirely 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 importance, because these affections often exist for a long time with- out materially injuring the health of the patient; and by treatment 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 evidently shorten- ed. 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 con- taining 1 fs to i 1 of axunge. In the preceding observations T shall probably be charged with attaching too little importance to mercu- ry 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 adaptation to all stages and all forms of diseases of the liver. In do- ing so I would be distinctly understood to express my- self in regard only 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 of- ten 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 condi- tions of this organ. If the liver is supposed to be in a state of torpor, mercury is given to excite it ; and if it is in a state of acute inflammation, mercury is given to moderate the circulation, and reduce its action. Effects the most indefinite, if not contradictory, are also some- times ascribed to it in regard to its influence on the se- cretion of bile, and in those affections which are com- 382 DISEASES OF THE LIVER. monly called bilious. Upon the principles of induction with regard to cause and effect, which are recognised in other sciences, it may be doubted whether all these maxims can be right, but I will not take upon me to de- cide 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 in- quirer ; and with hazarding the opinion, that much of the prevailing doctrine on derangements of the liver re- quires 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 vari- ance with the principles of philosophical inquiry. APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. HEMORRHAGE FROM THE LIVER. A gentleman mentioned by Andral, previously in perfect health, on getting up one morning complained of some uneasiness 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 in- spection, much extravasated blood was found in the cavity of the abdomen, which appeared to have pro- ceeded 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 CXXXVI.—A man sitting carelessly upon the edge of a cart was thrown from it by a sudden jerk 384 DEATH FROM A GALL STONE. upon the road. He immediately got up and scrambled into the cart which was still in motion, and 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 abdomen. 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 in- terest to offer beyond the facts which are familiar to every one, and shall only add the following case in which a gall-stone sticking in the common duct was fatal. Case CXXXVIL—A lady, aged 60, had been for several years liable to attacks of acute pain in the right hypochondriac region, 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 at- tacks, but which did not subside as usual. It contin- ued through the night, accompanied by frequent vomit- ing and constitutional disturbance. On the 15th, there was fever, with frequent vomiting and obstinate cos- DISEASES OF THE (.ALL BLADDER. 385 liveness, and the pain was more extended,—being re- ferred 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 injec- tion, but it was very scanty. Severe pain continued, with every expression 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 duode- num, where there was considerable appearance of in- flammation, 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 in- flammation. 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 peri- tonitis, fatal in eighteen or twenty-four hours. The symptoms preceding it will depend upon its cause, and consequently may be either very obscure, or such as in- dicate great distention of the gall bladder, with ob- struction of the bile in its passage out o£ it. The causes of the affection are chiefly referable to two classes. (1st.) 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, arid a pyri- 49 386 PATHOLOGY OF THE LIVER.--APPENDIX. form 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 obliterated. The gall bladder and the hepatic and cystic ducts bore marks of having been much dis- tended ; 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. (2d.) Perforation of the coats of the gall bladder by ulceration. A man mentioned in the Nouveau Journal de Medicine for 1821, had been affected for more than a month with pains in the abdomen and fever, which had various remissions and aggravations. On the 37th day of the disease, he was suddenly seized with symptoms of the most violent peritonitis, and died on the follow- ing morning after suffering inexpressible agony. On inspection, there were found marks of most extensive peritonitis. The inner surface of the gall bladder pre- sented numerous small circular ulcers from one to three lines in diameter; two of them had entirely per- forated its coats, so as to allow the escape of the bile into the peritoneal cavity. » PERFORATION OF THE CALL BLADDER. 387 SECTION IV. CHANGES IN THE QUALITY AND QUANTITY OF THE BILE. The chronic diseases of the liver seem to impair the functions of digestion, partly by the actual pressure up- on the stomach, 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 necessa- ry to healthy digestion. There is a good deal of hy- pothesis on this subject; but there are certain points, in regard to the changes of the bile, which we may con- sider as ascertained with some degree of precision. 1st. 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 chief- ly 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 dis- ease which have been described, shewing almost every point of the liver altered from the healthy structure, there were no symptoms indicating that the bile was either deficient or vitiated,—the motions being healthy, and the digestion little impaired, until a very short time before death. This occurred in a very remarkable manner in Case CXXXIV. 2d. The bile appears to be sometimes much altered in quality. The only means by which we can judge of this with any degree of precision, is from the appear- ance of the bile which is found in the gall bladder. In some diseases of the liver, accordingly, we find 388 PATHOLOGY OF THE LIVEU.--APPENhlX. there a fluid of an albuminous or watery appearance, without any of the sensible qualities of bile. When we observe a change so very remarkable as this, we may conclude 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. 3d. 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 colour, and, when it is mixed with the usual contents of the intestinal canal, it imparts to them a bright yellow. When the motions become of a dull white or ash colour, we judge with tolerable pre- cision 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 fact is produced by either of these authors in support of their opinion, and it seems to rest merely upon the pop- ular notion that the colour of the feces is derived from the bile ; but this doctrine seems rather to be taken for granted than proved."* * Mr. T} tier.—Calcutta Tiansactions, vol. iii, JAUNDICE. 389 SECTION V. PATHOLOGY OF JAUNDICE. Jaundice is produced by the absorption of bile into the circulation, and this is generally connected with some obstruction to its passage from the liver into the duodenum. It must be confessed, however, that there is much obscurity in the pathology of many cases of jaundice, and that some 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 hypotheses framed to correspond with the facts than as deductions from them, and there- fore not entitled to much confidence. When, with a view to practical utility, we consider the circumstances 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 the calculus is a considera- ble 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 se- vere, 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 differ- ent cases. This form of the disease is in general distinguished by the violence of the pain, but cases have occurred in which the disease was distinctly referred to this cause, 390 PATHOLOGY OF THE LIVER.--APPENDIX. 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 ac- companied by vomiting, and died the same night in a state of coma. A calculus was found sticking in the gall duct, and the duct was 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 producing jaundice, and tiie other symptoms indi- cative of having been impacted in the duct, have work- ed their way outwards, and have been extracted from an opening in the parietes. In a case of this kind men- tioned 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, discharging a yellow fluid ; in a third, it discharged calculi at intervals.* A case occurred to the late Dr. Graham of Dalkeith, in which a very large calculus was extracted from an abscess in the parietes of the abdomen ; and I believe ultimately did well. It has been doubted whether the very large biliary calculi, which are sometimes 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 have described a case in which a large calculus produced fatal ileus, after it had passed as far as the middle of the small intestine. The common duct was found so dilated as * See page 397, for a remarkable case of this kind. JAUNDICE. 391 to admit a full-sized finger, but without any other ap- pearance of disease. It has been disputed whether biliary calculi are ever formed in the substance of the liver, or in the gall-blad- der 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 eigh- teen drachms ; and I have mentioned one which meas- ured in its longer circumference four inches, and in its smaller three inches and a half. Biliary calculi seem in general to produce no incon- venience while they lodge in the gall-bladder ; but in some cases they appear to produce considerable de- rangement 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 discov- ered, except that the gall-bladder was distended with calculi which entirely filled it. A case has also been related tome 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 392 PATHOLOGY OF THE LIVER.--APPENDIX. year or more, he discharged some large biliary calculi, and speedily recovered perfect health. The passage of biliary calculi, when they are produc- ing 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. It is said that a peculiar disposition to the" formation of them has been remarked in persons, who, while in good health, have been subjected to much confinement, as in criminals during a long im- prisonment. II. Inflammatory affections of the liver. Jaundice ap- pears to be often connected with an inflammatory con: dition of the liver, existing in an obscure form, and of- ten of small extent. It may be suspected when the disease is attended with pain or tenderness in the region of the liver, though without fever, or any symptoms of inflammation in an active state. The cases of more de- cided inflammation of the liver seem to be attended with jaundice only when the inflammation is seated chiefly on or near its concave surface ; but in Case CXIX. we have seen very deep jaundice in a case rapidly fatal, in which the only morbid condition was a uniform black colour of the whole surface of the liver, while the inter- nal parts had a healthy appearance. In several cases, on the other hand, we have seen proofs of most exten- sive inflammation, terminating by suppuration, without jaundice, though in some of the cases nearly the whole substance of the liver seemed to have been involved in the disease. The black degeneration of the liver with remarkable diminution of size, we have seen attended with very deep jaundice in Case CXXIV; while there was no jaundice in connection with the very extensive encephaloid disease in Case CXXV, in which the symp- toms were more acute than in the former case. JAUNDICE. 393 It appears, however, that there is a stale of the liver which gives rise to jaundice, and which does not amount to inflammation, though it is evidently allied to it. The circumstances, under which we are chiefly able to trace this, affection, are when jaundice appears in connection with inflammation of the lower part of the right luno-. In a case of this kind, which had been accompanied by the usual symptoms of pneumonia, with the addition of violent, hiccup, I found an abscess of the lower part of the lung in contact with the diaphragm, but could not detect any appearance of disease in the liver, except that it seemed to be rather paler than usual on the sur- face. Bonetus relates a similar case in which the dis- ease was in the lungs, the liver being merely paler than natural. There had been fever with convulsions, and death in 1 5 days. It is probable, therefore, that the liver may be affected, in a manner analogous to that now referred to, from other causes which in a great measure elude our observation. To this principle we may per- haps refer some of those temporary cases of jaundice which appear to arise from disorders of the bowels,— also those cases which seem to be induced simply by external heat, and have been ascribed to overflow of bile. Jaundice is also occasionally observed in connec- tion with disease of the heart, arising probably from the impeded return of the blood from the liver; and it has been known to supervene upon suppression of the hsemorrhoidal discharge and other evacuations which had become habitual. Portal has seen it supervene upon suppression of leucorrhoea ; and he als«nientions 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 af- fection of the liver of an inflammatory character, it must of course be treated by the appropriate rem- 50 394 PATHOLOGY OF THE LIVER.--APPENDIX. edies,—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 jaun- dice is often produced by affections of the bowels, though the precise manner in which it arises from such causes is not easily ascertained. 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 shew, 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 afford- ed 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 care.f The doc- trine 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. JaundiceJ*however, even when arising from causes apparer^tly^transjent, 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 capa- + Dublin Hospital Reports, vol. iii. t Cocke on Derangements of the Digestive Organs. JAUNnrcE. 39^5 ble of accounting either for the jaundice, or for the fatal event. Several years ago, I saw a woman who became suddenly jaundiced a day or two after accoucb- ment. 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, mentioned 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 con- siderable quantity about the spinal cord. Another young man, mentioned by the same writer, was very much frightened by having a musket pointed at his breast. Next day he was jaundiced ; soon after deliri- ous ; 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 Por- tal, whose case was formerly referred to. After great agitation of mind, she was seized with suppression of the menses; this was speedily followed by very deep jaundice ; and she died next day. The liver in this case shewed marks of extensive disorganization. 396 PATHOLOGY OF THE LIVER.--APPENDIX. V. The cases of long continued jaundice are gen- erally referable to two heads, namely, chronic disease of the liver, or tumors, or other diseases of neighbouring 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 disease 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 induration of the coats of the duode- num, and tumors of various characters compressing the common duct. There is also reason to believe that old cases of jaundice are sometimes produced by contrac- tion of the calibre of the common duct, arising from chronic inflammation of the coats. In this outline, I have alluded only to those sources of jaundice which may be considered as ascertained with some degree of correctness. Others are mentioned, but are probably in a great measure conjectural ; and I am not entirely satisfied of the correctness of the doctrine by which jaundice has been considered as an effect of injuries of the head. The source of hesitation here is a doubt, whether, in the cases referred to, the injury of the head could be considered as the cause of the jaun- dice, or the liver had not also received an injury at the time of the accident. The yellow tinge in jaundice is said to have been ob- served in all the fluids of the body, except the milk. But Dr. Marsh mentio'ns, that, in examining the body of a woman who died in the Lock Hospital of Dublin from protracted disease, connected with jaundice, the mam- mae appeared full ; and by moderate pressure, there were obtained from them several ounces of a yellow te- nacious fluid, having all the visible properties of pure bile. He also mentions a case related to him by Dr. JAUNDICE. 397 Cheyne, of a lady affected with jaundice, whose linen was distinctly tinged by the exhalation from her skin. Case referred to in page 390. Since this sheet was sent to press, I have seen, along with Mr. Lizars, a man about 50, who has had a biliary fistula discharging for nearly three years. The com- plaint 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 colour, and some small biliary calculi. This opening closed, but another soon took place, which has continued to discharge ever since. The dis- charge 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 ex- tent. 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 examination exhibited all the properties of pure bile. The man has every appearance of good health, and, except the fistu- lous opening, there is no appearance of disease in the region of the liver. His appetite and digestion are good, his bowels are regular, and the evacuations of a natural appearance. PATHOLOGY OF THE SPLEEN. The morbid conditions to which the spleen is liable appear to be chiefly the following : § I.—Inflammation. Inflammation may be seated either in the substance or the peritoneal coat of the spleen. Active inflam- mation 6f the substance of the spleen is rarely observ- ed ; 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 ABSCESS. 399 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 con- nection with peritonitis, without any disease of its sub- stance. Inflammatory action of the spleen seems to occur more frequently in a chronic form, and to termin- ate in some cases by suppuration, in others by a pecu- liar black degeneration or softening. In both cases, the disease is generally protracted, and the symptoms are often exceedingly obscure. § II.—Suppuration of the spleen. The following is the only case of suppuration of the spleen that has occurred to me. Case CXXXVIIL—A gentleman, aged 52, who had enjoyed previously very good health, was affected in January, 1821, with cough and slight feverishness like a common cold. After a short confinement, the cough disappeared, and he felt otherwise much better ; but after some time, he was confined again, though without any defined complaint except weakness. When close- ly questioned, he sometimes mentioned an undefined uneasiness across the epigastric region, but it was slight and transient; his appetite was variable and ca- pricious, but, upon the whole, not bad, and he had no dyspeptic symptom ; his bowels were rather slow, but easily kept open ; his breathing was natural; and every other function was in a healthy state, except that his pulse continued a little frequent, and that he was be- coming progressively more weak and emaciated. In 400 PATHOLOGY OE THE SPLEEN. this manner, the complaint went on during the remain- der of the winter; in the beginning of 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 J 00 and weak ; his nights were generally good, but sometimes feverish ; his ap- petite was bad, but he still took a good deal of nour- ishment, and never complained of his stomach ; there was no cough and no pain ; the urinary secretion and bowels were natural ; but the debility and emaciation continued to increase progressively. On the 2d of July, he was seized with diarrhoea, and died on the 5th. Before the attack 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 contain- ing several ounces of purulent matter ; the surround- ing 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 gentle- man was under the care of Mr. William Wood, and in the progress of it he was occasionally seen by Dr. Thompson and myself; but we 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 pro- tracted and often obscure. A young man, mentioned by M. Jacquinelle, (Journal de Med. torn. 88,) had pain and fulness in the left hypochondrium, with palpi- r* ABSCESS. 40] tation of the heart, faintings, and progressive emacia- tion ; and ho died gradually exhausted, at the end of a year. A short time before his death, there was a ces- sation of pain, followed by discharge of very fetid and dark coloured 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 wrher, after various attacks 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 subsid- ed, 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 affec- ted with a swelling in the left hypochondrium, a tumor formed at the umbilicus which discharged purulent matter ; after it had discharged for a month she died hectic. A cavernous ulcer was found extending from the umbilicus, betwixt the peritoneum and the abdom- inal muscles, and forming a communication with an ab- scess of the spleen.* Abscess of the spleen may likewise burst into the stomach, as in a very interesting case mentioned by M. Coze.f The patient had pain in the epigastric region with a remarkable feeling of pulsation at the stomach, which was increased by exercise, and by any excess in diet; he had occasional vomiting, and slight uneasiness in breathing, was easily fatigued by exercise, and a sense of suffocation was induced by any exertion. On examination nothing could be dis- * Ileide Centuria Observ. Med.—Obs. xiii. f Jour, tie Med.—Tom. 82. 51 402 PATHOLOGY OF THE SPLEEN. covered but a slight tension across the epigastrium, and little change took place for ten or twelve months, except that his skin became slightly"yellow. He was then seized with vomiting of blood mixed with purulent matter, after which the pulsation at the stomach sub- 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 intimately to the stomach, and formed a bag full of purulent matter and clots of blood. The parietes oT it were in general about six lines in thick- ness; and it communicated, by a free opening, with the cavity of the stomaeh at the place of the adhesion. In some cases, the abscess of the spleen appears to have obtained a most remarkable size. In a case men- tioned in the Memoirs of the Academy of Sciences, it contained 30 lbs. of matter. In another case mention- ed in the same work by M. L'Hermite, 8 lbs. of mat- ter 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 suffered from the Walcheren fever, Mr. Wardrope found the spleen entirely reduced to a cyst full of pu- riform fluid.* § III.—Ramollissement or black degeneration of THE SPLEEN. This I believe to be the result of a low degree of in- flammatory action ; and it 4s found as the only morbid appearance, in cases in which the patients have died with obscure and protracted symptoms. The spleen so af- fected may be enlarged, or it may be of the natural * "Notes to Lis edition of the works of Dr. Baillie. RAMOLLISSEMENT. 403 size ; but the whole substance of it is reduced to a soft black broken-down mass like grumous blood, in some cases still softer, being of a pultaceous consistence, or nearly fluid. The following examples will illustrate the sort of case in which this affection occurs as the only morbid ap- pearance. Case CXXXIX.—A lady, aged 60, had been for seve- ral months affected with loss of appetite, dyspeptic symp- toms, and occasional vomiting. I attended her for about a month before her death, during which she had much nausea, and generally vomited three or four times a-day ; she had little or no appetite ; tongue loaded ; bowels rather costive, but easily regulated ; pulse nat- ural. She did not complain of any gain, and nothing could be felt on pressure that could account for the disorder. She died, gradually exhausted, without any other change in the symptoms. Inspection.—No morbid appearance could be disco- vered after the most careful examination, except in the spleen, which was of a very dark colour, and the whole substance of it was broken'down into a soft mass like grumous blood. • Case CXL.—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 painful ; 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 regain- ed pretty good general health ; and the swelling was very much reduced. I then lost sight of him for a year, during which I learnt that he enjoyed pretty good health, though he occasionally felt uneasiness in his 404 PATHOLOGY OF THC SPLEEN. side. He died in August 1828 after an ^ ^ about three weeks, which had the characters of contin- ued fever. I did not see him in this illness, but was present at the exmination 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 soil 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 grumous blood. The liver was of a remarkably dark green colour, 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 putrefaction, and others gan- grene ; 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 fort- night, without any other symptoms than nausea and fre- quent 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 Scnnei - tus, 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 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 SIMPLE ENLARGEMENT. 405 spleen ; and in some, it has been found combined with evident marks of inflammation in the neighbouring parts. This occurred in a case by Lossius ; and, in two cases by Crendal, it was found connected with ex- tensive peripneumony. I have likewise observed it in several cases in which there had been extensive inflam- mation of the lower part of the left. § 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 vascularity. In the older cases, the structure is sometimes of a bluish purple colour, 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 1 1 lbs. 13 ounces. In other cases, again, the disease presents a mixed character, resembling some of the chronic af- fections of the liver ;—some parts presenting a tolerably healthy appearance, others being indurated, approach- ing to scirrhus ; and perhaps there may be hydatids or cysts containing a thick matter like pus or softened tu- bercles. 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 extraordinary, that I sus- pected some fallacy, until I found similar cases described 406 PATHOLOGY OF THE SPLEEN. as of frequent occurrence by writers on the disease of India. Several years ago, 1 saw, along with Dr. Combe of Leith, a seaman who had contracted ague in En- gland 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 tu- mour 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 con- sideration ; 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 suppres- sion of long continued haemorrhoidal discharges. It is also met with, especially in warm climates, in feeble unhealthy 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 irregular ; the motions generally dark coloured. They are said to be liable to haemor- rhage from various parts of the body ; there is derang- ed digestion, with muscular debility ; and often a gen- eral unhealthy state of the system, with a tendency to sloughing sores from slight causes. There is frequently a dry cough ; and in protracted cases, hsematemesis, 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 indi- viduals in Lincolnshire affected with it for twenty years, though they had generally a pale or yellowish as- SIMPLE ENLARGEMENT. 407 pect ;* and Lieutaud mentions a spleen which weighed 32 lbs. in a woman who had had the disease in a great- er 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 ofc strength. In the earlier stages, when there is any considerable degree of tenderness, re- peated 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 es- pecially purgatives combined with tonics. The spleen powder, and spleen mixture of Bengal, are combina- tions of rhubarb, jalap, scammony, and cream of tar- tar, 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,f. as the period which is generally required for reducing by this treatment a very consid- erable tumefaction of the spleen, if the case has been recent. Others employ nitric acid, with regular alo- etic 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. * Dr. Crane, Edin. Ned. Jour. April, 1823 f Calcutta Transactions vol. iii. 408 PATHOLOpY 01' THE SPLEEN. § V.—Tubercles. Tubercles are of very frequent occurrence in the spleen,—generally in combination with tubercular dis- ease in other parts of the body ; and it may be seen completely studded with them, even in the bodies of in- fants a few months old. In these cases, they are gen- erally 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 colour, and the abdomen became tumid. The yomiting increased, with a quick pulse and anasarca ; and she died in five months. Con- siderable effusion was found in the abdomen; the spleen was enlarged and contained twenty tubercles full of thick purulent matter. § VI.—Pale induration of the spleen approaching TO SCIRRHUS. This appearance I have not seen, but it is mentioned by Portal 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. § VII.—Hydatids. Hydatids are of frequent occurrence in the spleen ; IM'.MOHRHAGE ANT) LACERATION. 409 they may be.imbedded in its substance, but I think ar« more commonly met with in cysts formed by its perito- neal coat. In one case of this kind, in which there was an immense swelling in the region of the spleen, I found the disease to consist entirely of a bag of hyda- tids coverifl by its peritoneal coat, the substance of the spleen being little altered from the natural appearance. VIII.--HAEMORRHAGE FROM THE SPLEEN, AND LACER- ATION BY EXTl'KNAL VIOLENCE. 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 sup- per. 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 external violence ; in some of them, death seems to have taken place from hgemorrhage, in others from inflammation. Cases of the former kind are men- tioned by Lieutaud and Tulpius. A man, mentioned by Dr. Chisholm, fell while carrying a burden, and struck his left side against a stone. He felt little un- easiness at the time, and next day was able for his work as a blacksmith ; but he was then seized with pain in the side, fever, delirium 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. 52 410 PATHOLOGY OF THE SPLEEN. Various other morbid conditions of the spleen are oc- casionally met with, but they are distinguished by no par- ticular symptoms; consequently it would answer no purpose to detail examples of them. Among these may be reckoned infiltration of the substance of the spleen with a gelatinous fluid ; deposition of fajty matter throughout its structure ; ossification or cartilaginous hardness of its external surface ; remarkable diminution of its bulk ; stony concretions, and a stony induration of its whole structure. A woman, whose case is quot- ed from the Swedish Transactions, in Dr. Johnson's Journal for 1828, had, after exposure to cold, suppres- sion 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 abdomen 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 trans- formed 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 atro- phy. PATHOLOGY OF THE PANCREAS. Facts are wanting upon this subject ; but it appears that the morbid conditions to which the pancreas is li- able, are chiefly the following : I. Inflammation and its consequences. Inflammation of the pancreas seems to be rather a rare disease ; but several cases are on record in which it was found suppurated and gangrenous. The symp- toms 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. Baillie found an abscess of the pancreas in a young man who had a good deal of pain in differ- ent parts of the abdomen, with spasms of the ab- dominal muscles, but did not complain of any fixed pain in the region of the pancreas ; there was sickness with distention of the stomach, especially after eating, and a tendency to diarrhoea, and at length he became drop- sical. 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 en- 412 PATHOLOGY OF THE I'ANCREA*. larged, and contained a considerable abscess; the duc- tus communis was obliterated by the pressure. Portal found a complete suppuration of the pancreas in a man who 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. Abscess of the pancreas is also mentioned by Tulpius and Bartholinus. 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 mentioned 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 gangrenous in a man who died of obscure pain in the abdomen, accompanied by wasting, with occasional nausea and diarrhoea. II.—Enlargement, with a mixed state of disease, PARTLY CONSISTING OF INDURATION, AND PARTLY OF A SOFTENED STATE, RESEMBLING THE MEDUL- LARY SARCOMA. Case CXLI.—A man, aged 56, had pain in the left hypochondrium, extending into the back, with oppres- sion at the stomach, indigestion, and gradual emacia- tion ; and he died gradually exhausted after two years without any other symptom, except that for a week or two before his death, there was a considerable decree of jaundice. lie never had any vomiting, and his 1 bow SCIRRHOUS INFLAMMATION. 413 els were easily regulated. No disease could be dis- covered on examination during life, even after he be- came to the last degree emaciated. Inspection.—The stomach and the intestines were healthy ; behind the stomach, in the seat of the pan- creas, there was a morbid mass four or five inches in breadth, and somewhat less in thickness; it was closely attached to the spine, and surrounded the aorta. It varied in its structure, some parts being of al- most 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 CXLII.—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 grad- ually, but without confining him from his usual em- ployment, until July, when he began to be affected with vomiting, which generally occurred two or three hours after dinner. At this time, he commonly retained his breakfast; but, in September, when I saw him, he vomited every thing. He was then much wasted ; and a large irregular tumor was distinctly felt in the epigastri- um, which was painful on pressure. He died, gradual- ly 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 shewing a mixed state of disease as in the former case. The sto- mach, the duodenum, and the arch of the colon, had formed adhesions to the mass ; and the stomach seem- ed somewhat thickened in its coats ; the other viscera were healthy. 114 PATHOLOGY OF THE PANCREAS. III.—Scirrhous induration, with little enlarge- ment. Case CXLI'IL—A woman, aged about 40, had slight uneasiness in the region of the stomach. The vomit- ing 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 abdomen when the body was examined. Inspection.—The pancreas was found in a state of uniform scirrhous 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 the diseased state of the pancreas has a most important influence upon the functions of diges- tion and assimilation, and that it may produce in this man- ner many serious effects upon the system, whijc the lo- cal symptoms are so obscure as not to indicate what or- gan is the seat of the disease. I shall only add the following remarkable example of this kind. Case CXLIV.—A gentleman, aged 35, died after an illness of about eighteen months duration, in which it was to the last impossible to say what organ was the seat of the disease. His complaints began with a fe- brile attack, which left hirn weak ; and from that time he was liable to dyspeptic symptoms, with variable ap- petite, and undefined uneasiness in the epigastric region. scirrhous induration. 415 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 being entirely without colour. About this time he had some vomiting, 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 loo*se; he had frequently perspirations in the night time, and appeared at all times languid and faint, but his pulse was natural; he took a good deal of food, and there was no symptom that accounted for his ema- ciated appearance. In February he became rather worse, with some diarrhoea and scanty urine ; but these symptoms soon subsided, and he afterwards complained 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 de- bility, 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, except that his pulse became frequent a few days before death. Inspection.—All the internal parts were found remark- ably pale and void of blood ; the heart was sound but re- markably empty. The pylorus was thickened and firm- er 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 disease of the pancreas, exhibiting the same diversity of symptoms 416 PATHOLOGY OF THE PANCREAS. which occurred in the examples now described, and nearly in the following proportion. 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 food. In several, there were drop- sical symptoms ; and in three or four there was jaun- dice from the tumor compressing the biliary ducts. In the morbid appearances, also, there was great vari- ety ; the pancreas being in some of the cases much en- larged, in others, in a state of scirrhous hardness with very little enlargement. 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 vomiting and diarrhoea, and died, grad- ually exhausted, at the age of thirty. Portal found the pancreas much enlarged and containing 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. Baillie, 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 finis __ *.-■ *• *. *KVr V? «* - ** /), rV^v ■r.*\ fe;*t< 4p» i-.