ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 ^SmII i*«%\ VlkjS^^^^Jl^P^p^J^^K 9/ N&^^^^^^^^V* Section____________ Nuraber ..J..3.3..5..^L. ------------------------■! Form 113c, W. D., S. G. O. -10543 (Revised Juno 13, 1936) I .yJ>. - PATHOLOGICAL \pcvn- ^ AND PRACTICAL RESEARCHES ^DISEASES OF THE STOMACH, THE INTESTINAL CANAL, THE LIVER, -Mr"* AND OTHER VISCE& T THE ABDOMEN. T7 li y • t v| BY JOHN ABERCROMBIE, M. D. MM* LLOW OF THE ROYAL COLLEGE OB* 'pUWUapjfr^JBmMKaMtf WB.'JkHB FIRST. PHYSICIAN 1AJESTY IN SCOTLAND. *fc*«k-.. * SECOND AMERICAN FROM THE SECOND LONDON EDITION, ENLARGED.... *.V-V fiJg^'? PHILADELPHIA: CAREY, LEA, AND BLANCHARD. 1834. \AlX )S2*t p.f»t £v4t> 2-4t '•■> z~ 4* PREFACE TO THE FIRST EDITION. Nothing appears to have had greater influence in retarding the progress ol knowledge, than misconception in regard to the proper objects of scientific inquiry. It was in this manner that so much talent was wasted and lost in former times, when learned and able men devoted their attention to searching after the hidden causes of events; and the great purpose of the illustrious fathers of 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 im- portant truth, that the philosophy of Bacon and of Newton consists entirely, to use the words of an eminent writer, in ' ascertaining the universality of a fact.' This cannot be better illustrated than by a reference to that department of science, in which the philosophy of modern times is so distinguished 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 carried on independently of any attempt to discover it. ' When Newton (says Mr. Stewart,) showed that the same law of gravity extends to the celestial spaces, and that the power by which the moon and planets are retained in their orbits, is precisely similar in its effects to that which is manifested in the fall of a stone,—he left the efficient cause of gravity as much in the dark as ever, and only generalised still farther the con- clusions of his predecessors.' If medicine is ever to attain a place among the inductive sciences, its first great step towards this distinction will be made, when medical inquirers agree to restrict their investigations to ascertaining the universality of a fact. By adhering to this rule, we shall avoid two errors, which will probably be ad- mitted to have been frequent in medical reasonings, and to have had no in- considerable influence in retarding the progress of medical science. The one is the construction of hypothetical theories, or the assumption of principles which are altogether gratuitous and imaginary; the other is the deduction of general principles or conclusions from a limited number of facts. Doctrines of the former class may be considered as almost independent of observation ; and those of the latter kind, though they have an apparent foundation of facts, IV PREFACE. are framed without due inquiry whether these facts are universal. The confi- dence is indeed remarkable with which general statements of this last descrip- tion are often brought forward, and the facility with which they are received, without due examination, as established principles. We even find some writers expressing such confidence in these deductions, as to talk of general rules in medicine, with exceptions to these rules; and in this manner new ob- servations, by which the rules might be corrected, are overlooked 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 gen- eral 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 exceptions; but, in physical science, to speak of exceptions to a general rule cannot be regarded in any other light than as an admission that the rule is not general, and consequently is unworthy of confidence. The best means of avoiding the errors which have now been referred to, will probably be, to keep in mind the important principle, that the object of physical science is ' to ascertain the universality of a fact.' A considerable number of medical doctrines, there is reason to apprehend, will come out of the examination in rather an unsatisfactory manner, if we apply to them the tests which this rule would furnish, namely,—are they facts, and are these facts universal 1 The object which the author has proposed to himself in all his medical re- searches has been, to furnish facts in a concise and accessible form, and to advance to conclusions by the first step of the most cautious induction. " If, in following out this course of investigation, he has sometimes had occasion to call in question doctrines which have been generally received, he has only to appeal to the principles which have now been stated. To opinions which fcave been received by others, he would never presume to oppose mere opin- ions of his own; but he cannot hesitate to submit both to the test of observa- tions, which are calculated to ascertain, whether they are facts, and whether the facts are universal. He is deeply sensible of the favorable manner in which the profession have received his Researches on the Pathology of the Brain. The volume which he now presents to them is intended to answer a similar purpose, namely, to furnish them with a connected series of authentic facts, from which he is anx- ious that they should draw their own conclusions. Those which he draws from them he will keep entirely distinct from the facts on which they are founded; and, with regard to all his conclusions, his only anxiety is, that they should be tried in the most rigid manner, both by the facts themselves and by farther observations on the same subjects. This volume is divided into five parts, in reference to the five organs to which it relates, namely, the Stomach, the Intestinal Canal, the Liver the Spleen, and the Pancreas. The two former are treated of at some length with a view both to pathology and practice; and the three latter are consid- ered with a more immediate reference to their pathological changes, Edinburgh, Octoeer, 1828. PREFACE TO THE SECOND EDITION. A new edition of this volume has been called for much sooner than the Au- thor expected; but he has been anxious to make such additions and correc- tions as the shortness of the time admitted. The new matter that is added consists chiefly of the following cases, and the observations connected with them: Cases XVII, LI, LII, LV, CXII, CXXI, CXXII, CXXVI, CXLII, CL, CLI. There are also some additional facts and observations on the sub- jects of Dysphagia, Diseases of the Duodenum, Tympanites, and the Theory of Ileus. Edinburgh, November, 1829. 2 CONTENTS. Page VIEW OF THE STRUCTURES CONCERNED IN THIS IN- QUIRY, AND THE PRINCIPAL MORBID CONDITIONS TO WHICH THEY ARE LIABLE ----- 27 I. Peritoneum ------ 27 II. Muscular Coat.....29 III. Mucous Membrane.....30 PATHOLOGY OF THE STOMACH 35 SECTION I. INFLAMMATORY AFFECTIONS OF THE STOMACH AND ULCERATION........3ti General Observations on Acute Gastritis ... 36 ------------------— on Chronic Gastritis 38 Progress and Termination of Chronic Gastritis - 41 $ 1. Succession of small Ulcers of the Mucous Membrane of the Stomach,—fatal by gradual exhaustion - 43 VIII CONTENTS. Page § 2- Circumscribed Ulceration with Thickening,—fatal by gradual exhaustion ...... 45 $ 3. Extensive Ulceration with Thickening, complicated with remarkable disease of the Omentum and Perito- neum,—fatal by gradual exhaustion 48 ^4. Ulcer of the Stomach,—fatal by Haemorrhage - 51 § 5. Simple Ulceration of very small extent,—suddenly fatal by Perforation of the Stomach .... 53 § 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......57 § 7. Perforating Ulcer of the Stomach, and communication with the Arch of the Colon.....58 $ 8. Extensive Ulceration of the Stomach of a Cancerous character........60 DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE STOMACH REFERRED TO UNDER THE PRECE- DING HEADS........62 Of some modifications of Inflammatory Affections of the Mucous Membrane of the Stomach ... 67 Diphtherite.........68 Of the Softening of the Coats of the Stomach - 71 SECTION II. OF ORGANIC DISEASES OF THE STOMACH - - - 72 $ 1. Induration and Thickening of the Coats of the Stom- ach .........72 § 2. Chronic Peritonitis of the Stomach, with disease of the Omentum and the Pancreas 73 § 3. Diseases of the Pylorus - - - - . 74 $4. Diseases of the Cardia..... 78 CONTENTS. ix SECTION 111. Page PATHOLOGY OF DYSPEPSIA......79 Various Sources of Deranged Digestion 80 Outline of the Treatment of Dyspepsia - - - - 82 Observations on some of the more troublesome Symptoms con- nected with Derangements of the Stomach - - 85 I. Gastrodynia ------ 85 II. Chronic Vomiting .... 87« III. Obstinate Pyrosis.....88 IV. Hasmatemesis - - - - 89 V. Sympathetic Affections of the Heart - 90 APPENDIX TO THE PATHOLOGY OF THE STOMACH 97 SECTION I. DERANGEMENT OF THE FUNCTIONS OF THE STOM- ACH BY TUMORS ATTACHED TO IT EXTERNALLY, WITHOUT DISEASE OF ITS COAT ... - 97 SECTION II. DISEASES OF THE (ESOPHAGUS......*» 1. Inflammation of the (Esophagus.....99 2. Pathology of Dysphagia......10° SECTION III. DISEASES OF THE DUODENUM 105 X CONTENTS. Pa. ^6 PATHOLOGY OF THE INTESTINAL CANAL - - 109 PA RT I. OF ILEUS ... Ill SECTION I. OF SIMPLE ILEUS .... - 112 § 1. Ileus Fatal in the state of Distention without inflamma- tion .........112 § 2. Ileus Fatal with Distention and a dark livid color of the patts without Disorganization - - - - 113 $3. Ileus Fatal by Gangrene without Exudation - - 114 $4. Ileus Fatal by Gangrene combined with Exudation 115 SECTION U. Ileus fatal with previous disease of such a na* ture that it seemed to act by deranging the muscular power of the canal without me- chanical obstruction - 116 ^ 1. Old adhesion of the Intestine of small extent - - 116 $ 2. Old adhesion of the parts concerned in a Hernia - - 118 $ 3. A slender band of adhesion betwixt two contiguous turns-of Intestine - - - - - - '118 $ 4. Singular Twisting of the Sigmoid Flexure on itself - 119 § 5. Ligamentous band confining a portion of Intestine to the mouth of-a Hernial sac - - - - 121 CONTENTS. X» SECTION III. ILEUS WITH MECHANICAL OBSTRUCTION, OR OTHER ORGANIC CHANGES IN THE STRUCTURE OF THE PARTS...........122 § 1. Old Disease of the Intestine connected with Hernia and Artificial Anus ,„,,„.- 122 § 2. Internal Hernia - - • • - 123 § 3. Intus-susceptio.......125 § 4. Fatal Ileus from a Gall Stone .... 127 § 5. Contraction of the Calibre of the Intestine - - 128 § 6. Remarkable Stricture of the Arch of the Colon - 130 § 7. Stricture of the Sigmoid Flexure of the Colon - 130 APPENDIX TO THE PATHOLOGY OF ILEUS - - - 132 § 1. General Distention and Lividity of the Intestinal Canal rapidly fatal.......133 • 2. Effects of Galvanism on Distended Intestine - 133 SECTION IV. PATHOLOGICAL AND PRACTICAL INDUCTIONS FROM THE PRECEDING FACTS......134 SECTION V. TREATMENT OF ILEUS 145 XH CONTENTS. PART II. Page OF THE INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CANAL, IN- CLUDING PERITONITIS AND EN- TERITIS ......150 SECTION I. SYMPTOMS OF INTESTINAL INFAMMATION UNDER THESE FORMS - - - - - 152 I. Simple Peritonitis .... 152 II. Enteritis ----- 155 SECTION II. EXAMPLES OF PERITONITIS AND ENTERITIS - - 151 § 1. Simple Peritonitis ...... 156 § 2. Peritonitis confined nearly to the descending Colon and Rectum........159 §3. Local Peritonitis of very small extent - - - 160 § 4. Peritonitis terminating by extensive Suppuration - 161 § 5. Peritonitis passing into Enteritis - - - - 164 § 6. Enteritis - - - - - - - 165 Practical Conclusions from the preceding facts - 167 SECTION III. OUTLINE OF THE TREATMENT OF INTESTINAL IN- FLAMMATION ------ 168 CONTENTS. Xiu SECTION IV, Page ERYSIPELATOUS PERITONITIS......175 SECTION V. CHRONIC PERITONITIS........182 § 1. Chronic Peritonitis in its more distinct form - - 185 § 2. Chronic Peritonitis in its more obscure form - - 187 § 3. Chronic Peritonitis supervening upon Measles - 190 § 4. Chronic Peritonitis of the Colon supervening on an Injury 190 § 5. Chronic Peritonitis complicated with disease of the Omentum - - - - - - - - 191 § 6. Chronic Peritonitis with-extensive Suppuration making its way outwards by the External Oblique - - 193 PART III. OF THE INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL - - 194 Preliminary Observations on the principal Morbid Appearances of the Mucous Membrane, and their influence on the Functions of the Bowels.....195 3 XIV CONTENTS. SECTION I. Page ACTIVE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL......204 Symptoms, &c........204 Terminations.......209 1. Fatal in the Inflammatory Stage.....209 2. Gangrene........ 209 3. Ulceration.........209 4. By passing into Peritonitis or Enteritis ... 209 § 1. Inflammation of the Mucous Membrane confined to the Rectum and part of the Ascending Colon - - 210 § 2. The Disease extending along the whole course of the Colon and Rectum,—Fatal in the Inflammatory Stage 211 § 3. The Disease occupying the whole Colon and Rectum, —Fatal by Gangrene......212 § 4. The Disease occupying the whole Colon and Rectum, and part of the Ileum ------ 214 § 5. The disease in the Colon,—Fatal by Extensive Ulcer- ation with Peritonitis ......216 § 6. The Disease confined to the Caput Coli, and part of the Ascending Colon,—the Patient dying of an Affec- tion of the Brain - - - - - - 217 § 7. Fungous Ulceration of the Caput Coli, and recent In- flammation of the Ileum, with a coating of False Membrane........218 S 8. The Disease in the Ileum, with Deposition of False Membrane -.....- 219 S 9. The Disease in the Ileum,—Fatal in the state of Red Elevated Portions, with Incipient Ulceration - - 220 §10. The Disease in the Ileum,—Fatal by Gangrene - 221 §11. The Disease in the Ileum, with Ulceration,—Fatal by a perforating Ulcer and Peritonitis - £ - . 222 § 12. The Disease occurring in Continued Fever, with Ulceration........ 223 Pathological and Practical Conclusions from the Pre- ceding Observations.....224 CONTENTS. XV SECTION II. Page OF THE CHRONIC DISEASES OF THE MUCOUS MEM- BRANE .......228 General View of the Morbid Appearances in the Chron- ic Cases........228 General View of the Symptoms .... 229 § 1. 'The Disease Fatal, with elevated Red Patches without Ulceration........231 § 2. Numerous small detached Ulcers, the intervening Mem- brane healthy.......231 § 3. Extensive continued Ulceration of the Mucous Mem- brane of the Colon......233 § 4. Extensive continued Ulceration in the Small Intes- tines .........235 § 5. Ulceration of the Mucous Membrane, with Thickening and Induration of the Coats of the Intestine - 237 SECTION III. ULCERS OF THE MUCOUS MEMBRANE WITHOUT PROM- INENT SYMPTOMS.....241 § 1. An Ulcer of this class Fatal by Haemorrhage without previous Symptoms in the Bowels - - - 242 § 2. An ulcer of this class suddenly Fatal with Peritonitis "243 § 3. An ulcer of this class suddenly Fatal by Perforation of the Intestine in continued Fever - - - 244 § 4. Ulcers of this class, without any previous illness, sud- denly Fatal by Perforation of the Intestine - - 245 S 5. Ulcers of this class found connected with obscure Symp- toms of long standing.....246 XVI CONTENTS. SECTION IV. Page OF THE TREATMENT OF THE AFFECTIONS OF THE MUCOUS MEMBRANE - - - - - 248 9 1. Treatment of the Acute Affections - - - 248 § 2. -----of the Chronic affections .... 250 SECTION V. OF THE INFLAMMATION OF THE MUCOUS MEMBRANE IN INFANTS ......257 SECTION VI. CASES SHOWING THE STATE OF THE MUCOUS MEM- BRANE AFTER THE CESSATION OF THE SYMP- TOMS, THE PATIENTS DYING OF OTHER DIS- EASES - -.....- 261 Concluding Observation on the Pathology of the Mucous Membrane, with Reference to the Investigations of Con- tinental Writers on this Subject .... 265 APPENDIX TO THE PATHOLOGY OF THE INTESTINAL CANAL. SECTION I. DISEASES OF THE MESENTERIC GLANDS . . 2&J SECTION II. Disease of the Omentum - - * . . 27] SECTION III. TYMPANITES 272 CONTENTS. XVlt SECTION IV. Page ARTERIAL HAEMORRHAGE FROM THE RECTUM - 277 SECTION V. OF A VERY OBSCURE AFFECTION, IN WHICH THE SYMPTOMS ARE CHIEFLY REFERABLE TO THE BOWELS.......279 SECTION VI. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI......280 SECTION VII. EXTENSIVE DISEASE OF THE RECTUM AND PROS- TATE GLAND.—STRICTURE OF THE ARCH OF THE COLON, &c......282 SECTION VIII. EXTENSIVE DISEASE OF THE BLADDER, AND COMMU- NICATION BETWEEN IT AND THE INTESTINAL CANAL, AT THE EXTREMITY OE THE ILEUM 283 PATHOLOGY OF THE LIVER - 285 SECTION I. OF THE MORBID CONDITIONS OF THE LIVER CONNECT- ED WITH ACUTE DISEASE - - - - 287 6 1. Inflammation of the Liver - - 287 0 XV11 CONTENTS. Page § 2. The Mass of the Liver more or less Enlarged, espec- ially on the right side; externally of a very dark color, or nearly black; its substance, when cut into also very dark colored, and giving out much very dark blood. In other cases the black color is only on the surface, the internal structure being tolerably healthy.....289 § 3. Abscess of the Liver - - - - 291 § 4. Simple Ramollissement of the Liver - - 297 I 5. The black Ramollissement of the Liver - 297 \ 6. The white or Encephaloid Ramollissement of the Liver ... - - 299 $ 7. Copious Deposition of Gelatinous Matter of a soft con- sistence and a reddish color ... 300 § 8. Remarkable Distention of the Biliary Vessels - 300 SECTION II. OF THE CHRONIC AFFECTIONS OF THE LIVER - 300 § 1. Chronic Inflammation of the Liver - - 301 § 2. Simple Enlargement, without Change of Texture 302 § 3. Tubera in the Liver, without other Disease in its Structure ..... 303 § 4. The Pale Degeneration, consisting of change of Color without remarkable Alteration of Texture - 304 § 5. Pale Color, with Induration - - - 305 A. Pale Indurated Liver, of the natural size - 305 B. -----------------with Enlargement - 306 C.-----------------with Remarkable Diminution of Size ...... 307 § 6. Dark Induration of the Liver - - - 308 § 7. Tuberculated Disease on the Surface of the Liver, with- out Disease of its Structure - - - 399 § 8. Tubercular Disease of the Liver, with severe Pectoral Complaints and Ulceration of the Stomach - 311 § 9. Tubercles, or Tubera of various characters diffused CONTENTS. XIX Page through the substance of the Liver, with Disease of the intervening Structure.....312 § 10. Hydatids........314 §11. Large Cysts, containing a Watery Fluid, contained under the Peritoneal Coat of the Liver - - - 314 Outline of the Treatment of Diseases of the Liver - 315 APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. HAEMORRHAGE FROM THE LIVER - - - - - 319 SECTION II. RUPTURE OF THE LIVER BY EXTERNAL VIOLENCE - 319 SECTION III. DISEASES OF THE GALL BLADDER. 1. Biliary Calculi - -.....320 2. Perforation or Rupture of the Gall Bladder, or one of its Ducts, and Escape of the Bile into the Peritoneal Cavity........321 » SECTION IV. CHANGES IN THE GlUALITY AND GtUANTITY OF THE BILE...........*» XX CONTENTS. Page SECTION V. PATHOLOGY OF JAUNDICE.......323 PATHOLOGY OF THE SPLEEN. § 1. Inflammation - - - - - - - - 331 $ 2. Suppuration of the Spleen.....332 § 3. Ramollissement or Black Degeneration-of the Spleen 334 § 4. Simple Enlargement of the Spleen .... 336 § 5. Tubercles........339 § 6. Pale Induration of the Spleen .... 339 I 7. Hydatids........339 $ 8. Haemorrhage from the Spleen, and Laceration by Ex- ternal Violence.......340 PATHOLOGY OF THE PANCREAS. 1. Inflammation and its consequences - 342 2. Enlargement with a mixed state of Disease, partly con- sisting of Induration, and partly of a softened state, resembling the Medullary Sarcoma - - . 340 3. Scirrhus Induration, with little enlargement - . 24r 4. Calculous Concretions •-•-.. o47 PATHOLOGICAL AND PRACTICAL RESEARCHES DISEASES THE STOMACH, THE INTESTINAL CANAL, THE LIVER, AND OTHER VISCERA OF THE ABDOMEN. PATHOLOGY OF THE STOMACH AND INTESTINAL CANAL. VIEW OF THE*STRUCTURES CONCERNED IN THIS INQUIRY, AND THE PRINCIPAL MORBIB CONDITIONS TO WHICH THEY ARE LIABLE. • In entering upon the pathology of th*e stomach and intestinal canal, it will be advisable first to take a general view of the vari- ous structures which enter into the formation of these organs, and of the principal morbid conditions to which they are liable. The structures are chiefly three, namely, the peritoneal, the muscular, and the mucous coats of the canal. I. The Peritoneum is a serous membrane, which is 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 changes of structure, some of which are evi- dently the result of inflammation, while others seem to have a (lif- erent origin. The first effect of a certain low degree of inflam- matory action upon serous membranes, appears to be simply an increased deposition of the serous fluid; and, in this manner, it is probable, that a certain state of these membranes, which, if not actually inflammatory, closely borders upon it, is sometimes re- lieved ; the increased quantity of fluid being afterwards absorbed, and the parts thus recovering their healthy relations. But, in different states of the disease, we find remarkable varieties in the 28 STRUCTURES OF THE STOMACH characters of the fluid which is deposited : in one case, it is sim- ply opake and milky,—in another, it contains shreds of floccu- lent matter,—in a third, it has all the sensible properties of pus. All these varieties of the effused fluid are sometimes found without ariy remarkable change in the membrane itself; but, in general, it has undergone some sonsiderable deviation from the healthy struc- ture. These deviations are chiefly two. The first is a slightly softened and thickened state of the membrane, giving it somewhat the appearance of a part which has been boiled. This I think is commonly connected with the opake milky deposition. The sec- ond and the more common appearance consists in the surface being covered by a coating of false membrane. This may be connected with the milky flocculent fluid, or with fluid which has all the sen- sible qualities 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 disappeared will thus become a per- manent 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, whfte it is lined by a complete and uniform cyst of false membrane. We are entirely unacquainted with the causes which regulate these varieties in the deposition from inflamed serous membranes. Under the influence of inflammation, also, whether acute or chronic, serous membranes are liable to form ad- hesions betwixt their opposite surfaces, and this may consist of simple adhesion with very little appearance of any interposed sub- stance ; or there may be an interposition of false membrane, which is often of very considerable thickness. In their structure, serous membranes are liable chiefly to three morbid conditions. 1. Simple thickening. This is seen most strikingly in the peritoneum, which is sometimes found thickened i?n a most remarkable degree; and it appears to be the result of inflamma- tion which has gone on in a chronic form. 2. Tubercular disease—the whole surface of the membrane being found studded with innumerable tubercles, generally of a very small size, and of a firm consistence. They appear to be covered by cysts, and present the same characters with tubercles in other parts of the body. AND INTESTINAL CANAL. . 29 3. There is another affection, often met with in the peritoneum, which appears to be in its nature quite distinct from tubercular disease. It consists in the surface of the membrane being covered by nodules of various shapes and sizes,—of a semi-pellucid charac- ter 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 speci- mens which I have had an opportunity of examining, it appeared to be of an entirely different nature. The nodules were of a uniform firm gelatinous consistence, or even more dense at the centre than at the circumference. They did not appear to be covered by a cyst, and they were entirely soluble in boiling water. . II. The second structure is the Muscular Coat. It completely invests the whole extent of the canal; and the healthy function of the parts depends upon this muscular covering performing at all times its healthy and regular action. We know little of the diseases of muscular fibre, except in as far as relates to derangement of its functions. In a muscular covering which invests a cavity, the principal deviations from the healthy state appear to be the following. 1. A morbidly increased but uniform and harmonious action. This appears to arise chiefly from causes of irritation applied to the internal surface of such cavities. In this manner we see vom- iting produced by various irritations applied to the stomach, and diarrhoea by similar causes applied to the intestinal surface. A similar effect seems to arise from a morbid irritability of the sur- face itself, provided it be uniform over a considerable extent of the membrane; the ordinary stimuli producing in this case the same effect that the irritating causes do in the healthy state of the mem- brane. 2. A morbidly increased but partial and irregular action. This appears to arise chiefly from morbid irritability of small por- tions of the internal surface ; the ordinary stimuli producing, at these parts, a morbidly increased action, with which the other parts do not harmonize. This appears to be the state which is often expressed by the indefinite term spasm. It is seen in the urethra, and the oesophagus, in the affection which is called spasmodic stricture; and a similar condition appears to occur in the bowels, 30 STRUCTURES OF THE STOMACH particularly in certain states of dysentery, in which we find fre- quent irritation and morbid discharges from the lower part of the canal, with retention of the natural feces in the parts above. 3. Diminution or loss of muscular power. In a muscular covering investing a cavity, this appears to arise from two causes, namely, over distention and inflammation. The former we see distinctly take place in the bladder, and there is reason to believe that something similar occurs in the bowels in certain states of Ileus. Inflammation seems also to destroy the action of muscular fibre. Thus, intestine which has been highly inflamed is generally found in a slate of great distention, showing the complete loss of its healthy muscular action ; and, if the disease has gone on until the intestine has either become ruptured, or has given way by ulceration, 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 immediate effects of inflammation upon muscular fibre, there is considerable obscurity; but, one point may be con- sidered as known and established, which is of considerable impor- tance for our future inquiries, namely, that a result of inflammation in muscular fibre is gangrene. When, therefore, we find gan- grene in the intestinal canal, we have reason in general to con- clude 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 oiven 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 membrane, we have to keep in view the fol- lowing circumstances. 1. The whole surface of the membrane is constantly secretin» a mucous fluid, which is transparent, glutinous, and is said to have slightly acid properties. It appears to be formed in large quantity ■ AND INTESTINAL CANAL. 31 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 mucous sur- face, there is a distinct formation, from numerous follicles or simple glands, of a liquid which has been called the follicular fluid. These follicles exist in great numbers along the whole course of the intestinal 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 dis- tinct from the general mucous secretion,—because, in observations upon living animals, the latter may be seen to be produced from portions of the membrane, where no follicles appear to exist. The mucous and follicular fluids of the stomach, mixed with similar fluids from the oesophagus, and with saliva, are considered as forming the gastric juice. 3. There is likewise from the whole mucous surface a serous exhalation, similar in its properties, as far as is known, to the ex- halation from serous membranes. 4. The intestinal mucous membrane is also to be considered as an absorbing surface;—numerous absorbents opening from every part of it, and conveying the absorbed fluids towards the thoracic duct. These are most numerous in the small intestines. We are to attend to various forms of disease, in mucous mem- branes connected with these peculiarities of structure. These are chiefly the following. 1. Infiamation and its consequences. This appears to exist in mucous membranes in various forms, or rather 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 mu- cous membrane, 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 bron- 32 STRUCTRUES OF THE STOMACH chial membrane; it is also met with, though more rarely, in the mucous membrane of the intestine. In a more advanced stage, inflammation of the mucous intestinal membrane terminates by ramollissement, or an ash-colored pulpy degeneration of portions of the membrane ; these fall out and leave spaces, which are apt to pass into ulceration. A considerable extent ef the membrane is also occasionally found in a state of uniform dark softening, re- sembling gangrene. Adhesion of the opposite surfaces of the mu- cous membrane of the intestine is sometimes met with, producing complete obliteration of the canal; but this is very rare. A case has been related to me, in which it was found to have taken place in the parts included in a hernia. Inflammation of mucous mem- branes exists in a more chronic form, in which it goes on for a long period, and is chiefly distinguished by increased and morbid secretion from the parts. In its progress in these cases, the mem- brane is apt to become thickened and even indurated, so as consid- erably to diminish the capacity of the cavity. In this manner is formed stricture of the urethra, and similar diminution of the area of the intestinal canal. The diseased surface in those cases is fre- quently found covered with fungous elevations : and these frequent- ly alternate with portions of the membrane in a state of ulceration. The French writers have started a controversy, whether the change of structure in these cases be in the mucous membrane it- self, or in the subjacent cellular texture. It is a point which it must be next to impossible to decide, and of no practical impor- tance. 2. Diseases of the follicles, or simple glands of the membrane. This subject is involved in much obscurity, but seems to promise some interesting results. The follicles appear to be liable to a ves- icular or pustular disease, which passes into small defined dis- tuct 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 commonly met with in some par- ticular 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 al- imentary matter, so that, though elaborated in the usual manner it passes off without entering the circulation. The cause of this AND INTESTINAL CANAL. 33 most familiar to us, is disease of the glands of the mesentery; but the same effect appears to result from certain conditions of the sur- face of the mucous membrane itself. This slight outline of the varions morbid conditions, to be con- sidered in regard to the intestinal canal, will serve to show the im- portance of the subject; and the extent of it will farther appear, when we recollect, that the various diseases are also greatly mod- ified 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 anxious that what is given may be correct and authentic, as fas as it goes, and that it may be of some use in directing the researches of those who have opportunities of prosecuting the in- vestigalion. 5 PATHOLOGY OP THE STOMACH. There are few points in medical science which have under- gone more discussion than affections of the stomach; and yet, it must be confessed, that when we come to investigate the subject, according to the rules of pathological induction, we find little that is satisfactory. This has in part arisen 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 opportunities occur of investiga- ting their pathology, except when the patient dies of another dis- ease. The great proportion of these seem also to be entirely of a functional nature, leaving no morbid appearance that can be dis- covered after the death of the patient; and, in others, the appearan- ces are of so doubtful a kind, that they do not afford sufficient ground for any precise principle in pathology. In a practical point of view, also, this is perhaps more encumbered with uncertainty than almost any other department of medical practice; for the diseases are so much under the influence of moral and other adventi- tious causes, that the action of remedies is aided, modified, or coun- teracted, in a manner which entirely eludes our observation, and is often altogether beyond our control. From these various causes, diseases of the stomach have presented a wide field for specula- tion, conjecture, and empiricism ; a vague and indefinite phraseol- ogy has often been allowed to take the place of principles; and the whole subject is removed in some measure out of the usual limits of pathological inquiry. Amid this uncertainty we must en- deavor to discover what is truth; and/should this prove to be more 36 INFLAMMATORY AFFECTIONS limited than a slight view of the subject might lead us to -expect, something will at least be done by ascertaining its extent, and trac- ing 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 ulceration and its consequences. II. Affections which more properly come under the class of organic. III. Functional affections,—embracing a slight outline of the subject of dyspepsia. In an appendix, I shall briefly allude to the affections of the oesophagus—and the duodenum—and to derangement of the func- tions of the stomach by tumors attached to it externally. SECTION I. OF THE INFLAMMATORY AFFECTIONS OF THE STOMACH AND ULCERATION. Acute gastritis is a disease described by all systematic writers, but in the records of pathology it is very difficult to find a pure example of it in an idiopathic form. I have been often very much astonished to find, in my own observation, how seldom the stomach shows marks of inflammation, even when the organs most nearly connected with it have been inflamed in the highest deo-ree. In cases of very extensive peritonitis, the peritodeal coat of the stom- ach is sometimes affected; but even this is rare, and a case of pure inflammation of this membrane I have never seen, and do not find described by any writer. Dr. Armstrong, in the first fascicu- lus of his work on the morbid anatomy of the stomach and bowels, gives a plate representing inflammatory deposition on the periton- eal coat of the stomach ; but no account is given of the case from which it was taken, so that it does not appear whether it was an example of pure idiopathic gastritis, or whether the appearance occurred in connection with.more general peritonitis. OF THE STOMACH. 37 The disease which we call gastritis is to be considered, there- fore, as seated chiefly or entirely in the mucous membrane, and even here- it is extremely rare as an acute and idiopathic disease. It is from the action of the acrid poisons that we chiefly find in- flammation of the mucous coat of the stomach, but we cannot consider these cases as necessarily exhibiting the same symp- toms which would accompany the disease in its idiopathic form. The symptoms which are usually described as those of gastritis are pain and tenderness in the region of the stomach, with urgent vomiting and fever; but, in as far as we have facts on which we can proceed with confidence, it does not appear that the symptoms are so uniform as systematic writers would lead us to believe. A man mentioned by Haller, having swallowed a large quantity of very cold water when he was much heated, was seized with acute pain in the stomach and fever, and died delirious in fifteen days,— no other symptoms being mentioned. The stomach was found to contain a fetid ichorous matter; and the fundus of it was inflamed with gangrenous spots and ulcerations. In another case, by the same writer, which was complicated with disease of the lungs, the chief symptoms were, pain and oppression of the breast, with per- petual hiccup and difficult degultition. The stomach is said to have been everywhere inflamed, with effusion of blood into its cel- lular texture. In a case by Morgagni, the principal symptoms were anxiety and sense of fullness in the stomach, with frequent vomiting of a brown matter, in which were floating shreds of a membranous appearance; and these symptoms were followed by hiccup, delirium, and convulsion. A young man mentioned by Storck complained chiefly of a burning uneasiness in the abdo- men, with hiccup and intense thirst; and a man mentioned by Lieutaud had intense fever, and violent pain in the stomach, with urgent vomiting, distention of the epigastrium and difficult breath- ing. 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 ulcera- tion is mentioned; and the cases described by Broussais appear to be equally unsatisfactory. On the other hand, we find De Haen, Stohl and Frank describ- ing cases of what they term inflammation and gangrene of the stomach, in which none of the usual symptoms of gastritis had oc- curred ; and other cases which had exhibited all the symptoms of 38 INFLAMMATORY AFFECTIONS gastritis, while no appearance of inflammation could be discovered on dissection. The last mentioned writer farther admits, that symp- toms, closely resembling those ascribed to gastritis, frequently sub- side 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. Yeloly 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 mucus 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 consist- ing of mere change of color or increased vascularity, without some decided change in the structure of the part, or some of the actual results of inflammation ; and, upon the whole view of the subject, the conclusion seems to be, that we are still very much in the dark in regard to idiopathic acute gastritis. For my own part, I have never seen a case which I could consider as being of this na- ture ; and lam disposed to regard as points not yet ascertained, what are the characters exhibited by the mucous membrane of the stomach in the earlier periods of acute gastritis, and in what they differ from appearances which may exist without any symptoms of gastric disease, or take place after death. If we might proceed in any degree upon the analogy of the corresponding affection in the mucuous membrane of the bowels, L should be inclined to suppose that the disease exists under two forms ;—that in the one, it is seated chiefly in the follicles or simple glands, in the other, in the mucous membrane itself;—that, in the former case, it would consist, in its early stage, of detached and minute pustules or vesicles, and would terminate at an early period in minute and detached ulcers •__and that, in the other, it would exhibit in its first stage, the appearance of defined portions of the mucous membrane of a red or livid-brown color, and sensibly elevated above the level of the surrounding parts—these portions afterwards terminating by softening or ulcer- ation, or passing into a chronic stafe of disease with ulceration, thickening, or fungoid elevations upon the diseased parts. This is in some measure conjectural, but I think we may safely assert, that, in this investigation, nothing can be founded upon a mere gen- OF THE STOMACH. 39 ral or extensive redness of the membrane, discoloration, or in- creased vascularity,—whether more or less extensive,—venous turgescence, extravasation of blood into the cellular texture, or upon any appearance which consists of mere change of color, without any decided change in the structure of the part. In a case men- tioned by Mr. Annesley, in his late work on the diseases of India, which was fatal in seven days, the mucous membrane of the stom- ach was found covered with small defined ulcers, discharging a thin sanious fluid. The symptoms were incessant vomiting and hiccup, with fever of a tertian type, without any complaint of pain. In another case, by the same writer, there was at first acute pain in the stomach, increased by pressure, with very slight fever, and no vomiting. On the fourth day vomiting began, and he died on the seventh. The coats of the stomach in this case appeared to be thickened, hut 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 practical importance, in regard to which we have numerous interesting facts on which we can proceed with confidence. We have every reason to believe, that the mucous membrane of the stomach is liable to inflammation in a chronic form, which often advances so slowly and insidiously, that the dangerous nature of it may be overlooked, until it has passed into ulceration, or has even assumed the characters of organic and hopeless disease. Farther, we shall find, that even ulceration may exist in the stomach without producing any symp- toms 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 derange- ment of the functions of the stomach, and are apt to be included under the general term dyspepsia. The patient perhaps complains of extreme acidity, eructations,^ flatulence, and oppression of the stomach after eating. There is' generally some degree of pain in the region of the stomach, but it varies very much both in its de- gree and its duration. In many cases, it is complained of only after eating, continues in considerable severity while the process of digestion is going on, and subsides when that process is com- pleted. The appetite is often unimpaired, but the patient is afraid of taking food on account of the uneasiness which is produced by it, and he is entirely free from complaint when the stomach is empty. A frequent expression of such patients is, 'I should be 40 INFLAMMATORY AFFECTIONS quite well, if I could do without eating.' In other cases, there is more permanent uneasiness, which is aggravated by taking food ; and sometimes there is pain in the back at the part corresponding to the seat of the stomach. In other cases, again, there is no actual pain, but the uneasiness is described as a feeling of heat, or a great degree of pyrosis. The tongue is, in some cases, little altered from the healthy appearance; but in others, it shows a peculiar rawness and tenderness, and occasionally minute* ulcers may be observed on its edges. Vomiting is apt to occur, but in the early stages is only occasional, and is ascribed to some error in diet, or other accidental cause. Afterwards it becomes more frequent, but still without that regularity which would seem to indicate serious disease; by attention to diet it maybe, in a great measure, pre- vented, and in this manner the disease may go on for months without exciting alarm. The vomiting then, perhaps, becomes more frequent, and the uneasiness in the stomach more permanent, until the patient either sinks by gradual wasting, or is suddenly cut off by one of those rapid attacks to be afterwards particularly described. In all the forms of this insidious disease there is great diversity in the symptoms. In some cases, there is little or no vomiting, the prominent symptoms being pain excited by taking food, with gradual wasting, and, as the disease advances, a feeling as if the stomach were incapable of holding any thing beyond the smallest possible quantity. In other cases, there is chiefly a con- stant and most painful feeling 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 vomiting, and with scarcely any symptom except the uneasiness which is produced, by eating, and which subsides entirely in a few hours after a meal. This most interesting modifi- cation of the disease will be strikingly illustrated 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, mentioned by Andral, this discharge amounted to about four pints in twenty-four hours; and she never vomited either food or drink. Sometimes this discharge is streaked with a black matter, or is entirely of the color of chocolate, and not unfrequently is mixed with grumous blood. OF THE STOMACH. 41 The disease which i3 going on during the course of symptoms now described, consists of chronic inflammation of the mucous membrane of the stomach, which in many cases appears to com- mence 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 neighboring parts and ulceration. The result which we have occasion to attend to most frequently as the immediate cause of urgent symytoms, is ulceration of the inner surface of the stomach; and we shall find that it exists in various forms, the most important of which, in a practical point of view, are the following:— 1. A small defined ulcer of limited extent, with evident 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 disease, which after all may be found to have been of no great extent. In the cases of this first class, there is no general disease of the coats of the stomach, the ulcer being confined entirely to the mucous membrane, or per. haps to the follicles. 2. Ulcers like the former, of small extent, perhaps the size of a shilling, but complicated with thickening and induration of the parietes of the stomach, perhaps to the extent of a crown piece or more around the ulcer, all the rest of the stomach being perfectly healthy. 3. Extensive irregular ulceration of the inner surface of the stomach, generally complicated with thickening and induration of the coats, and fungoid elevations. In some cases there is no actual ulceration,—the prominent morbid appearance being a thickened state of the mucous mem- brane to a greater or less extent. The thickened portion in this case may be of a pale ash color, or of a brown color, or of a dark color with the characters of melanosis; and .these appearances may be farther complicated with thickening and induration of all the coats of the stomach at the part affected, and perhaps adhesion 6 42 INFLAMMATORY AFFECTIONS to some of the neighboring organs. In other cases again portions of the mucous membrane have been found softened or entirely destroyed. In the progress and termination of this disease, there is con- siderable variety: the most important modifications in a practical point of view may be thus stated. 1. The disease may be fatal by gradual exhaustion after pro- tracted suffering. In these cases we find either a succession of small 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 neighboring parts; and this is frequently complicated with disease of other organs, as the liver, the pancreas, or the omentum. In some cases of this class we find the thickened and fungoid disease of the mucous membrane, or thickening and induration of a 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 ha?matemesis, 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 giving rise to exten- sive peritonitis, which is fatal in a period of from eighteen to thirty- six hours. In cases of this class we find on inspection two impor- tant modifications of the morbid appearances. In the one, the simple ulceration seems to have advanced gradually through the coats, without any other disease, until the complete perforation took place. In the other, there is much thickening at the part • the ulcer seems to have perforated the thickened substance, and to have cicatrized at the edges, leaving a round defined cavity with smooth sides and edges, and the bottom of it formed merely by the peritoneal covering of the part. From the smooth appearance of the edges of the cavity which is 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 away. This remarkable modification of the disease will be illustrated by Cases IX. and X. The same symp- toms arise from a similar affection occurring in the duodenum. FATAL BY GRADUAL EXHAUSTION. 43 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 neighboring parts most commonly the liver, in such a manner that a portion of the surface of the liver supplies the place of the portion of the stomach that has been destroyed, and thus no escape of the con- tents takes place. This remarkable circumstance will be found exemplified in Case VIII. which was afterwards fatal by a small perforation immediately adjoining the portion where this adhesion had been formed. Another important modification arises from adhesion of the stotnach to the arch of the colon, and a communi- cation being formed between them by the ulceration. This will be found illustrated, with very remarkable symptoms in Case XI. In some examples of adhesion of the stomach to the neighboring parts, it will be found that it has taken place to various organs, and perhaps also to the parietes of the abdomen,—showing that inflammatory action had existed in the coats of the stomach at various places and probably at different times, until one of the attacks had terminated in the fatal ulceration. This had probably occurred in Cases III. and VI. In other cases, again, we find a dense and thick mass of a tubercular character deposited betwixt the adhering surfaces, as was very remarkable in Case XI. The principal modifications of this important class of diseases will be illustrated by the following selection of Cases. In the arrangement of them I shall not study minute pathological accu- racy, which is in fact unattainable; but shalladescribe them in the manner which seems best calculated for practical utility. § JT—Succession of small ulcers of the mucous membrane of the stomach, fatal by gradual exhaustion. Case I.—A gentleman, aged 50, had been many years in the West Indies, where he had enjoyed good health; but, after his return to Scotland, he began to have various dyspeptic complaints, which were supposed to be connected with an affection of his liver. 44 ULCERATION OF THE STOMACH These complaints began about two years before hie death, but never assumed any serious aspect till the winter 1823—4, when he was confined to trie house, and his general health became consider- ably impaired. He now complained of pain in the region of the stomach, which was not constant, but occurred at irregular inter- vals, and was sometimes dull and sometimes acute. He had vom- iting, 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 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 beginning 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 vom- iting 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 detected on the most careful examination. He died about a week after this, without any change in the symptoms, except that for a day or two before death he was a little incoherent and slightly lethargic. Inspection.—The stomach was large and distended with air, but externally healthy. On laying it open, there were observed about the middle of the small curvature two or three small round ulcers, not more than an eighth of an inch in diameter, with in- flamed margins, but without any appearance of thickening of the parts. Higher up towards the cardia, there were.numerous white or ash-colored spots, of various sizes, like the marks of small-pox. They were much smoother than the surrounding membrane, and of a much lighter color; and there was every reason for considering them as the cicatrices of small ulcers. They were numerous along the cardiac portion of the stomach, were all smooth and cicatrized, except the two or three spots with inflamed edges already men- FATAL BY GRADUAL EXHAUSTION. 45 tioned, which were in a state of actual ulceration. The disease seemed to be entirely seated in the inner membrane, without any thickening of the coats, and there was no other appearance of dis- ease in any part of the stomach. The liver seemed smaller than natural, but was quite healthy. 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. § H.—Circumscribed ulceration with thickening, fatal by gradual .exhaustion. Case II.—A woman, aged 45, had long complained of her stomach, but without any uniformity in the symptoms. She had occasional pain, with sense of oppression at the stomach; her ap- petite was variable, and she sometimes vomited, but at long and irregular intervals. For some months she had been sensibly fall- ing 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 un- easiness in the abdomen. She was first seen by Dr. Begbie, about a fortnight after the commencement of these symptoms, when she complained of a fixed pain across the region of the stomach, where a considerable hardness was felt. She was much wasted,—had a 46 ULCERATION OF THE STOMACH small, quick pulse, and frequent vomiting; and, without any other change in the symptoms, she died exhausted in about six weeks. Inspection.—In the small curvature of the stomach, the coats were thickened and indurated, so as to form a hard mass about three inches long and two broad, and about three-fourths of an inch in thickness at the thickest part. When cut through, this portion presented a uniform white structure of almost cartilaginous hard- ness, except the internal surface of it, which was in a state of white, soft, fungous ulceration. The stomach was in other respects en- tirely healthy. The mucous membrane of the intestines presented many spots, which were of a dark red color and highly vascular, but without any change of structure. Case III.—A lady, aged 50, had been for many years affected with dyspeptic complaints, and about eight years before her death, was first attacked with copious discharge of dark grumous blood both from the stomach and bowels. She soon recovered from this, and enjoyed tolerable health, though with constant dyspeptic symp- toms, until 1826: she then had much pain in the stomach, constant feeling of acidity, and frequent vomiting of tough ropy mucus of a brown color. She recovered from this attack after three or four months, but the stomach continued to be easily disordered; she was liable to vomiting of sour matter, and there was occasional discharge of grumous blood both by vomiting and by stool. Soon after this, she 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 remarkable degree ; but from this time, she continued liable to pain and distention of the stomach and bowels, and vomiting of acid matter; and occasionally she vomited considerable quantities of the tough brown mucus ■ she was now much reduced in flesh and strength, but for the last six or eight weeks of her life a remarkable change took place in the symptoms. There was little or no uneasiness in the epigastric region, even on very firm pressure, and scarcely any remains of the tumour could be perceived. Her food was relished and re- tained, and the bowels were natural; but she became progressively more and more emaciated, Avithout suffering, and died in April, 1828. FATAL BY GRADUAL EXHAUSTION. 47 Inspection.—The stomach was drawn up into the left -hypo- chondriac region, and adhered in several places by loose mem- braneous bands to the parietes of the abdomen, to the spleen, and to the left lobe of the liver. The spleen was not above one-sixth of its usual size. The stomach when laid open presented a circu- lar 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 indurations like small glands. The pancreas was enlarged, and felt throughout of scirrhous hardness. Opposite to, and connected with, the ulcerated part of the stomach, the blood vessels of the omentum were very numerous, turgid, and more matted together than usual; and this appearance occupied the space where the tumour had been felt in the course of the disease. The coats of the stomach were considerably thickened at the place of the ulceration, and for a small space around it; the other parts of it were healthy. These cases will serve to illustrate some of the varieties and" the changes of symptoms which occur in this formidable disease, and the insidious manner in which it is apt to advance with symp- toms which are liable to be considered as merely dyspeptic. Other remarkable varieties occur both in the symptoms and in the mor- bid appearances of which it is impossible to give any general state- ment. A woman mentioned by Chardel had dyspeptic complaints, with pain in the stomach and back, and occasional vomiting. Solids only were vomited, and by great attention to diet, she suf- fered little inconvenience for several months. The vomiting then became more frequent; at length it occurred daily, and several times in the day. She then wasted, and died gradually exhausted about eight months from the commencement of the disease, and between two or three months from the time when the daily vomi- ting began. The stomach was found adhering to the liver, the spleen and the pancreas; along the great arch it was considerably thickened, and internally ulcerated and beset with granulations; there was ulceration also about the cardia. A man mentioned by the same writer had for five months vomiting after meals, and died by gradual wasting, without any other symptom: nothing could be felt in the region of the stomach on the most careful ex- amination. After death, the stomach was found adhering intimate- ly to the concave surface of the liver f&nd an ulcer at this place 48 ULCERATION OF THE STOMACH had perforated the stomach, and penetrated a considerable way into the substance of the liver; there was also ulceration in the neigh- borhood of the cardia. A man mentioned by Pinel had great acidity of the stomach, and other dyspeptic symptoms, with occa- sional attacks of acute pain;—afterwards vomiting and gradual wasting; and a tumour 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 gathered up into a mass under the great arch of the stomach. The mucous membrane of the stomach was much destroyed, and there was an ulcer three inches in length near the pylorus. A different course of symptoms occurs in a case related by Frank. A man, aged 50, was seized, after violent exertion, with copious vomiting of blood, followed by discharge of blood by stool: these symptoms continued several weeks, and then ceased. He then had dyspeptic symptoms, with debility and emaciation; his appetite was good; but he had great uneasiness after eating; and some tenderness was felt in the right hypochondrium, with difficul- ty of lying on the right side. He became gradually more and more emaciated, and had some 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 was a very large ulcer which perforated the stomach, and penetrated into the substance of the liver. § III.—Extensive ulceration, with thickening, complicated with remarka ble diseases of the omentum and peritoneum ;—fatal by gradual exhaustion. Case IV.—A gentleman, aged 53, consulted me in autumn, 1825, on account of pain in the region of the stomach, which at- tacked him only after dinner. It usually continued an hour or two, and frequently extended considerably upwards alono- the thorax on both sides. He'was cupped in the epigastric region, FATAL BY GRADUAL EXHAUSTION. 49 was put upon a carefully regulated diet, with the use of the oxide of bismuth ; and, after a short time, he got into very good health, and so continued through the following winter. In summer 1826, he frequently complained of his stomach, without any regularity in the symptoms: but in the following winter, the affection returned with the same violence as before. 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 Edin- burgh, in the beginning of June, 1827. He had then his usual look of good health, but the pain continued undiminished, so that he could only take the mildest kinds of food, and in very small quantity, without severe suffering for some time after. No organ- ic disease could be discovered, and no particular tenderness in the epigastric region. He had never had any vomiting; his pulse was natural; and his bowels, though rather slow, were easily reg- ulated. After the usual treatment for a day or two, he left town on particular business, with the promise of returning in a very few days ; but he did not return for a 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 as formerly of acute pain, but had a feeling of intolerable 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 quantity distended it in an intolerable manner. A variety of treatment was now employed without relief, and he died about the 25th of July. For some weeks before his death, a small tubercular mass was felt in the abdomen a little way to the right of the umbilicus. There was no other appearance of organic disease. His pulse had continued calm and regular to the last. He vomited a few times, but to no extent, and his bowels were easily regulated through the whole course of the disease. Inspection.—There was a considerable quantity of fluid in the 7 50 ULCERATION OF THE STOMACH abdomen. The peritoneum lining the cavity was through its whole extent remarkably thickened, very firm, and uniformly cov- ered with small miliary tubercles ; and the same appearance ex- tended 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 omentum presented a large mass of a tubercular structure, of nearly cartilaginous hardness, about four inches in extent, and in some places about an inch in thickness. The right extremity of this mass had formed an adhesion to the par- ietes of the abdomen, and it was at this spot that the hardness had been felt for a few weeks before death. The diseased omentum also adhered so intimately to the contracted and thickened stomach, that they seemed to be blended into one mass. It likewise adhered to the arch of the colon, but this was not otherwise diseased. The duodenum from its very commencement was entirely healthy; but among the other small intestines there were some slight adhesions. The liver was rather pale, and seemed diminished in size, but upon the whole was very slightly diseased. I have been particular in the description of this case, because it would be difficult to find one calculated to show in a more strik- ing manner the insidious nature of this affection, and the extent of disease which may be going on with such symptoms only as, up to a very advanced period, might have been considered merely indi- cating a high degree of dyspepsia. The important characters 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 until a vejy 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 Char- del had dyspepsia and acute pain after eating, which subsided after the process of digestion was completed. By restricting himself to very mild food in small quantities he felt little uneasiness; but after some time, without any change in the symptoms, he lost strength so much that he was confined to bed. His appetite continued but he was afraid to satisfy it; he had very little nausea, and did not vomit above two or three times during his illness which contin- FATAL BY HEMORRHAGE. 51 ued many months. On inspection there was found thickening of the coats of the stomach at the upper part, without ulceration, and enlargement of the lymphatic glands in the neighborhood of the stomach. A man mentioned by the same writer had pain in the right 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 stomach was found adhering both to the diaphragm and the colon. At the place of adhesion to the diaphragm, a portion of the stomach was entirely destroyed by ulceration, and, by means of the adhesion, a por- tion 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 fre- quent. The stomach adhered to the liver and the pancreas; the mucous membrane was irregularly destroyed and ulcerated; and at the place of adhesion to the liver the parietes were perforated by the ulceration. The pyloric extremity was considerably thickened, and the omentum was thickened and indurated. § IV.— Ulcer of the stomach fatal by haemorrhage. Case V.—A gentleman, aged about 40, had been long dys- peptic, and liable to pain in his stomach, which had not assumed any fixed or regular character; but he required great care in re- spect of his diet, and many articles were apt to disagree with him. He was otherwise in good health, and applying himself actively to business till Saturday, 5th November 1825, when he was suddenly seized in his counting-house with a feeling of extreme faintness. He was assisted with difficulty to his dwelling-house, which was in the neighborhood, and soon after vomited a large quantity of black fluid resembling ink. On Sunday he 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. 52 SIMPLE ULCERATION OF THE STOMACH On Tuesday he still felt very unwell, but without any marked symptom. On Wednesday he was seized with pain in the stomach, followed by vomiting of pure blood to the amount of several pounds. This was followed by extreme faintness and coldness, and the vom- iting of blood returned in the afternoon, I now saw him for the first time along with Dr. Robert Hamilton, and found him extreme- ly pale and exhausted, his skin cold, and his pulse very feeble. He complained of nothing but great faintness: but every attempt to rally him proved ineffectual, and he died in the night, having been again seized, sometime before his death, with violent pain in the stomach. Inspection.—The stomach was of immense size, but showed no appearance of disease in its structure, except at a part in the small arch about half way between the cardia and pylorus. Here a round defined portion about the size of a half-crown piece was much.indurated and abouthalf an inch in thickness. On the inner surface of this portion, tlvere was a small defined ulcer about half an inch in diameter, and more than a quarter of an inch in depth, andthe bottom of it was occupied by a firm fungous mass of a dark brown color. No other disease could be detected in any organ. Case VI.—A woman, aged 45, had been for several years lia- ble to attacks of pain in the stomach, which at first passed off in a short time ; but they gradually became more severe, and of long- er continuance, until at length they continued for several weeks at a time, and were little affected by any remedies. I saw her in sev- eral of these attacks during the last eighteen months of her life. While affected by them, she complained of acute pain in the epigas- tric region, chiefly referred to a particular spot of very small ex- tent; 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 be- fore her death, after having been for several months free from any uneasiness, she was exposed to cold by getting her feet wet, and almost immediately complained of uneasiness at the stomach. At first it was slight, with loss of appetite, but after several days it became more severe with some vomiting; there was no fever, and nothing could be discovered by examination. The pain was chiefly referred to a small spot in the epigastric region, rather to FATAL BY PERFORATION. 53 the left side; and no symptom occurred different from those in her former attacks, until, after eight or ten days, she was sudden- ly seized with copious vomiting of blood. This occurred re- peatedly ; and she died rather suddenly about a week from the first occurrence of it, and about three weeks from the commence- ment of the attack. Inspection.—The.stomach had contracted an adhesion of small extent to the left lobe of the liver, and another of greater extent, and very firm, to the pancreas. At both these places, the coats of «he stomach, were diseased, but in the greatest degree at the adhe- sion to the pancreas. Here they were much thickened and indu- rated, for a space about three inches long, and two inches broad ; and the internal surface of this portion was entirely in a state of ulceration. There were also on this ulcerated surface several points which penetrated more deeply, and some of these contained coagulated blood, giving every 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 viscera 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 per- fect health. There seems every reason to believe that the parox- ysms had been connected with inflammatory action, confined to a circumscribed portion of the mucous membrane of the stomach, subsiding from time to time, and leavingthe part in a comparatively healthy state; but that, under these successive attacks, the parietes had become gradually thickened at the part, until the last attack ter- minated by ulceration, and this by the fatal haemorrhage. ^ V.__Simple ulceration of very small extent, suddenly fatal by perforation of the stomach. Case VII.—A young woman, aged 18, had been affected, for about six months, with variable appetite, and occasional pain in the stomach, which made her frequently sit with her body bent for- ward, and her hand pressed upon the epigastric region. Little no- tice was taken of the attacks, as she was going about, and other- wise in good health, and for some weeks previous to the attack now to be described, her appetite had greatly improved. On 54 SIMPLE ULCERATION OF THE STOMACH the 26th November 1824, while in a room by herself late in the evening, she was heard to scream violently ; and when a person went into the room, she was found unable to express her feelings, except by violently pressing her hand against the pit of the stomach. When she was soon after seen by Mr. M'Culloch, she was moan- ing 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 appearance of e* treme suffering, and unable to speak, till seven o'clock in the morn- ing of the 27th, when she said the pain was considerably easier, but was still very severe in the pit of the stomach, and was extend- ing downwards over the abdomen. The abdomen was now becom- ing distended, and when I saw her about three o'clock in the after- noon, it was distended to the greatest degree and very tense. The pulse was extremely feeble ; she was scarcely able to speak, but her countenance was expressive of extreme suffering. Nothing afforded the smallest relief, and she died about two in the morning, 29 hours from the attack. Inspection.—The cavity of the peritoneum was distended with air, and likewise contained upwards of eight pounds of fluid of a whitish color, and fetid smell. There was slight but extensive in- flammatory deposition on the surface of the intestines, producing adhesions to each other, and to the parietes of the abdomen. In the upper part of the small curvature of the stomach near the car- dia, there was a small perforation of a size which admitted the point of the little finger. Internally this opening communicated with an ulcerated space on the mucous membrane, about the size of a shilling, with slightly thickened and hardened edges, and a considerable perpendicular loss of substance. The stomach in all other respects was entirely healthy. Case VIII.—A gentleman, aged about 60,—in the year 1825, had for a considerable time suffered from complaints in his stom- ach. He had occasional pain, but it was not severe; his more prominent symptoms were an intense feeling of Pyrosis, and occa- sional vomiting. He was often obliged to leave the table suddenly during meals from attacks of this kind, in which he chiefly brought up small quantities of an extremely acrid fluid. He became much FATAL BY PERFORATION. 55 emaciated, and had every appearance of extensive organic disease, though none could be discovered on examination. He required to be kept upon the most cautiously regulated diet; and after contin- uing for some months in a state from which he was not expected to recover, he gradually got into his former good health, and his stomach entirely recovered its healthy functions. He had at vari- ous times, however, slight threatenings of his former symptoms, 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 distressing feeling of Pyrosis, impaired appetite, and occa- sional vomitting. On account of these symptoms he was keeping the house, though able to attend to the affairs of an extensive busi- ness, until Saturday evening, 3d February 1827, when he was sud- denly seized with excruciating pain in the pit of the stomach, ac- companied by some vomiting, coldness of the body, and a small fre- quent 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; the whole abdomen became distended and tender, with sink- ing of the vital powers, and he died on Sunday night, about 30 hours after the attack- • Inspection.—On the posterior surface of the stomach near the Pyloric extremity, there was a space rather larger than a shilling, where the substance of the stomach was entirely 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 usual marks of ex- tensive but recent peritonitis. Except the two spots now referred to, the stomach was perfectly healthy. These examples will be sufficient to illustrate this most formi- dable modification of the disease. Many others are on record, in some of which the previous symptoms were very slight and ob- scure. A young lady, aged 15, mentioned by Dr. Carmichael 56 SIMPLE ULCERATION OF THE STOMACH Smith, had for many months complained occasionally of pain in the stomach : but it was so slight, that no attention was paid to it, until one evening she was seized with violent pain and vomiting, and died in 24 hours, with symptoms of peritoneal inflammation. In the anterior part of the stomach there was a round ulcer no larger than a sixpence, with hard callous edges, and some thick- ening 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 me- moir, ' Des Perforations Spontanees de 1'Estomac' In some of these there had been previously chronic vomiting, and other symp- toms indicating disease in the stomach ;• but in others the previous symptoms were slight and obscure ; and some had enjoyed tolera- bly good health. The fatal attack and the morbid appearances corresponded with the cases now described ; and death took place in periods of from 12 to 24 hours. Several cases of the same kind are described by Dr. Crampton and Mr. Traverse, in the Medico- Chirugical Transactions. In a lady mentioned in the Journ. Gen. de Medicine for August, 1821, .the attack commenced with severe pain in the epigastric region, extending towards the left kidney, and accompanied by cold shivering, dyspnoea, and prostration of strength. These symptoms subsided, but returned in the same manner every day, after taking food, for four days, leaving her in the intervals free from complaint. On the fifth day it returned, but did not subside, and was fatal in 20 hours. In the anterior part of the stomach there was a perforating ulcer nine lines in diameter, and surrounded by a margin of slight inflammation. There was peritoneal inflammation, with effusion of a brown fluid, mixed with portions of food. The kidneys were healthy. To these observations, may be added, the remarkable case of Admiral Wassenaer, mentioned by Boerhaave, who died suddenly in the act of vomiting, or rather of attempting to vomit, soon after he had dined. The lower part of the oesophagus had given way at the seat of an ulcer, and the food and drink Avhich he had taken at dinner were found in the cavity of the thorax. A similar case is related in the first volume of the Arch. Gen. de Medicine. A man who had for six months suffered severely from his stomach especially after eating, was seized with violent vomiting, which SUDDENLY FATAL. 57 continued three days. He was then seized with palsy, and in four days more died comatose. Effusion was found in the brain. The oesophagus had given way a little above the cardia, by a rent an inch and a half long, and much fluid had been discharged into the right cavity of the pleura. § VI.—Old ulceration with thickening—the ulcer cicatrized on its inner surface, with loss of substance, leaving a 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 50, had been for several years in bad state of health; her principal complaints were referred to the region of the uterus, and the os uteri was felt to be hardened. She was also liable to pain in the stomach, capricious appetite, and oc- casional vomiting; but these complaints had not been so severe or regular as to attract much attention, until she was suddenly seized with most violent pain, referred to a small spot in the epigastric region, accompanied by vomiting, and followed by pain and tension of the whole abdomen: and she died in eighteen hours. Inspection.—The stomach was healthy on its whole anterior aspect. On the posterior part, there was a portion about three inches in extent, which was much indurated, and about half an inch in thickness at the centre. In the middle of this portion, there was a round excavation about one-third of an inch in diame- ter, 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 respects was healthy. The neck of the uterus was scirrhous. In all the examples now described, there had been some symp- toms indicating more or less disease in the stomach; but in the following remarkable case, for which I am indebted to the late Dr. Kellie, there had been no complaint of any kind previously to the attack, which was fatal in eighteen hours. Case X.—A strong and healthy looking servant girl, aged about 21, while engaged at her work between seven and eight 8 58 PERFORATING ULCER OF THE STOMACH AND o'clock in the morning, of one of the last days of September, 1827, was suddenly seized with excruciating pain in the abdomen, sick- ness, and vomiting. 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 medicine, which did not operate ; but there was no alleviation of the symptoms. The belly became tense, tender, 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 ap- pearance of the liquids she had swallowed. There was extensive peritoneal inflammation, with a coating on the bowels of puriform matter. In the middle of the smaller curvature of the stomach, there was a round opening about one-third of an inch in diameter. At the part where it was situated, the coats of the stomach were in some places nearly half an inch in thickness, and the thickening extended in a greater or less degree over a portion five or six inches 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 cicatrized. It was fully half an inch in diameter, and a third of an inch or more in depth, having pene- trated 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 complain of her stomach, or to show the smallest deviation from most robust health; and the only farther information that Dr. Kellie could obtain in regard to her was, that she had had fever in the spring. y VII>—Perforating ulcer of the stomach, and communication with the arch of the colon. Case XI.—A gentleman, aged 56, who had previously enjoyed good health, except occasional dyspeptic complaints, began to feel languid, with impaired appetite, some loss of flesh, and occasional pain in the abdomen; but he was able to go about and attend to all COMMUNICATION WITH ARCH QF THE COLON. 59 his engagements, which were extensive and fatiguing. These symptoms had continued two or three weeks, when one day, while walking in the street, he was seized with vomiting, and the matter vomited had the odor and appearance of feces. He felt no farther inconvenience till about a week after, when he was again seized in the same 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 appetite. His bowels were easily reg- ulated, and no appearance of organic disease could be detected. Dr. Combe was disposed to doubt his account of the feculent vom- iting, 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 vom- iting returned 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 con- sistent 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 al- ways 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 gradu- ally exhausted, without 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 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 pylorus and whole pyloric extremity were healthy. In the centre of the ulcerated part there was a ragged, irregular opening fully two inches in diameter, which made a free 60 EXTENSIVE ULCERATION OF THE STOMACH communication with the arch of the colon ; and, around the open- ing, 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 feculent matter, and the colon throughout contained healthy well formed feces. y VIII.—Extensive ulceration of the stomach of a cancerous character. I conclude this part of the subject with the following remarka- ble case, which I do not attempt to refer to any class. It is per- haps one of the most extraordinary examples on record of destruc- tion 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 weakness and a con- stant uneasiness across the region of the stomach, with occasional attacks of acute pain towards the left side. In May 1812, she be- gan to have vomiting, which continued from that time, and became 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 hardness was felt; and she vomited a portion of everything she took, sometimes immediately after taking it, and sometimes a considerable time after. She continued with little change till the beginning of September, when the vomiting subsi- ded, and she was free from it for more than a fortnight. But dur- ing this time she was affected with diarrhoea ; her strength sunk, and she died on the 23d,—the vomiting having returned, thouo-h with less severity, three or four days before death. During the pe- riod 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 stom- ach, a large irregular opening presented itself, which was found to lead into the cavity of the stomach, in consequence of a large ex- tent of its great arch being entirely destroyed. In the left side there was a large irregular mass, which appeared to consist of an OF A CANCEROUS CHARACTER. 61 enlarged and diseased spleen and the remains of the great arch of the stomach, so blended into one mass, that it was impossible to distinguish one part from another ; in the substance of it there was a cyst full of very fetid matter. This mass was attached to the cardia by a narrow portion, which remained of the coats of the stomach at that place ; and when the parts were taken out and dis- played, 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 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. 1 he left side and the lower part of the great arch of the stomach were entirely wanting to such an extent, that, when the parts were extended in the 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 dis- eased 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 ul- cerated edge, where the separation 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 vis- cera were healthy. Various instances are on record of the true melanosis of the stomach, but I have not thought it necessary to detail examples of it, as they do not present phenomena remarkably different from the affections which have been described. The affected portion of the stomach is generally much thickened, and, on its internal surface, ulcerated. In its structure it presents various degrees of consist- ency, but the whole is more or less deeply tinged with that pecu- liar black matter from which it has derived its name. The symp- toms do not differ from those of the other cases of organic disease of the stomach with ulceration, except that the matters vomited arc often deeply tinged with the dark melanotic discharge from the ulcerated surface. 62 DIAGNOSIS AND TREATMENT DIAGNOSIS AND TREATMENT OF THE AFFECTIONS OF THE STOM- ACH REFERRED TO UNDER THE PRECEEDING HEADS. From the facts which have been related, we have every reason to conclude, that the dangerous affection referred to in the pre- ceding observations exists in two conditions; namely, chronic in- flammation of a defined portion of the mucous membrane of the stomach, or the mucous follicles,—and the termination of this by ulceration. In both these conditions, it may probably be the sub- ject of medical treatment; for we have reason to believe, that the inflammation may be arrested and prevented from passing into ul- ceration, and that the ulceration may heal before it has become con- nected with any permanent change in the organization of the part. Hence appears the importance of minutely watching the progress of the disease in its early stages, in which only it is likely to be treated with success. The difficulty here is in the diagnosis, —the disease often assuming the character of a mere dyspeptic affec- tion through a great p°.rt ofhs progress; while, in fact, a morbid condition of a very serious nature is going on, which would re- quire treatment in many respects very different from that adapted to dyspepsia. The disease may be suspected, when there is pain in the stom- ach 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 far- ther suspected, if the pain continues severe until the patient is re- lieved 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 sometimes indicated by vomiting occurring occasionally, without any regular periods, and with very little pain. In the ca- ses will be seen other important varieties in the symptoms, which are of great interest in a practical point of view, particularly the in- tense and peculiar feeling of pyrosis mentioned in Case VIII. When this feeling occurs with great intensity after food of all sorts, taken even in the most moderate quantities, we have reason to suspect disease of the mucous membrane of the stomach. The feeling appears to be in some cases connected with the formation of an acrid fluid, which we often see brought up in considerable OF CHRONIC GASTRITIS. 63 quantities ; and in others, seems to depend merely upon the mor- bid condition of the mucous membrane itself, in consequence of which, ordinary articles produce that peculiar feeling of irritation, which in the sound state of the parts is produced by matters of an acrid quality. It is common to hear such patients say, that atten- tion to diet makes little difference in their feelings, but that every- thing turn immediately to intense acidity, even a bit of meat or a glass of cold water. The disease may be also suspected, when, along with any of the above mentioned symptoms, though in a mild and obscure form, the patient is becoming weakened and emacia- ted in a manner which a mere dyspeptic affection could not account for. The affection, again, is sometimes accompanied and charac- terized by a raw and tender state of the tongue and throat; and in some cases, with minute ulcers; and in others, with the formation of slight aphthous crusts. One gentleman lately stated to me that hiscdmplaint began with minute ulcers and a burning sensation on the tongue, and that he afterwards distinctly felt the same state of disease extending gradually along the oesophagus, and at last into the stomach. Amid such a diversity of symptoms as occur in connection with this disease, our chief reliance in the diagnosis must probably be on a careful examination of the region of the stomach itself, with the view of discovering the existence of tenderness referred to a particular part. This examination should be made with the most minute attention, at various times, both when the stomach is full and when it is empty. If induration be discovered, the character of the case will be obvious; but we have seen, that most extensive ulceration may exist without any induration; and likewise, that extensive induration may exist without being discovered by exter- nal examination. Other important cautions in regard to the diagnosis will be learned from the cases which have been described. In particular, we should not be deceived, either by the pain having remarkable remissions and the patient enjoying long intervals of perfect health, or by remarkable alleviation of the symptoms taking place under a careful regulation of diet; for these circumstances we have found occurring in a very striking manner, while the disease was mak- ing progress to its fatal termination. ° When the disease is detected at an early period, the treatment must consist chiefly of free and repeated topical bleeding, followed 64 DIAGNOSIS AND TREATMENT by blistering, issues, or the tartar 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 absti- nence from all stimulating liquors; and it would appear to be of much consequence to guard against any degree of distention of the stomach, that can possibly be avoided even by the mildest articles. The patient should abstain in a great measure from bodily exer- tions, and hence the importance of endeavoring to distinguish the disease from mere dyspepsia, as the regimen and exercise which are proper and necessary in a dyspeptic case, would in this case be highly injurious. In the early stages, little probably is gained by medicine given internally, beyond what is required for the regulation of the bowels. In the more advanced stages, or when there is reason to suspect that the disease has passed into ulceration, the same observations will apply in regard to external applications and regimen; and benefit may now be obtained by some internal 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 frequently 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 instances in which I suspected this disease to be going on, I have found remarkable benefit from the sulphate of iron. Dr. Maiden recommends borax, in doses of from ten grains to half a dram, taken in solution three or four times a day, as of great efficacy in cases of this class: he sometimes combines with each dose, one or two drops of laudanum* Whether the disease can be cured, after it has advanced to ulceration, must indeed remain in some degree a matter of doubt; because, in a case which has terminated favorably, we have no means of ascertaining with certainty that ulceration had existed. In some of the cases, how- ever, which have been described, we have seen every reason to believe that some of the ulcers had cicatrized, though the disease had afterwards gone on to a fatal termination ; and from what we observe in the intestinal canal, we can have little doubt that simple ulceration of the mucous membrane may cicatrize. I am satisfied ♦ Midland Medical and Surgical Reporter, May, 1829. OF CHRONIC GASTRITIS. 65 that I have seen the cicatrices 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 referable to the affection which has been the subject of the pre- ceding observations. In a practical point of view it is of some im- portance. Case XIII.—A lady, aged about 30, came to Edinburgh from a distant part of the kingdom in summer, 1818. She was affected with violent pain in the stomach, which seized her every day im- mediately after dinner, continued with great violence through the whole evening, and gradually subsided about midnight; it some- times occurred after breakfast, but more rarely. The complaint was of two year's standing, during which time a great variety of practice and every variety of diet had been tried, but with very slight and transient benefit The paroxysms 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 reo-ion no hardness could be discovered, but there was considerable tenderness on pressure at a particular spot. Various remedies were employed during the summer with little advantage ; at last, however, she appeared to derive some benefit from lime water, and returned home in the autumn rather better. But the affection soon recurred, and she returned to Edinburgh in 1819 as bad as ever. After another trial of various remedies, this severe; and intractable affection subsided entirely under the use of the very simple reme- dy to which I have above referred. She took two grains of the sulphate of iron three times a day, combined with five grains of the aromatic powder and one grain of aloes, which was found suf- ficient 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 at- tention to diet, both as to quality and quantity, is of essential and indispensable importance. The farinaceous articles and milk are those which seem in general to agree best; and some cases have 9 G6 DIAGNOSIS AND TREATMENT, &C. 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 char- acter 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 labored 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 smallest quantity of food was taken in, with great tender- ness upon pressure, and constant vomiting, which occurred regu- larly about the same period after eating, at which it usually takes place in affections of the pylorus. A variety of treatment had been employed without benefit, when Dr. Barlow determined upon trusting entirely to regimen, by restricting her to a diet consisting wholly of fresh-made uncompressed curd, of which she Was to take but a table-spoonful at a time, and to repeat it as often as she found it advisable. On this article she subsisted for several mouths, and recovered perfect health. An inflammatory affection of the mucous membrane of the stomach of a peculiar kind, is frequently met with in practice, in conjunction with a general inflammatory condition of the whole course of the mucous membrane from the pharynx downwards. I think it sometimes occurs as an idiopathic disease, but I have gen- erally observed it taking place at an advanced period of other dis- eases,—as simple fever, or any of the inflammatory affections, as pneumonia. There is a peculiar 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 aph- thous crusts; and, in some cases, the whole pharynx presents one continued dense crust of an aphthous character. There is gener- ally tenderness on pressure in the epigastric region, with uneasi- ness in swallowing along the whole course of the cesophao-us, 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 vomitin^ DIPTHERITE.* 67 and diarrhoea. I have not seen the affection fatal, when the origi- nal disease had been removed; but I have seen it assume a very alarming character, with a very rapid pTilse, and extreme exhaus- tion. The remedy which I have generally found most useful is lime water, or equal parts of it and a strong decoction of quassia. Small opiates are required, with very mild articles of food; and, when there is much sinking, wine or brandy, mixed with arrow root. The following case will illustrate the affection. Case XV.—A woman, aged 30, and previously healthy, after some continuance of a febrile disorder, with very mild symptoms, became affected with pain and tenderness in the epigastric region, extending over the abdomen. The mildest articles of food pro- duced great pain; there was diarrhoea, with much griping, and fre- quent vomiting. The affection was accompanied 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 some- times fatal to infants, seems to be allied to this diseased condition of the mucous membranes; and it is often found to be connected with minute ulcers of the mucous membrane of the intestine. A similar condition occurs in advanced stages of phthisis, and is often the prelude to the. colliquative diarrhoea. It is likewise found af- fecting the mouth and throat, accompanied by tenderness along the oesophagus and in the stomach, where there is no affection in the bowels. Another modification of disease in the mucous membrane of these parts, is that to which the French have given the name of Diphtherite. It does not appear to be a common affection in this country ; but I have had opportunities of seeing it at various times, particularly in summer 1826, when it was frequent and fatal in Edinburgh. It is an epidemic chiefly affecting children. The first symptom is a deep redness of the tonsils or velum, without swelling or ulceration; but with the formation of aphthous crusts, which are generally of a pure white color. When these crusts either are removed, or drop off spontaneously, the membrane be- 68 D1PHTHER1TE. neath is seen to be deeply red without breach of surface, and the crust is reproduced in a few hours. We find usually excoriation, or very minute ulcers along the inner membrane of the cheeks and lips, and a painful excoriation of the membrane of the nose,—often sponginess and bleeding of the gums; and, in some cases, the whole mouth becomes inflamed in a manner resembling the effects of mercury. There is in general little fever, but great prostration of strength, and often a diseased state of the whole system, in which blistered parts run to gangrene, and even the slightest scratch is apt to assume an ulcerative action, with some vesication, and in- flammation of the neighboring lymphatics. The disease is in some cases a slight affection, confined to the fauces ; but in others, it evidently extends along the oesophagus and to the stomach, pro- ducing tenderness of the epigastrium and vomiting; and in a few cases there was diarrhoea, with excoriation about the anus. 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 epi- demic of 1826, 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 previ- ously 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 consider- able quantities; and benefit seemed to be obtained from the free use of the vegetable and mineral acids; careful regulation of the bowels, without strong purging; very free ventilation, and fre- quent sponging of the body with tepid vinegar and water. When there was much affection ofthe stomach, the bismuth appeared to be useful, or lime water, with small opiates. Gently stimulating or acid gargles were in some cases beneficial. Dr. Hamilton rec- ommends 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 affect- ed, 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. DIPHTHEfUTE. 69 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 Muqueux.' 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 mem- brane of the fauces and oesophagus, which may go no farther, or may extend, in one case to the stomach, in another to the'larynx. It is distinguished from the cynanche maligna, and the sore throat of scarlatina, by the absence of ulceration ; and it is evidently an affection quite distinct from the idiopathic inflammation of the mem- brane of the larynx and trachea, to which we commonly apply the name of croup. The distinction is of much practical importance ; for when, either in this disease or in the cynanche maligna, the in- flammation 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 active inflammation, in which, by early and decided treatment, we have the fairest prospect of being able to arrest its progress. Dr. Cheyne has described a remarkable affection, in some re- spects very similar to that now mentioned, which was fatal to four individuals in one family, all adults. The symptoms were aphthae covering the pharynx, tenderness of the epigastrium, and untracta- ble vomiting of a fluid the color of verdigris. The body was ex- amined in one of the cases only. The veins on the internal sur- face of the stomach were remarkably turgid : the mucous mem- brane, particularly at the great extremity, was of a dark mahogany color, which appeared to be owing to vascular distention and gen- eral extravasation into the submucous tissue. The mucous mem- brane of the oesophagus was of a deep red color, and highly vas- cular.* ' 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, indi- ♦ Dublin Hospital Reports, Vol. IV. 70 RAMOLLISSEMENT eating extensive disease of that organ ; or even when the patient had died of another disease, without any symptoms referable to the stomach. This appearance has been ascribed by Hunter and oth- ers to solution of the substance of the stomachby the gastric juice; but it must be confessed that this doctrine seems extremely ques- tionable ; for, were the gastric juice capable of producing such an effect, the appearance ought to be of much more frequent occur- rence. This curious subject has been carefully and ably investi- gated by Dr. Gairdner, in the first volume of the Med. Chirurgical Transactions of Edinburgh. In his cases, the appearance oc- curred in children, and was preceded by obscure symptoms, indi- cating general febrile disturbance, usually accompanied by some symptoms referable to the stomach and bowels, as vomiting or di- arrhoea. On the other hand, the appearance 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 instances the great arch of the stomach dissolved to a great extent and perforated, es- pecially 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 gelati- nous or pulpy regeneration of the substance of the stomach. Part of the softened portion commonly has fallen out, leaving an open- ing which is surrounded by the parts in a thin state, and partially softened, but in general without any appearance of increased vas- cularity. The perforation is in some cases very large ; in others, there are four or five perforations, separated by narrow portions in a partially softened state; and, frequently, there is no actual per- foration, but merely a considerable extent of the stomach much soft- ened, which tears upon the slightest touch. For various interest- ing details in regard to it, I refer to Dr. Gairdner's Essay. Upon the whole, the conclusion, in regard to this singular af- fection, seems to be, that it takes place after death; that it has been OF THE STOMACH. 71 in some cases preceded by disease of the stomach ; but that, in oth- ers there has been no ground for believing the existence of any such disease. It is certainly not an appearance on which any patholog- ical principle can be founded, in regard to previous disease; and this is a point of the utmost consequence, especially in reference to the judicial examination of bodies in cases of suspected poisoning. For a variety of most important matter on this subject, I refer to the valuable work on Poisons, lately published by Dr. Christison. Some experiments of Professor -Autenrieth and Dr. Camerer, seem to render it probable, that in the affections of children, in which this softening of the stomach is chiefly observed, the gastric juice acquires a peculiar acrimony, which enables it to dissolve the parts after death, though it is incapable of acting upon the living stomach. Dr. Fels, again, and other German writers, consider the affection as a peculiar disease of infancy, which they describe at great length under the name of Gastromalaxia. From a full view of the subject, however, the truth seems to be, that it is not to be considered as a peculiar and distinct disease, but as a peculiar state of the parts which may occur in various diseases, and, as was al- ready stated, may take place without any previous disease. The affections of children, in connection with which it had been chiefly observed, are principally febrile diseases, accompanied with diar- rhoea and vomiting. ^ Nearly the same observations seem to apply to the ramollisse- ment of the mucous membrane of the stomach, on which much at- tention has been bestowed by some of the French writers, particu- ' larly in a very interesting memoir by M. Louis.* This appear- ance consists in portions of the mucous membrane being found in a soft state like semi-transparent mucus, 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 complained sometime before death of pain and heat in the epigastric region, with loss of appetite, nausea, and occasional 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 func- tions 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 * Louis' Memoires et Recherches Anatomico-pathologiques. 72 ORGANIC DISEASES OF THB STOMACH. this ramollissement of the mucous membrane existing where there had been no symptom referred to the stomach. Upon the whole, there seems reason to doubt whether this is to be considered as an appearance on which can be founded any principle in pathology. SECTION II. OF ORGANIC DISEASES OF THE STOMACH. Many of the cases referred to under the former section, might properly have come under the head of organic disease, from the thickening of the coats of the stomach, and other permanent chan- ges in the structure of the parts; but, in most or all of them, the ulceration of the mucous coat appeared to have been the primary disease. In this section I shall refer to some affections more purely organic; and, as they are seldom the objects of medical treatment, I shall mention them very briefly under the following heads: I. Induration and thickening of the Coats of the Stomach. II. Chronic Peritonitis of the Stomach, with disease of the Omentum and the Pancreas. III. Diseases of the Pylorus. IV. Disease of the Cardia. ^ I.—Induration and thickening of the coats of the stomach. Case XVI.—A woman, aged 56, (August, 1816.) had been liable, for about a year, to disorders of the stomach, consisting chiefly of distention, acidity, and occasional attacks of acute pain. After several months from the commencement of these symptoms, she began to be affected with vomiting; and, for three or four last months, had vomited daily, generally in the afternoon or evening, at irregular periods after dinner. Sometimes she escaped it till she went to bed ; but then it always came on early in the night. A hard tumor of considerable extent could be felt in the epigastrium. CHRONIC PERITONITIS OF THE STOMACH, &£C. 73 She died in September, in a state of extreme emaciation, having, before death, discharged much blood, both by vomiting and by stool. Inspection.—The stomach adhered to all the neighboring parts, so that it was with difficulty separated from them. The cardia and pylorus were healthy, and also a small portion of the stomach adjoining to each of these openings. The Avhole of the smaller curvature, except these two portions, presented one con- tinued mass of scirrhus hardness, in general, about an inch in thickness ; and, when cut into, white and very firm. On the inner surface of this portion, about its centre, there were two tumors, the one the size of a pigeon's egg, and the other of a hazel nut. Externally they were of a dark purple color, internally white. The large curvature and the anterior part of the stomach were extensively ulcerated, dark colored, and of very irregular thick- ness ; and at one place, there was a perforation the size of a shil- ling. 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 appearance of a mass of tubercular disease: frequently, a considerable part is of a soft texture resembling the substance of the brain, and this sometimes forms a mass of tumors projecting internally. In a case by Pinel, a large abscess had formed in the substance of the diseased mass, and had burst into the cavity of the stomach. A large tumor in this case had been felt in the epi- gastric region, had been gradually increasing, and suddenly disap- peared during a fit of coughing, a considerable time before the death of the patient. ^ Jl__Chronic peritonitis of the stomach, with disease of the omen- tum and the pancreas. Case XVII.—A gentleman, aged about 60, a year before his death, began to complain of pain, which was referred chiefly to the right side of the abdomen, with some tenderness on pressure and a confined state of the bowels. There were also frequent griping pains referred to various parts of the abdomen ; and extending 10 74 DISEASES OF THE PYLORUS. with much severity to the back,—the pulse was natural. He de- rived temporary benefit from the usual means; but the complaints were not removed. After several months, he began to lose flesh and strength; and a hard defined tumor was discovered between the umbilicus and the region of the stomach, which was somewhat painful on pressure. His appetite became much impaired, but he never had any vomiting; his bowels became irregular, being some- times confined and sometimes loose. Dropsical swellings at length took place, and he died in March 1825, after a violent attack of pain in the abdomen, accompanied with yellowness of the skin, which continued two days. Inspection.—The stomach adhered extensively and closely to the liver, the colon, the pancreas, and all the other adjoining parts. The pancreas was much enlarged and hard, and when cut into, discharged a milky fluid. The omentum was drawn up, and formed a firm fleshy mass attached to the stomach. There were slight adhesions of the intestines to each other. The substance of the liver was healthy. $ III.—Diseases of the Pylorus. In a pathological point of view, there are some facts relating to the diseases of the pylorus, which are worthy of being recorded, though they can seldom become the objects of medical treatment. Disease of the pylorus may begin in a slight and insidious manner, like a mere dyspeptic affection, and gradually exhibit its more confirmed characters ; or, it may come on in a more rapid manner, with acute symptoms resembling an inflammatory attack. In its advanced state, it is generally distinguished by periodical vomiting, occurring at certain regular intervals after meals, gener- ally with fixed uneasiness in the region of the stomach; and we can commonly discover, on examination, more or less induration in the region of the pylorus. But we find remarkable deviations from these, which we are apt to consider as the established charac- ters of the disease. The cases which I shall here introduce are in- tended to illustrate some of these deviations, by showing extensive disease of the pylorus, existing with remarkable remissions in the symptoms, and considerable intervals of good health,—without any vomiting,—and without any induration that could be discovered on examination. DISEASES OF THE PYLORUS. 75 Case XVIII.—A gentlemen, aged 30, had been for several years liable to paroxysms of pain in the stomach, which usually continued for several hours, and went off with vomiting. . They returned at uncertain intervals, frequently of many weeks; and, upon several occasions, he seemed to have got entirely free from the disorder. He was in other respects in tolerable health, until about a year before his death, when he was suddenly seized with copious vomiting of blood. From this time, his attacks of pain in the stomach became more frequent, and he had repeated attacks of the vomiting of blood; but still he had considerable intervals of health; no hardness could be discovered by examination; and that uniformity of symptoms was entirely wanting which usually ac- companies organic disease. After having complained for two days of pain in the stomach in the usual form, he was found in the morn- ing of the third day exhausted and without pulse, and died in a few hours: but he was not emaciated ; and, three days before his death, he had been able to walk out a good deal, and made no particular complaint. Dissection.—The pylorus was surrounded by a mass of scirr- hus, the size of an orange, very firm, or nearly cartilaginous. The stomach in other respects was entirely healthy, as were also the liver, the spleen, and the pancreas. There were considerable ad- hesions among the intestines ; and there was slight ossification of the valves on the right side of the heart. Case XIX.—A man, aged 40, came under my care in Decem- ber, 1817. He was weakened and emaciated to the last degree, with a weak pulse at 120, but without any other complaint; he had no pain, and no cough, his appetite was good, his bowels were nat- ural, and the functions of the stomach were entirely healthy. About half way between the ensiform cartilage and the umbilicus, a hardness was felt which could be traced for several inches, and was painful upon pressure. He had been ill eighteen months, and the affection had commenced with vomiting, which occurred gener- ally five or six times a day. This continued for five or six months, when the vomiting ceased entirely ; and for the last twelve months, he had no complaint, except progressive debility and emaciation. He died completely exhausted in the beginning of February, hav- ing continued without any other symptom than repeated attacks of violent pain in the abdomen. 76 DISEASES OF THE PYLORUS. Inspection.—A mass of scirrhus, four or five inches in diame- ter, surrounded the pylorus ; and the pyloric orifice was so nar- rowed,, as scarcely to admit the point of a very small finger. The inner part of the mass opened upon the internal surface of the stomach, by an ulcerated space covered with large cancerous look- ing tubercles. The other parts of the stomach were tolerably sound, and the other viscera were healthy. Case XX.—A gentleman, aged 66, came under my care only a few weeks before his death. He was then emaciated in an ex- treme degree, with an exhausted, withered look. He had been long in bad health, but particularly for the last four months, during which period he had been affected with frequent 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 extreme uneasiness which took place in his stomach ; and, accordingly, by putting him upon a regulated diet, it appeared that he could in a great measure prevent it. His debility and ema- ciation, 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. Inspection.—The pylorus was surrounded by a mass of scirr- hus, the size of a small apple ; and the internal part of it projected into the cavity of the stomach, in the form of numerous hard papilla?. 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 orifice was not much contract- ed, as it admitted the point of the thumb. The stomach was in other respects sound, and the other viscera were healthy. These cases show disease of the pylorus existing with remark- able deviations from the more common characters of the affection ; but they are not in these respects 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 pulsa- ting tumor was felt corresponding with the pulsation of the heart. It was most troublesome when his stomach was full, but his appe- tite was good, and the functions of his stomach were unimpaired. He became gradually exhausted, and died without any other symp- tom, except diarrhoea and oedema of the legs. The tumor was DISEASES OF THE PYLORUS. 77 found to be an enormous mass of scirrhus, 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 ex- hausted with diarrhoea and ascites. On dissection, there was found scirrhus of the pylorus and of the pancreas ; and the latter com- pressed the ductus communis.. In another case, complicated with enlargememt of the liver, the patient died, gradually exhausted by violent pain in the epigastrium, without vomiting. A mass of scirrhus three inches in length occupied the pylorus, and extended along the small curvature of the stomach. It does not appear that these varieties in the symptoms depend upon the degree of contraction of the pyloric orifice; for, in Case XX. there was little contraction; and in a case by Chardel, there did not appear any contraction at all, though a large mass of scirr- hus surrounded the pylorus. In this case, there had been frequent vomiting, with violent attacks of pain. In Case XIX. on the other hand, there was great contraction of the orifice; and in a case men- tioned in the ' Journal de Medicine,' for October, 1815, the pyloric orifice was nearly closed, though the patient had died of gradual emaciation, and there had been no vomiting until three days before - death. We have seen that there may be extensive disease of the pylo- rus 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 XX. But besides this, the disease may be of so small extent as not possibly to be detected in this manner, while it is capable of producing the usual symptoms m their most violent form. In a case by Dr. Morrison,* the pylorus was almost totally obstructed by small tubercles arising from its internal sur- face, without any external disease. The patient died, after several years'illness, with pain of the stomach and vomiting; and in a case by Charpel with the same symptoms, the pyloric orifice was reduced to a very small chink, but with very little external en- largement; consequently nothing had been discovered during life, though the patient was very much emaciated. * Med. Ob. and Enq. vol. vi. 78 DISEASE OF THE CARDIA. § IV.—Disease of the Cardia. Case XXI.—A man, aged 38, consulted me in summer, 1815, on account of difficulty in swallowing. The articles swallowed seemed to lodge at a spot to which he pointed, (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 re- jected^ He died gradually exhausted in November. 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 XXII.-—A man, aged 60, had been liable for many months to difficulty in swallowing, which had at various times been better or worse, and sometimes entirely removed for a week at a time: but he was now emaciated to a great degree. By the probang an obstruction was felt about the middle of the oesophagus ; and under treatment directed to this in the usual manner, he seemed to improve considerably in swallowing. But his strength continued to sink, and he died after a few weeks. Inspection.—There was a slight contraction about the middle of the oesophagus, two inches in extent, without any thickening of its coats. The cardiac orifice was compressed by a tumor the size of a walnut, situated on the outside of the oesophagus, or rather Confined under its external membranous covering, without any oth- er disease of the parts. PATHOLOGY OF DYSPEPSIA. 79 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 pul- taceous 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 lim- ited when the quantity is large, being then in a great measure con- fined 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 intesti- nal canal, by a certain consecutive muscular action, which is called its vermicular or peristaltic motion. In 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 excremen- titious 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 stomach. It is evident that it bears an im- portant 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 stomach now referred to. In healthy digestion, it appears that no gas is generated in the stomach, but that a certain quantity ' is evolved in the farther progress of the alimentary matters through the intestines, especially in the colon ; and it is said to be composed of carbonic acid, hydrogen, and azot, in various proportions. When these actions are in any respect deranged or deficient, the alimentary matters are not converted in the regular manner into healthy chyme; but, remaining perhaps longer in the stomach 80 DYSPEPSIA. than, in the healthy state of the process, they would do, they under- go 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 various kinds, and the lodgment in the stomach of matters imperfectly digested, partly fermented, perhaps partly putrid; hence, also, irregular muscular contrac- tions, arising from the morbid stimuli thus produced, giving rise to regurgitations of matter into the oesophagus, eructations, and per- haps vomiting; or, the muscular coat yielding to the distending force of the evolved gaseous fluids, there are produced painful dis- tention, oppression, and anxiety, or in other words, a paroxysm of dyspepsia. For the healthy condition of the process of digestion, in all its stages, the following circumstances appear to be necessary : 1. A healthy state of the muscular action of the stomach. 2. A healthy, consecutive, and harmonious action of the mus- cular coat of the intestinal canal. 3. A healthy state of the fluids of the stomach, both as to qual- ity and quantity. 4. A healthy state as to quality and quantity of the other fluids, derived from the liver, pancreas, and intestinal 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 dis- coveries of modern physiology; but nothing of a practical nature has hitherto been deduced from it. In the preceding part of this treatise, we have seen these func- tions 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 neighboring parts. Upon the strict princi- ples of pathology, it is extremely difficult to ascertain the exact na- ture 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. * DYSPEPSIA—CAUSES. 81 1. We have much reason to believe, that the muscular action of the stomach may be deficient, so that the alimentary matters re- main in it too long, are imperfectly changed, and pass into chemical decompositions. 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 emptied by the catheter, it does not contract equally, as in the healthy state, but falls flat like an empty bag. A state analogous to this we not unfrequently see in the stomach on dissection, a state in which it appears much en- larged, and collapsed by flattening, without healthy contraction. 2. There may be a deficiency of the corresponding and har- monious and 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 quantities, in a morbidly tenacious state, quite different from the healthy ap- pearance of the fluids of the stomach ; and we have reason to be- lieve, that similar changes may take place in the other fluids con- cerned in digestion, particularly the bile. 4. If the mucous membrane be morbidly irritable, the muscular coat will probably be too easily excited to action, and a different state of things will arise. If this occur in the stomach, the articles will not be allowed to remain in it a sufficient time for healthy di- gestion ; but, after producing much uneasiness, they will-either be rejected by vomiting, or propelled in a half-digested state into the in- testine, there to prove a source of new irritation. This is probably the state to be afterwards more particularly referred to, in which an- imal food produces much uneasiness in the stomach, often followed by vomiting; but in which digestion goes on in a healthy manner on a regimen restricted to farinaceous articles and milk. If the irritability occur in the intestine, the articles may undergo their proper change in the stomach, but will be propelled too rapidly through the intestinal canal, without time being afforded for the complete process of healthy chylification ; and, accordingly, in many affections of the stomach and bowels, we see articles, even 11 82 DYSPEPSIA--TREATMENT. of the most digestible kind, pass through partially digested, or sometimes entirely unchanged. I have no intention of entering at any length upon the treat- ment of indigestion; but there are a few obvious and important rules, which, upon the strict grounds of pathology, may be deduced from the points which have been briefly referred to. I. It appears that the muscular action of the stomach is both more vigorous and more extensive when its contents are in small quantity, than when it is much distended; and, if we 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 indispensible impor- tance 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 treatment 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 various de- grees 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 articles which are of difficult solution, but also to avoid mixing various articles which are of different degrees of sol- ubility. Attention to this rule will probably favor in a great meas- ure 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 arti- cles of more difficult solution, appear to be fatty substances, tendi- nous 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 supposed, that the solubility of animal food is in the order of pork, mutton, veal, beef. Articles in small peices are much more speedily dissolved than in larger, the action being found to begin at the circumfer- ence of the portion ; and hence the importance of careful mastica- tion. III. If digestion go on more slowly and more imperfectly than in the healthy state, another important rule will be, not to take in DYSPEPSIA—TREATMENT. 83 additional food until time has been given for the solution of the for- mer. If the healthy period be four or five hours, the dyspeptic should probably allow six or seven. The injurious infringement 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 im- portance in the treatment of dyspepsia than any means whatever. I believe that every stomach, not actually impaired by organic dis- ease, will perform its functipns if it receive reasonable attention ; and when we consider the manner in which diet is generally conducted, both in regard to quantity, and to the variety of articles of food and drink which are mixed up into one heterogeneous mass, Instead of being astonished at the prevalence of indigestion, our wonder must rather be, that in such circumstances, any stomach is capable of digesting at all. In the regulation of diet, much cer- tainly 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 de- pends upon the quantity ; and I am even disposed to say, that the dyspeptic might be almost independent of any attention to the qual- ity of his diet, if he rigidly observed the necessary restrictions in regard to the quantity. It is often, indeed, remarkable, how arti- cles 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 vege- table diet. The following case occurred to me some time ago, in which this experiment was made in the most complete and satisfac- tory manner. A gentleman, accustomed to moderate but very comfortable liv- ing, had been for many years what is called a martyr to stomach complaints, seldom a day passing in which he did not suffer greatly from pain in his stomach, with flatulence, acidity, and the usual train of dyspeptic symptoms ; and in particular, he could not taste a bit of vegetable, without suffering from it severely. He had gone on in this manner for years, when he was seized with com- plaints in his head, threatening appoplexy, which, after being re- lieved by the usual means, showed such a constant tendency to re- 84 DYSPEPSIA--TREATMENT. cur, that it has been necessary ever since, to restrict him to a diet almost entirely of vegetables, and in very moderate quantity. Un- der 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 neveT been known to complain of his stomach. In the regulation of the diet for all affections of the stomach, however, strict attention must always be paid to the nature and source of the disease. Animal food is in general the most digesti- ble, but there are many cases which depend upon an irritable state of the mucous membrane, in which the diet found to be beneficial or even necessary, is one restricted to farinaceous articles and milk. The higher degrees of this affection, in which the disease amounts to inflammation of the mucous membrane, have already been referred to; but there appear to be modifications of it, which, without assuming this formidable character, have a similar effect on the functions of the stomach, and require a similar treatment, es- pecially in regard to diet. The subject is one of great interest, and opens a most important field of observation to him who, re- nouncing a mere empirical treatment of dyspeptic affections, shall direct his attention to the important varieties in the nature and source of the disease. Such a person will be astonished to find the improvement 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 animal diet, with wine or brandy and water, and the usual round of Stomachic remedies. Other cases again agree better with animal diet in very small quantity, and the mod- erate use of stimulating liquors. The diagnosis is often difficult, and must be guided more by the judgment and attention of the prac-. titioner, than by any general rule. This subject has been well il- lustrated by Dr. James Johnson, in his treatise on Morbid Irritabil- ity of the Stomach. In the medical treatment of dyspeptic complaints, it is impossi- ble to advance any thing new. One thing, however, has always appeared to me to be of the utmost importance in regard to the reg- ulation of the bowels, which in general are habitually slow. It con- sists in regulating them by the daily use of very small doses of lax- atives combined with tonics, so as, without ever purging, to imitate at all times that moderate but regular action, which constitutes the DYSPEPSIA—TREATMENT. 85 most healthy state of the bowels. For this purpose various combi- nations will be found to answer : such as Columbo powder with carbonate of potass and a few grains of rhubarb, taken once or twice a day; sulphate of iron with aloes ; sulphate of quinine with aloes or rhubarb, and a few grains of ginger; oxide of bismuth with rhubarb or aloes, &c. Lime water is often useful, and the mineral acids. The nitric acid, in particular, is often 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 stimulants, and by active purging; and I must also ex- press my apprehension that no small injury is done by the indis- criminate use of mercury. There are indeed some affections of the stomach, probably connected with derangements of the liver, in which a very cautious use of mercury appears to be beneficial; but in many others, it is decidedly hurtful; and 1 conceive that in all disorders of the stomach, mercury in any form or in any quantity ought not to be employed, when the desired effect can be accom- plished 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 illustra- ted in a striking manner by cases to be afterwards described. In concluding this slight outline of the pathology of the stom- ach, it may be right to add a few observations on some points which frequently become objects of attention in the treatment of diseases in this organ. 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 affection. 1. Pain occurring when the stomach is empty, and rather re- lieved by taking food. This probably depends upon some degree of acrimony of the fluids of the stomach itself, and is generally re- lieved by absorbent and alkaline remedies. 2. Pain occurring immediately after taking food, and continu- ing either during the whole process of digestion, 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 preceeding observations. 86 GASTRODYNIA. 3. Pain beginning from two to four hours after a meal, and con- tinuing for some hours. This is probably seated in the duodenum, and connected with inflammatory 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 hypochon- drium, and, on that account, is apt to be mistaken for disease of the liver. In the course of the paroxysm, the pain is apt to extend ob- liquely downwards and backwards in the direction of the right kidney, and thence again inwards towards the umbilicus. The duodenum evidently bears an important part in the function of di- gestion, and is probably the seat of some affections which are apt to be mistaken for diseases of the stomach and liver. Facts are wanting upon this subject, but the investigation promises important results. All that we can say at present is, that, if the disease be chiefly or entirely seated in the duodenum, the patient will be com- paritively well for two or three hours after a meal; and that his uneasy sensations will then commence, and will in the first instance be chiefly seated in the right side. Much confusion has arisen from the prevailing fashion of ascribing all such affections to disease of the liver. It is difficult to say what remedies are best adapted to each of these forms of gastrodynia. I have found nothing of more gener- al 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 affection proves more obstin- ate, it must be treated by topical bleeding and blistering, with farin- aceous diet. 4. Pain in the stomach takes place in a fourth form occurring at uncertain intervals, in most violent paroxysms; accompanied generally by a feeling of distension, much anxiety, and extreme restlessness ; and, in females, it is frequently combined with hyster- ical symptoms. This form seems to depend upon over distention of the stomach, and is relieved by carminatives; but it is often very severe and untractable. I think the most effectual relief, in gener- al, is obtained from exciting a brisk action of the bowels, by means of a strong injection. From the facility with which such affections often yield to this remedy, it is probable that the uneasiness is sometimes seated in the arch of the colon. External stimulants, CHRONIC VOMITING. 87 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 par- oxysms, 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 to be treated by topical bleeding and blis- tering, if it do not soon give way. There is also a violent affection of the stomach, occurring chiefly in females of an irritable habit, and assuming a spasmodic or neuralgic character. It seems in general to be relieved by opiates combined with absorbents or al- kalies. 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 in- flammation 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, attention to regi- men is, of course, of the utmost consequence. On this head it is impossible to lay down any general rules, as the diet must be reg- ulated by attention to the nature and character of the case. One rule is applicable to all of them, namely, that the food ought always to be in the smallest quantity. In regard to quality, there is great diversity. Some of the cases agree best with farinaceous diet and milk, while in others, the pain is aggravated by articles of this kind ; and the patient goes on most comfortably upon animal food in small quantities, with bread, or a little rice. For a variety of interesting facts on this subject, I refer to a work by M. Barras, ' Sur les Gastralgies et les Enteralgies.' It is directed against the prevailing doctrine of the French school, by which all affections of this class are referred to the ' gastro-enterite chronique ;' and shows in a satisfactory manner the evils which arise from the in- discriminate 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 88 CHRONIC VOMITING AND PYROSIS. to be connected with a morbid irritability of the mucous membrane of the stomach, and sometimes proves very untractable. It may occur at a short period after taking food, or at the distance of three or four hours. In the former case, the disease is probably seated in the stomach ; in the latter, in the pylorus or the duodenum. The treatment is very uncertain-; the oxide of bismuth is in some cases extremely useful, and in others lime-water. In some forms of the affection, again, articles of a stimulating nature are beneficial; and I have known some very protracted cases yield to the use of a strong tincture of garlic; and others, to small doses of calomel. Much depends upon regimen, and some of the most severe and protracted cases have got well under a diet restricted entirely to milk. External applications are also frequently useful, as blister- ing, and tartar emetic ointment. It is to be kept in mind, that ha- bitual vomiting often depends upon diseases of other organs, affect- ing the stomach sympathetically, such as affections of the kidney, the liver, the spleen, the pancreas, and sometimes the brain. Protracted cases of vomiting which have resisted much treat- ment, sometimes yield to the practice of keeping up a slight but continued action on the bowels? by very small doses of laxatives re- peated at short intervals. An interesting example of this is men- tioned by Dr. Parry, in which the vomiting was in such a degree, that everything was rejected, even a tea spoonful of water. The case had gone on in this manner for several weeks, and the pa- tient was reduced to the last degree of emaciation, when Dr. Parry ordered half a grain of aloes to be given every four hours, moist- ened only with a few drops of liquid. This was retained, and acted gently on the bowels, and in less than two days, the complaint en- tirely subsided. The bowels had been freely moved from time to time during the previous treatment, and other remedies in great va- riety had been employed without any benefit.* III. Obstinate and untractable pyrosis often accompanied with discharge of quantities of thin acrid mucus by eructation, or with a feeling of constant and intense acidity, produced by articles which are not likely to become acid. These symptoms are probably con- nected 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 * Collections from the unpublished writings of Dr.'Parry. Vol. II. HJEMATEMESIS. 89 appears thickened, pale, and spongy, with an increased and un- healthy secretion. A woman mentioned by Andral, vomited every day about four pints of white glairy mucus like the white of eggs ; and she never vomited either food or drink. On dissection, no other morbid appearance could be discovered than a general thick- ened state of the mucous membrane of the stomach, which was of a brownish color, and the follicles were remarkably developed. When the fluid discharged is tinged of a brown or chocolate color, ulceration is to be suspected: in other cases, only a thickened state of the mucous membrane is met with, combined with an appear- ance of melanosis. The fluid in these cases has been found to con- tain a lame proportion of albumen, and the color appears to arise from the coloring matter of the blood. The affection is very un- tractable; it is often benefitted by lime water, bismuth, the stimu- lants, as garlic and benzoin, and frequently by the acids, particu- larly the nitric; likewise by blistering and mild farinaceous diet. IV. Hcematemesis. This, which we have seen as the result of ulceration, also occurs without any such disease; and I have seen it fatal where no organic disease could be discovered, and even the source of the haemorrhage could not be detected. In other cases, a varicose state of the veins is observed in the mucous membrane of the stomach. The quantity of blood brought up is often immense, so that the patient is reduced to the last degree of exhaustion ; and yet the disease is not often fatal. Some persons, especially women, are liable to frequent or almost periodical attacks of it, sometimes in connection with retention of the menses. When the patient is much exhausted, it is necessary to give small quantities of brandy at short 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, repeated every three or four hours, for thirty-six or forty-eight hours, if necessary; also the acids,'the muriated tincture of iron, bismuth, alum, and kino in powder or tincture. The blood is apt to pass into the bowels, from which it must be discharged by the mildest means, as injections re- peated 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. 12 90 SYMPATHETIC AFFECTIONS OE THE HEART. V. Sympathetic Affections of the Heart. These are often among the most troublesome symptoms that accompany affections of the stomach, and are always the most alarming to the patient. They appear under various forms, and frequently assume, in a very great degree, all the characters of fixed disease of the heart or large vessels. The slightest and perhaps the most common form consists of a momentary feeling of a rolling or tumbling motion of the heart, like that which is produced by a sudden surprise or fright, and it is accompanied by an intermission of the pulse. This feeling may be repeated only once or twice at a time, and occur at long intervals; or it may return in rapid succession, for half an hour or an hour together: or it may be felt occasionally^ irregu- lar intervals, for several days or weeks, or for a still longer period. It is sometimes accompanied by a feeling as if the heart were vio- lently grasped. In other cases, the affection assumes the form of continued fits of palpitation, or strong and irregular action of the heart, which continue without any remission for an hour or more at a time, and recur in this manner daily, or several times in a day, for a length of time; or recur at uncertain intervals. In other cas- es, again, these fits of palpitation continue for several days togeth- er. They are of course accompanied by irregularity of the pulse, when the action of the heart is itself irregular; but frequently there is no irregularity in the action,—the affection merely consist- ing of a strong pulsation, which the patient feels or hears throb- bing in his ear, and can count distinctly by the sound, especially when he lies in bed. In other cases, again, there is only an in- creased frequency of the action of the heart, showing itself by par- oxysms of quick pulse, accompanied with a feeling of anxiety, con- tinuing for an hour or two at a time, without any irregularity. I shall mention in the sequel a remarkable case, in which an affec- tion of this kind continued with little remission for a year. Betwixt the various forms of this affection and disease of the heart, the principle 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 stom- ach, and relief by treatment directed to that organ,—and, particu- larly, by the symptoms being most apt to occur while the patient is at rest, especially after meals, not being increased by bodily exer- cise, but rather relieved by it,~and not being excited by such bod- ily exertion as we should naturally expect immediately to influence SYMPATHETIC AFFECTIONS OF THE HEART. 91 a disease of the heart. The affection is always very alarming to a patient, and sometimes perplexing to the practioner; 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 de souffet 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 follow- ing selection of facts will perhaps be acceptable to practical men. Between four and five years ago, a gentleman, aged 52, con- sulted me on account of paroxysms of violent palpitation of the heart, which occurred at irregular but rather short intervals, and generally contiued for several days together. He was otherwise in good health, and accustomed to take a great deal of exercise, and he did not complain of his stomach. His pulse in the intervals was quite natural; his bowels were rather confined, but very easily regulated. The affection had been going on for about three years, and a great variety of treatment had been employed without benefit. I confess I did not expect to do any good in this case, and, rather by way of doing something, than from much expectation of benefit, advised him to take every night one grain of the sulphate of iron, with one grain of aloes, which was found sufficient to regulate his bowels. Cautions were given him with regard to his regimen ; but I believe they were not attended to, for under the simple rem- edy now mentioned, this severe affection very soon disappeared. After a short time, he left off the regular use of the medicine; but afterwards recurred to it occasionally for a few days, and in this manner he enjoyed very good health for upwards of two years. He then went to the continent, and I lost sight of him for about a year. I saw him on his return, as he passed through Edinburgh, on his way to his seat in the north, and found him very unwell. His pulse was frequent and extremely irregular ; the action of the heart was diffused, irregular, and tumultuous; he had attacks of dyspnoea, amounting at times to a feeling of suffocation; his appe- tite was impaired, and his general feelings were in the highest de- gree uncomfortable. He left Edinburgh next day, and I wrote to his surgeon in the country, expressing great apprehension, and re- questing him to watch the case very narrowly. In a short time I 92 SYMPATHETIC AFFECTIONS OF THE HEART. received notice, that the patient had been attacked with gout, and that all his other symptoms had disappeared. Since that time he has had repeated attacks of gout, but in other respects has en- joyed tolerably good health. A gentleman, aged 48, in November 1 825, 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 generally continued about an hour at each time; and they were occasionally accompanied with a considerable degree of dyspnoea. During the intervals, the pulse was calm and regular, and the action of the heart quite natural. The period of the attack was generally soon after meals ; but it likewise occurred at various other times; sometimes on first getting up in the morning, and sometimes in the night. During the paroxysm, he could take walking exercise without increasing the symptoms. His digestion was imperfect, and his stomach easily disordered; his bowels were rather slow, and the motions were dark and unhealthy. A great variety of treatment, and every possible variety of diet, were em- ployed with very little benefit. He went to London, and then to Chelthenham, where much treatment was again had recourse to with lutle effect. He sometimes lost greatly in flesh and strength, and sometimes improved again; his digestion was sometimes better 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 contin- ued in this manner for two years and a half, it at last subsided un- der the use of the colchicum wine, in very moderate 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 account of the effect of it is in these words :—• At the time of com- mencing the use of the colchicum, I had at once, at least every day a severe fit of palpitation of an hour's duration; often two, and sometimes three fits in a day. So immediate was the effect of the colchicum, that, with the exception of the first and third days after beginning its use, I have not had a single paroxysm of the palpita- tion.' He adds, that he continued the use of it for a month,' and then left it off entirely; and that the quantity did not, in general, exceed from fifteen to twenty drops in a day. SYMPATHETIC AFFECTIONS OF THE HEART. 93 About four years ago, a gentleman, aged 65, began to be af- fected with some uneasy feelings in his chest, accompanied by an occasional sense of dyspnoea. On examination, his pulse was found lobe very rapid, seldom under 120, often 130 or more, with some irregularity, and it was uniformly thus frequent at all hours of the day. The action of the heart was frequently irregular ; his digestion was impaired ; his nights were often very disturbed ; and during the night he had frequently a feeling of dyspnoea, which obliged him to sit up in bed. A variety of treatment was employed 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 assummed 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 dis- order, it disappeared spontaneously, and rather suddenly. The patient has now enjoyed good health for more than three years, and circumstances have come to my knowledge, which induce me to believe that the scource of the affection had been continued anx- iety 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 gentlemen has frequently consulted me, who is affected in the following manner: In an instant, and without any warning, he is seized with a most painful feeling in the region of the heart, ac- companied 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 uneasiness by fre- quent and very deep inspirations, which are performed without difficulty. While the lungs are in a state of full inspiration, a sound is heard by himself and by persons sitting near him, exactly resembling the loud tick of a watch ; it corresponds in frequency with the pulse, and is only heard while the lungs are fully inflated; but it continues to be heard as long as he keeps them inflated, by resting upon a deep inspiration. The attack generally continues from 15 minutes to half an hour, and then passes off in an instant, with a feeling of some obstruction suddenly giving way; every uneasy sensation is then instantly removed, and the pulse becomes full, soft, regular, and of the natural frequency. * This affection 94 PATHOLOGY OF THE STOMACH. was originally brought on by intense anxiety of mind nearly 30 years ago; it continued to recur since that time, but at very uncer- tain intervals, often of weeks or months, and has never 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 im- paired digestion, about five years ago, began to be affected in the following manner:—At various times of the day, and without any warning, he was suddenly seized with an uneasy feeling in the ep- igastric region, accompanied by a violent and very loud sound, as from the belching of wind. At the instant when this sound took place, he was seized with a violent pain in some part of the lower extremities, generally on the inside of the thigh, a little above the knee. This was accompanied by a convulsive start of the limb, and the pain for the time was so acute, that he generally at the in- stant 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 sore- ness 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 continuance of the complaint, his limbs became considerably 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 sometime recovered their strength. The affection has continued to recur from time to time, though it is very much diminished, both in frequency and in violence. The only treatment that appeared to have any influence over it was tegular 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 PATHOLOGY OF THE STOMACH. 95 a more correct diagnosis of this class of diseases. Some of them appear to be merely functional, or what may properly be called dys- peptic ; while others are connected with most important and defined diseases of the mucous membrane, or the other coats of the stom- ach ; and it appears that many of these cases, though of a very formidable nature, may be treated with success, if their characters are ascertained, and the necessary means adopted, at an early period of the disease. Other cases will be afterwards mentioned, which are connected with corresponding diseases of the mucous membrane of the bowels, or with affections of the neighboring organs. It 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 differ- ent degrees; and, in this manner, have introduced much ambigu- ity into the inquiry. Thus, when we find these writers talking of a stage of dyspepsia in which it terminates by ulceration, or vari- ous organic affections of the parts concerned, I cannot avoid con- sidering them as using a phraseology which is at variance with the principles of sound investigation, and calculated to obscure a sub- ject of the utmost practical importance. APPENDIX TO THE PATHOLOGY OF THE STOMACH. In this appendix I mean to introduce a few observations on the following subjects, closely allied to the pathology of the stomach, though not connected with disease of that organ itself. 1. Derangement of the functions of the stomach by tumors attached to it externally, without disease of its coats. 2. Outline of the pathology of the oesophagus. 3. Outline of the pathology of the duodenum. SECTION I. DERANGEMENT OF THE FUNCTIONS OF THE STOMACH BY TUMORS ATTACHED TO IT EXTERNALLY, WITH- OUT DISEASES OF ITS COATS. Of the singular phenomena connected with some of the affec- tions of this class, 1 shall only give the following example : Case XXIII.—A lady, aged about 70, had been affected for more than thirty years with periodical vomiting, which occurred so regu- larly a few hours after meals, that during the whole of this period 13 98 TUMORS ATTACHED TO THE STOMACH. she had vomited-a part of almost every meal. It was brought up without nausea, or any unpleasant effort, and the affection had never injured her general health. I was in the habit of seeing her for several years, during which time she continued to enjoy good health, till she began to fall off rather suddenly, and died after a short illness with diarrhoea and rapid failure of strength. Inspection.—The only morbid appearance that could be discov- ered, was a tumor the size of a hazel nut or a very small walnut, and resembling an enlarged gland. It lay in contact with the out- side of the stomach, near the pylorus, and slightly attached to its outer coat, but without any appearance of disease in the stomach itself. In a similar case by Morgagni, in which the symptoms had gone on for 24 years, the only morbid appearance was a slight in- duration of the pancreas. I have seen one case which was fatal in about a year, with constant vomiting, in which the only morbid appearance was a scirrhus hardness of the pancreas, without en- largement ; and I have seen several in which the pancreas was en- larged and diseased in various ways. Similar symptoms may also arise from diseases of the other neighboring parts, as the liver, the spleen, and the omentum. Many years ago, I examined the body of a woman who died gradually exhausted by daily vomiting, which had continued more than a year, and I could discover no morbid appearance except the gall bladder distended by a large number of biliary calculi, which completely filled it. In the Phil- adelphia Journal of Medical Science, a case is mentioned in which symptoms resembling those of deep-sfeated disease in the stomach were connected with a tumor attached to the oesophagus at the third, fourth, and fifth dorsal vertebrae. The patient had knawing pain in the stomach, much flatulency, emaciation, and frequent vomiting; and he died after a protracted illness. The stomach and all the abdominal viscera were sound DISEASES OF THE OESOPHAGUS. 99 SECTION 11 . DISEASES OF THE (ESOPHAGUS. § I.—Inflammation of the oesophagus. Case XXIV.—A gentleman, aged 26, Came to town in June, 1826, to consult me about complaints in his head. On his journey he thought he caught cold in crossing the Firth 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 color without much swelling, but were covered in several pla- ces with aphthous crusts. He was at this time not confined, and there was no fever; but, after a few days, he became feverish, the other symptoms continued as before. He was now confined to bed and actively treated, and after eight or nine days he was much bet- ter, so as to be able to be out of bed ; but there was still some raw- ness of the throat, with small aphthous crusts, and a husky sound of the voice. After a few days there was a recurrence of fever which now assumed a typhoid type, with considerable appearance of exhaustion. He had some dyspnoea, with considerable difficul- ty of swallowing. The attempts to swallow excited sometimes cough, and sometimes vomiting; and by both he brought up con- siderable quantities of a soft membranous substance. He became more and more exhausted, without any remarkable change in the symptoms, and died at the end of about three weeks from the first appearance of the disease. For twelve hours or more before his death he swallowed pretty freely. Inspection.—The whole of the pharynx was covered by a loose soft adventitious membrane, which also extended over the epiglottis, and portions of it were found lying in small irregular masses, within the larynx, at the upper part. A similar membrane was traced through the whole extent of the inner surface of the oesophagus, quite to the cardia.* Near the cardia, it lay slightly at- tached, forming a soft continuous mass about a third of an inch in diameter, and with the oesophagus closely contracted around it. The other parts were healthy. ' 100 DYSPHAGIA. § //.—Pathology of dysphagia. The subject of dysphagia has been so fully treated by various writers, particularly Dr. Monro, that it is not necessary to intro- duce more than a slight outline of it in connection with these in- vestigations. The causes of dysphagia, in as far as I have had oc- casion to observe them in practice, are chiefly the following: 1. Enlargement of the epiglottis and disease of the larynx. These affections are generally distinguished 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 symptom, so as to lead to the supposition of disease of the oesopha- gus rather than of the trachea. In one of these cases, the epiglottis was thickened and much elongated; the patient had no constant difficulty of swallowing, but was liable to sudden attacks of it dur- ing his meals, which threatened instant suffocation. In another case, the dysphagia was permanent, and was combined with a hoarse husky cough and slight dyspnoea. The whole body of the larynx was much enlarged and thickened ; and it was in some de- gree ulcerated both internally and towards the oesophagus. In both cases, the oesophagus was entirely healthy. 2. Paralysis of the oesophagus, generally connected with dis- ease of the brain or spinal cord. Of this I have given some re- markable examples in a treatise on the Pathology of the Brain, and one in particular, in which the patient was entirely supported by nourishment introduced through an elastic gum tube, for five weeks before his death. Dr. Monro has described several remarkable cases, in which complete loss of the power of the oesophagus seemed to take place without any other disease. The peculiar character of the affection was a sudden and complete loss of the power of swal- lowing, while a full-sized probang could be passed without any dif- ficulty. The cases in general got well in a short time; and sev- eral of them seemed to derive remarkable benefit from electricity. One of the patients could not for some time swallow at all except when he was seated on the electrical stool. 3. The simple structure of thefcesophagus, which consists of a contraction of small extent at a particular spot, generally con- nected with thickening of the mucous membrane at the part, with- out disease of the other coats. DYSPHAGIA. . 101 4. Contraction with more extensive disease, as thickening and induration of the coats of the oesophagus, often of great extent, and frequently combined with ulceration of its inner surface, which sometimes assumes a cancerous character. Stricture, referable both to this and the preceding heads, may take place gradually without any knpwn cause, or may be distinctly traced to a cause which produced inflammation or other injury of the parts. A case occurred lately to Dr. Renton of Pennycuick, in which nearly to- tal obliteration of a considerable extent of the oesophagus followed an injury produced by swallowing a preparation of potass. Dr. Cumin has described a very interesting case of this kind, produced in a girl 7 years of age, by swallowing American potash in a state of deliquesence, which the child mistook for treacle. After the first violence of the symptoms was subdued, sloughs were dis- charged, and it was hoped that the danger was over. But difficult deglutition then took place, and when Dr. Cumin saw her, nearly four months after-the injury, she was emaciated to the last degree and in a state of extreme distress. She had an eager desire for food, and most urgent thirst, which she attempted to relieve by con- stant attempts to swallow, but the liquids were instantly returned. This very unpromising case Dr. Cumin succeeded in treating suc- cessfully by elastic gum catheters. By these he at first injected nourishment into the stomach, while he acted upon the disease, but such a power of deglutition was soon recovered as to render the former unnecessary. The final "cure of the disease was accom- plished in eight or nine months.* 5. Tumors external to the oesophagus, formed by enlargement of the thyroid gland, the bronchial glands, or the glands in the posterior mediastinum ; and morbid productions of various kinds formed within the thorax, so as to compress the oesophagus ; also certain affections of the vertebras; and diseases of the diaphragm. Great distention of the pericardium appearedjo be the cause in a case mentioned by Bleuland.f 6. Polypous tumors, growing from the inner surface of the oeso- phagus itself. Some remarkable examples of this are related by Dr. Monro. 7. Collections of matter behind the oesophagus, or betwixt its coats, and forming a tumor projecting into its cavity. These some- * Trans, of the Medico-Chirurgical Society of Edinburgh. Vol. iii. part ii. t Bleuland de Sana et Morbosa (Esophagi Structura. 102 DYSPHAGIA. times 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 sev- eral examples of this in the upper part of the oesophagus, so situ- ated that they could be reached by the point of the finger and opened by a curved instrument. They all did well, but from the quantity of matter discharged from one of them, the disease must have been of immense extent. The breathing was much affected in this case, and swallowing was almost impossible. A remarka- ble case occurred to Mr. George Bell, in which the dysphagia had existed so long that it was considered as an example of stricture of the oesophagus, and a probang was introduced. When this reached the part, which was very low down, it ruptured the abscess, and an immense discharge of matter took place, with immediate and per- manent relief. A fatal case from the same cause is mentioned by Bleuland: the matter was collected between the vertebrae and the upper part of the oesophagus. In a case by the same writer, a com- munication was found between the oesophagus, and an abscess in the right lung. A similar case is mentioned by Kunze, in which there was much disease of the glands in the posterior mediastinum, and a communication between the oesophagus and an abscess in the left lung.* 8. Aneurism of the aorta. I have seen several examples of this affection, and the symptoms had not been such as to excite any apprehension of the disease, until the fatal event took place by rup- ture into the oesophagus. I have described one remarkable case in which the fatal attack was complicated with ramollissement of the spinal cord. In another, a gentleman, in the vigor of life, there had been for a few weeks, difficulty in 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 oesopha- gus ; it occasioned rupture of the aneurism, and almost immediate death. « * Kunze de Dysphagia. DYSPHAGIA. 103 9. Disease of the Cardia. This has been already briefly re- ferred to. 10. Dysphagia appears to exist, assuming all the characters of a fixed disease of the oesophagus but really connected with a mor- bid 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 in- definite doctrine of spasm will certainly not account for it. My at- tention was first particularly drawn to the disease by the case of a lady 40 years of age, who had been under treatment more than a year, for what was considered a stricture of the oesophagus, accom- panied 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 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 astonish- ment, the affection was completely removed, by four or five appli- cations of this instrument. The patient continued well for more than a year, and then had a return of the complaint, which was removed in the same manner; and she had afterwards several slight 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 raw- ness and tenderness a short way down the oesophagus. I have no doubt that they depended upon a superficial disease of the mucous membrane, at a particular spot; but the precise nature of it I can- not determine; and I confess myself unable to explain the speedy removal of the complaint, by the means which I have mentioned, especially in the first attack, when it had continued for more than a year, with all the characters of a severe and permanent stricture. In an interesting case described by Dr. Cumin, the affection came on in connection with dyspeptic symptoms, with vomiting and great derangement of the bowels, produced, in a young woman, by want of exercise in attendance upon a sick relative. Pain was felt be- hind the cricoid cartilage, and articles swallowed were rejected with a sense of choaking and stricture of the gullet. She derived immediate relief from passing a large elastic gum catheter through the part, the vomiting and the spasms of the gullet having ceased immediately. After some time the symptoms returned, and were again removed in the same manner. She was then sent into the 104 DYSPHAGIA. country.* For numerous interesting facts relating to what has been called the spasmodic stricture of the oesophagus, as well as to the whole subject of dysphagia, I refer to the learned work of Dr. Monro.f 11. Mr. Mayo has described a remarkable case of fatal dyspha- gia connected with a dilated state of the oesophagus. The affection had existed .in a greater or less degree for about ten years, and was at length fatal by exhaustion. Articles that were swallowed lodged for a few minutes and then were brought up again, very small quantities only appearing to reach the stomach. The oeso- phagus at the upper part was healthy, but about half an inch below the pharynx it began to enlarge and gradually acquired an extra- ordinary degree of dilatation. Its greatest enlargement was about four inches above the cardia ; it then contracted abruptly, and an inch of the lower extremity was healthy. The inner membrane of the dilated part was opake and thickened, and was marked by numerous longitudinal furrows, and by numerous depressions of various sizes and figures.! This singular affection must have been connected with a total loss of the muscular action of the di- lated part. Dilatations of a more limited kind have been observed, as in a case by Marx, in which a part of the oesophagus was dila- ted into a cyst five inches long and three broad. 12. Dislocation of the Os Hyoides. An eminent medical man, now deceased, was liable to this accident, and I have seen him seized with it in an instant, while engaged in conversation. It produced slight difficulty of articulation, and total inability to swal- low. He easily relieved himself by a particular movement of the parts with his hand, which had become familiar to him from the frequent occurrence of the accident. A man mentioned by Dr. Mugna,|| while swallowing a large morsel of tough beef, suddenly experienced a sensation as if it stuck at the entrance of the oesopha- gus, and immediately lost aH power of deglutition. A sound hav- ing passed without difficulty, Dr. Mugna suspected dislocation of the os hyoides. He accordingly introduced the fore and middle fingers of the right hand beyond the root of the tongue, and, on * Trans, of the Med. Chirurgical Society of Edinburgh, vol. iii. t Morbid Anatomy of the Gullet, Stomach, and Intestines. t Medical Gazette, vol. iii. II Annali Universali, quoted in the Medical Gazette, vol. iv. DISEASES OF THE DUODENUM. 105 moving the parts a little by the left hand applied to the front of the neck, the affection was speedily removed. SECTION III. DISEASES OF THE DUODENUM. Facts are wanting on this interesting subject, but it is probable that the duodenum is the seat of several diseases, which are apt to be mistaken for affections of the stomach or the liver. The lead- ing peculiarity of disease of the duodenum, as far as we are at present acquainted with it, seems to be, that the food is taken with relish, and the first stage of digestion is not impeded; but that pain begins about the time when the food is passing out of the stomach, or from two to four hours after a meal. The pain then continues, often with great severity, sometimes for several hours, and generally extends obliquely backwards in the direction of the right kidney. In some cases, it gradually subsides after several hours, and, in others, is relieved by vomiting. The peculiar characters of disease of the duodenum are well illustrated by a case related by Dr. Irvine, in the Medical Journal of Philadelphia for August, 1824. The patient was liable to at- tacks of pain and vomiting, which at first occurred at long inter- vals, but gradually became more frequent, until they occurred reg- ularly 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 time when the attacks began to occur daily. About three weeks before his death, a tumor was felt in the right hypochondrium, which after eight or ten days subsided. On inspection, the stomach was found distended but healthy, and the liver was sound. The duode- num was enlarged and hardened, and internally showed an exten- sive surface of ragged ulceration. It was also studded with tuber- 14 106 DISEASES OF THE DUODENUM. eles, varying in size from that of a hickory nut to a hazel nut. In the largest there was a soft, white matter, and the cavity of the duodenum contained about four ounces of pus. In a case by Broussais, the symptoms seem to have been very obscure, or rather are slightly detailed. A man, 63 years of age had suffered much from dyspeptic symptoms, which are 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 movements, and soon died. The intestinal canal was full of blood; in the first portion of the duodenum, there was an ulcer which had formed a communication with the hepatic artery.* In a case by Dr. Hastings, the patient, a woman of 30, had vomiting which usually occurred once in twenty-four hours, and a very confined state of the bowels. She complained of severe pain in the epigastric region, in the right hypochondrium below the margin of the ribs, and in the back between the shoulders. In the two former situations there was great tenderness on pressure. She had a teasing cough, by which the pain was aggravated, but her breathing was easy. Pulse 96. She became emaciated, and her countenance was expressive of much suffering. She died in about three nonths. Ten or twelve days before death her skin be- came yellow. On inspection, the thoracic viscera, the stomach, and the liver, were found healthy. In the duodenum, beyond the opening of the biliary duct, there was an ulcer, the size of a crown-piece, of a cancerous character, with ragged and everted edges, and its surface was irregular from fungous excrescences. The coats of the intestine around the ulcer were much thickened. All the other viscera were healthy.f This case might very readi- ly have been mistaken for disease of the liver. 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 affection of the stomach. There is a preparation of this kind in the Museum of the Royal College of Surgeons of Edinburgh, but no account is given of the case, ex- * Broussais sur la Duodenite Chronique. t Midland Medical and Surgical Reporter, May 1829. DISEASES OF THE DUODENUM im cep't that it was fatal in twenty-four hours, with symptoms of enter- itis ; these of course occurred after the perforation had taken place. A very interesting case has been described by M. Roberts.* A man, aged 27, had complained for some months of wandering pains in the epigastric region. For the last six weeks there had been diarrhoea, and for six days preceding the following attack, he had complained of nausea and loss of appetite. On the 10th of December, 1827, 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 peritonitis, and the cavity of the peritoneum contained much gas, and a considera- ble quantity of fluid. The stomach was healthy ; but, in the duo- denum, near its origin, there was an ©val 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, af- fecting only the mucous membrane. In a very singular case described by Dr. Streeten.t a communi- cation took place between the duodenum and an external opening on the side of the thorax, between the seventh and eighth ribs, and articles of food or drink were frequently discharged by it. The duodenum was found greatly contracted beyond the seat of this communication, which was produced by means of a canal two inches and a half in length, passing from the opening in the duo- denum through thickened cellular texture to the external aperture. The affection was complicated with extensive disease of the liver, and of the thoracic viscera. The patient appears to have lived about a month after the communication took place between the .duodenum and the external parts. In concluding this imperfect outline of the pathology of the stomach, and the parts immediately connected with it, I add the fol- lowing observations as possessing considerable interest in a practi- cal point of view. * Nouvelle Bibl. Medicale, Juin 1828. t Midland Medical and Surgical Reporter, November, 1829. 108 EPIGASTRIC HERNIA. A gentleman from the country consulted Dr. Kellie and myself, in regard to a tumor in the epigastric region, of about a year's standing; and the commencement of it was dated from a violent exertion in lifting some heavy body. The tumor was large, flat, and firm, and free from pain or tenderness. On first inspection, it had the appearance of a mass of organic disease of great extent; but, when we considered that his health was good, and the functions of the stomach little impaired, we departed from this opinion, and were disposed to believe that it might be formed in the parietes. After repeated examinations, we were prepared to send him home with general instructions, when, on making a final examination, Dr. Kellie perceived in the tumor an obscure feeling of crepitus. Following this indication, persevering pressure was now employed, and the tumor gradually disappeared. It was distinctly a hernia, but what the contents of it were we cannot decide. A lady from the country consulted me respecting paroxysms of pain in the epigastric region, accompanied by vomiting, to which she was liable at short but uncertain intervals: and they had very much impaired her general health. After repeated examinations, I could detect no organic disease; but at last, by mere accident, discovered a minute opening through the abdominal, 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 cov-^ ered only by a thin integument. There was every ground for considering it as the aperture of a small hernia, though the patient had never observed any protrusion at the part; and, by adapting to it a light and slender truss, the paroxysms were prevented. PATHOLOGY OF THE INTESTINAL CANAL. In attempting to trace the pathology of the intestinal canal, we have to keep in mind the three distinct structures of which it is composed, namely, the peritoneal, the muscular, and the mucous coats. These structures perform separate functions, and are liable to be the distinct seats of disease. One of the most interesting points in this investigation, is to trace the different classes of symp- toms which arise from or are connected with these varieties of structure. This I think we are enabled to do with some degree of accuracy, by tracing, in other parts of the body, in which the three structures are more distinct from one another, the leading phenom- ena connected with the diseases of each. Thus, from ample obser- vation, we have reason to believe, that the most frequent result of inflammation in a serious membrane, is deposition of false mem- brane,—in a mucous membrane, ulceration,—and in a muscular part, gangrene. There are various modifications of these termi- nations, but those now mentioned are the most prominent, and the most peculiar to the different structures. When, therefore, in a fatal disease of the intestinal canal we find ulceration of the inter- nal surface, we have reason to conclude that the disease has been seated chiefly in the mucous membrane ; when we find only false membrane, that it has been in the peritoneum; when we find gan- grene, that the muscular coat had been affected; and when we find both gangrene and false membrane, that both the muscular and per- itoneal coats were involved in the disease. 110 PATHOLOGY OP THE INTESTINAL CAKAL. In tracing the symptoms connected with inflammatory affections of the abdomen, we find them resolving themselves into three most important modifications. Thus, we meet with inflammation exist- ing in the intestinal canal, with a perfectly natural state of the bow- els,—with a loose state of them,—and with a state of insuperable obstruction. In the progress of this investigation, we shall see reason to believe, that these three states of disease, so different from each other, are connected with three distinct varieties in the seat of the inflammation; that, when it is seated in the mucous membrane, there is an irritable state of the bowels assuming the characters of untractable diarrhoea or dysentery; that, when the muscular coat is affected, there is obstruction of the bowels ; and that inflammation may exist in the peritoneal coat alone, and go on to a fatal termination, while the functions of the bowels continue in a perfectly natural state, through the whole course of the dis- ease. It is necessary to anticipate these results, in connection with the arrangement of this extensive subject. But, besides the vari- ous forms of inflammatory affections of the intestinal canal, there is a class of diseases entirely distinct, namely, those which affect it simply as a muscular organ. This includes the various modifi- cations of Ileus, which, though it very often terminates by inflam- mation and its consequences, is in its early stages to be considered as a disease of the canal, affecting chiefly its muscular action. The investigation of the pathology of the intestinal canal might, therefore, divide itself into diseases affecting it as a muscular organ, including the varieties of Ileus,—and the inflammatory dis- eases under three classes ; namely, 1st, Simple Peritonitis, without any derangement of the muscular action of the bowels,—2d, Peri- tonitis combined with obstruction of the bowels, constituting the dis- ease 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 con- sider peritonitis and enteritis together, and the diseases of the mu- cous membrane separately. On this plan, the actual division of the subject will be, I. Ileus. II. The inflammatory affections of the more external parts, in- cluding peritonitis and enteritis. III. The diseases of the mucous membrane. ILEUS. Ill The principal organic affections, and the various forms of chron- ic disease of the intestinal canal, are so connected with one or other of these classes, that the consideration of them must be very much combined. PART I. OF ILEUS Colic and Ileus are different degrees or different stages of the same affection, and the name, therefore, may apply to both. The symptoms, in the early stages, are pain of the bowels, chiefly twist- ing with great severity round the umbilicus, obstinate costiveness, and generally vomiting,; but without fever, and commonly at first without tenderness,—the pain, on the contrary, being rather re- lieved by pressure. As the disease advances, and if no relief be obtained, the abdomen becomes tense, tender, and tympanitic; the vomiting very often becomes stercoracious, with severe tormina, in- tense suffering, and rapid failure of strength. In this manner, the disease may be fatal without inflammation, or, at an advanced pe- riod, it may pass into inflammation, and be fatal by extensive gan- grene. The first part of our enquiry is to investigate the conditions ot 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. 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. 112 ILEUS. SECTION I. OP SIMPLE ILEUS. $ I.—Ileus fatal in the state of distention without inflammation. Case XXV.—A man, aged 40, 20th August, 1814, had violent pain of the abdomen, urgent vomiting, and costiveness. The pain was at times increased by pressure, but not uniformly so ; his pulse was generally about 96, but at last rose to 120. The attack had commenced with symptoms resembling cholera, which had speed- ily passed into those of ileus. Repeated blood-letting and the other usual means were actively employed, and his bowels were moved on the 29th, but without relief. I saw him on the 30th. His abdo- men was then distended, tense, and tympanitic: his strength was rapidly sinking; and he died the same afternoon. For some time before this attack, he had been affected with slight symptoms, which had been referred to the liver. Inspection.—A large portion of the small intestine was in a state of great and uniform distention, without any appearance of inflammation. The lower part of the right lobe of the liver was unusually soft. No other morbid appearance could be discovered on the most careful examination. In the symptoms of this case at its commencement, there was a complication which, perhaps, may remove it in some degree from the correct history of ileus; though the fact of cholera passing into ileus is by no means uncommon, and the fatal symptoms were simply those of ileus. The following, perhaps, was a more de- cided example, and showed the. affected parts in the state of high distention, with a slight and recent blush of redness, not amounting to inflammation, or, at least, not to such a state of it as could be considered the fatal disease. Case XXVI.—A woman, aged 20, (23d June, 1813,) was af- fected with violent pain at the upper part of the abdomen, extend- ing towards the left side, and at times increased by pressure : fre- FATAL WITHOUT DISORGANIZATION. 113 quent and violent vomiting, and obstinate costiveness. The belly was distended and tense ; the tongue white ; pulse 76, and small. On the 16th, she had got wet during the flow of the catamenia, which ceased, but returned at night; pain about the umbilicus be- gan on the 17th, and increased gradually ; vomiting began on the 21st, with hiccup.. Blood-letting, with various purgatives, injec- tions, warm bath, &c. were actively employed by a physician of eminence. (24th.) Incessant screaming from the violence of pain; fre- quent hiccup; no stool; pulse 88, and small; frequent vomiting; belly distended and tender ; every medicine was instantly vomited. (25th.) No stool; everything vomited ; pain almost gone; pulse very feeble. (26th.) No stool; free from pain ; vomiting continued with hic- cup. 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 color, and seemed perfectly healthy. The remainder of the small intestine was distended to the greatest degree, so as to appear thin and transparent; its contents were chiefly watery matter and air. On the surface of the distended intestine, there was on several places, especially at the lower part near the contracted portion, a superficial blush of vivid redness, but Avithout any appearance of exudation. There was a small abscess in the left ovarium. All the other parts were healthy. A remarkable feature in this case is the mode of its termination, namely, by rapid sinking and cessation of pain, resembling the symptoms of internal gangrene, yet with the inflammatory appear- ance in its earliest stage. It is also to be observed, that the pain was increased by pressure as early as the 23d, when we can scarcely suppose any inflammation to have existed; and the same happened in the former case, where there was no appearance of in- flammation. § II—Ileus fatal with distention, and a dark livid color of the parts without disorganization. Case XXVII — A lady, aged 70, after her bowels had been confined for several days, was seized on the 5th of January, 1820, 15 114 ILEUS^ with violent pain of the abdomen and vomiting; pulse natural. The usual means- were employed by Mr. White without relief. On the 6th, the pain was considerably abated, but there was severe sickness, with frequent vomiting and obstinate costiveness ; the pulse from 80 to 90. The belly was natural to the feel, and with- out any degree of tenderness. On the 7th the same symptoms con1- tinued; the pulse 80. Towards the afternoon, sinking began to take place, and she died in the night. Inspection.—The colon contained a great deal of hardened feces, but appeared quite healthy and without any flatulent disten- tion. The lower extremity of the ileum, to the extent of 18 inches, was empty, contracted,, and of a white color, like the intestine of an infant; immediately above this, a portion from 18 to 24 inches in extent, was throughout ©fa dark livid brown color, or nearly black, but without disorganization or softening, and without any appear- ance of exudation. This portion was considerably distended, and the whole of the remaining part of the small intestine to the very commencement of the canal was in a state of uniform and great distention, and of a dull leaden color, with here and there portions of a dark livid brown. It contained only thin fluid feces and air. There was considerable disease of the internal surface of the ab- dominal 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 gan- grene ; and it is worthy of observation, that it was without any ap- pearance of inflammatory exudation. § ///.—Ileus fatal by gangrene without exudation. Case XXVIII— 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, tension and tenderness of the abdomen. Blood-letting was used in the morn- ing,, and again at 3, P. M., after which the pulse fell to 11-2. The FATAL BY GANGRENE. 115 other usual means were employed without procuring any evacua- tion from the bowels ; the pain continued unabated; sinking took place, with coldness of the body; and he died between 7 and 8 o'clock in the evening, having continued in violent pain until im- mediately before death. I did not see this case during the life of the patient, but was present at the examination of the body. Inspection.—The stomach was healthy ; the small intestine was a little distended and slightly inflamed, especially at the lower part where it had contracted some adhesions. The whole right side of the colon was in a state of gangrene, especially the caput ccecum, which had burst and discharged into the cavity of the peritoneum a large quantity of fluid feces. The diseased parts appeared to have been much distended, and, after being emptied by the rupture, had not contracted, but had fallen flat, presenting a very broad sur- face like an empty bag. There was no inflammatory exudation; and, at the upper part of the ascending colon, this diseased part ter- minated at once in healthy intestine, which was white, collapsed and empty. This was the state of the remainder of the colon, except the sigmoid flexure, with the rectum, contained much consistent feces. ^ IV.__Ileus fatal by gangrene combined with exudation. Case XXIX—A young man, aged 19, (17th Oct. 1813,) was affected with violent pain round the umbilicus ; incessant vomiting; abdomen hard, tense, and tumid; bowels obstinately costive; pulse 84 ; countenance depressed and anxious. He had been ill six days, during which a variety of remedies had been employed without re- lief. He was no.w treated by repeated general and topical bleeding, blistering, various purgatives, 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 tympanitic ; the vom- iting was urgent, but not feculent, and there was some slight fecu- lent discharge by the injections. On the 19th, the symptoms were somewhat abated; but, on the 20th, they again increased; the pain violent, the vomiting incessant, the belly much distended ; the pulse from 92 to 96; slight discharge of watery matter by stool. He died on the 21st. 116 ILEUS Inspection.—The stomach was healthy. Almost immediately below it, the intestine was distended to the greatest degree. It was in some places thin and transparent; in others, highly inflamed and gangrenous, and bursting when handled ; and in others firm, though perfectly black. This state continued to the middle of the small intestine, where a portion twelve inches in length, was empty, contracted, and healthy. Below this, the canal was again diseased as in the parts above, distended, inflamed, gangrenous, and adher- ing by extensive exudation, until three inches from the extremity pf the ileum, where it became again contracted, empty, and of a healthy color. These contracted portions were quite previous, easily dilated, and, in their coats, appeared perfectly healthy. The colon was healthy and collapsed, except at its lower part, wheTe it contained some consistent feces. The distended portions of intes- tine 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. 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. K I—Old adhesion of the intestine of small extent. Case XXX.—A gentleman, aged 17, had been for a considera- ble time liable to attacks of vomiting, accompanied by a very con- stipated 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 bowels open, and his pulse natural. On the evening of the 29th, he was seized with vomiting and pain of WITH OLD ADHESIONS. 117 the abdomen,—pulse natural, bowels confined. (30th.) Vomiting of almost everything that was taken ; occasional attacks of pain in the abdomen ; pulse natural; bowels confined. I saw him on the morning of the 31st. His face was then cadaverous, and exhausted, —body cold; pulse extremely feeble ; severe pain in the abdomen, increasedby pressure ; urgent vomiting; no stool. He died at four in the afternoon. Inspection.—The small intestines were uniformly distended, and had a blush of redness. From the caput coli, the extremity of the ileum took a turn downwards into the pelvis, and adhered to the par- ietes of the pelvis by an attachment of old standing for several inches, without any contraction of its area. The ileum beyond this part to the extent of from 20 to 24 inches, was highly inflamed and gangrenous, with extensive recent adhesions. Case XXXI.—A gentleman, aged 24, had been for several years liable to attacks of pain in the abdomen, affecting chiefly the right side. They usually continued for several hours; sometimes they recurred every evening for weeks together; and sometimes he was for weeks or months perfectly free from them. One of his longest intervals was ascribed to taking daily a small dose of Ep- som salt. On the 11th of June, 1818, he was seized with violent pain across the lower part of the abdomen, which was drawn into balls,—pulse 60 ; no vomiting. He was seen by Mr. White, who gave him an opiate and a purgative, with relief, and his bowels were freely moved. On the 12th, he was free from complaint; and on the 13th, he walked out, but, at night, the pain returned with violence; pulse 60. At four in the morning of the 14th, the pain continuing unabted, 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 continu- ing severe. He died at two in the afternoon. I saw him only two hours before death. Inspection.—The small intestine was greatly distended, and, on many places, especially on the ileum, there were inflamed portions with exudation of false membrane, and other parts of a dark color, approaching to gangrene. The right side of the colon was singu- larly turned upwards upon itself, so that the surface of the caput ccecum was in contact with the surface of the ascending colon im- mediately above it, and was attached to it, for about two inches, by 118 ILEUS a very firm adhesion of old standing. The parts concerned in it, did not 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 XXXII.—A man, aged 63, had been for 40 years affect- ed with double inguinal hernia, easily reducible ; and he was liable to violent paroxysms of pain in the abdomen, during which he said the hernise were generally forced out. In November, 1812, he suffered one of these attacks, more severe and longer continued than usual. During this attack, the hernia? had protruded frequently, but he always reduced them with ease, till the morning of the 29th, when he failed. They were easily reduced by a gentleman who then saw him, but, at night, when I saw him, they had again pro- truded ; they were then also easily reduced, but protruded again almost immediately, though he was lying on his back ; he had some vomiting and violent pain in the abdomen, which was hard and tender ; pulse 120, feeble, and irregular ; features collapsed. The bowels had been moved by injections. He died at night. Inspection.—Both hernia? 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 inflamed and sloughy. The small intestine, down to the middle of the ileum, was greatly distended, and in many places in- flamed and gangrenous. The disease stopped at the part of the ileum, which had formed the hernia of the right side ; the surfaces of this portion, where they had been in contact in the hernia, were firmly attached to each other, by an old adhesion about three inches jn extent. The coats of the intestine at this place appeared slightly thickened, but scarcely produced any sensible diminution of its area. § III.—A slender band of adhesion betwixt two contiguous por- tions of intestine. Case XXXIII.—A boy, aged 8, had frequent vomiting and ob- stinate costiveness; belly swelled and tympanitic; countenance ex- WITH TWISTING OF SIGMOID FLEXURE. 119 hausted, pulse frequent and feeble. He had been ill 10 6r 12 days, during which the complaint had resisted every remedy ; and he > died in two days more. Inspection.—The small intestine was distended to the greatest degree, down to a point on the ileum, where the following cause of the disease was discovered. Betwixt 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 remained contiguous, had produced no effect; but, by some relative change of situation of the parts, another turn of intestine had insinuated itself betwixt the two adhering portions. This por- tion, however, was healthy. The origin of the disease seemed to be, the band of adhesion being thus but upon the stretch, so that the peristaltic motion had been interrupted: for at the lower at- tachment of the band, the intestine was drawn aside into puckers, and, precisely at this point, the distention ceased, and the canal be- came white, collapsed, and empty. At this part, however, there was no actual obstruction, and the coats of the intestine were per- fectly healthy, except a "circumscribed redness on its inner surface, at the point corresponding to the attachment of the band of adhe- •sion. On the distended portion of intestine, there was a slight ap- pearance of superficial inflammation, but it was of small extents and appeared to be quite recent. $ IV.—Singular twisting of the sigmoid flexure upon itself. Case XXXIV— A man, aged 60, (23 April, 1815,) had been ill for a week, with the usual symptoms of ileus, which had resisted all the ordinary remedies ; he was now much exhausted ; and his belly was enlarged and tympanitic, with frequent vomiting. He lived in great distress till the 28th, and the swelling of the abdomen progressively increased, until it resembled the abdomen of a woman at the most advanced period of pregnancy; yet to the last he could bear pressure upon every part of it; his pulse varied from 108 to 116. Inspection.—On opening the abdomen, a viscus came into view, which at first appeared to be the stomach enlarged to three or four times its natural size. On more accurate examination, however, 120 ILEUS, this turned out to be the sigmoid flexure of the colon, in such a state of distention that it rose up into the region of the stomach, and filled half the abdomen. The stomach was contracted and healthy. The small intestine was healthy at the upper part; lower down, it became distended and of a dark color; and, at the lowest part, it was much distended, with some spots of gangrene. The colon was greatly distended, being in some places not less than five or six inches in diameter; and the sigmoid flexure was also enormously enlarged in the manner already mentioned, and of a dark livid color ; it contained only air and thin feces. The rectum was collapsed and healthy. The following appeared to be the cause of this remarkable state of disease. The sigmoid flexure was found to have taken a singular turn upon itself, so that the rectum lay to the left, in contact with the descending colon; and the as- cending portion of the sigmoid flexure passed in front of this por- tion, and lay on the right. In consequence of this transposition, the rectum, as it descended, passed behind the lower curve of the sigmoid flexure, where it takes the first turn from the descending colon ; and the rectum itself at this part received a twist, as if half round. Exactly at the point where this twist had taken place, the distention and dark color of the diseased intestine terminated* abruptly, and the remainder of the gut became white and collapsed. At this point, however, there was no mechanical obstruction, for the part was quite pervious, and, excepting the slight twist, perfectly healthy. In this singular case also, I had an opportunity of ascertaining the state of the part during life. For or on the 25th, three days before the man's death, having exhausted all the usual means, I was induced to examine the rectum with a large ivory-headed probang; when I found, at a certain depth, which was afterwards seen to correspond with the point where the rectum was twisted, a very slight obstruction to the passage of the instrument, which, however, passed Avith 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 in- jecting water into it. This was retained for some time in the dis- tended state, and then slowly withdrawn ; but no discharge follow- ed, though, as I have already stated, the distended intestine con- tained only air and fluid feces. WITH A LIGAMENTOUS BAND. l2l § V.—Ligamentous band confining a portion of intestine to the mouth of a hernial sac. Case XXXV.—A man, aged 53, May, 1814, was affected with vomiting and uneasiness in the bowels, which seized him in the fol- lowing manner. The attack commenced with a feeling of common tion, or, as he termed 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 everything 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 affected with a small hernia of the leftside, which often came down, but was easily reduced. He had never used a truss until a few weeks before I saw him. From that time his hernia had never appeared, but very soon after he applied the truss, the above men- tioned complaint began. There was no fixed pain in the belly ; his pulse was natural; his bowels were confined, but motions were procured by medicine. For a month after I saw him first, he con- tinued to attend to his work. He was then confined to his house, and soon after to bed. with increasing debility and emaciation ; and he had frequently violent paroxysms of pain in the abdomen. The other symptoms continued as before. His hernia never appeared; the pulse was natural; evacuation from the bowels was procured by medicine. He died of gradual exhaustion, about ten weeks from the commencement of the vomiting. Inspection.—The hernia was found to have been femoral; a portion of the sigmoid flexure of the colon adhered to the mouth of the sac, and a fine ligamentous band, connected by both its extrem- ities 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 pla- ces of the small intestine ; and the lower part of the ileum was in- flamed. The colon was collapsed.; the pylorus was hard, and a little thickened; and the inner surface of the stomach at the pylo- ric extremity was considerably eroded. 16 122 ILEUS. SECTION 111 ILEUS WITH MECHANICAL OBSTRUCTION, OR OTHER OR- GANIC CHANGES IN THE STRUCTURE OF THE PARTS § J.—Olddisease of the intestine connectedwith hernia and artificial anus. Case XXXVI.—A lady, aged about 60, had twenty-seven years before her death suffered from strangulated hernia, which termina- ted in artificial anus in the right groin. This continued open for very considerable time, and then gradually closed. Ten years after this, she had another attack, which was reduced without operation ; but, from this time, she had been liable to attacks of pain in the abdomen, accompanied by obstruction of the bowels. It was in one of these attacks, more violent than usual, and which had not yielded to the usual remedies, that I saw her along with Mr. Young on the 12th March, 1827. There were then severe pain and tension of the abdomen, urgent vomiting and obstinate costive- ness ; the pulse little affected. In the right groin the cicatrix left by the artificial anus was very obvious; a small puffy tumor pro- truded 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. Ballingall, to attempt her relief by an in- cision 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. T his IMTERNAL HERNIA. 123 body, on farther examination, was found to be a small finger-like process of the intestine, and had evidently formed the communica- tion betwixt the intestine and the artificial anus,—the extremity of' it being closely attached to the ■cicatrix. It had been accidentally opened in making the first incision, and was afterwards more freely laid open; and the finger introduced by it, could be freely carried into the intestine, in every direction, without any feeling of ob- struction. No relief followed the operation: the symptoms contin- ued unabated, with stercoraceous 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 pro- cess, or appendix, went off from one side of the intestine at the part, and descended into the hernial sac. The coats of the intes- tine were 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 color, or structure. It contained only air and liquid feces; and no obstable appeared to the free discharge of these by the orifice in the groin, for the feculent matter began to flow freely during the dissection. § //.—Internal hernia. Case XXXVII.—A gentleman, aged 25, on 8th August, 1821, was seized with pain in the abdomen, and other symptoms of ileus, for which he was treated by Dr. Macaulay in the most judicious and active manner, but without relief. I saw him on the 10th; his pulse was then 96, and weak, and his countenauce 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 returned with great violence in the abdomen, with vomiting and rapid failure of strength, and he died in the night. Inspection.—The whole tract of the small intestine was greatly distended, and there was superficial inflammation in many places. 124 ILEUS. 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. Case XXXVIII.—A girl, aged 17, was seized, on the 5th of July 1818, with violent pain and tendernes of the abdomen, vomit- ing and obstinate costiveness. Various remedies were employed for four days without relief. I saw her on the 9th ; the abdomen was then enormously enlarged, tense, and tender ; there had been no evacuation of the bowels; the pulse was feeble and rapid; and she died at night. Inspection.—The small intestine was much distended and in- flamed ; and in several places it had burst, and discharged thin fec- ulent matter into the cavity of the peritoneum. At the root of the mesentery, on the right side, and on a line with the head of the colon, there was a mass of diseased glands the size of a large egg. To this mass the appendix vermiformis adhered very firmly by its apex, and, as it stretched across betwixt this tumor and the caput coli, it left beneath it a space which admitted three fingers. In this space, a turn of intestine, six inches in length, was strangulated and gangrenous. Case XXXIX.-—A man, aged 28, was seized with the symp-= toms of Ileus'in the usual form, on the 15th August, 1815, and died on the 18th. Inspection.—There was a hard glandular mass of considerable size formed in the mesentery. To this mass several turns of intes- tine 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 fof intestine adhered to the mass by two contiguous points, leving betwixt them a space which admitted a 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 Jiis death, this man had suffered much, for some months, from deep-seated pain in the abdomen; but he had got well, and from that time had enjoyed tolerable health, ex- cept two attacks of pain in the abdomen and vomiting, which wery intus-susceptio. 125 of short duration; the second was about a fortnight before his death, and was relieved by a dose of castor oil. § ///.—Intus susceptio. Case XL—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 par- oxysms 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 13th. Inspection.'—The small intestine was greatly distended. About three inches from the lower extremity of the ileum, there began an inversion of the intestine to such an extent, that more than eighteen inches of the ileum had passed into the cavity of the caput coli. The inverted parts were inflamed, and extensively gangrenous, some portions being reduced to the state of a soft pulp. The colon was healthy. Case XLI.—A young man, aged 19, awoke in the night of 23d October, 1819, complaining of violent pain in the abdomen, with urgent vomiting. Pulse at first natural, but in the course of the day became frequent—pain little increased by pressure. All the usual remedies were employed without relief. I saw him on the 25th; pulse then 120, and feeble; urgent vomiting; belly not tu- mid, and little or no pain on pressure ; no stool; features collapsed. He died in the night. Inspection.—The small intestine was considerably distended, with inflamed portions and spots of gangrene. Near the lower end of the ileum, there was an intus-susceptio, in which the in- cluded portion, about eight inches in extent, was very soft and gan- grenous. Below this, there was in the cavity, of the ileum, a con- siderable quantity of coagulated blood, 126 ileus, Case XLII.—A boy, aged 2 years and 5 months, (7th May, 1812) had vomiting, pain in the lower part of the belly, and tenes- mus, by which he passed small quantities of bloody mucus, and some pure blood. Pulse very frequent; abdomen to the touch, nat- ural; much restlessness; countenance depressed and anxious. On the 8th, while he was straining at stool, a tumor of a dark bloody color protruded from the anus, to the bulk of an egg. It was easily reduced, but, on examination, was distinctly ascertained to be inver- ted intestine; and a probang, being introduced, passed to a great depth by its side, without reaching the commencement of the inver- sion. The child died on the following morning. Inspection.—A most remarkable inversion of the intestine was discovered, which began at the middle of the arch of the colon; and the parts concerned in it, including the remainder of the colon and a corresponding portion of the ileum, measured thirty-eight inches. The part that had protruded at the anus was the inverted caput coli. The inverted portion of the colon was of a dark livid color, very soft, and, in some places, thickened. The portion of the ileum included within this was tolerably healthy. Besides the mesentery connected with the inverted intestine, a portion of omen- tum was included. I have seen another case exactly resembling this, except in the extent of the inversion, which began at the lower part of the colon. The patient was a boy of about 4 years of age, and he survived five or six days. Case XLIII.—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 ; contin- ued through the day without any change in the symptoms, and died in the night. Inspection.—A portion of the ileum, more than twelve inches in extent, was inverted, and firmly impacted within the caput coli; some inflammation had commenced in the parts above. Case XL1V.—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 FROM GALL STONE. 127 hours; had also frequent vomiting. (29.) Some vomiting, but not urgent; 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 disten- tion of the abdomen; increasing exhaustion; evacuations from the bowels the same as yesterday ; died at night. Inspection.—Extensive intus-susceptio ; the inversion began at the middle of the arch of the colon ; and the remainder of the colon and the corresponding extent of the ileum, were included in the inversion, and extended as low as the sigmoid flexure of the colon. The included parts were very dark colored, turgid, and in some places ulcerated. $ IV.—Ileus from a gall stone. Case XLV.—A man, aged 45, had been repeatedly affected with violent paroxysms of pain, followed by jaundice, which had been supposed to indicate the passage of gall stones. On 3d June, 1822, he was seized with one of those paroxysms in the usual manner, and the pain continued in great violence through the whole day, accompanied by vomiting. On the 4th, the violent pain in the region of the gall ducts had subsided ; but he now complain- ed of more general pain over the abdomen ; his pulse was becoming frequent, and his bowels had not been moved. On the 5th, the symptoms were those of complete 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 distend- ed and inflamed, with considerable exudation. The lower half was collapsed, empty, and of a healthy appearance. At the place where the distention ceased, there was found a large biliary calcu- lus, 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. 128 ILEUS* $ V.—Contraction of the calibre of the intestine. Case XLVI.—A man, aged "70, had complained for several weeks of a deep-seated pain referable to a defined spot at the lower part of the abdomen; but it was not so severe as to prevent him from following his usual employments. On the 27th July, 1815, he was seized with symptoms of ileus, and died on the 31st. Inspection.—The whole of the small intestine and the colon were in a state of great and uniform distention, and of a dark color. The distention stopped at the second turn of the 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 scarcely to admit the point of the little finger. The inner surface of this portion was covered with red fungous excrescences, like grandulations. Much feculent matter was accumulated in the parts above. Case XLVII.—A woman, aged 60, had complained for some time of frequent uneasiness in her bowels, with much flatulent distention. (27th August, 1817.) The uneasiness in the 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 tenderness; and little vomiting ; but the bowels did not yield, and the belly became gradually more and more distended. She died exhausted on the 4th September. Inspection.'—The whole tract of the intestinal canal was prodi- giously distended, and there was in several places recent inflam- mation, with exudation of false membrane. The disease extended to the rectum, about four inches from the anus, where the canal was so contracted as scarcely to admit the point of a very small finger. Behind this spot, there was a large mass of diseased glands, and the contraction was occasioned by a firm flat substance, which crossed the intestine in front, and was 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 XLV1II.—A woman, aged 63, had enjoyed tolerable health till within three months of her death. She then had vomiting and Contraction of the intestines. 129 costiveness for a week, and was relieved by purgatives. After this, she complained of nausea, without vomiting, and without pain; the abdomen was at first tumid, but afterwards subsided. After a month, she was confined to bed, with constant nausea and an obsti- nate state of the bowels, and she had frequent attacks of vomiting, which sometimes continued 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 induration of the coats of the ileum at its termination in the colon, and the opening was so narrowed that it only admitted the point of the little finger. The ileum was distended and dark colored. Case XL1X—A girl, aged 14, previously enjoying excellent health, was seized with symptoms of ileus on the 2d April, 1828. She was treated in the most judicious manner by Dr. Ross, but without relief, and I saw her along with him on the 3d. The pulse was then rapid and feeble; countenance anxious and exhausted.; abdomen distended, tympanitic, and tender ; no stool except small discharges of white mucus; frequent vomiting. She died on the 5th. Inspection.—The whole tract of the small intestine was in the highest state of distention, and of a livid color, with some exudation of false membrane. This state terminated abruptly at about ten inches from the lower extremity of the ileum, and the remainder of the ileum was of a healthy color, but appeared unusually thick, firm, fleshy, and of a tortuous figure. The 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 singulur mass was formed by numerous small turns of the intestine adhering to each other in a very firm man- ner; and the outer surface of the mass was so covered over by a new membrane, as to make its external appearance smooth and uni- form. When this membrane, was removed, and the adhesions were separated, which was" done with difficulty, the coats of the intestine appeared to be quite healthy. The disease was evidently of very old standing, but the patient had never been known to complain of any uneasiness in the bowels till the fatal attack. 17 130 STRICTURE OF THE COLON. § VI.—Remarkable, stricture of the arch of the colon. Case L.—A man, aged 24, had an attack of cholera about a year before his death, and from that time was liable to uneasiness in his bowels, with costiveness. After some time, he had great en- largement of the abdomen, which however subsided after some weeks ; and the only symptoms then were, progressive loss of strength and most obstinate costiveness. When I saw him, a few weeks before his death, he was much wasted, had a very small pulse, his belly was tense and a little tender, his bowels were obsti- nately costive, and the strongest medicines and injections often failed in producing the smallest evacuation. He had occasional vomit- ing, but it was not urgent; he died, gradually exhausted, 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 down- wards, was completely collapsed into a cord not larger than a fin- ger. From the stricture, the right side became immediately disten- ded to upwards of twelve inches in circumference ; it continued of this size to the caput coecum, and the whole was completely impac- ted with firm consistent feces. A great part of the small intestine was also distended with consistent feces. § VII.—Stricture of the sigmoid flexure of the colon. The following case shows the disease taking place in the same manner as in the preceding example, viz. by supervening on an acute affection of the mucous membrane; but the subsequent course of the symptoms was very different. Case LI.—A gentleman, aged 20, had been long in rather del- icate health, having suffered considerably from pectoral com- STRICTURE OF THE COLON. 131 plaints, and from scrofulous sores. In December, 1828, he had an attack of an inflammatory character in his bowels, accompanied by dysenteric stools, for which he was actively treated by Dr. Ballin- gall. The urgency of the symptoms subsided in eight or ten days, but he continued from this time in a very deranged state of health. He complained of a constant uneasiness over the abdomen, which he referred chiefly to the lower part, immediately above the pubis. He attempted to relieve it by the frequent use of small doses of lax- atives, which operated readily, but the motions were in general scanty, and occasionally he had frequent calls with mucous dischar- ges. He had an unhealthy look, with bad appetite, debility, grad- ual emaciation, and considerable urinary irritation ; but when I saw him with Dr. Ballingall in April, 1829, the abdomen was free from distention, and no organic disease could be discovered. His bowels at that time were managed with difficulty, being sometimes confined, and sometimes rather irritated, with frequent slimy dis- charges. He continued without any change in the symptoms, ex- cept progressive wasting, till about the 26th of May, when sud- denly his bowels became completely obstructed, and all the usual means failed in procuring the smallest relief. The abdomen now became distended, tense, and timpanitic. He survived seven days in this state of complete obstruction, but with very little vomiting; and died gradually exhausted on the 3d of June. Inspection.—The peritoneal cavity was distended with gas, and also contained an immense quantity of fluid feces. On the surface of the intestines there was a tinge of recent peritonitis. The small intestines were moderately distended ; the colon appeared to have been in a state of extreme distention; but it had burst at the caput coli by an irregular opening, and had fallen together without con- traction. At the bend of the sigmoid flexure next the rectum, the intestine formed a hard mass about two inches in length, and the calibre of the canal, as it passed through this part, was contracted to a space which only transmitted a full-sized catheter. The con- traction was occasioned by a uniform thickening of the parietes at the part; they were of scirrhous hardness, and the internal surface had an ash-color and an irregular tubercular aspect. The portion thus affected was about two inches in extent, and the intestine im- mediately above and below was entirely healthy. In the following case, for which I am indebted to Dr. Beilby, the progress of the symptoms was different. 132 ileus. Case LII.—A lady, aged 63, had been liable for several years to a confined and flatulent state of her bowels. In June, 1829, she had an attack of violent pain of the abdomen with hiccup, which continued for several days. In July, she had diarrhoea ; and this was succeeded by another attack of violent pain, which was fol- lowed by several evacuations, consisting chiefly of blood. From this time the bowels were very irregular, being sometimes confined and sometimes loose, until August, when, after a severe attack of diarrhoea which continued several days, she was seized with severe pain, followed by tumefaction of the abdomen, with a small rapid pulse, and great failure of strength. The pain now recurred in paroxysms, with intense severity; and there was occasional vomit- ing. The bowels, which at first were moved with difficulty, after some time became entirely obstructed. She died gradually ex- hausted, about three weeks from the commencement of this attack, and a week from the time when the total obstruction of bowels took place. Inspection.—The intestines were in a state of extreme disten- tion, especially the colon, which was enormously distended, from the caput coli to the sigmoid flexure. It then became abruptly contracted, and at this place a stricture was found, by which the canal of the intestine was so contracted as scarcely to admit the point of the blow-pipe. The part was of nearly cartilaginous' hard- ness, and was covered by irregular scirrhous indurations. The intestine below the stricture was collapsed and healthy. APPENDIX TO THE PATHOLOGY OF ILEUS. The two following cases, though not immediately connected with the subject of the preceding section, are given in the form of appendix, as they seem to illustrate points in the pathology of ileus. EFFECTS OF GALVANISM. 133 $ I.—General distention and lividity of the intestinal canal, rabid- ly fatal. Case LIII.—A man, aged 40, had undergone an operation for fistula of small extent, which healed favorably; and he was prepar- ing to return to the country, whefi in the night preceding 1st September, 1825, he was seized with vomiting. He vomited re- peatedly through the night, and his bowels were moved moder- ately. In the morning he was somewhat feverish ; he had pain in his bowels, the abdomen was tense, and there was occasional vom- iting, but not urgent. He took laxative medicine, which produced several dark watery evacuations, without relief; and in the even- ing he was becoming exhausted, with a rapid pulse. I saw him on the morning of the 2d. He was then extremely exhausted ; per- spiration standing in drops on his forehead; extremities cold; pulse 160, and feeble; abdomen much distended and tympanitic; it was somewhat pained when pressed, but not acutely tender ; some vomiting continued; bowels moved several times; stools dark, watery, and scanty; every attempt was made to rally him without effect; he died early in the afternoon. Inspection.—The whole tract of the bowels, to the very extrem- ity of the rectum, presented one continued state of great tympan- itic distention; in some places they were tinged of a deep red color; in others, of a livid or leaden color, but without any change in their structure. There was a slight appearance of inflammation on the omentum at the lower part, and in the cavity of the pelvis there were a few ounces of a yellowish sanious fluid, slightly puriform. § II.—Effects of galvanism on distended intestine. Case LIV.—A gentleman, aged 50, for whose case I am in- debted to Mr. Clarkson of Selkirk, was affected with vomiting and pain in the right side of the abdomen, which was hard, distended, and acutely tender to the touch. His bowels were obstinately cos- tive, and resisted the action of the strongest purgatives, except when assisted by repeated and strong injections. Treatment upon 134 GENERAL CONCLUSIONS. this plan had been continued for a fortnight, with very slight effect, when Mr. Clarkson determined upon trying the application of gal- vanism to the part of the abdomen which was hard and tense. The applicatios 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, thereTisually commenced a commotion of the bowels, with a rumbling noise; and this was soon followed by a copious 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 be- came so urgent during tfyj application, as to oblige him to suspend it, and allow the patient to retire. The tension and tenderness of the right side of the abdomen rapidly subsided, and in a few days every feeling of uneasiness was gone. At first he discharged much black hardened feces, but they became gradually more natural, and at the end of ten days the galvanism was discontinued. Farther observations on this curious subject, and on some re- markable affections of the bowels referable to the head of Tympan- ites, will be found in a subsequent part of our inquiry; namely, in the appendix to the Pathology of the Intestinal Canal, Section III- SECTION IV. PATHOLOGICAL AND PRACTICAL INDUCTIONS FROM THE PRECEDING FACTS. From the cases now detailed, illustrative of the various modifi- cations of ileus, some principles appear to be deducible, of much pathological interest and practical importance. At the earliest period at which we have an opportunity of see- ing the condition of the parts in a fatal case of ileus, it seems to consist in a*state of simple distention without any visible change in the structure of the part.—(Case XXV.) At a period a little more advanced, we find on the distended part a tinge of vivid red- GENERAL CONCLUSIONS. 135 ness.—(Case XXVI.) In another state of the disease, the disten- ded part presents a leaden or livid color, without any sensible change of texture,—(Case XXVII); and, afe a period still more advanced, this seems to pass into gangrene,(Case XXVIII.) 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 peritonitis, But it also appears that the affection, in its more advanced stage, may be com- bined with peritonitis, as in Case XXIX, in which we find the gangrene combined with exudation of false membrane. The next interesting point in this investigation is to mark the condition of the muscular action of the bowels, during the progress of these morbid changes. At the more advanced period of. them, it is evident that the muscular action is entirely destroyed; for we find the part which has been distended fallen flat when it is emp- tied, and presenting a broad surface like an empty bag, without any tendency to contraction, (Case XXVIII.) This case, indeed, shows 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 remarkable case, (Case XXXVI.) in which the patient lived for eighteen hours, with a free external opening directly communicating with the distended intes- tine, hut without any discharge taking place, though the part con- tained only air and fluid feces. In this case the intestine, for a considerable space above the opening, must have been entirely de- prived of its muscular action, and yet, upon examination after death, the part presented only a uniform distention, without any re- markable change either in color or texture. A similar condition of the parts must have existed in Case XXXIV, in which the ob- struction was within reach by the rectum, and was repeatedly dila- ted by various mechanical means, without any discharge following. A remarkable illustration of these principles is derived from Case LIV, in which an obstruction, which had resisted the most active purgatives, and was accompanied by an evident and painful disten- tion of a part of the bowels, was removed by the repeated applica- tion of galvanism to the part; each application being immediately followed by a copious evacuation. It is probable, therefore, that there occurs in the state of ileus a certain loss of the muscular power in a portion of the canal, in consequence of which it does 136 ILEUS. 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 an- other part empty and collapsed, presenting nearly the form of a cord; and there has been supposed to be a difficulty in determin- ing which of these is the primary seat of disease,—-some having contended that the collapsed part is contracted by spasm, and thus proves a source of obstruction, which leads to the 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 follow- ing considerations seem to bear upon the inquiry :— 1. The collapsed state, in which it assumes the form of a cord, appears to be the natural state of healthy intestine when it is emp- ty. We often see nearly the whole tract of the canal in this state in the bodies of infants, who have died of diseases not connected with the abdomen, but in whom the bowels have been kept very open up to the period of death. We cannot doubt that a similar state of uniform contraction is the healthy condition of other muscu- lar organs when they are empty, such as the bladder. We have then no sufficient ground for assuming that the state of uniform contraction of intestine is a state of disease; on the contrary, the facts favour the supposition of this being its healthy condition when it is entirely empty. 2. On the other hand, we learn from various cases, particu- larly from the remarkable case, (Case LIIL) that a state of uni- form distention, with lividity, may occur as a primary disease of the intestinal canal, without any appearance of obstruction, and without any part of it being in a contracted state. 3. In a case of ileus, the collapsed parts are almost invaria- bly found in a healthy condition at all periods of the disease ; the morbid appearances, whether inflammation, lividity, exudation, or gangrene, being almost entirely confined to the distended parts. 4. In Case XXXVI, every obstruction below was entirely removed, while the parts above were, to external appearance, in a healthy state,—and yet the action was entirely suspended. GENERAL CONCLUSIONS. 137 5. In Case LIV, the cause, which uniformly acted in so sin- gular a manner, must be supposed to have acted upon a part only whose action was impaired, not upon one which was spasmodically contracted. , 6. In Cases XXX, XXXI, and XXXII, we see the state of distention arising from causes entirely of a different nature, with- out the peculiar contraction here referred to ; and on the other hand, in Cases XXXIII, XXXIV, and XLV, in which the disease was distinctly traced to a mechanical cause, this peculiar contrac- tion existed below the seat of the obstruction, but could not be con- sidered as having had any influence in producing the disease. In Case XXXIV also, it is to be remarked, that the contracted part was repeatedly and freely dilated during the course of the disease, without any effect in relieving the parts above. Farther, it is to be kept in mind, as already stated, that we often see this peculiar state of contraction, without distention and without any symptoms of ileus; and on the other hand, we find extensive distention with the most severe and rapid ileus, existing without any appearance of the contraction. This important fact will be strikingly illustra- ted by the next case to be described, (Case LV.) The extent of the contraction, also, in some of the cases cannot be reconciled with the notion of spasm. For even if we suppose that a small part of the canal might be spasmodically contracted, we cannot imagine a spasm which should affect at once the whole of the colon, and a considerable part of the small intestine, as occurred in Case XXVI, and in a less remarkable degree in some other examples. On these grounds, I submit the probability of the opinion, that, in a case of ileus, the distended part is the real seat of the disease ; and that the contracted partis not contracted by spasm, but is mere- ly collapsed, because it is empty, its muscular action being un- impaired. On a subject of this nature, it is dangerous to speculate beyond simple induction from the facts which are before us; but there ap- pear to be certain points connectedwith the acfoi of the mtes.mal canal, which may be ventured upon in connection wt.h th.s nupmy. f we suppose then that a considerable tract of the canal ts m a ollapsed state, and that a mass of alimentary matter .s p^pdtod into it by the contraction of the parts above, the senes of acfons which will take place, will probably be the followmg: When a 18 138 ILEUS. portion which we shall call No. 1, is propelling its contents into a portion No. 2, the force exerted must be such, as both to propel these contents, and also to overcome the tonic contraction of No, 2. The portion No. 2 then contracts in its turn, and propels the matter into No. 3; this into No. 4, and so on. Now, for this process, going on in a healthy manner, it is necessary, that each portion shall act in consecutive harmony with the other portions; but there appear to be several ways in which we may suppose this harmony to be interrupted; (1st.) If the portion No. 1 has contracted and propelled its contents into No. 2, and No. 2 does not contract in its turn, the function of the whole will be to a certain extent inter- rupted, 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 con- tinued ; or, new matter being propelled into No. 2, this will be more and more distended, until an interruption of a very formidable nature takes place in the function of the canal. (2d.) If, in the series of actions now referred to, No. 2 contracts in its turn, while some obstacle exists to the free dilation of No. 3, it is probable the mo- tion may be so inverted, that the contraction of No. 2 may dilate No. I, and that the action may thus be communicated backwards. Something of this kind seems to have occurred in a striking man- ner in Case XXXV. In the state of parts here referred to, varie- ties may occur, which appear to give rise to important differences in the phenomena. The obstruction to the dilation of No. 3 may exist in various degrees ; in a smaller degree, it may not prevent it from acting in harmony with the other parts, when the quantity of contents is small, and only a small degree of dilation is required; but, when there is an increased distention of the parts above, either from increase of solid contents, or from some accidental accumula- tion of flatus, then a greater degree of expansion may be required than No. 3^ is capable of, and, in this manner, interruption may take place to the harmonious action of the canal. It is probably, in this manner, that, in connection with slight organic affections of the canal, we find the patient liable to attacks of pain and other concomitant symptoms, which at first occur only at long and un- certain intervals, but at length terminate in fatal ileus. This im- portant modification of the disease is strikingly illustrated by Cases GENERAL CONCLUSIONS. 139 XXX, XXXI, and XXXVI; in the two former of which, it is particularly to be remarked, that there was no mechanical obstruc- tion. 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 evidently occurred in the very interesting case, (Case XXXV,) in which evacuation from the bowels was regularly procured, though the action of the canal was uniformly inverted whenever it reached the seat of the disease. In proposing the preceding doctrine respecting the pathology of ileus, I would be understood to refer only to the actual condition of the parts in what may be called a fully formed case of the disease. To this extent I think we may consider it as established by the facts which have been stated, that the leading peculiarity which exists in such cases is, that a certain part of the canal is in a state of over distention, and deprived of, or greatly impaired in, its muscular ac- tion. A farther question here arises, viz. respecting the manner in which this condition takes place, and what is the first step in the chain of circumstances which lead to it. This I admit is a question of considerable difficulty, and one, perhaps, which we have not at present the means of answering in a satisfactory manner. In as far as we can approach the truth in regard to it, the probability seems to be, that the affection which we call ileus, expresses a con- dition of the canal which may arise in very different ways, and from very different causes. These causes seem to be referable to two classes, viz. primary diminution or destruction of the muscu- lar power of a portion of the canal,—and impediments to its action, the consequence of which is, that a part which is at first healthy, becomes impaired under the effects of this interruption. 1 Primary destruction or diminution of the muscular power of a portion of the intestinal canal seems clearly to take place from the poison of lead ; and we can scarcely doubt that the same effect arises from inflammation. Thusthe part effected in enteritis becomes distended and evidently deprived of its muscular action without any appearance of obstruction in the parts below. In this case, we as- certain the presence and the seat of the inflammation by the pseu- do-membranous deposition fro* the peritoneal coat; but we have also seen reason to believefc that inflammation may exist m the mus- cular coat alone, giving rise to disease which does not assume the characters of enteritis, but of a peculiarly severe and rapidly latal 140 ILEUS. form of ileus. This affection, as we have seen, appears to be fatal by extensive gangrene without membranous deposition, as in Case XXVIII. It seems probable^that it may also be fatal at an earlier stage, showing only, distention and lividity without actual gangrene, as in several of the cases which have been described. It appears to be in the this manner that ileus, or extensive tympanites, super- venes upon inflammatory affections either of the peritoneal or mu- cous coats. Examples of this will be afterwards mentioned when we come to to treat of peritonitis and inflammation of the mucous membrane; and there seems every reason to believe that an inflam- matory affection of the peritoneum was the first step in the impor- tant and remarkable example, Case LII I. It is probable that pri- mary diminution of the muscular power of a portion of the canal may arise from other causes which elude our observation, or per- haps, which have not been investigated. 2. Interruption to the action of a portion of the canal, giving rise to distention and consequent impaired action of the part above, we see taking place from a variety of causes ; such as hernia, par- tial contractions of the intestine, adhesions, and other circumstan- ces interfering with its healthy action, which have been exempli- fied in the cases. A similar effect may probably arise in some in- stances from accumulations of indurated feces; and one case has been related to me, in which an attack of ileus seemed to arise from a large quantity of nuts which the patient had ate, and which had been accumulated into a mass in an undigested state. Under this head I am not disposed to deny that there may be, in some cases, an irregular or morbid contraction of a portion of the canal, con- stituting a state analogous to that to which the term spasm has been applied ; and that this may sometimes prove the first step in that chain of derangements of the harmonious action of the canal, which leads to an attack of ileus. The doctrine of spasm, however, must admitted to be in a great measure conjectural; but while I do not deny the existence of it to the extent now stated, my objection is to the vague and indefinite manner in which it has been applied to the whole phenomena of this interesting class of diseases. In finally comparing the two doctrines of spasm, and loss of action with over distention, two points I think must be conceded: (1.) That the former is entirely assumed and gratuitous; and that no direct proof can be adduced of its actual existence in the intestinal canal, or certainly not in such a degree and such contin- GENERAL CONCLUSIONS. 141 uence as could possibly explain the phenomena of a protracted case of ileus. In regard to the contracted portions of intestine in the cases, also, it may be argued, that their very existence in that con- dition in the dead body may itself be considered as a proof, that this was the healthy state of empty intestine, and not the result of spasm; for we cannot conceive such a spasmodic contraction con- tinuing 24 or 30 hours after death : (2.) That the condition of dis- tention and impaired action is proved actually to exist, and to exist independently of any obstructions in the parts below. This ap- pears from several of the cases which have been described. With these remarks I dismiss the speculation, merely pointing it out as worthy of being investigated by farther observation; and shall only add the following case, which I have received from my friend Dr. Duncan. • Without deducing from it any general con- clusions, I think it will appear that it is entirely inconsistent with the doctrine of spasm, and can only be explained by the supposi- tion of sudden distention and loss of muscular power. Case LV.—A man, aged 60, was admitted into the clinical ward on the 26th June, 1829, affected with deep-seated pain in the ab- domen, and constant vomiting; the abdomen was hard and very much distended; the hypogastric and umbilical regions were pain- ful on pressure; respiration was quick and laborious ; countenance anxious. No evacuation for two days, pulse 80, small and weak. He stated that, on the 22d, while perspiring profusely, he drank two quarts of cold beer ; that during the following night he Avas attacked with severe pain and sudden distention of the abdomen, accompanied with a loud noise in the right hypochondriac region. On the 23, the symptoms continued unabated, with the addition of vomiting ; and various purgative medicines were given without effect, being almost immediately rejected. On the 24th, enema produced several copious bloody stools. It was repeated on the 25th, when it brought off only blood, without any appearance of feculent matter. From the time of his admission on the 26th, every remedy that his situation admitted of was employed in the most assiduous and judicious manner, but without relief. On the 27th, his strength was still more exhausted, without any change in his other symp- toms, and he died early in the evening. Inspection.—The small intestines were much distended and 142 ILEUS. were filled with a fluid of a yellow color, similar to that which had been vomited. They were externally much injected, with some adhesions. In their substance they were easily torn, giving way even when gently handled. The lower end of the ileum and the caput coli were of a deep red or port wine color. The great intestines contained chiefly gas, and a small quantity of fluid feces, and no appearance was discovered of any contraction or obstruc- tion, except what arose from a slight narrowing of the ileum near the ileo-colic valve. At this place there existed an ulcer, which extended quite round the circumference of its inner surface, and was about an inch in breadth. It had gangrenous edges, and the bottom of it seemed to be bounded only by the peritoneum, the mucous and muscular coats being destroyed. The man had en- joyed perfect health up to the period of this attack. I shall conclude this part of the subject by certain inductions of a practical nature, which appear to arise out of the cases which have been described. 1. The most uniform morbid appearance, in fatal cases of ileus, is a greater or less extent of the intestinal canal in a state of great and uniform distention. 2. This distention appears to constitute a morbid condition, which may be fatal without passing into any farther state of dis- ease. 3. The usual progress of the disease, in the fatal cases, is into inflammation and its consequences; and we have seen it fatal, while the inflammation was in various stages of its progress, from a recent tinge of redness 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 XXVI. which was fatal on the 9th day, and in Case XXXIV. which Avas fatal about the 13th, while in Case XXVIII. it had passed into extensive gangrene as early as the 3d day. 5. Pain increased upon pressure does not appear to be a cer- tain mark of inflammation in the bowels ; for it occurred in Case XXV. in Avbich there was no inflammation; and, in several of the other cases, it was met with before probably inflammation had com- menced. 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 attention, can generally be distinguished from the acute tenderness of peritonites. GENERAL CONCLUSIONS. 143 6. Sudden cessation of the pain, and sinking of the vital poAv- ers, are not necessarily indications of internal gangrene ; for we have seen these symptoms existing with recent inflammation; and, in a subsequent part of this inquiry, I shall have occasion to refer to several cases in which they were recovered from. 7. On the other hand, we have seen cases of extensive gan- grene, in which the pain continued violent to the last. 8. The pulse appears to be a very uncertain index of the con- dition of the parts in ileus. In Case XXVI. in which there was considerable inflammation, it was less affected than in Case XXV. in which there was none. In Case XLVII. again, there was neither frequency of pulse, nor tenderness of the abdomen, though there Avas inflammation with exudation to a very considerable ex- tent. Many other important circumstances, with regard to the state of the pulse, may be remarked in the cases; one of the most important is in Cases XXVIII— XXXI. which were fatal, with extensive inflammation and gangrene, within eight or ten hours from the time*when the pulse was first 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 connected with fecu- lent accumulation, or with any condition of the contents of the canal; for we have seen it fatal while these contents were of a nat- ural appearance, almost entirely fluid, and in very small quantity. 10. Ileus does appear to be necessarily connected with obstruc- tion in any part of the canal; for we have seen it fatal without ob- struction, and we have seen every thing like obstruction entirely removed Avithout relieving the symptoms. 11. We must be cautious in forming a favorable prognosis in ileus,- from the appearance of feculent evacuations. For these, Ave have reason to believe, may occur 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 un- changed. 12. Organic disease of great extent may exist in the intestinal canal, Avithout sensibly interrupting its functions, until at length, from some cause which eludes our observation, it suddenly pro- duces fatal ileus. (Cases XXXIX, XLVI, XLVII.) 144 ILEUS. 13. On the other hand, such organic disease may be fatal by gradual exhaustion, without ileus. (Cases XXXV, XLVIII and L.) From a review of the Avhole subject, it appears, that there is a remarkable variety in the morbid appearances in those cases which are usually included under the term ileus. We have seen simple distention without any change of structure, we have seen extensive inflammation and gangrene. We have seen, in several instances, the distention apparently taking place at an early period, and grad- ually increasing through a protracted case, and then fatal with lit- tle 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, exten- sive inflammation and gangrene. It would, therefore, appear prob- able, that, in the cases which assume the characters of ileus, there is great diversity 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 period; while in others, it is at an early period connected with inflammation as a part of the primary disease. These cases seem to differ from enteritis in their symptoms, chiefly by the absence of fever; and, in the mor- bid appearances, by being fatal with simple gangrene, uncombined with the flocculent or pseudo-membranous deposition, which is so prominent a character of enteritis. Now, gangrene in the intes- tinal 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 dis- tinguished by their own peculiar symptoms, and they do not affect this part of the inquiry. When, in the cases now under consider- ation, therefore, we find gangrene uncombined with any other morbid appearance, we are perhaps warranted to conjecture 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 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 disease which may be fatal without any interruption of the action of the canal; or that it may affect the peritoneal and muscular coats at once, giving rise to the disease which Ave commonly call enteritis. ILEUS. 115 SECTION V. TREATMENT OF ILEUS. In entering upon the treatment of a case of ileus, the first point to be kept in vieAV is, to make an accurate examination in re- gard to the existence of hernia; and here two circumstances are to sbe kept in mind,—1st, That hernia may exist Avithout the patient being aware of it, or making any complaint that would lead to the supposition of its existence,—2d, That the hernia may be so very small as to include only a minute portion from one side of the intes*- tine, and yet be the cause of fatal ileus. In the medical management of cases which are referable to the* general head of ileus, there are important distinctions to be kept in mind as to the state of the symptoms, Avhich seem to require impor- tant diversities in the treatment. It is impossible to delineate mi- nutely all these distinctions, but there are certain leading varieties, which, in a practical point-of vieAV, may be briefly refered to. These are chiefly the following :— 1. Obstinate costiveness with distention of the abdomen', and considerable general uneasiness, but without tenderness, and Avith- out much acute suffering. 2. The same symptoms, combined with fixed pain and tender- ness, referred to a defined space on some part of the abdomen, fre- quently about the head of the colon. 3. Violent attacks of tormina, occurring hi paroxysms, like the strong impulse doAvnwards from the action of a drastic purgative, —the action proceeding to a certain point,—there stopping and be- coming inverted,--followed by vomiting,—the vomiting often fecu- These forms of disease will be recognized by the practical phy- sician, as constituting affections distinct from each other. In a practical view, the importance of the distinction consists in pointing at two modifications of the disease which seem to lead to differen- 19 146 ILEUS. ces in treatment; namely, a state in which there is a deficient action of the canal, and one in which there is a violent action limited to a certain part of it, though ineffectual for overcoming a derangement which exists below. The practical application of the distinction refers chiefly to the use of purgatives in ileus ; and to the question, whether, in every case of ileus, the action of the canal requires to be excited by 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 de- mands the utmost discretion; and it is impossible to lay down any general rules for it. There are some cases which yield at first to a powerful purgative, and there are others in which an active pur- gative is highly and decidedly injurious. A large dose of calomel will frequently settle the stomach, and move the boAvels ; but, upon the whole, I think the best practice, in general, is the repetition, at short intervals, of moderate doses of mild medicine, such as aloes combined Avith hyosciamus. The peculiar and intricate character of the disease appears very remarkably from the fact, familiar to every practical man, and there are cases Avhich yield to a full dose of opium, after the most active purgatives have been tried in vain. In regard to the use of purgatives, indeed, it may perhaps be said, that they form but a part of the treatment of ileus, and a part, too, Avhich, in some forms of the disease, requires to be used with the utmost discretion. The other remedies on which reliance is to be placed are chiefly the following. (1.) Blood-letting. We have seen the tendency of ileus to ter- minate 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 fatal form. On both these views, therefore, blood-letting is a most important remedy in every case of ileus, except distinctly contra-indicated by the age or habit of the patient; and the fact is familiar to every practical man, that the relief is often so immediate, that there is no time to raise the patient out of bed, or scarcely to tie up the arm, before complete evacuation takes place. (2.) The tobacco injection, as far as my observation extends, is the remedy of most general utility in all forms and stages of ileus. Lt should be given at first with much caution,—perhaps not more TREATMENT. 147 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 produced, 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 Avith the precautions now mentioned, I have never seen any unpleasant effect from the free use of this powerfnl remedy. If, while the tobacco injection is used in this manner, mild pur- gatives, such as aloes and hyosciamus, are repeated in full doses, every hour or two, the treatment is perhaps that which is most gen- erally adapted to the ordinary cases of ileus; with the assistance of one or two bleedings, especially if the patient should be of a full habit, if the pulse should be rising, or if there 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 can- not say that I have seen benefit from it. The best effects, however, I think are often produced by the continued application of cold to the abdomen by cloths wet in vinegar and Avater. In tympanitic states of the abdomen, when not accompanied by coldness of the surface, and in cases attended with local circumscribed pain and tenderness, this remedy is often followed by the most beneficial re- sults. Cold injections have also been recommeded. Of these I have had less experience, but, for various" interesting statements in regard to the effects of cold in this class of diseases, I refer to a paper by Dr. Smith in the 9th volume of the Edinburgh 'Medical Journal. (4.) Opiates. I have already alluded to a modification of the disease which yields to a full opiate, more readily than to any other mode of treatment. The case to Avhich this practice is partic- ularly applicable, is perhaps chiefly characterized by the paroxysms of violent tormina. If these are accompanied by frequency of pulse, and fixed pain or tenderness, a full bleeding, followed by an opiate, is often a successful mode of treatment; and, when the patient has been brought fully under the influence of these, the bowels will often be moved Avithout any other remedy, or yield to the very mildest means. The tobacco injection, however, is also peculiarly 148 ILEUS. . adapted to these cases, and it is, perhaps, in general a safer remedy than opiates. (5.) In the advanced stages of the disease, Avhen the system begins to become exhausted, stimulants must be given freely; and under the use of these, a case will often give AAray Avhich had previ- ously resisted the most active treatment. The aloetic wine is a convenient remedy in this stage of the disease, combining the stim- ulating with the mild purgative quality ; and it is often found of great efficacy when given in full doses, of one or two ounces, re- peated at the intervals perhaps of an hour. Tincture of aloes may be given in the same manner; and it is a remarkable fact, that, in this state of the system, and even with a tympanitic state of the abdomen, the tobacco injection, if given with sufficient caution, may still be employed Avith much advantage, along Avith the use of stimulants. Of a recovery under these circumstances, I give the folloAving example, which also tends to show the formidable char- acters Avhich the disease may assume, without having gone or} be- yond the chance of recovery. Case LVI.—A Avoman, aged 20, was affected with the usual symptoms of ileus in a very violent form, Avhich, 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 abdo- men, Avith urgent vomiting, and there had been no evacuation from the bowels. Farther bleeding Avas now employed, and vari- ous other means, without relief. In the afternoon, the pain nearly ceased; there was .collapse of the features, Avith coldness of the surface; the pulse 140 and very weak; the vomiting contin- ued; 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 injec- tion was employed, at first in very small quantity, and was re- peated several times. It did not increase the sinking, but seemed rather to abate both it and the vomiting. On. the following day, there Avas a decided improvement, and some scanty evacuation had taken place from the bowels; wine was continued in smaller quan- tities, and the tobacco injection was repeated several times with pai- tial but good effect. The vomiting abated, and some Epsom salt 'vas retained, and operated. In the evening she Avas free front TREATMENT. 149 pain, and the pulse 96; and from this time she continued conval- escent. The remedies which I have noAv mentioned are those of which I have most experience; but various others are to be kept in mind, as being sometimes useful. The warm bath is often beneficial at an early period of the disease, before there are any inflammatory symptoms. Crude mercury, in doses of one or two pounds, I have tried repeatedly, and in some cases it certainly appeared to allay the vomiting ; I have not observed any other effect from it. The forcible injection of a large quantity of fluid, to the amount of six or eight pounds, is said to have been successful in some cases. In the memoirs of the Medical Society of London, vol. ii. some inter- esting cases are described in which it Avas used with advantage- Large blisters over the abdomen are likewise extremely beneficial; also the oil of turpentine applied, externally or by injection. When the vomiting is very urgent, so as to prevent medicines from re- maining on the stomach, large doses of calomel, of from fifteen to twenty grains, often remain better than any other medicine, and even seem to allay the vomiting. In such cases, also, I have some- times found benefit from giving poAvdered aloes, repeated at short intervals in combination with the oxide of bismuth. Whatever practice is is employed ought to be zealously persevered in, not- withstanding the most unfavorable appearances; for the disease has been known to resist the most active remedies, and yet termin- ate favorably, as late as the 17th day. PART II. INFLAMMATORY AFFECTIONS OF THE MORE EXTERNAL PARTS OF THE INTESTINAL CA- NAL, INCLUDING PERITONITIS AND ENTERI- TIS. In tracing the phenomena connected with inflammation in the intestinal canal, we cannot fail to take notice of three remarkable varieties in the symptoms. We find inflammation existing in the canal, and going on to a fatal termination, with a natural or easily regulated state of the boAvels,—Avith insuperable obstruction of the bowels,—and Avith severe and uncontrollable diarrhoea or dysen- tery. In the first of these forms of the disease, Ave find on dissec- tion extensive adhesion of the parts from pseudo-membranous de- position, and frequently some puriform fluid; in the second, we generally 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 appear- ance in the external coats. From what we observe of the results of inflammation in the corresponding structures in other parts of the body, we have every reason to believe, that, in the first of these ca- ses, the inflammation was seated in the peritoneal coat; that, in the second, the muscular coat was also involved in the disease; and that, in the third, it was seated in the mucous membrane. The grounds upon which these distinctions are made, Avill 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 intestinal in- flammation may be confined to the peritoneal coat, and that in this case, it may run its course without interrupting the muscular action INFLAMMATORY AFFECTIONS. 151 of the canal; (2.) that the inflammation may affect the peritoneal and muscular coats at once, in which case,. Ave have the symptoms of peritonitis, combined with obstruction of the bowels, constituting the disease to Avhich Ave give the name of enteritis ; (3.) that the in- flammation may be entirely confined to the mucous membrane, pro- ducing 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 believe, that these forms of disease may pass into each other, by spreading of the inflammation from one structure to another; that a case, for example, may begin as simple peritonitis, and may afterwards pass into enteritis ; and that another may begin with severe diarrhoea, or dysentery, and afterwards ter- minate by inflammation of the other coats. In treating of ileus, I have alluded to the important fact, that cases of ileus which have not shown any inflammatory symptoms, or not till a very advanced period, are sometimes fatal by extensive gangrene, without any inflammatory exudation; and, as gangrene, in such cases, must probably be considered as an affection of the muscular coat, I have proposed a conjecture, that the worst forms of ileus may sometimes depend upon inflammation confined to that coat. On the other hand, it will be found, that the cases which ex- hibit the characters commonly assigned to enteritis, are fatal either by extensive inflammatory exudation and adhesion, or by these com- bined 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 observation, it will give probability to the following conjec- tures : I. That inflammation may exist in the intestinal canal, con- fined to the muscular coat, and marked by symptoms of ileus, with- out exhibiting the symptoms usually considered as a characteristic- of inflammation. It is unnecessary to add, that this is not meant to imply, that such inflammation occurs in all cases of ileus, but only in one modification of the disease, which is characterized by symp- toms of ileus, without exhibiting those of enteritis. 2. That in the more acute affections of the bowels, assuming those characters which are usually considered as indicating inflammation, the dis- ease 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, 152 PERITONITIS. I shall consider peritonitis and enteritis in connection, because they are very generally combined, ot pass into each other; and I shall then treat separately of the inflammation of the mucous mem- brane. SECTION I. SYMPTOMS OF INTESTINAL INFLAMMATION UNDER THE FORMS OF PERITONITIS AND ENTERITIS. 1. Simple Peritonitis is distinguished by pain in some part of the abdomen, varying very much in its seat, its degree, and its gen- eral characters. It in some cases extends nearly over the whole abdomen, and in others, is confined to a particular space, as one side, or frequently, the lower part, immediately above the pubis. It is increased by pressure, and frequently is little complained of ex- cept 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 ten- derness ; but this is sometimes in such a degree, that even the weight of the bed clothes is complained of. This form of the dis- ease is very apt to be mistaken foi»a spasmodic or flatulent affec- tion, from the remarkable remissions of the more violent padn. The paroxysms appear to be excited chiefly by flatus moving through the bowels, and distending the inflamed part; and the ac- tion of a purgative is often followed by a violent aggravation of all the symptoms. The pain is also aggravated by various exertions, such as coughing, sneezing,-^-often by a deep inspiration; and sometimes by any kind of muscular exertion, so that the patient lies extended upon his back, being afraid of the least motion out of that position, or even of the action of the abdominal muscles-or of the diaphragm. In some cases the pain is apt suddenly to shift its place from one part of the abdomen to another. According to the seat of inflammation, various neighboring or- PERITONITIS. 4 153 gans become affected. When it is in the loAver part of the abdo- men, there is often a frequent painful desire to pass urine, and an acute pain extending along the urethra; Avhen it is in the neigh- borhood of the kidneys, the secretion of urine is often greatly di- minished, or nearly suspended; when it is in the upper part of the canal, there is frequently vomiting, and sometimes a peculiar spasmodic action like the belching of wind, which continues with- out intermission for a considerable time, and is accompanied by acute pain. In many cases, there is violent hiccup, with quick short breathing, probably connected with the disease extending to the diaphragm. The pulse is often little affected, especially in the early stages; it is perhaps from 80 to 90 or 96, but is often scarcely above the natural standard; as the disease advances, however, it is apt to rise, and often rises to great frequency. A leading pecu- liarity of the affection is, that the bowels are not obstructed, being either natural, or easily moved by mild medicines ; but these evac- uations produce no relief; on the contrary, they are generally at- tended by violent pain, and sometimes, after the disease appears to have been subdued, the operation of a purgative is immediately folloAved by a renewal of the symptoms in all their original vio- lence. 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 paroxysms,—and in the absence of vomiting, except in certain cases already referred to. These peculiarities are chiefly observed in the early stages; as the dis- ease advances, the pain becomes more fixed and permanent, the pulse rises, the belly becomes tympanitic, and, at a certain period, obstruction takes place, and the case assumes all the usual charac- ters of enteritis. It may, hoAvever, be fatal without this change, the bowels continuing natural, and the pulse from 80 to 90, until a short time before death. At a certain period of the disease, there is a remarkable tendency to a tympanitic state of the abdomen. This is always a symptom to be watched with much anxiety, but is not necessarily a fatal one. It may either be connected with the progress of the inflammation, destroying the action of the parts; or it may arise merely from the loss of tone, after the inflammation has been subdued. In the former case, it is generally a fatal symptom, but, in the latter, it may be recovered from. 20. 154 PERITONITIS. Simple peritonitis may be fatal in three days, but frequently it is more protracted, and in some cases after the first activity of the symptoms has been subdued, the disease passes into a chronic form, and is fatal after several weeks or months. On dissection, we generally find extensive deposition of fiocculent matter and false membrane, producing extensive adhesions, and frequently copious effusion of a limpid or milky fluid, and sometimes of a fluid with all the characters of pus. Gangrene is rare, and, as far as my observation extends, does not occur as a prominent appear- ance; but when it is met with, is slight and partial, and always accompanied with extensive deposition of false membrane. I have already stated my conjectures in regard to the nature of this dis- ease. I conceive that the inflammation is confined to the peritoneal coat; that in this state it may be fatal Avithout interrupting the mus- cular action of the bowels ; or that the inflammation may extend to the muscular coat, and then assume the characters of enteritis. Inflammation of the peritoneum may occur in a more limited form than that which I have now described, and, according to the seat of it, may assume the characters of diseases of other organs, as the bladder, the kidney, or the liver j 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 fatal by coma and effusion in the brain; it may likeAvise take place in the omentum, as will appear from some of the cases to be mentioned. I do not know whether it ever occurs in the peritoneum lining the parietes, without affecting the covering of the intestine. I have seen some obscure cases, which appeared to be of this nature, but have not ascertained it, the cases having terminated favorably. Simple peritonitis may occur in a still more limited form, pro- ducing no urgent symptoms at the time, but giving rise to partial adhesions, which may afterwards prove the source of much de- rangement in the action of the canal. Several of the cases de- scribed under the head of ileus must have been originally of this nature; and this form of the affection will also be illustrated by Case LXI, in which it was ascertained at an early period in conse- quence of the patient dying of another disease. A remarkable circumstance in the history of peritonitis is, that PERITONITIS. 155 the activity of the disease may subside, leaving apparently the patient in a convalescent state, and with all the abdominal functions in a healthy condition, while most extensive disease remains, which may go on for some time without its presence being sus- pected, 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 illustrated by Case LXII. II. Enteritis differs from simple peritonitis chiefly in the presence of vomiting and obstinate obstruction of the bowels. The pulse also is in general more permanently frequent, and the pain more violent and constant, often resembling the tormina of ileus. This, however, is not invariably the case; enteritis, on the con- trary, being sometimes characterized chiefly by fever, with urgent vomiting and. obstruction of the bowels, with tenderness of the ab- domen, but without much complaint of pain. This variety seems to occur chiefly in young persons, as is exemplified in Cases LXVII. and LXVIII. The pulse in enteritis is generally small and rapid, but not uniformly so, for we may find the disease with a full pulse and little increased in frequency, as in Case LXIV. Enteritis is generally fatal with a tympanitic state of the abdo- men and rapid sinking, and Ave commonly find on dissection exten- sive deposition of false membrane, with adhesion, often combined Avith deposition of flocculent or puriform fluid, and generally liv- idity, or some degree of gangrene. The disease, we have reason to believe, consists in inflammation affecting both the peritoneal and muscular coats at once; and it is probable that it may supervene either upon ileus or peritonitis, or may take place at first in its com- plete form. We shall afterwards see cause to conclude that it may likewise supervene upon inflammation beginning in the mucuous membrane. 156 PERITONITIS? SECTION II . EXAMPLES OF PERITONITIS AND ENTERITIS. $ I.—Simple Peritonitis. Case LVll.—A girl, aged 15, on Sunday, 2d March, 1817, was at church in her usual health ; in the evening she complained of some pain of the abdomen ; (3d.) had pain of the belly and some vomiting; took castor oil, Avhich operated copiously; (4th.) pain continued with some vomiting, but not urgent, and the complaint excited no alarm; bowels quite open. Was seen by a surgeon, who found her pulse 116 and very small, and the belly painful on pressure. (5.) Belly tense and tympanitic ; other symptoms as before. Was bled Avithout relief; sunk rapidly and died at night. I did not see this case during the life of the patient, but Was pres- ent 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 in- terstices filled up by an immense deposition of coagulable lympth which Avas quite soft and recent; and the mass likewise adhered to the parietes of the abdomen. There was a similar deposition, though in smaler quantity, on the surface of the great intestine; and it was traced nearly to the extremity of the rectum ; it also appeared on the surface of the liver. The omentum Avas inflamed and dark colored ; and there were considerable marks of inflammation on the peritoneum lining the parietes of the abdomen. Case LVIIL—A girl, aged 15, (12th May, 1818) had fever, Avith pneumatic symptoms ; Avas bled with relief; the fever subsided gradually, and on the 19th she was considered as well. On the 20th, at night, she complained 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 ENTERITIS. 157 was also much alleviated, arid Avas only complained of upon pres- sure. The purgative did not operate during the day, but operated freely in the night four or five times. I saw her for the first time on the morning of the 22d, and found her moribund; the pulse not to be counted from its frequency; features collapsed; belly tympanitic. She died in less than an hour after the visit. Inspection.—On the surface of the bowels on many places, es- pecially on the ileum, there Avas peritonitis with deposition of false membrane. On the inner surface of the ileum, near the caput coli there was an inflamed portion, in the centre of which, there Avas a white spot the size of a shilling; and in the centre of this spot a round perforating aperture, which transmitted a quill; the edges of it were rounded, and a little thickened. Much fluid feces and gas had escaped into the cavity of the peritoneum, and the bowels Avere not distended ; there Avere in some places a few livid spots, but no gangrene. This case illustrates a highly dangerous, or indeed hopeless form of the disease, in Avhich it originates in an ulcer perforating the intestine, and allowing the escape of its contents into the perito- neal cavity; the same form of the disease has already been exem- plified in connection Avith perforating ulcer of the stomach ; and we shall have occasion to refer to it again, when we come to the con- sideration of ulcers of the mucous membrane. These cases may be sufficient to establish the existence of the disease alluded to under this section, namely, fatal abdominal in- flammation, with an open state of the bowels; but, as the disease is not of very common occurrence, I shall here introduce the fol- lowing case described by Dr. Marshall Hall, which illustrates in a very striking manner the peculiar characters of this interesting affection. * A man, aged 50, had acute pain in the hypogastric region, with frequent desire and difficulty of voiding his urine. After some relief during the night, his complaint was renewed on the fol- lowing day, and, after the operation of a dose of castor oil, it in- creased to such a degree as to produce Avrithing of the body, Avith urgent ineffectual attempts to void urine ; the pulse natural. Re- lief was obtained from the warm bath, after which urine was voided (3d day.) Pain and dysuria continued, and the pain extended more *Edin. Med. Jour. Vol. XII. 158 PERITONITIS. generally over the abdomen ; the bladder was found empty by the catheter ; pulse nearly natural. (4th day.) There had been co- pious evacuations by stool; some high colored urine passed; pulse 90, and soft; tongue white. (5th day.) Pain returned after a saline purgative, which operated scantily; it Avas now chiefly referred to a spot on the left iliac region, increased by pressure, but also attended with a more general pain over the abdomen ; great, restlessness, and much flatus in the stomach; a little vomiting for the first time on taking anything, but no continued nausea or retch- ing; pulse 96; in the evening 84, soft, and regular. (6th day.) The chief pain had shifted to the right iliac region,—the former pain in the left having now ceased; pulse 124, and small; features collapsed; body cold ; died at 4, p. m. Inspection.—Much exudation and adhesion over the surface of the bowels ; the ileum, coecum, and colon, were injected with nu- merous vessels in some places, so as to acquire a dark color ; but the texture was firm and entire. The appendicular pinguedinosae were injected and covered with a viscid effusion, communicating the appearance of a mass of disease. The external and posterior por- * tion of the bladder appeared also a little injected; the other viscera were natural. The following case bears a remarkable similarity in its symp- toms to the very important case of Dr. Hall. Case LIX.—A gentleman, aged 25, (18th Sept. 1816) was af- fected with pain in the bowels, accompanied by considerable dysu- ria, 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 unabated, accompan- ied Avith tenderness of the abdomen, and aggravated by motion; the more violent pain Avas not constant, but occurred in paroxysms; pulse in the evening 80. He was bled to 16 ounces, and took a moderate opiate. (19th.) Easy in the night, but, in the morn- ing, the pain returned with such violence as to occasion screaming, and extreme distress; it Avas chiefly about the umbilicus, but some- times shifted to the stomach; and there Avas violent pain in the re- gion of the bladder, extending along the urethra, with much dysu- ria ; great tenderness of the abdomen ; some vomiting; pulse from 90 to 100; several feculent consistent stools after a mild enema. Was bled to 16 ounces, and took a dose of aloes. After the bleed- PERITONITIS. 159 ing, the violent pain subsided, but the tenderness continued, with occasional short paroxysms of pain, and repeated vomiting. The dysuria continued, and at one time amounted to retention, Avhich was relieved by a mild enema; bowels freely opened. At night took an opiate. (20th.) MugIi depression, sickness, and faintness; abdomen tender, and a little tympanitic; no constant pain, but occasional paroxysms of short duration ; respiration short and quick ; and, on taking a full inspiration, he felt severely pained, and cramped across the epigastrium. He lay on his back, but could not bear the pressure of the bed clothes; countenance anxious ; voice feeble ; pulse 100; dysuria abated; some vomit- ing ; 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 flatus, 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 Avere moved four or five times Avith much relief ;~pulse 80 ; all the symptoms abated. From this time he continued well, but discharged much hardened feces for several days. In this very important case, I believe that bleeding ought to have been pushed more actively in the early stages; and particu- larly that it ought to have been repeated on the evening of the 19th. § II.—Peritonitis confined nearly to the descending colon and rectum. Case LX.—A gentleman, aged about 60, (17th May, 1827,) complained of pain about the umbilicus, without fever. Took cas- tor oil, aided by injections, and discharged much scybalous matter with relief; but the pain returned in the evening, and he continued in great pain through the night; was bled from the arm by Mr. White. (18th.) Much pain complained of in the very lowest part of the ab- domen, about the region of the bladder; and there were considera- ble 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 Avere freely moved ; but the pulse continuing 160 PERITONITIS. about 90^ he Avas again freely bled from the arm at night. Through the night, his bowels were moved repeatedly and freely, and the mo- tions were feculent and healthy. (19th.) Seemed much relieved ; pulse natural; but the same feeling of tympanitic distention con- tinued 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 Avas 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 color, with very slight patches of false mem- brane on the small intestines, but they appeared to be quite recent. The chief seat of the disease was on the rectum, the sigmoid flex- ure of the colon, and the lower part of the descending colon. These parts Avere 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 blad- der was healthy. § 27/.—Local peritonitis of very small extenti Case LXI.—A young man, aged 20, was recovering from an attack of natural small-pox; but, going out too soon in cold weather, he Avas attacked with a febrile affection, and complained of a circum- scribed pain in the left side of the abdomen near the umbilicus. There Avas no vomiting, and the bowels were quite natural. Gen- eral and topical blood-letting were employed, by which he seemed .to be entirely relieved ; but after two or three days he became de- lirious, and then comatose. In this state I saw him, and the usual treatment was employed without any relief. He died in two days more. By the medicines which were given him during this period, his bowels Avere moved readily and freely. Inspection.—There was high vascularity of the membranes of the brain, and considerable effusion under the arachnoid. In the left side of the abdomen, there was adhesion of two contiguous turns of the small intestine, through a space about six inches in extent; and the inner surface of one of the portions was extensively ulcer- ated. The other parts Avere healthy. PERITONITIS WITH SUPPURATION. 161 § IV.—Peritonitis terminating by extensive suppuration. The follovving remarkable case shoAvs, in a striking manne/, Avhat extensive disease may remain after an attack of peritonitis, though every symptom has been removed. Case LXIL—A young lady, aged 20, (9th July, 1822,) was seized with symptoms of peritonitis, which Avere relieved by blood- letting, and the other usual means; and on the 12th, she appeared to be convalescent. At night she took some pills of aloes and col- ocynth, which operated frequently with much irritation. After this, the pain of the bowels returned, and continued through the 13th. (14th.) There Avas severe pain of the boAvels, with tender- ness, and the pulse was again becoming frequent. She was noAV bled from the arm, and a second time a few hours after; and, after the 3econd bleeding, she became very faint and low. I now saw her for the first time, and found the pulse extremely frequent and small j she had a look of extreme 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 injec- tions, 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 tenderness subsided ; the pulse came down ; the bow- els 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 ap- peared to be recovering perfect health ; the pulse and functions of the stomach were natural; the bowels easy, or easily regulated by the mildest medicine; and her strength improved daily. About the 25th, she began to be troubled with a parotid swell- ing, which gave her a good deal of uneasiness; but in other re- spects she was well; she was in the drawing-room the greater part of every day, and every function was natural. The swelling ad- vanced slowly to suppuration, and Avas of very considerable size; it discharged a little matter by the ear, but she would not submit to have it opened. On the night of the 2d of August, she went to bed in her usual health, having been in the drawing-room through the 21 162 PERITONITIS WITH SUPPURATION. day, and without any complaint except the paroid swelling. Early in the morning of the 3d, she awoke in great distress, with cough rfnd oppressed breathing. When I saw her about 11 o'clock, her fate was cadaverous; her breathing frightfully oppressed, with a rattling sound. The pulse was very frequent, and there was in the room an intolerable fcetor. My first impression was, that the parotid SAvelling had burst into the larynx; but upon opening it, healthy pus was discharged, while small quantities of frothy fluid, which she coughed up, were intolerably feted. She died about twelve. Inspection.—Betwixt the diaphragm and the upper surface of the liver, there was formed a distinctly defined cavity, lined by a cyst of coagulable lymph, and containing at least a pound of thin puriform matter of intolerable fcetor. The right lung adhered ex- tensively to the diaphragm ; and the diaphragm was perforated by a small opening, by Avhich the matter from the abscess had passed freely into the bronchial canals, and it was traced as far as the trunk of the trachea. The liver was sound in its internal struct- ure, but on its peritoneal coat there were some marks of inflamma- tion. 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 Avithout tearing these adhesions, which were soft. Throughout this mass of disease, there were in several places cavities of A'arious sizes, containing purulent matter; one of these on the right side seemed to commu- nicate by a small canal with the great abscess above the liver. In the posterior part of the pelvis, behind the uterus, another great ab- scess was discovered, containing nearly a pound of thin, fetid pus. It Avas formed by adhesions betwixt the intestine, the uterus, and the ovaria, so that it was completely cut off from the other parts, and remained entire, after the examination of them had been con- cluded. That in this case the boAvels should have continued to discharge their functions in the most healthy manner for a fortnight, is per- haps 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 dis- ease was entirely confined to the peritoneal coat. Case LXIII.—A woman, aged 40, after exposure to cold in the beginning of November, 1813, Avas affected with pain in the PERITONITIS AVITH SUPPURATION. 163 left side of the abdomen, at first remitting, but aftenvards more con- stant, though without confining her to bed. This had continued for nearly a month, when I saw her in the beginning of December Avith symptoms of more active peritonitis, from which she was re- lieA'ed by repeated blood-letting, and the other usual means. The bowels were at first obstinate, but soon yielded to the usual reme- dies, and the immediate urgency of the symptoms was thus soon re- moved ; 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 SAvelling began to be observed on the left side of the abdomen, which gradually increased, with much pain and constitutional irritation, until the second week of Febru- ary, when it broke and discharged a large quantity of verd fetid pus. During this time her bowels Avere open, and the motions Avere natural. The discharge of matter now continued from the side, and several new openings were formed ; but it gradually di- minished, and all the openings were healed in the beginning of April. During the discharge she had been much emaciated and hectic, but she now began to improve; she was able to be out of bed in the end of April, and to Avalk out about the beginning of May. The attacks of pain in the abdomen still returned occasion- ally, but at longer intervals ; and they were relieved as formerly by purgatives and opiates. On the 5th of May, she was attacked by a violent paroxysm of pain, which did not yield to any of the remedies that were employed, and she died early in the morning of the 6th. Inspection.—Almost universal adhesions of the intestines to each other, and to the parietes of the abdomen ; some of these Avere 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 doAvn by adhesions to the spine ; above the contraction, the canal Avas dilated into a large sac. No trace remained of the abscess except the cicatrix in the integuments, Avhich nearly corresponded in situation with the place Avhere the intestine was so much contracted. 164 PERITONITIS PASSING INTO ENTERITIS. § V.—Peritonitis passing into enteritis. Case LXIV—A gentleman, aged 20, (3d September, 1812,) had pain and tenderness in the lower part of the abdomen ; pulse from 84 to 90, and full; bowels natural. Was bled and took laxative medicine which operated fully. The bleeding was re- peated on the 4th, and on the 5th and 6th, he was much better, complaining only of occasional griping, and his pulse was quite natural. Took laxative medicines which operated fully; the mo- tions copious but rather watery and of a greenish color. (7th.) Free from complaint in the morning, and the bowels open. In the afternoon, he complained that some laxative medicine had produced most unusual pain; and at night he had fixed pain in the upper part of the abdomen, with shivering followed by heat; pulse 84. Through the night had copious feculent evacuations, Avithout relief of the pain, and repeated vomiting. (8th.) Pulse 96; fixed pain in the abdomen, which was hard, tender, and tympanitic; repeated vomiting ; the boAvels obstructed ; repeated blood-letting and all the other usual remedies were employed without relief. (9th.) Pain unabated ; belly tympanitic; but less tender; vomiting abated; no stool except some very scanty discharges of watery matter; pulse from 100 to 126; hiccup. At night the pain abated ; the boAvels were moved, but sinking took place; and he died at nine in the morning of the 10th. Inspection.—All the intestines much distended and glued to- gether by most extensive adhesions; omentum highly inflamed and adhering to the intestines. At the lower part of the small in- testine, an extensive portion was gangrenous, and another at the lower part of the descending colon. The appendix vermiformis Avas gangrenous, and an opening had taken place in it through which liquid feces had escaped into the cavity of the abdomen. Case LXV— A gentleman, aged 20, (10th December, 1817) late at night, was found Avrithing and screaming from intense pain in the abdomen, every part of Avhich was extremely tender to the touch; frequent vomiting; much dysuria; pulse 96 and soft. Had felt pain for several days, but it had increased on the evening of the 9th, with vomiting; took laxative medicine on the morning of the 10th, which operated freely three or four times ;. but after these ENTERITIS. 165 evacuations the pain was much increased. He Avas largely bled; and on the 11th he was greatly relieved; pulse 90. The bleeding was repeated, and his bowels were moved by a mild enema. In the course of the day he had some paroxysms of pain, and vomited twice; but there was much less tenderness of the abdomen, except at one spot at the lower part of the right side, where it was still acutely tender ; bowels open. Bleeding was repeated at night. (12th.) 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 frequent; abdomen enlarged at the lower part and tender ; 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 in- flamed parts were extensively glued together, and pressed down into the cavity of the pelvis, by the distension of the parts above, which were also inflamed but with less exudation. Bladder in- flamed and collapsed; omentum inflamed ; about a pound of puri- form matter in the cavity of the peritoneum. § VI.—Enteritis. Case LXVI— 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, various laxatives, &c, continued through the 4th, 5th, and 6th, the inflammatory symptoms subsided; but the boAvels con- tinued very unmanageable, and were not moved in a satisfactory manner till the 12th. From the beginning of the attack she had complained of pain in the ear, which at first attracted little notice, but afterwards became more severe ; and on the 22d she died of ab- scess of the cerebellunq_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 Avere of a very dark livid color, Avithout any change in their structure. ♦ Researches on the Pathology of the Brain, Case XLIII. (2d Edit.) 166 ENTERITIS. Case LXVII.—A child, aged 3 years and 3 months (12th, February, 1812) had urgent vomiting and great thirst; all the li- quids taken being vomited almost immediately, mixed Avith large quantifies 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; boAvels moved by medicine on the 9th ; and on the 10th she seemed much better, and the bow- els 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 10th, and was very urgent through the whole of the I lth; and the bowels had not been moved since the commence- ment of the vomiting. The usual remedies were employed Avith- out benefit; the vomiting continued urgent, and the bowels obstin- ately obstructed. (13th.) Vomiting abated; medicines were re- tained but produced no effect. She continued through the day at times restless and feverish, at others oppressed and exhausted; and she died in the night. Inspection,—Stomach externally healthy,—internally showed increased vascularity, and contained much dark colored fluid. About a fourth part of the small intestine, at the upper part, was highly inflamed,—in some places black and gangrenous, in others adhering and covered with false membrane. The diseased portion was greatly distended and contained much dark colored fluid, but no feces. Immediately below this part the intestine became at once narrow and contracted, empty, and of a white color, except a few streaks of superficial redness. Case LXVIII.—A boy, aged 10, (10th May, 1823) was out at play in the morning before breakfast in perfect health; returned home about nine, complaining of pain in his belly. Laxative med- icine was given him, and was repeated at intervals through the day Avithout effect. In the evening, he began to vomit, and passed a restless night Avith frequent vomiting ; the pain in his belly contin- uing. (11th.) Pain continued in the ear% part of the day, but subsided in the afternoon ; was seen by a surgeon, who ordered a succession of purgatives, but they Avere constantly vomited. I saAV 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 Avhole belly continued, with frequent vomiting; and there had been no stool. Bleeding from the arm was employed Avith much PRACTICAL CONCLUSIONS. 167 apparent relief, followed by leeches, &c. The bowels Avere now moved by a mild enema, and he had afterwards one or tAvo 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 Avas much distended; in the lower part there was high inflammation, Avith ex- tensive adhesions.' By the distension of the upper portion, a great part of the ileum was pressed together into the cavity of the pelvis, forming a mass of disease, the different parts of which adhered extensively to each other, to the rectum, and to the sides of the pelvis; much force being required either 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 considerable quan- tity of puriform fluid. The high importance of the subject must be my apology for de- tailing so many cases, calculated to illustrate the pathology of this interesting and .dangerous class of diseases. They seem to war- rant the following practical conclusions. CONCLUSIONS FROM THE PRECEDING FACTS. 1. Extensive and highly dangerous inflammation may exist in the intestinal canal without obstruction of the bowels; and it may go on to a fatal termination, Avhile the bowels are in a natural state, or easily regulated by mild medicines, through the whole course of the disease. 2. No diagnosis can be founded in such cases on the appearance of the evacuations. These may be slimy, and in small quantity ; they may be copious, watery, and dark colored ; or they may be entirely natural. 3. Extensive and fatal inflammation may be going on with every variety in the pulse. It may be frequent and small; it may be frequent and full; or it may be little above the natural standard through the Avhole course of the disease'. 4. Extensive inflammation may go on Avithout vomiting and Avithout constant pain : the pain often occurring in paroxysms, and leaving long intervals of. comparative ease. 168 TREATMENT OF INTESTINAL INFLAMMATION. 5. Keeping in view these sources of uncertainty, our chief re- liance, for the diagnosis of this important class of diseases, must be on the tenderness of the abdomen. This symptom should always be watched with the most anxious care, whatever may be the state of the boAvels, or of the pulse, or the actual complaint of pain,— and though the tenderness itself should be limited to a defined space of no great extent; for, we have seen, that Avith every variety in these respects, a disease may exist 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 attentive practitioner can in general have no difficulty in making the distinction. When the tenderness exists Avithout distention, as is frequently the case in the early stages of peritonitis, there can be no difficulty in the diagnosis. SECTION III. OUTLINE OF THE TREATMENT OF 1NTSTINAL INFLAM- MATION. In the treatment of this most important class of diseases, the great principle to be kept in view is, that the affection which we have to contend with is simply inflammation. This inflammation may exist with every variety in the state of the bowels ; Ave have seen them obstinately obstructed, and we' have seen them easily moved through the whole course of the disease ; and, when ob- struction had existed, we have found it give way, and free evacua- tion take place, without in any degree improving the situation of the patient. Our first great object, then, is simply to combat the in- flammation ; 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 a»d the strength of the patient, aided by large topical bleeding, blistering, &c. In a considerable num- ber of cases, I have used with evident advantage the application of TREATMENT OF INTESTINAL INFLAMMATION. 169 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 probable, might be used Avith advantage. In all cases of active inflammation, blood-letting can be of com- paratively 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 par- tial 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, Ave 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 produced by five ; and, besides, the dis- ease has in the interval been gaining ground, its duration is pro- tracted, and the result consequently rendered more uncertain. The inflammation of a vital organ should not be lost sight of above an hour or two at a time, until the force of it be decidedly broken, and, unless this takes place within 24 hours, the termination must be considered as doubtful. The means now alluded to, are those calculated for subduing the inflammation, Avhich is our first and great object in the treat- ment of this disease ; but there is another point Avhich must ever be a prominent object of attention in cases of this class, namely, the state of the bowels. On this head, Ave have seen very great diversity; we have seen the bowels obstinately obstructed, and we have seen them spontaneously open or easily regulated; and, in both cases, the disease has run its course with equal rapidity to a fatal termination. We have found no reason to believe that the re- tention of feces Avas in itself injurious in the one case, or the free evacuation of them beneficial in the other; on the contrary, Ave have had evident reason to believe, that in several cases, in which the inflammation appeared to be subdued, the action of a purgative was immediately followed by a renewal of the symptoms. Along 22 170 TREATMENT OF INTESTINAL INFLAMMATION. with these considerations, we must keep in mind the fact, that, in the ordinary cases of enteritis, the action of purgatives is in gen- eral entirely fruitless; they are usually vomited as often as they are given, and consequently can only prove additional sources of irritation. I know that much difference of opinion exists among practical men upon this subject; but upon the grounds noAV referred to, I confess my own impression distinctly to be, that the use of purgatives makes no part of the treatment in the early stages of en- teritis ; 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 injec- tions will often be found to have the effect, after the most active pur- gatives had previously been given in vain. In the general treat- ment of enteritis, indeed, it is desirable to keep the bowels, if possi- ble, free from distention; but this object, may, I think, in general, be obtained by mild injections, 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 sub- duing the inflammation. Before concluding these general remarks, I would briefly allude to some circumstances which often occur during the treat- ment of enteritis, and which are apt to embarass the young practi- tioner :— I. The pulse continuing very frequent after the inflammation appears to be subdued. In this state digitalis may be given very freely with much advantage. II. Cessation of the pain, sinking of the vital powers, great weakness of the pulse, and coldness of the body. These symptoms are generally considered as indicating gangrene, and consequently a hopeless state of disease. When treating of ileus, I have pro- duced evidence that this is by no means invariably the case; for I have shown these symptoms connected with slight and recent in- flammation, and I have shown them recovered from. I shall now only add the following example :— TREATMENT OF INTESTINAL INFLAMMATION. 171 Case LXIX.—A man, aged 40, was affected vrith enteritis in .the usual form, for which he was treated in the most judicious manner by a respectable practitioner. On the 5th day, the pain ceased; the pulse was 140, and extremely feeble and irregular; his face was pale, the features were collapsed, and his whole body was covered with cold perspiration; his bowels had been moved. In this condition, I saw him for the first time. Wine was then given him, at first in large quantities, and, upon the Avhole, to the extent of from two to three bottles during the next 24 hours. On the following day, his appearance was improved; his pulse 120 and regular ; the wine was continued in diminished quantity. On the 3d day, his pulse was 112, and of good strength, and in a few days more he was well. In such a case as this, there could be no doubt as to the only practice that could be adopted; but there are cases in which, at a particular period of the disease, wine is given with much advan- tage, though the symptoms are much more ambiguous, and it is difficult to decide upon the practice which ought to be followed. This is strikingly illustrated by the following ca^se :— Case LXX.—A lady, aged 35, on the seventh day after deliv- ery, Avas seized with symptoms of peritonitis, with much tender- ness and urgent vomiting ; respiration short and oppressed; pulse 140 and sharp. The pain was aggravated by inspiration, and by every motion of the body. She was bled and blistered, and took laxative medicine, which operated freely. After the bleeding, she Avas very much relieved, and could breathe Avithout uneasiness; the vomiting subsided, and the pulse was much diminished in fre- quency ; 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 quan- tity of a small glass every hour, and injections of beef tea contain-* ing bark in powder 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 gradu- ally improved. On the second day, the pulse Avas from 125 to 130; and on the third day, from 112 to 120; but for several days she continued to take a bottle of wine in each 24 hours. For some time she suffered severely from an aphthous state of the mouth and 172 TREATMENT OF INTESTINAL INFLAMMATION. 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 symptom, and gives reason to apprehend, that the disease is passing into a somewhat chronic state, with ex- tensive adhesions and effusion; but that this is not a necessary consequence will appear from the following case. The nature of the affection is obscure. Case LXXI.—A young man, aged 17, was affected with en- teritis in a severe form, which required much active treatment ; but the case yielded favorably, and about the 7th day he Avas free from complaint. On the 9th day, his pulse began to rise again, and the abdomen became enlarged, very hard and tense, and tender to the touch ; the bowels open ; his pulse when sitting up 120. In this state, in spite of every remonstrance, his friends carried him to the country. I expected to hear of his death, but the affection gradu- ally subsided, and he returned to tOAvn in a feAv weeks in perfect health. IV. A tympanitic state of the abdomen. This occurs in con- nection Avith several forms of the disease, and in every form of in- testinal inflammation is a symptom to be watched with the most anxious attention. The most unfavorable is the true tympanites abdominalis, which arises from perforation of the intestine, and the escape of flatus into the cavity of the peritoneum. Some examples of this have been already mentioned, and others will be referred to when we come to treat of ulcers of the mucous membrane perforat- ing the intestine. In the early stages of enteritis, a tympanitic state may occur from a temporary derangement of the muscular action, and may subside as the inflammation is subdued. At a more advanced period of the disease, it must be looked upon Avith much anxiety. If it occur at this period Avhen the inflammation has not been subsided, it is generally a fatal symptom, depending upon a complete loss of the tone of the bowels ; and it is commonly found to be connected with very extensive adhesions. Tympanites, however, may occur from mere loss of tone of the parts, after the TREATMENT OF INTESTINAL INFLAMMATION. 173 inflammation has been subdued; and in this case, it may be recov- ered from, though the appearance of the patient for the time is most alarming. In this state of the case, it is often impossible,to ascertain with certainty on which of these two conditions of the disease the affection depends; but the safe rule always is, to act upon the supposition of it being in the more favorable form, from which the patient may recover. This is to be treated by small quantities of wine or brandy given at short intervals; gentle com- pression and friction of the abdomen ; and injections of beef tea, to Avhich may be added considerable quantities of bark or sulphate of quinine, turpentine, or tincture of assafoetida, and a moderate quan- tity of laudanum,—these to be repeated once in two or three hours. The bowels may be moved by very mild laxatives, such as aloetic Avine or aloes and hyosciamus ; but laxatives require to be given Avith the utmost caution. The affection is one of very great inter- est 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 examples. Case LXXIL—A lady, aged about 36, a few days after her accouchement, was seized with symptoms of peritonitis, which was treated in the usual manner by a judicious practitioner. The ac- tivity of the symptoms was subdued by two bleedings; the bowels yielded to laxative medicine, which, in fact, operated rather fully and with irritation. This was followed by a state of exhaustion, in consequence of which I saw her. I found her with a haggard and exhausted look; the skin 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 treatment she improved rapidly, and in a few days was in her usual health. Case LXXIII.—A boy, aged 6, had acute pain in the abdo- men1, much increased by pressure and by inspiration ; short anxious breathing; pulse extremely frequent. He Avas bled from the arm, and took some laxative medicine, which operated, and he Avas very much relieved. He then did well for two days,-when on visiting, him at night, I found him oppressed and restless ; countenance 174 TREATMENT OF INTESTINAL INFLAMMATION. anxious; pulse above 140; the belly enlarged and tympanitic, and painful on pressure. Injections, containing bark in powder with tincture of assafoetida, were given every three hours, aided by friction, &c. with great relief. Under this treatment the affection soon subsided, and in a few days he was able to be out of bed; but he continued feeble and sallow, with cough, bad appetite, frequent pulse, and a Avithered, 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, ap- peared to consist of mere derangement of the muscular power, yet assumed characters which might have been considered as indicat- ing mesenteric disease; and I believe it is an affection of frequent occurrence, especially in children, in whom it often assumes char- acters resembling those of fixed and serious disease. It is treated by air and exercise, tepid bath, friction of the abdomen, and vegeta- ble bitters, as the Colombo powder combined Avith small doses of rheubarb or aloes, or small doses of the sulphate of iron combined with rheubarb. A tympanitic state of the abdomen, such as occurred in the above mentioned cases, occurs also from other causes, though put- ting on the same alarming characters. Case LXXIV.—A lady, aged about 35, had suffered for some days from a loose state of the boAvels, accoihpanied by a good deal of pain and irritation; but the complaint was considered as a com- mon diarrhoea, and attracted 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 Avhen I saw her a day or tAAro 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, Avith careful watching night and day, she rallied gradu- ally, and AA'as soon in her usual health. ERYSIPELATOUS PERITONITIS. 175 SECTION IV. ERYSIPELATOUS PERITONITIS. 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 simple acute peritonitis. But there is another form of the disease of very great interest, and, in several respects, remarkably distinct from the former. The 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 character of this affection is, that it terminates chiefly by effusion of fluid, without much, and often without any, of that inflammatory and adhesive exudation, Avhich 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 proportion of pus, which separates and subsides to the bottom of a vessel in which the fluid is left at rest; in other cases it is milky or whey-colored, or con- tains 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 in- testine varies considerably; in some cases, the surface is, for a considerable extent, of a uniform dark red color; in others, there is only a slight increase of vascularity; and frequently little or no deviation can be discovered from the healthy structure. In some cases again, the peritoneal coat, or a portion of it, has a slightly thickened and softened appearance, like a part that has been boiled; and in some examples of this form of the disease, it ap- pears that the omentum has been a principal seat of the inflamma- tion. The symptoms of this affection are sometimes slight and in- sidious, but sometimes very severe; and they are chiefly distin- guished by the rapidity with which they run their course, and by a remarkable sinking of the vital powers, Avhich occurs from an 176 ERYSIPELATOUS PERITONITIS. early period, and often prevents the adoption of any active treat- ment. A remarkable circumstance in the history of the affection is its connection Avith 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 LXXV—A lady, aged 50, in June, 1823, was seized Avith extensive erysipelas of the'left leg, accompanied by acute pain, and considerable swelling of the upper part of the foot. After six or seven days the erysipelas of the leg subsided gradully,—the SAvel- ling" and pain of the foot continuing undiminished. After another day these disappeared suddenly, and a few hours after she Avas seized with acute pain in the region of the stomach, which, after a short time, moved downwards, and settled with great severity in the lower part of the abdomen, and around the umbilicus. This took place in the night, and I saw her in the afternoon of the fol- lowing day. She Avas then moaning with most acute pain, but did not complain much of pressure; great anxiety and restlessness; pulse about 100; bowels open. I advised bleeding, a blister, &c, but the former, I afterwards found, was not done at the time. At night the pain continuing unabated, she Avas bled Avithout relief. The other usual remedies Averethen 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 morn- ing of the following day, being little more than 24 hours from the attack. Inspection.—The lower half of the small intestine was of a uniform deep dark red color, but without any exudation : the upper half Avas of a dull leaden color; and the whole was considerably distended. In the cavity of the peritoneum there was a considera- ble quantity of bloody sanious fluid. No other morbid appear- ance could be discovered. Case LXXVI.—A woman, aged 30, had been ill for several days Avith the erysipelatous inflammation of the throat, accompan- ied Avith considerable fever. She felt better and was able to be out of bed, Avhen, having taken some laxative medicine, she was se- verely pained during its operation; and in the evening was seized with most violent pain over the whole abdomen, accompanied by ERYSIPELATOUS PERITONITIS. 177 vomiting. I saw her on the folloAving day, along with Dr. Begbie, and found her pulse very frequent and extremely small; skin rather cold ; countenance expressive of exhaustion; severe pain and acute tenderness of the whole abdomen; some vomiting; no stool. A bleeding was attempted, but she bore very little; and it gave no relief. Blistering, opiates, tobacco and other injections, &c, were then employed without benefit. She continued in the same condition, and died in the evening of the following day being about 48 hours from the attack; the bowels had been partially moved. Inspection.—The bowels were in general considerably distended and of a dark livid color without exudation. In the cavity of the peritoneum, there was a considerable quantity of puriform fluid. There was much appearance of inflammation upon the omentum, especially at the loAver part, Avhere it was for several inches highly inflamed and thickened, and had formed an adhesion to the sigmoid flexure of the colon. In the Merchant's Hospital of Edinburgh, (a charitable institu- tion for the education of girb,) an epidemic appeared in the begin- ning of March, 1824. Its principal character was a slight erysip- elatous affection of the throat, generally beginning with vomiting and accompanied by slight fever ; and in many of the cases, there Avere swelling of the glarids of the neck. It spread with great rapid- ity, 15 or 20 girls being sometimes bed in at a time; but was in gen- eral a very slight affection, disappearing in three or four days with little treatment. The epidemic had gone on in this manner for about a week, when, on the 13th, a girl, aged 10, was affected in the same slight manner as in the other cases. On the 14th she seemed much better, and on the 15th she complained only of slight headache, on account of which she Avas still kept in bed. About two o'clock in the afternoon, she suddenly got out of bed in a state of incoherence, and was soon after affected with repeated vomiting and diarrhoea, by which she discharged a green and Avatery 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 betAveen four and five, she was unable to answer any question ; pulse scarcely to be felt; body cold ; face cadaverous ; occasional vomiting continued. Stim- 23 178 ERYSIPELATOUS PERITONITIS. ulants Avere ordered, and I saw her along Avith Mr. Wood between nine and ten at night; she was then lying Avith her eyes open, and seemed to observe those about her, but made no attempt to speak ; pulse scarcely to be felt; action of the heart tumultuous and irreg- ular ; body cold ; occasional vomiting; no return of diarrhoea; she died about eleven at night. Inspection.—Extensive marks of peritoneal inflammation with slight deposition of lymph in flakes on various parts of the intes- tines; in the cavity of the peritioneum there was a considerable quantity of milky puriform fluid. The appendix vermiformis was large, turgid, and of a very dark color approaching to gangrene; the brain, and viscera of the thorax were sound; and nothing un- usual Avas remarked in the mucous membrane either of the stomach or bowels. After the occurrence of this case, the epidemic Avent 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 turgescence 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, a slight affection, requiring little treatment except confinement to bed for a few days, and gentle laxatives ; and no other urgent case oc- curred until Sunday the 4th of April. A girl, aged 12, had been in the sick ward for three or four days with the usual symptoms, and on Saturday was considered as convalescent. On Sunday she complained of considerable pain in the bowels, with frequent de- sire 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, when Mr. Wood found her complaining of severe pain, Avith tenderness over the whole abdo- men, and the pulse was frequent. He then bled her freely from the arm, and ordered the other usual means. I saw her along with him in the afternoon. Her pulse was 120 and rather small; abdo- men tense and tender; no vomiting, and not much expression of suffering; bowels not moved since the former day; a number of leeches were ordered, with injections, blister, &c. (7th.) Bowels ERYSIPELATOUS PERITONITIS. 179 moved several times; stools feculent, and healthy; abdomen still tense and tender when touched, but not much complained of at other times ; no vomiting ; pulse frequent and rather weak, so as to prevent us from using farther general bleeding; free topical bleeding was repeated with apparent relief; and in the afternoon she bore pressure much better, though the tenderness was not en- tirely removed. In the evening she began to sink without any other change of the symptoms, and died in the night. Inspection.—There were extensive marks of inflammation on the surface of the intestines, with deposition of lymph in flakes in many places, and some slight adhesions; there Avas extensive de- position of puriform fluid in the cavity of the peritoneum ; the upper surface of the liver was covered by a thin deposition of false membrane. The remarkable epidemic referred to in the preceding observa- tion, seems to have been very analogous to the Diptherite formerly described, though in its progress and terminations it differed con- siderably from the epidemic of 1826,—in which, as I have already mentioned, the disease often extended to the larynx. This termin- ation occurred in a large proportion of the cases, and nearly the whole of these were fatal. In the epidemic in the Merchant's Hospital, there was no example of the larynx being affected, and there Avas no fatal case, except the two now described from this pe- culiar affection of the peritoneum. About the time when this epi- demic 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 membrane of the nose, accompanied with a copious mor- bid secretion, and great tenderness of the membrane. The inflam- mation extended gradually forwards, until at last it spread outwards upon the integuments of the nose, and thence over the face in the usual form of erysipelas. These cases showed in a very striking manner the identity of the inflammation which had appeared in the three situations with different characters; namely, in the membrane of the throat with extensive aphthous crusts; in the membrane of the nose, Avith a copious discharge of morbid mucous; in the in- teguments of the face in the ordinary form of erysipelas. 180 ERYSIPELATOUS PERITONITIS. The folloAving case seems to be referable to this part of the subject, though, in some respects, it differs considerably from the cases now described. Case LXXVII.—A gentleman, aged about 50, of a feeble and broken down constitution, about four Aveeks before his death, suffered for some days intestine pain in the rectum, which terminated in an abscess; and, in connection Avith it, sinuses were formed along the buttocks. These were opened, and appeared to be going on favorably; and though he was a good deal confined to bed by them, he made no particular 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 griping pain in the bowels. On Wednesday, the vomiting had subsided, the bowels were moderately open, and the stools were healthy; but there was much general uneasiness over the abdomen, with some hiccup, and his look was depressed and anxious. His pulse was 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 Avas still natural, and the boAvels moderately open. The ab- domen was not distended, but he eomplained of considerable un- easiness upon pressure across the epigastric region. His look was depressed, anxious, and exhausted; and without any change in the symptoms, he died in the night. Inspection.—The cavity of the peritoneum contained a large quantity of purulent matter of intolerable fcetor; three pounds and upwards, were collected besides much that Avas lost. The surface of the intestines was in general of a dark livid color, but Avithout any appearance of exudation. The right lobe of the liver, on its concave surface, was considerably softened, rugged, and unequal; no disease could be discovered in any other organ. The most dil- igent 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, Avithout speculating farther upon the na- ture of it, Ave may merely add, that its alliance to erysipelas seems to be an obvious and remarkable character of the disease. We have every reason to believe that inflammation of an erysipelatous ERYSIPELATOUS PERITONITIS. 181 character may affect the same parts which are liable to the ordi- nary acute inflammation, but giving rise to symptoms remarkably different. We see this strikingly exemplified in the erysipelatous inflammation of the throat, compared with the ordinary cynanche tonsillaris; and there are many other facts which tend to show that erysipelatous inflammation, when transferred to internal organs, produces diseases deeidedly different from the common acute inflam- mation of the same parts. The subject has not been much investi- gated, 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 puerperal women. I have not seen so much of this disease as can entitle me to offer a decided opinion from personal observation ; but, from Avhat 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 liable to two distinct forms of peritonitis, Avhich in the discussions on this subject, have probably not been sufficiently distinguished from each other. They are liable to the common acute peritonitis,—present- ing 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 disease, in Avhich the symptoms are more insidious, and are accompanied, from an early period, by great prostration of strength, and fever of a typhoid character. This affection runs its course with great ra- pidity ; 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 Avithout 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 con- veyed from one woman who is affected with it, to another who is in the puerperal state. It appears as an epidemic at particular times, being very frequent and very fatal while 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 Ave have seen may be fatal Avith- out any remarkable change in the organization of the parts ; and 182 CHRONIC PERITONITIS. 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 re- solved by the effusion, without leaving any injury to the organiza- tion of the parts. Several cases of this kind have been reported to me, in which, after symptoms of peritonitis, chiefly in the puerpe- ral state, purulent matter either found a vent for itself through the parietes of the abdomen, or was evacuated by tapping, and the pa- tients recovered. I have even observed some facts which induce me to believe that, in some modifications of this affection, a certain degree of peritonitis 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 cer- tainty ; but I have seen cases, with slight and obscure peritonic symptoms, leave a tumefaction of the abdomen with much suspicion of effusion, which after some time entirely disappeared. SECTION V. CHRONIC PERITONITIS. This insidious affection is more common than persons not fa- miliar Avith pathological investigations are generally aware of. It is a disease of the utmost danger, 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 considerably in ac- tivity in the early stages. There is generally pain in some part of the abdomen, which may either be permanent, or only occur in paroxysms. The pain is in some cases referred to one 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 shrinking from pressure on any part of the abdomen. CHRONIC PERITONITIS. 183 There is occasionally vomiting, Avhich in some cases becomes ur- gent in the more advanced stages. There is in general more or less distention of the abdomen, Avhich is very often in some degree tympanitic; and, in some cases, defined spots of deep-seated indura- tion 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 merely speaks of a feel- ing of distention, with variable appetite and irregular boAvels, and, with these complaints, becomes progressively emaciated. In many cases, indeed, the early symptoms are so light, that no attention is paid to them until the emaciated appearance of the patient excites alarm. The abdomen on examination is then probably found tu- mid, 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 Avhich 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 with- out any complaint either of tenderness or pain. The boAvels are commonly more or less confined, but in general easily regulated by mild medicines; in other cases, laxative medi- cine is very uncertain in its operation, 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 the advanced stages; in other cases, as the disease advances, great obstinacy of the bowels takes place. The appearance of the motions varies considerably ; in general, I think, they are of a pale color, and of a peculiar foetor, but sometimes they are dark colored, and sometimes natural. The disease may come on gradually and insidiously, without any cause to which it can be ascribed. In other cases, it super- venes upon attacks of acute affections of the bowels, or upon other febrile diseases, as measles and scarlatina; it may also supervene upon injuries, as in Case LXXXV. It occurs most frequently in young persons from 10 to 15, and is, I think, less common in in- fants and children, though in these it also met with occasion- ally, and is generally 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 de- scribed a remarkable case, in which it Avas complicated with exten- 184 CHRONIC PERITONITIS. sive tubercular disease, both in the lungs and in the brain. The progress of the disease is generally by increasing emaciation, with small frequent pulse and hectic symptoms, sometimes Avith diarrhrea. In some cases matter forms and may find its Avay outAvards, either through the parietes of the abdomen, or by the ring of the external oblique, as in Case LXXXVII. On dissection, the bowels are generally found more or less ex- tensively glued to each other and to the perietes of the abdomen, and the omentum is often involved in the disease. There is some- times ulceration of the mucous membrane, and not unfrequently the peritoneum is in many places much thickened and studded Avith small tubercles ; in some cases again there is great thickening of all the coats of the insestine at particular parts. In many cases there are left, amid the adhering portions of the intestine, cavities full of purulent matter, Avhich 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 affection, every thing depends upon endeavoring to arrest it at its very earli- est period ; for after it has advanced but a little way in its progress, it is probably irremediable. It'seldom assumes so acute a charac- ter as to admit of general bleeding, and we must therefore trust chiefly to repeated and free topical bleeding, blistering, confinement, rest, antiphlogistic regimen, and the mildest possible diet. When, under such treatment, the case terminates favorably, we cannot in- deed decide.Avith confidence that this formidable disease had existed ; but we have.always good reason to suppose its existence, when, in a young person, there is deranged health, with tenderness over the abdomen. All that I can say farther on this subject is, that I have seen cases terminate favorably in families, which had formerly 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 dangerous character, and the frequency of its occurrence. CHRONIC PERITONITIS. 185 § /.—Chronic peritonitis in its more distinct form. . Case LXXVIII.—A lady, aged 32, had been affected with pain in the abdomen through the winter 1813—14, but was not con- fined, except sometimes a day at a time, until the middle of April, 1814. I saAV her on the 4th of May, and found her affected with great pain over the whole abdomen, accompanied by some diarr- hoea ; pulse about 90. Two days after this, she was suddenly seized with severe pain and tenderness over the whole abdomen, accompanied with great tympanitic distention, repeated vomiting, and such a degree of sinking 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 laud- anum 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, and in a few days more subsided, so that she was able to retain food and medicine. The boAvels now became rather con- fined, requiring the use of small quantities of laxative medicine; but they were easily acted upon, and the motions Avere ahvays thin and very copious. There was still some degree of tympanitic dis- tention 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 Avas felt, and it Avas acutely painful on pressure. Under the .usual treatment, she seemed now for some time to improve, but soon began to fall back again ; the pulse be- came more frequent, with hectic symptoms, loss of appetite, some cough, and increasing debility and emaciation. The tympanitic swelling continued, Avith the hardness in the left side of the abdo- men, which was still acutely tender; but it did not give her much trouble except when it was pressed. The bowels Avere easily reg- ulated, but the stools were always thin. She died, gradually ex- hausted, 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 Avhich it was impossible to trace any part of the intestine. The parts appeared to be most diseased at the place on the left side, 24 186 CHRONIC PERITONITIS Avhere she had complained of the greatest pain. Here the agglu- tinated intestines formed a broad, firm surface, Avhich, adhering by its circumference to the parieties of the abdomen, produced a large cavity, internally presenting a surface of dark, ragged ulceration. Similar cavities of smaller size Avere 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 Avere tolerably healthy. Case LXXIX—A boy, aged 10, (16th June, 1816) complained of pain in the abdomen, Avhich 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 liable to swelled glands; had complained of his abdomen for sev- eral 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; boAvels open; pulse from 108 to 112. (1st August.) Progressive emaciation and hectic fever; occasional attacks of diarrhoea and of vomiting. (10th.) Almost constant vomiting immediately after taking any thing ; occasional diarrhoea. Died on the 16th. Inspection.—All the viscera of the abdomen were glued togeth- er into one mass, except where their union Avas interrupted by cavities containing purulent matter of a scrofulous character, and presenting a surface of unhealthy scrofulous ulceration; the mass likewise adhered so extensively to the parietes, that it was impossi- ble to open the abdomen Avithout cutting into the cavity of the intes- tine. The stomach, the liver, and the bladder, were included in the adhesions, but the substance of the liver was healthy. Case LXXX.—A girl, aged 10. In this case, the disease went on for a year or more, and Avas chiefly distinguished by the pecul- iar and remarkable tenderness of the whole abdomen, Avithout much complaint of pain. She was thin, and looked ill, and the pulse Avas rather frequent; but she was cheerful, and able to go about; her appetite was tolerable, and the functions of the bowels were natural; she made little or no complaint Avhen her abdomen Avas not pressed, but she shrunk from the most gentle touch on every part of it. She went on in this manner, Avith little change, IN ITS OBSCURE FORM. 187 through the Avinter and spring of 1823—4. During the summer, she began to fall off more rapidly, with cough and anasarca, 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 ad- hered 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 extensively tubercular; the right was healthy. ^ 77.—Chronic peritonitis in its more obscure form. Case LXXXI.—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 Avithout making any com- plaint. She was now a good deal debilitated, and easily fatigued ; had a hectic look; pulse 120; tongue rather foul; appetite bad; abdomen tumid and somewhat tympanitic; made no complaint of any pain; she only said that she felt ' stuffed in the belly.' She had not menstruated. Such was the first report of one of the most insidious cases of this affection that has ever occurred to me. The patient Avas 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 fort- night she continued without any change ; she was restless, and hot in the night, and languid through the day, with bad appetite, and quick pulse, but made no complaint of any uneasiness. In the middle of April, she seemed to improve considerably; her appetite was much better, and she slept well in the night. She also im- proved in looks, in spirits, and in strength ; but the pulse continued frequent, being generally from 100 to 120, and the abdomen re- tained a considerable degree of tympanitic fulness. The bowels were open, sometimes rather loose, with occasional griping pain, but no fixed uneasiness, and the motions Avere quite natural. In May, she began to decline again, Avithout any particular change in the symptoms, except progressive loss of flesh and strength. There 188 CHRONIC PERITONITIS * 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 A'omiting, and occasional diarrhoea; the vomiting became more and more frequent^ until at last she could retain nothing ; she died early in June, having been confined to bed only two or three days before her death. Inspection.—The whole contents of the abdomen presented one solid mass of adhesion, in Avhich it was impossible to distinguish one intestine from another. The mass likewise adhered exten- sively to the parietes of the abdomen; and, in various parts of it, there were cavities containing purulent matter, and presenting, on their internal surface, unhealthy scrofulous ulceration. There Avas also much purulent matter in the cavity of the pelvis. There was much disease of the mesenteric glands,'and the liver was consider- ably enlarged. The lungs were sound. Case LXXXII.—A lady, aged 24, had been in delicate health through the winter, 1823—4, being affected chiefly with cqugh and palpitation of the heart. In the end of April 1824, these symp- toms ceased, and she began to complain of pain in the abdomen, which affected her chiefly in Avalking; it was sometimes a sharp, stinging pain, and sometimes a dull uneasiness. She continued to go about, but her health was somewhat impaired. She had dyspep- tic symptoms, occasional vomiting, irregular bowels, hysterical af- fections, and a long train of symptoms, which Avere often consid- ered as in a measure imaginary. On one occasion only she com- plained of so much pain in the abdomen that a bleeding was em- ployed, and the pain was immediately removed. In this manner the complaint went on till about the middle of July, when she felt herself much better, and was preparing to go to the country. She was then suddenly seized with acute pain and tenderness over the Avhole abdomen, accompanied Avith vomiting, costiveness, and fre- quent pulse. This attack continued two days, and then subsided, having been relieved by topical bleeding and laxatives; and she returned to nearly her former state, except that she Avas more re- duced in flesh and strength, and her pulse continued frequent. Her boAvels Avere now easily kept open ; but the stools Avere thin and very offensive; she Avas considerably emaciated, with a look of ex- haustion, bad appetite, and a frequent pulse. The abdomen Avas natural to the feel, except at the loAver part, Avhere there Avas an ir- IN ITS OBSCURE FORM. 189 regular, knotty hardness, with some tenderness. In this state I saAv her for the first time, along with Dr. Thomson, and Mr. NeAvbig- ging, in the end of July. She was much exhausted, with a small, frequent pulse, but Avithout much suffering ; the lower part of the abdomen was tumid and painful. On the following day the exhaus- tion suddenly increased, and she died at night. Inspection.—The first incision through the parietes of the ab- domen gave vent to a large quantity of purulent matter of remark- able foetor, Avhich was collected to the amount of several pounds. The lower part of the small intestines, the uterus, and the urinary bladder, Avere firmly agglutinated to each other, and to the parietes of the abdomen, except where they left irregular cavities, lined with a thick deposition of yellow flocculent 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 floceu- lent matter, which was so abundant below. The peritoneal coat of the liver was covered by an extensive deposition of yellow floccu- lent matter, and there Avas a similar deposition on the lower sur- face of the diaphragm on the right side. The thoracic viscera were healthy. Case LXXXIII.—A child, aged 5 years, had been observed for some months to be rather out of health, but Avithout any com- plaint that could be discovered, except that the abdomen had be- come 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 Avith some vomiting, and great enlargement of the abdomen. I saw him, along with Dr. Begbie, a few days after the occurrence of these symptoms ; the bowels did not yield to any remedies that were employed; the belly became more and more tumid; and he died about the end of a Aveek from the commencement of this attack. Inspection.—There were extensive adhesions of the bowels to each other, some of Avhich 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. 190 CHRONIC PERITONITIS ^ III.—Chronic peritonitis supervening upon measles. ' Case LXXXIV.—A boy, aged 5 years, (Sept. 1813,) was much emaciated, Avith a dry Avrinkled 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 boAvels were irregular, being sometimes confined, and sometimes rather loose. About two months before I saw him, he had passed through measles in a very mild form; but a few days after the termination of the disease, he began to complain of pain in his belly Avhich had continued from that time Avith progressive loss of flesh and strength. Various remedies were employed without benefit. He became gradually more and more emaciated, with constant pain in the belly, and occasional diarrhoea; and died in the end of Novem- ber. 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, OAving to close and extensive ad- hesions of the intestines to the parietes in every direction. They were also found to adhere so extensively to each other, that it was impossible to distinguish one intestine from another; and the intes- tines adhered likewise to the stomach, to the liver, and the urinary bladder. In the cavity of the peritoneum, there were found large quantities of coagulable lymph, in the form of a consistent trans- parent jelly. The mesenteric glands Avere much enlarged ; and the liver Avas also someAvhat enlarged, but healthy in its structure. The lungs were studded Avith numerous tubercles, but they Avcre all in a solid state; and there was considerable effusion in the cav- ity of the pleura. k iv.—Chronic peritonitis of the colon supervening upon an in- jury. Case LXXXV—A man, aged 21, a carter, (July, 1818,) was emaciated to a great degree, with effusion in the abdomen, and anasarca of the legs ; some difficulty of breathing; pulse small and frequent; bowels quite open, sometimes rather loose; com- plained of pain extending across the upper part of the abdomen ; sometime before, it had been chiefly referred to the right hypo- WITH DISEASE OF THE OMENTUM. 191 chondrium, 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 Avas unloading a cart, and from that time he had complained of uneasiness in the abdo- men, hut not so severe as to confine him from his work, until some Aveeks after, when he received another injury by being squeezed betAveen his cart and a wall. After this the pain in his bowels in- creased, and he had frequent attacks of nausea and some vomiting; but these symptoms ceased after a short time, and the complaint then Avent on in a gradual but obscure manner, till the time when I saAV 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 neighboring parts. They formed a mass of disease, the parts of which could not be separated from each other, and in which were included the stomach and several turns of the small intestine. The coats of the colon Avere much thickened, especially on the left side, where they were in some places an half an inch in thickness. The . pancreas was hard, and contained several small abscesses. In the cavity of the peritoneum, there was copious effusion of a whey colored fluid. The lungs were healthy. § V.—Chronic peritonitis complicated with disease of the omen- tum. Case LXXXVI.—A gentleman, aged 54, of a full habit, and previously enjoying good health, about Christmas, 1823, com- plained of nausea and loss of appetite. After a few days, he was seen by Dr. George Wood, who found his tongue white, his boAv- els irregular, and his pulse a little frequent. His nights were rest- less, and his general feelings extremely uncomfortable, but with- out any defined uneasiness, except some obscure and wandering pains extending along both sides of the abdomen, sometimes into the back, and sometimes along the sides of the thorax. He had continued in this state for about three weeks, when I saw him along Avith Dr. Wood in the middle of January, 1824. His look Avas then anxious, but Avithout much wasting; tongue Avhite ; pulse 192 CHRONIC PERITONITIS 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 post- ure, so that he Avas either out of bed and dressed, or sitting in bed supported by pillows. The abdomen Avas somewhat tumid, Avith an obscure feeling of fluctuation. Immediately below the epigas- tric region, there was a deep-seated hardness, extending across for five or six inches; and there was another hard spot of small ex- tent, about half Avay betwixt the umbilicus and the pubis. Press- ure occasioned little uneasiness. The bowels were easily moved, and the motions Avere natural, but scanty. He had a constant feel- ing of nausea, which, in fact, Avas the principal uneasiness that he complained of. Various remedies with little benefit, and, for some time, there was little or no change in the symptoms. He than began to have occasional vomiting; his nights became very disturbed ; and he frequently laid his hand across the upper part of the abdomen, as being the seat of much undefined uneasiness; his bowels contin- ued to be easily regulated. The vomiting 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 tumor in the epigastrium was formed by the omentum drawn up into an ablong mass, nearly two inches in thickness, and internally of a pale color and firm tubercular sub- * sistence. The intestines Avere of a very dark color, 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 parietes of the abdomen was diseased through its whole extent; in many places much thickened and in some almost cartilaginous. Its internal surface presented a varie- gated appearance of dark red portions mixed with others which Avere almost black ; and in some places there were spots resem- bling small superficial ulcers. In the cavity of the abdomen there Avas considerable effusion of a cleaf serou3 fluid. WITH SUPPURATION. 193 § VI.—Chronic peritonitis with extensive suppuration making its way outwards by the ring of the external oblique. Case LXXXVII.—A man, aged 40, (August, 1814,) had se- vere pain of the abdomen, which was hard and tense, with occa- sional vomiting; much Avasting ; bowels irregular; had been ill for four or five months. A short time after I first saw him, he Avas suddenly seized with a swelling, which appeared at the ring of the external oblique of the left side, and extending rapidly along the scrotum. After watching the progress of this swelling for some days, the scrotum was punctured, and discharged very fetid puru- lent matter, in such quantity as immediately shoAved a communica- tion betwixt the swelling and the cavity of the abdomen ; and press- ure upon the abdomen made it flow very freely. # About a week after this, a fluctuating SAvelling appeared on the right side of the abdomen, Avhich 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 tubercles; and it adhered intimately both to the intestines and to the parietes of the abdo- men. The intestines likeAvise adhered most extensively to each other, and to the parietes: the peritoneum was in general much thickened. On the right side of the abdomen, there was an exten- sive collection of purulent matter, which extende'd upwards behind the intestines as far as the liver. It had eroded the peritoneum by a small round opening, about an inch in diameter; and had spread itself among the muscles, and under the integuments, forming the swelling which was opened on the right side. On the left side, the matter seemed to have been contained in a cavity betwixt the peri- toneum and the abdominal muscles. To this outline of a subject of much practical importance, I have only to add, that cases referable to it, sometimes terminate favorably under circumstances apparently most unpromising. During the present season, I saw, along with my friend Dr. Ross, a girl about twelve years of age, whose case he had been watching with much anxiety and interest. Her complaints began with symptoms of a peritonic character, which at first were acute, and afterwards as- 194 INFLAMMATORY AFFECTIONS. sumed a chronic form, Avith various remissions and relapses. After several weeks, a defined, deep-seated swelling Avas felt in the left side of the abdomen, which gradually increased, with much consti- tutional disturbance, debility, and emaciation. At the end of about two months, this swelling suddenly diminished, and she then began to discharge from the bowels purulent matter, in large quantities, and often without any mixture of feces. Her general health was now much impaired, and the case had a most unpromising aspect; but the discharge of matter, after continuing for many Aveeks, grad- ually subsided; the swelling in the abdomen disappeared in the same gradual manner, and she has recovered excellent health. The Avhole duration of the complaint Avas about five months. PART III. INFLAMMATORY AFFECTIONS OF THE MUCOUS MEMBRANE OF THE INTESTINAL CANAL. The inflammatory affections of the mucous membrane of the intestinal canal present a subject of great interest annd considerable difficulty. In the diagnosis of them, much attention is required in their earlier stages ; because it is only at this period that many of them can be treated with any prospect of success; and because, without very great attention, they are apt to be confounded with dis- eases of a much less dangerous character. This arises from the circumstance, that symptoms, very similar to those which proceed from extensive disease of the mucous membrane, may be produced by various irritations applied to the membrane in a healthy state, constituting two classes of disorders, very different in their nature, and implying very different degrees of danger. Thus, we may have the symptoms of diarrhoea or cholera, arising either from the presence of acrid matters, or from disease of the mucous mem- MUCOUS MEMBRANE OF THE INTESTINE. 195 brane; in the one case, constituting an affection of little danger; in the other, a disease of the most alarming kind, In the former manner are produced the common diarrhoea and cholera of this country, which are seldom fatal affections ; in the latter, the vari- ous forms of dysentery, and the cholera of India, one of the most formidable diseases with which the human race has ever been visited. It is necessary to keep in mind certain sources of fallacy, in re- gard 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 considered as marks of disease, are merely changes of color, or accidental vascular congestions, Avhich may take place a short time before death, dT even after death. They are accordingly met with in the bodies of persons who have died of other diseases, Avithout any symptoms referable to the bowels ; and of those who have died from violent deaths, as execution or drowing, without any suspicion of previous disease. Among the appearances refer- able to this head, may be reckoned the following; suffusion or in- creased vascularity of particular parts of the mucous membrane, or a uniform redness of portions of it, more or less extensive; spots and patches of various sizes, and various colors, as red, blue, green, livid, brown, or black, without any change of texture of the part; and ecchymosis or slight extravassion of blood into the cellular texture connected with the membrane. These and some similar appearances, not connected with any change of texture, and not shoAving any of the actual results of inflammation, are not worthy of any confidence in a pathological inquiry. In entering upon this subject, therefore, I shall first describe the*principal changes, observed in the mucous membrane of the intestinal canal, which Ave are Avarranted to consider as morbid. I. Portions of the membrane of greater or less extent, shoAving a uniform and high degree of redness, with slight flakes of coagu- lable lymph, pr a more continued coating of false membrane, at- tached to its surface in various places. This appearance is seldom observed in this country, but it seems to mark the intense form of the disease, such as occurs in the most rapid cases of the cholera of India. It is exemplified in Case XCIII, and probably marks 196 INFLAMMATORY AFFECTIONS. 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 LXXXIX. In a modification of the disease, which seems to be different from the former, the affected portion is covered by a thin uniform coating, like the crust of aph- tha? ; the membrane beneath showing a high degree of redness when the crust is removed. This uncommon appearance is shown in CaseXCIV; 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 color, and sensibly elevated above the level of the surrounding parts. These portions vary in size, being in general, one or two inches in diameter, Avith sound portions of considerable extent interposed between them. They are, in some cases, covered by a brownish tenacious mucus; in others, by flakes of false membrane; and frequently the surface of them is studded with minute vesicles, which at a more advanced period seem to pass into very small ulcers. These are the appear- ances 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 they are seated in the small intestine, and the colon is healthy, the symptoms differ remarkably from those which commonly receive the name of dys- entery, as we shall see in the sequel. The appearance of circum- scribed elevated portions of the membrane is also met with in a chronic form, gradually fatal by long protracted disease, as in Case XCIX. III. An extensive portion of the mucous membrane exhibiting a soft consistence of a uniform black color, or what may be prop- erly termed gangrene of the membrane. This appearance is il- lustrated by cases LXXXIX, and XC VI. The result of it lias sometimes been the separation of considerable portions of the mem- brane, so as to expose the muscular coat, or even to leave the cav- ity 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 more probable supposition; and there is every reason to believe, that the disease differs in its nature, Mi^uUS MEMBRANE OF THE INTESTINE. 197 by being, in some cases seated in the mucous membrane itself, in others, in the mucous follicles; and in others, by involving both these structures at once. Another form has likewise been supposed to exist, in which it is primarily seated in the cellular texture be- twixt the mucous and muscular coats ; but this must be considered as in a 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 LXXXVIII; and this, at a more advanced period, seems to pass into the irregular continued ulceration to be afterwards de- scribed. It appears to be a different state or form of the disease from that which terminates by the uniform covering of false mem- brane, as in Case XCIII, or by the actual gangrene, as in Cases LXXXIX, and XCVI. IV. Minute dark colored spots spread extensively over a portion of the membrane and each surrounded by a small but distinct areola of inflammation. This appearance 1 have observed only when the patient has died of another disease, the symptoms in the bow- els having been nothing more than a tendency to diarrhoea. It is exemplified in Case CI. It is probably a disease of the mucous follicles, and the earliest period of an affection, which would have terminated in the formation of small detached ulcers, such as in Case C. Another disease of these follicles is exemplified in Case CXII. in which the progress of the affection is shown in an in- teresting manner: being first a solid tubercle—then a pustule—and then an ulcer. V. Small round or oval portions of the mucous membrane, of a dark gray colour, and soft pultaceous consistence. These are easily separated, and leave ulcers, or rather excavations, correspond- ing to their size. This appearance seems to be the termination of inflammation confined to small defined portions of the membrane; or, perhaps, is primarily situated in the mucous follicles, and in- volves a small portion of the membrane immediately surrounding them. VI. The surface of the mucous membrane covered by numer- ous small spots of an opake white color, which are found, upon examination, to be vesicles, very slightly elevated, but containing a small quantity of clear fluid. This uncommon appearance is ex- emplified in Case CXIX. VII. Ulcers of various appearance and extent. The principal varieties of these seem to be referrable to the following heads: 198 INFLAMMATORY AFFECTIONS. (1.) Small defined portions of excavation rather than actual ulceration, as if a portion of the membrane had been dissected out. This appearance is probably produced in the manner referred to under the fifth head. (2.) Portions of various extent in a state of more decided ulceration ; covered at the bottom with yellowish or dark colored sloughs, and often having irregular and elevated edges. These may be detached and at some distance from each other, and vary in size from that of a sixpence to a shilling or more; or an extensive portion of the membrane may be in a state of almost continued ulceration,—the diseased surface being merely variegated by por- tions in a state of dark red fungous elevation, running irregularly over it, and separating the ulcerated spaces from each other. This appearance generally occurs in chronic cases, and is exemplified in Cases CII and CIII; but is also met with in connection with recent and acute disease in the very remarkable case (Case XC.) In other examples, the elevated inflamed patches described under the second head are found covered with small ulcers, sometimes not more than a line in diameter. (3.) Small round well defined ulcers like the deep pits of small pox, or sometimes very much resembling chancres; deeply exca- vated Avith round and elevated edges. They are generally at a considerable distance from each other, and the intervening mem- brane is healthy. The cases in which these occur are generally chronic, as in Case C, but they are found in connection with acute disease in Cases XC and CXII. 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 intestine; but perhaps, only one or two of them may be met Avith, of the size of a shilling or upwards; and they are generally accompanied by some degree of thickening of the portion of intestine in Avhich 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 symptoms which lead to a suspicion of their existence. They may MUCOUS MEMBRANE OF THE INTESTINE. 199 be fatal by haemorrhage, as in Case CX; or by perforating the intestine and leading to rapid peritonitis. They are also met Avith in acute diseases very rapidly fatal, as in Case CXI; but we are not prepared to say, whether in such a case they had been the cause of the symptoms, or had existed previously, and by the acute attack, been hurried on to a fatal termination. Ulceration of the mucous membrane, under all its forms, fre- quently 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, Ave sometimes see several of the appearances now de- scribed combined in the same diseased portion, so as to show the affection in its different stages. We may find, for example, a small deep ulcer, Avhich has perforated the intestine by an aperture, which would admit a quill; this surrounded by a circle in a state of superficial ulceration, and this by a ring of inflammation. VIII. Portions of the mucous membrane are sometimes found covered by small, firm tubercles. Pustules resembling small pox are also occasionally met with. During the whole progress of the various diseases of the mu- cous membrane, the peritoneum sometimes continues entirely healthy, so that, on first opening the abdomen, even in very pro- tracted cases, there is no external appearance of disease. In others, there are patches of a deep red or livid color, as if shining through the peritoneal coat, or the uniform black tinge of actual gangrene, as in Case, LXXXIX,—the peritoneum itself, however, still con- tinuing entirely healthy. The affection sometimes passes into extensive peritonitis a short time before death, and this happens in two ways. In the one, a small ulcer perforates the intestine, and the inflammation spreads rapidly in all directions, probably pro- duced by the escape of the contents of the intestine into the peri- toneal cavity, as is exemplified in Cases LVIII—XCVII, and CXII. In the other, the peritonitis seems to take place more di- rectly from the inflammation extending through all the coats, with- out any appearance of perforation. This probably occurred in Case XCI. In many of the acute cases, the diseased intestine acquires a soft ^nd thickened appearance, which has been compared to that of boiled tripe; in the chronic, thickening is still more common,—the affected part acquiring a great degree of thickness, and an almost cartilaginous hardness, which seems to involve the whole structure 200 INFLAMMATORY AFFECTIONS. of the intestine. In some of these the intestine becomes contracted at the thickened portion ; in others, it becomes distended into large defined cysts, Avith an internal surface of dark, ragged ulceration; and the parietes of these cysts sometimes acquire such a degree of thickness and hardness, as to exhibit, during the patient's life, the characters of a mass of organic disease. This affection is strikingly illustrated by Cases CVII and CIX. Extensive adhesions of the peritoneal surface likewise occur, so that the whole bowels may be glued together, as in the common cases of chronic peritonitis. The appearances now described may probably be considered as the principal morbid conditions of the mucous membrane of the intestine; and the enumeration seems to include all those Avhich, in the present state of our knowledge, can be considered as essential in this investigation. The inquiry has been involved in much obscurity hy a practice prevalent among continental Avriters, of giving a place in the pathology of mucous membranes, to mere changes of color, and these often of very small extent. The prin- cipal 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 pathology of mucous membranes, they are entirely unworthy of confidence. Among the symptoms which chiefly engage our attention in reference to the diseases of the mucous membrane, the state of the boAvels 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 exists, when they are feculent and of a healthy appearance. We shall see reasons in the sequel to be satisfied of the fallacy of this con- clusion ; and to be convinced that most extensive and deep seated disease may be going on, with feculent and healthy evacuations. The effects upon the functions of the bowels in connection with these diseases, are chiefly referable to the following heads : (1st.) A simply irritable state of the bowels, with thin feculent discharges. (2d.) Morbid discharges from the diseased surfaces of various kinds, as watery, mucous, bloody, puriform. (3d.) Various mix- tures of these matters with the feculent evacuations. (4th.) Vari- ous changes in the appearance of the feculent evacuations them- selves, in consequence of articles passing through in a partially digested state, or frequently almost entirely unchanged; also from MUCOUS MEMBRANE OF THE INTESTINE. 201 the mixture of bile or other matters from the upper part of the bowels. In this general outline it is impossible to give a full accountof the different appearances Avhich the evacuations assume, in connection with the various forms of the disease; but the fol- lowing 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 appear- ance, and of great fcetor. 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 recognized when the disease is in the colon ; when it is in the small intestine, the appearances are disguised or modified by the mixture of these dis- charges with thin feculent matter, or with articles of nourishment partially changed. II. The appearances described under the second head produce, when seated in the lower part of the intestine, the dysenteric stools commonly so called ; namely, 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 dis- ease 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 Avhole tract of the colon is affected, there are no scybaloe, but occasional discharges of thin feculent matter from the healthy parts above; Avhile the more frequent evacuations consist of the bloody mucus, dark watery matters, or muco-purulent discharges from the dis- eased surface, coming off sometimes alone, and sometimes mixed with the feculent matter from the parts above. But when the dis- ease is in the small intestine, and the colon healthy, the appear- ances are entirely different. The proper discharges from the dis- eased surface are then seldom seen uncombined, and their charac- ters are disguised by being mixed, either with thin feculent matter, or Avith articles of food or drink partially changed. The chronic form of the disease referred to under this head, I think in general produces merely an irritable state of the boAvels, Avithout any thing particularly morbid in the character of the evacuations. 26 202 INFLAMMATORY AFFECTIONS. 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 Avashings of pu- trid 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 Avithout anything- particularly unhealthy in the evacuations. V. The same observations will probably apply to the appear- ance described under the fifth head, except that it may oocasionally be possible to recognise in the evacuations the softened and sepa- rated portions of the mucous membrane, which however is not pTobable. VI. The discharges connected with the case more particularly referred to under the sixth head, consisted of large quantities of very firm tenacious mucus, assuming sometimes the form of tubes, and sometimes that of solid cords of remarkable density; and these were varied at other times, by the evacuation of large quanti- ties of semi-transparent gelatinous matter. These discharges, however, had entirely ceased for -a considerable time before the death of the patient. VII. The appearances connected with ulceration of the mem- brane vary exceedingly, according to the extent of the disease, and the seat of the ulcers. (1.) The ulcers described under the first and third varieties, I think merely produce an irritable state of the bowels, with gradual wasting, without any peculiar discharge. (2.) The ulceration described under the second head produces copious discharges of rnuco-purulent matter, generally streaked with blood, and sometimes mixed Avith sherds of flaky matter. When the disease is in the colon, this discharge comes off in large quantities,—sometimes quite uncombined, and at other times mixed with feculent matter. When it is confined to the rectum or the lower part of the colon, this feculent matter may be consistent, formed, and entirely healthy; but, when the Avhole tract of the colon is diseased, the feculent matter is thin, and comes off more mixed Avith the morbid discharge. On the other hand, when the disease is in the small intestine, and the colon healthy, the peculiar discharge will seldom be 3een uncombined, as it will generally come off mixed with thin feculant matter. Portions of flaky mat- MUCOUS MEMBRANE OF THE INTESTINE. 203 ter may occasionally be seen in such cases floating in the evacua- tions ; but in other cases, they have merely a thin feculent appear- ance, and are generally of a pale color, and of a remarkable and peculiar foetor. (3.) The symptoms connected with the large ulcers, No. 4, are very obscure. They have been found where no symptom had in- dicated their existence, previously to the attack which was suddenly fatal, as in Cases CXIII. and CXIV. In other cases, they appear to ha\^been productive of deranged health, with impaired digestion and an irregular state of the bowels, but without any symptom which had distinctly indicated the nature of the disease. The preceding outline, I am aware, may be considered as te- dious and uninteresting, but it appears to be of importance in the pathology of the mucous membrane of the intestinal canal.. In a practical point of view, the affections seem to arrange themselves into three classes. I. Active inflammation of the mucous membrane, which varies considerably in its characters, according to the extent and the seat of the disease. It may be fatal in the inflammatory stage,—by gan- grene,—by ulceration,—and by passing into peritonitis. II. Chronic disease of the membrane. This may supervene upon an acute attack, or may come on in a gradual and insidious manner without any acute symptoms. It generally goes on for a length of time, and is fatal by gradual exhaustion; and shows upon dissection fungoid disease of the membrane,—ulceration of various characters,—or thickening and induration of all the coats of the intestine. It may be fatal more suddenly by perforation of the intestine and rapid peritonitis. III. An interesting modification of the disease may be consid- ered separately, as a matter of practical interest, though there is no real distinction in its pathological characters. It is that in which ulcers of some extent seem to exist for a length of time in the mu- cous membrane, without producing any symptoms which lead to a knowledge of their existence, until they are unexpectedly fata1 in the manner to be hereafter mentioned. 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. 204 INFAMMATION OF THE MUCOUS MEMBRANE. SECTION I ACTIVE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE INTESTINE. The symptoms accompanying active inflammation of ^e mu- cous membrane vary considerably according to the scat 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 sensibility which accompanies the inflammation of the peritoneum. There is more or less irritability of the bowels, sometimes in the form of diarrhoea, with copious stools; and sometimes of painful tenesmus with frequent scanty discharges of bloody mucus. There is gen- erally some degree of fever, with thirst, febrile oppression, and a parched tongue ; but occasionally the pulse is little affected through the whole course of the disease. There is frequently vomiting, but not urgent; sometimes hiccup; and sometimes a peculiar irritability of the stomach and bowels,—articles taken exciting a burning un- easiness, succeeded by irritation, and a sensation as if they almost immediately passed through the canal. The calls to stool are sometimes very frequent, occurring, per- haps, every ten or fifteen minutes, with much painful tenesmus; but in other cases the disease may be going on in the most alarm- ing manner, Avhile the bowels are not moved above four or five times a-day. The evacuations vary exceedingly in their character; con- sisting in some cases, of small quantities of bloody mucus, or al- most pure blood ; in others, of a tenacious semi-purulent matter of a peculiar foetor, without blood, or with only slight streaks of it; and sometimes membranous crusts are discharged, like coagulable lymph, in irregular portions; but in some instances, the evacuations are more abundant and consist of a watery matter of a dark brown color, and remarkable foetor; or of a bloody watery fluid like the washings of flesh. The natural feces are in some cases retained, or discharged only in small scybalous masses mixed with the mor- bid evacuations. On the other hand, it is a most important fact, in SYMPTOMS. 205 the history of the disease, that the evacuations are, in some cases, thin and feculent, like those of a common diarrhoea; that they may continue so through nearly the whole course of the disease; or, that they may consist of thin and healthy feces in the early stage of the attack, and that the morbid discharges may not begin to appear until it has gone on for several days- In certain states of the dis- ease, again, the evacuations are farther varied by a mixture with bile, either in a healthy or a morbid state, and by articles of food or drink which pass through nearly unchanged. I have endeavored to state the principles which appear to regu- late these important varieties. The disease seems to exist in sev- eral different forms, in one of which the discharge from the dis- eased 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 rec- tum and lov/er part of the colon, the discharge from the diseased surface comes off uncombined, while the healthy feces are apt to be retained, or discharged only in small scybalae, except when, by the operation of purgative medicine, natural feces are brought down from the healthy parts above. When the disease extends along the whole course of the colon, or into the small intestine, the first effect of the increased irritability of the parts appears to be, to empty the lower bowels of all their feculent contents; after which, the evacu- ations will consist, at one time, of the morbid discharges from the diseased surface, at another, of fluid feces from the parts above, and of various combinations of these with each other. On the other hand, if the disease be chiefly seated in the small intestine, while the colon is healthy, the morbid discharges will be less apparent, because they will seldom come off uncombined. The effect in this case will probably be, a general increased action of the whole canal; and the matter evacuated will be either fluid feces, more or less mixed with the morbid discharge, articles of food or drink par- tially changed, or various combinations of these three substances, producing frequent changes in the appearance of the evacuations. In other cases, again, when the appetite and digestion are much impaired or nearly suspended, the first effect of the disease maybe 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 206 INFLAMMATION OF THE MUCOUS MEMBRANE. be healthy, like those of a simple diarrhoea, and afterwards consist of the morbid discharges from the diseased parts. These state- ments agree with Avhat we actually observe in the history of the disease, and on dissection. In some cases, healthy feces in a firm state may be found retained above the seat of the disease ; and in Case XCVIII. there Avas fluid feces of a perfectly healthy appear- ance in immediate contact Avith the diseased surface. On the other hand, in Case LXXXVIIL, in which, after the period when the description begins, the evacuations consisted entirely of small quan- tities of bloody mucus, there was no appearance of feculent matter in the whole course of the canal. We shall also see the affection running its course to a fatal termination, with feculent evacuations of a healthy appearance, when the disease is seated in the small intestine ; and in one very severe example, we shall find the evac- uations 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 Avhich had been taken, pass through four hours after in the form of soft curd, moulded into shape by the action of the intestine; and he adds, that it occasioned excruciating pain, and required constant fomentation to allay the tormina which it excited in its passage through the dis- eased portion of intestine. The principles now referred to indicate the sources of impor- tant varieties in the phenomena of this class of diseases; but there are other circumstances worthy of much attention. Inflammation of mucous membranes exists in different states or degrees; in some of which it has a tendency to a spontaneous cure,—the discharge from the membrane gradually undergoing certain changes, during the progress of which the inflammation subsides. This is most re- markably exemplified in the catarrhal inflammation of the bronchial membrane; but we see also that the danger of this disease, in its mildest form, is in proportion to its extent; and Lsennee has well remarked, that a simple catarrh affecting the whole bronchial mem- brane, 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, and by the degree or the intensity of the inflammation. A corresponding variety ap- SYMPTOMS. 207 pears to exist in the inflammation of the intestinal membrane. In one form, it seems to be a highly dangerous disease Avhatever 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 constitu- tional irritation by Avhich it is attended. These two forms of the disease are well illustrated by Cases LXXXVI1I. and LXXXIX. The affection, as it occurred in the former, would probably have been free from danger, had it been of small extent; while as it oc- curred in the latter, it would have been, of whatever extent, a disease of the utmost danger. With these varieties in the symptoms, the affection may go on for some time before its real nature is suspected, 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 dis- ease 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 diagnosis is often difficult. The disease should be suspected 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 suspicious; 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 folloAV other febrile diseases, especially measles; and there is reason to believe, that it may supervene upon affections of the bow- els which Avere at first free from any dangerous character,—a case beginning like a simple diarrhoea, and, after several days, exhibit- in o- symptoms which mark the presence of this dangerous affec- tion. In a less active form, it accompanies or follows many dis- eases of a scrofulous nature, forming Avhat 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 Ave shall see abundant reason to believe, that its characters vary in a remarkable degree, according to its seat,—and that some of the most dangerous modifications of it are those which, according to 208 INFLAMMATION OF THE MUCOUS MEMBRANE. the characters laid down by systematic Avriters, 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 feces : 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 portion of the lower part of the intestine, it may be a disease of little danger; but it is to be kept in mind, that its danger is generally in proportion to its extent. If it be 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 effects 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 vary in the manner which has been already referred to; being either mucous, watery, or feculent, or consisting of various com- binations of these matters with each other. In all affections of the mucous membrane, the appearance of the tongue is deserving of particular attention. In many cases it shows no peculiar character, or only the usual appearances of fe- brile diseases; but in others its indications are more important; and there are two conditions of it Avhich are to be considered as marking dangerous conditions of the disease. The one is the dark parched tongue of typhus ; the other is a peculiar raAvness, redness, and tenderness often accompanied Avith aphthous crusts ; and fre- quently these crusts may be seen extending along the pharynx. A very interesting modification of the disease of the mucous membrane occurs in the course of continued fever. This may either have been known to exist for sometime by the usual symp- toms, or it may not have been discovered until it proves rapidly SYMPTOMS. 209 fatal. In either case the affection may be fatal by exhaustion, by peritonitis, or by hajmorrhage. There is also a modification of the disease of very great impor- tance, Avhich 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 intestine may terminate in several ways, the most important of which are the fol- lowing:— I. It may be fatal in the inflammatory stage,—a greater or less £xtent of the membrane presenting numerous patches of redness, Avhich are in genera] sensibly elevated above the level of the sur- rounding parts : and in some cases, these elevated portions present on their surface numerous minute vesicles. These are most com- monly observed in the disease as it appears in infants; and at a certain period of their progress, the vesicles seem to pass into mi- nute ulcers. II. By gangrene, a portion of the mucous membrane appearing of a uniform black color, and of a very soft consistence, in Avhich the muscular coat in some cases appears to participate. Vesicles full of a putrid, fetid fluid have also been observed upon the mem- brane. 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 Avays. In the one, the inflammation seems to extend uni- formly through the coats, until they are all affected; in the other, one of the ulcers perforates the intestine, its contents escape into the peritoneal cavity, and very rapid peritonitis immediately follows. The leading phenomena connected with the various forms of this important class of diseases will be illustrated by the following examples. 27 210 INFLAMMATION OF THE MUCOUS MEMBRANE- § I.—Inflammation of the mucous membrane of the intestiner confined to the rectum and part of the ascending colon. This is the dysentery of systematic writers, in Avhich there is much tenesmus with scanty discharges of bloody mucus, and re- tention of the natural feces, or the occasional appearance of. scyba- lae. I have not seen it as a fatal disease; but it is evidently the af- fection described by Dr. Donald Monro and other writers of his period, and the disease on which Dr. Cullen has founded his defin- ition of dysentery. Dr. Monro gives few details of individual cases ; but his account of the appearances on dissection, even in the older cases; is, 'in all of them the rectum was inflamed, and partly gan- grened, especially the internal coat; in two, the lower part of the colon Avas inflamed, and there were several livid spots on its great arcade.' In one, whose body was much emaciated, and who had been seized Avith violent pain of the bowels a few days before death all the small guts were red and inflamed; and in another, there were livid gangrenous spots in the stomach. In his account of the symptoms which attended this affection, he says, • the stools 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 with the stools little pieces of hardened excre- ment.' At other times, though more rarely, little pieces of white stuff like tallow or suet Avere discharged; and frequently filaments or pieces of membrane Avere found floating in the evacuations.* In some of Bampfield's cases, the sensation of the patient was de- scribed to be as if a stake or hot iron Avere forcibly perforating the rectum; and in many of these, the verge of the anus in its whole circumference appeared red, "inflamed, and tumid. The tenesmus in cases of this class, goes on Avith scanty morbid discharges from the diseased surface, while the colon above may contain much har- * Monro on the diseaes of the British Military Hospitals in Germany, pages 61 and 63. CONFINED TO THE RECTUM, &C. 211 dened feces, which are retained by the interruption of the peristal- tic 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. § //—The disease extending along the whole course of the colon and rectum, fatal in the inflammatory stage. Case LXXXVIII.—A gentleman, aged 60, had been for some years liable to "an irritable state of the bowels Avhich affected him chiefly after exposure to the cold, and was generally accompanied by mucous discharges tinged with blood. He was seized with one of these attacks, Avhile he was at a distance from home, in Septem- ber 1827, which seems to have been more protracted than usual, and on his return home, in the end of September, he Avas again seized in a still more violent degree. When I saw him along Avith • Mr. Gillespie, about the third or fourth day of this attack, he had a look of much exhaustion and febrile anxiety; his tongue was parched, and his pulse was frequent and rather small. He com- plained of much general uneasiness of the abdomen, especially across the epigastric region, Avhere 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 rem- idies were employed Avithout benefit; the symptoms continued un- abated ; the vomiting became more urgent; his strength sunk rapidly; and he died in four days more, being about the eighth from the commencement of the disease. The evacuations retained throughout the same character, Avithout the least appearance of feculent matter, even Avhen laxative medicine was given. Inspection.—The whole tract of the colon appeared moderate- ly and uniformly distended. Externally, it presented no morbid appearance, except some degree of that softened and slightly thick- ened state which has been compared to boiled tripe. Internally, it showed most extensive disease of the mucous membrane. This 212 INFLAMMATION OF THE MUCOUS MEMBRANE, consisted of portions of the membrane, of various forms and de- grees of extent, being of a fungous appearance and bright red color and sensibly elevated above the level of the more healthy portions that were interposed between 4hem; this morbid appearance, in patches seperated by healthy portions of the mucous membrane extended through the whole course of the colon and rectum; and it preserved throughout nearly the same character, without any appearance that could be considered as ulceration or even abrasion of the membrane. The small intestine and all the other parts were entirely healthy; and there was no appearance of feculent matter in any part of the canal. $ III.—The disease occupying the whole colon and rectum, fatal by gangrene. Case LXXXIX.—A man, aged 50, (7th Oct. 1827) was seized with general uneasiness over the abdomen. On the 8th he took • castor oil, from the operation of which he had numerous evacua- tions consisting almost entirely of blood. On the 9th, he Avas seen by Mr. White, who found him complaining of great uneasiness in the bowels, chiefly referred to the lower part, but without much tenderness. He had frequent calls to stool, with scanty discharges which seemed to consist almost entirely of blood. His tongue was parched, but his pulse was little 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 character, being watery, dark colored, and Avith a remark- able and peculiar foetor; they are compared by Mr. White to the Avashings of putrid flesh. For several days from this time there was little change. The evacuations continued watery, of a dark brownish color, and remarkable foetor, and without any appearance of feculent matter. They varied much in frequency, sometimes oc- curring every ten minutes, and sometimes leaving him quiet for several hours. There Avas much thirst, and the tongue was parched; but the pulse continued little affected till an advanced period of the disease. He had some hiccup, and vomited a few times, but it was not urgent. I saw him for the first time on the 15th. He Avas COLON, &C.—FATAL BY GANGRENE. 213 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 rec- tum, was found to be greatly and uniformly distended. From the extremity of the rectum to nearly the middle of the arch of the colon, the intestine was of a uniform black color, as if completely gangrenous. From the middle of the arch to the caput coli, the appearance was more healthy, but was variegated by numerous patches of a deep red or livid color. These seemed to be deep seated, and were seen shining through the peritoneal coat, which appeared to be healthy. The large intestine being laid open, the mucous membrane at the black parts was throughout of a deep uniform black color, very soft and easily separated; the muscular coat was black and easily torn; the pertioneal coat was healthy. These appearances were continued from the extremity of the rec- tum to nearly the centre of the arch of the colon; the mucous . membrane then assumed an appearance more resembling that de- scribed in the former case,—being elevated into irregular patches of a dark red color, with interspersed portions in a more healthy state. Towards the lower part of the right side of the colon, there Avas an appearance of erosion or superficial ulceration; and on the inner surface of the caput coli, there were several distinctly de- fined ulcers. The ileum, for a few inches from its junction with the caput coli, Avas slightly distended, and its mucous membrane Avas reddened; the'other parts of the canal Avere healthy. The inner surface of the urinary bladder, at its posterior part, showed a considerable degree of increased vascularity. It may be of importance to mention, that the wife of this man was affected Avith 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 cosceive to be of very great 214 INFLAMMATION OF THE MUCOUS MEMBRANE value in this investigation; for they show the disease running its course in about the same period; affecting the same extent of in- testine, and shoAving similar constitutional symptoms,—Avhile the actual morbid condition of the parts was remarkably different. The following case shoAvs the affection fatal in nearly the same period, and with a remarkable extent of disease; but with a very important difference in the character of the evacuations. ^ IV-—The disease occupying the whole colon, and rectum, and part of the ileum. Case XC—A lady, aged 35, on Monday, 7th July, 1828, Avas suddenly seized with vomiting and purging, accompanied by considerable uneasiness in the abdomen ; various remedies were employed Avithout 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 saAV her on the afternoon of the 9th; she had then occasional 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 tender- ness of the abdomen; pulse 120; skin hot; countenance febrile and anxious; tongue very loaded., A full bleeding was now cm- ployed 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 resisted every remedy. The pulse continued from 120 to 130, and it soon became weak, with a parched tongue and typhoid aspect, so that it was necessary to give her 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, hoAvever she might be in this respect, her aspect never im- proved from a febrile and anxious expression, characteristic 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 saAV one motion Avhich Avas scanty and consisted of bloody mucus, but the evacuations were in general copious, thin, COLON, RECTUM, AND PART OF THE ILEUM. 215 and of a feculent appearance. In the early period of the case, they presented nothing different from those of diarrhoea ; about the fifth and sixth days, they became extremely fetid, and, though of a fecu- lent appearance when they Avere first discharged, they separated on standing, and deposited at the bottom of the vessel, a quantity of a thin puriform fluid of remarkable foetor, and variegated with small round spots of blood ; on the two last days of her life, they became of a dark brown color, and of a more watery consistence, Avith less appearance of feculent matter. She had noAv the aspect of an ad- vanced state of typhus, with a small frequent pulse and some delir- ium, and she died on Tuesday the 15th, being the ninth day of the disease. Inspection.—>The small intestines were externally healthy, ex- cept a tinge of redness on the loAver part of the ileum ; the colon had a thickened appearance, with a tinge, on various places, of a dark red color, which seemed deep-seated as if shining through the peritoneal coat; about the sigmoid flexure and the upper part of the rectum, there was slight deposition of false membrane. The mu- cous membrane was healthy in the stomach, and in the upper part of the small intestine. In the ileum there began to appear spots of increased vascularity, which Avere at first at considerable distances from each other, but afterwards became more numerous ; and, for about twenty-four inches at the loAver end of the ileum, the whole mucous membrane Avas of a uniform deep red color, without any remarkable change in its structure. In the caput coli, the same dark red state of the membrane continued ; and it was here covered by numerous well defined ulcers, some of them the size of a six- pence. In the ascending colon, there was a more irregular state of disease, consisting of wandering undefined ulceration, variegated AA'ith dark fungoid elevations of portions of the mucous membrane. 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 mucous membrane betwixt them was of a pale color and quite healthy. In the descending colon, the whole of the mucous mem- brane shoAved one continued surface of disease,—being of a dark brown color, fungoid and spongy, Avithout 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 fa- bric, and of a dull brown color ; and the mucous membrane, along 216 COLON, FATAL BY ULCERATION WITH PERITONITIS. the part so affected, Avas uniformly and greatly thickened. Along this portion, also, all the coats of the intestine were considerably thickened, and in some places were almost of cartilaginous hard- ness. 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 re- mained showed only marks of recent inflammation or increased vascularity. This very remarkable case shows nearly all the modifications of disease of the mucous membrane; and I confess I found it diffi- cult to believe that it had been the result of a disorder of only nine days' duration. But the body was full in flesh, and showed no ap- pearance of previous disease; and all that I could learn was, that, about four years before her death, the patient had an attack which was said to have been similar to that of which she died; and that she occasionally complained of some uneasiness in her bowels; but that, up to the day of the attack, she was apparently in perfect health, and able for a great deal of exercise. I likewise ascer- tained, that her boAvels were habitually rather costive, requiring the frequent use of gentle laxatives. \ V.— The disease in the colon fatal by extensive ulceration with peritonitis. Case XCI.—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 bow- els had been loose, but not very troublesome; the motions had been sometimes mucous, but not remarkably morbid ; and some that I saw were quite healthy. The belly had been for some days tense and tympanitic, Avith much tenderness upon pressure, but no actual complaint of pain. When I saw her on the 9th, the pulse Avas fre- quent, the face pale, but full, as if from oedema, and there was some oedema of the legs; breathing oppressed and anxious ; bowels mod- erately open, and the stools feculent and healthy; the abdomen was tumid, and at the upper part tympanitic ; and there Avas some ten- COLON, FATAL BY ULCERATION WITH PERITONITIS. 217 derness upon pressure. I saAV her again on the 10th, and found that the bowels had been moderately moved, and the stools Avere fecu-, lent 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 party on the 2d of January, two days before the commencement of the fatal attack. Inspection.—The left lung was a mass of tubercular disease; the right was tolerably healthy. In the cavity of the abdomen, there Avas more than a pound of purulent matter with much floccu- lent deposition. The spleen was enlarged and entirely enveloped in a covering of false membrane; the liver was completely cov- ered in the same manner. The whole tract of the small intestine Avas contracted and healthy. The colon, through its Avhole extent, was.distended, and of a bright color; it was thickened in its coats, and its appendicular were very turgid and of a bright red. This ap- pearance was presented by the whole tract of the colon and the caput caacum ; and the mesocolon was also of a bright red color, and much thickened. Internally, the colon presented nearly one continued surface of ulceration of the mucous membrane, which was most remarkable about the sigmoid flexure, in the ascending colon, in the left side of the arch, and in the caput caecum. There was a little of it at the commencement of the ileum, but the rest of the small intestine was healthy. ^ VI.__The disease confined to the caput coli and part of the as- cending colon,—The patient dying of an affection of the brain. Case XCIl.__A girl aged 6, Avas affected Avith severe and ob- stinate diarrhoea, which reduced her to great Aveakness and emaci- ation. It subsided after three or four weeks, and was succeeded, after tl short interval, by severe pain in the belly, headache, and vomiting, the bowels being then rather bound ; the pulse was from 30 to 40 in a minute; the urine was high-colored, and diminished in quantity. The headache continued, with vomiting, and a con- H 28 218 INFLAMMATION OF THE MUCOUS MEMBRANE. stant 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 death, Avhen it rose to 70, and occasionally to 80. I did not see this case during the life of the patient, but wai present at the examination of the body. Inspection.—There Avas considerable effusion in the ventricles of the brain, with ramollissement of the septum and of the cerebral substance surrounding the ventricles. The inner surface of the caput coli, and of a great part of the ascending colon, was of a dark red color, and covered with numerous patches, also of a dark red color and fungous appearance, which were considerably ele- vated above the level of the surrounding parts. $ VII.—Fungous ulceration of the caput coli and recent inflamma- tion of the ileum, with a coating of false membrane. Case XCIIL—A seaman, for whose case I am indebted to the late Dr. Oudney, was affected with dysentery, accompanied with the usual symptoms. The stools Avere in general copious, and va- ried very much in appearance, being sometimes slimy, sometimes watery, and sometimes consisting of mucus mixed with green mat- ters of various shades. There was fever with rapid emaciation ; at first, he had acute pain, and afterwards a dull uneasiness over the lower part of the abdomen; and towards the conclusion, there was a sharp pain increased by pressure, confined to a small spot on the lower part of the abdomen, towards the right side. He died in about five weeks. Inspection.—There were some superficial ulcerations of the mucous membrane towards the lower extremity of the colon ; but the principal seat of the disease appeared to be the caput coli, in which there Avere numerous 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 covered with false membrane. There were small abscesses in the liver, and the mesenteric glands were enlarged. ILEUM-—FATAL WITH INCIPIENT ULCERATION. 219 $ VIII.—The disease in the ileum with deposition of false mem- brane. Case XCIV.—A Avoman, aged about 30, in November, 1827, was received into the clinical Avard of the Royal Infirmary of Ed- inburgh, affected with symptoms of continued fever in a very mild form; and after five or six days she was considered as convales- cent. She recovered strength so slowly, however, that she was al- lowed to remain in the hospital; and she went on for ten days with- out any symptom except weakness. She then seemed to relapse, complaining chiefly of headache and pain of the back. After this, she had sickness and a good deal of vomiting, and complained of pain with some tenderness, referred to the region of the liver, which was relieved by topical bleeding. She still had sickness, with occa- sional vomiting; the pulse continued frequent and weak; her strength sunk rapidly; and she died in four days from the com- mencement 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 mu- cous membrane, eighteen inches in extent, was covered by a thin uniform film like the crust of aphthae ; beneath it the membrane showed a high degree of redness. The peritoneum covering this portion of intestine showed some minute flakes of coagulable lymph for three or fcmr inches. All the other parts Avere healthy. For this important case I am indebted Dr. Alison. The ap- pearance described in it, and which also occurred in the ileum in the preceding case, is rather uncommon. It differs entirely from the appearance of the disease as it occurred in the colon in the former cases, and which also will be found occurring in the ileum in the cases to be next described. In the present state of our knowl- edge, 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 appear- ance in the epidemic dysentery of Ireland. It occurred in his dis- sections both in the large and small intestines, but seems to have * Trans, of King's and Ctueen's Colleges, vol. v.] 220 INFLAMMATION OF THE MUCOUS MEMBRANE. been most frequent and most remarkable in the colon and rectum. He describes it in some cases as occurring in patches ; but in oth- ers, the mucous membrane was covered by a uniform layer of Avhite lymph, Avhich Avas in greatest quantity in the neighborhood of the rectum; and it adhered to the surface of the membrane in rugged folds. Dr. Cheyne has mentioned the same appearance as occur- ring in the small intestine, in his able account of the Dysentery of Dublin of 1818.* The appearances to be described as occurring in the ileum in the following cases, correspond Avith the appearances described in regard to the colon in cases LXXXVIII and LXXXIX. $ IX.—The disease in the ileum fatal in the state of red elevated portions with incipient ulceration. Case XCV.—A girl, aged 3 years, about three Aveeks before her death was attacked with vomiting, frequent calls to stool, and pain in the abdomen ; the evacuations Avere reported to have been frequent, slimy and fetid. After eight or ten days, Avhen she Avas first seen by the late Dr. Oudney, she had frequent irregular febrile paroxysms; she had vomiting and frequent stools, Avhich Avere of a clay color, and the abdomen was tender upon pressure. Her tongue was Avhite, and there Avas urgent thirst, especiallly during the febrile paroxysms. In this state she continued until a feAv 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 color, mixed with specks of yel- low. The pupil was natural, and continued sensible to light, until a few hours before death, which happened on the 8th of February, * 1820. Inspection.—The ileum, from its termination in the colon to near the jejunum, Avas highly vascular, its minute vessels appear- ing as if injected. Its mucous membrane Avas covered Avith nu- merous irregular inflamed patches, which had a fungous appear- ance ; they Avere considerably elevated above the level of the sound * Dublin Hospital Reports, vol. iii. ILEUM FATAL BY GANGRENE. 221 parts, and were covered with minute ulcerations. Some of these patches were the size of a shilling, others smaller; they were gen- erally at the distance of an inch or two from each other, and the membrane in the intervals was healthy. The mesenteric glands Avere greatly enlarged and very vascular. $ X.— The disease in the ileum fatal by gangrene. Case XCVI.—A woman, aged 25, was admitted into the In- firmary of Edinburgh, affected with pain over the abdomen, tenes- mus and diarrhoea. The pain intermitted occasionally, and was most severe on going to stool and on passing urine. The evacua- tions were free from scybalae or blood. She had headache, thirst, some cough, nausea, occasional vomiting, and a pale emaciated look; pulse 72. She ascribed her complaints to cold, and they had been gradually increasing for three weeks. Various remedies Avere em- ployed without benefit, consisting chiefly of opiates, absorbents and calomel. The disease went on for eight days more, and the follow- ing selection from the reports show a state of the functions of the bowels, which, when compared with the morbid appearance to be described, presents a case of very great importance. (2d day) Two stools ; severe tormina, which were relieved by fomentation. , (3d day) Nearly free from tormina ; one stool; which seemed to consist of broth which she had recently taken, little changed. (4th day) Two scanty evacuations without griping; abdomen hard and painful; vomited once; a mild enema produced a copi- ous discharge and relieved the pain. (5th day) Less pain ; vomited several times ; one stool thin and feculent; pulse 78; took six grains of calomel. (6th day) Tavo stools ; one of them thin and feculent, the other much tinged with blood ; much pain before the evacuations; abdomen tense and painful ; pulse 80 ; vomited a considerable quantity of slimy matter tinged with blood, and having some pur- ulent matter mixed with it. She took gr. viii. of calomel. (7th day) Two stools, thin, feculent, and of a natural appear- ance, but preceded by much pain; vomited repeatedly some green- ish slimy matter, mixed with bloodj pus ; less tension of the abdo- men ; pulse from 60 to 70; took some calomel with opium. 222 INFLAMMATION OF THE MUCOUS MEMBRANE. (8th day) No stool and no vomiting; died in the night. Inspection.—The vessels on the stomach, duodenum and jeju- num were usually distended with blood. The ileum Avas livid, with some adhesions; its internal surface was quite black; and it contained dark colored slimy matter, mixed with very fetid pus. The colon, on the left side, was found livid, with adhesion to the abdominal parietes, and to the lower part of the omentum, Avhich also was of a livid color; and between these parts there Avas much fetid pus. § XI—The disease in the ileum, with ulceration, fatal by a per- forating ulcer and peritonitis. Case XCVII— A woman, aged 38, had been ill for more than a Aveek with fever, want of appetite, frequent diarrhoea, and much pain in the abdomen. On the 19th of June, 1819, she was sudden- ly 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 discharge from the bowels. (21st) I saw her for the first time. Pain still severe ; urgent vomiting and hiccup; no stool; pulse 140. Died in the afternoon. Inspection.—Extensive inflammation on the outer surface of the small intestine, especially at the lower part, where there were con- siderable exudation and gangrene. There was extensive inflamma- tion of the mucous membrane of the small intestines, in various places ; and the inflamed portions were covered with minute ulcers. At one place, at the loAver part of the ileum, there was a more ex- tensive ulcer about the size of a shilling ; this was surrounded by a ring of inflammation, which Avas covered by minute ulcers; and in the centre of the large ulcer, there was a small opening which perforated the intestine; the outer surface at this place Avas of a dark, livid color. WITH ULCERATION—IN CONTINUED FEVER. 223 y XII—The disease occurring in continued fever with ulceration. Case XCVIII.—A girl, aged 9, was seen by Dr. Alison, in December, 1819, affected with the usual symptoms of contagious fever which Avas very prevalent in a narrow 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 healthy appearance. These symptoms continued, with frequent pulse and foul dry tongue, till about two days before her death, when the diarrhoea suddenly subsided, and was succeeded by violent pain, acute tenderness of the abdomen, and every symptom of peritoneal inflammation. The duration of the case was about three weeks. I am indebted to Dr. Alison for the above outline of it, and for an opportunity of being present at the examination of the body. Inspection.—There was considerable peritoneal inflammation, especially on the ileum, Avhere there was extensive adhesion, with considerable deposition of flocculent matter. The intestine was also seen to be in several places perforated by small ulcerations, through which feculent matter had escaped into the cavity of the peritoneum. The ileum being laid open, discovered a most exten- sive tract of disease on its inner surface, the mucous membrane be- ing extensively eroded, and in many places completely destroyed, by round well defined ulcers, many of 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 thickened. It contained a considerable quantity of fluid feculent matter, which was quite healthy in its appearance. The higher parts of the small intestine were healthy, and contained a small quantity of a dark green viscid fluid, like inspissated bile. The colon was colapsed, and externally healthy; internally, there were in several places, especially on the left side, patches of redness on its mucous mem- brane, 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 orig- inal disease Avas contagious fever, the affection of the bowels may 224 REVIEW OF THE SUBJECT. perhaps be considered as symptomatic. This occurred still more distinctly in a case mentioned by Dr. Duncan in his clinal reports. The patient (a woman aged 60) seemed to be convalescent from fever with petechiae, when, about the 23d day of the disease, she was attacked with diarrhoea, without any complaint of pain ; the stools fetid and dark colored; the pulse varying from 80 to 100. About the 7th day from the commencement of these symp- toms, began to have pain and bloody evacuations, and died on the 9th day. On inspection, the disease was found nearly in the state of simple inflammation. At various parts of the mucous mem- brane, from the jejunum to the rectum, there were purple patches, occurring, at first, at intervals of one or two inches, and then run- ning 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 rec- tum, in addition to this appearance, there Avere numerous fungous looking patches, from a quarter, to half an inch broad, and ele- vated fully an eight of an inch above the surface of the intestine; they had a very vascular appearance, and their surface was covered Avith a thin yellowish crust, The various observations which have been detailed in this sec- tion, appear to illustrate the principal phenomena connected with inflammation of the mucous membrane of the intestine; and they lead to some conclusions of much practical 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 Avith which the more extensive degrees of it are attended. In others, it seems to be highly dangerous from the intensity of the in- flammation and its consequences, whatever may be the extent of the . surface that is affected. This important distinction in the nature or form of the disease is well-illustrated by Cases LXXXVIII, and LXXXIX. II. It appears that the more intense forms of the disease may be fatal, though of small extent, by gangrene or by ulceration ; and that the ulceration may perforate the intestine, and terminate speed- ily by extensive peritonitis. III. We see some evidence of the contagious, or at least the REVIEAV OF THE SUBJECT. 225 epidemic character of the disease ; as, in the family in which Case LXXXIX occurred, five individuals were affected in quick succes- sion, and two of them died. IV. It is probable that the symptoms vary considerably, accor- ding to the extent of the disease, and the part of the canal which is the primary seat of it. This appears most remarkable in the character of the evacuations. 1. When the disease is confined to the rectum or the lower part of the colon, the evacuations appear to be scanty, and mucous or bloody, Avith 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, Ave 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 constituting the most formidable of all the modifica- tions of it,—the Indian cholera. The important practical conclusion from the whole vieAV of the subject, is, that this highly dangerous disease may be going on with every variety in the appearance of the evacuations ; and this conclusion is in accordance with the statements of the best practical writers. It will now perhaps be generally admitted, that in talking of dysentery, we have been too much influenced by the distinctions of systematic writers, in applying this term to an affection which is characterized by tenesmus and scanty discharges f gr. i. or ii. three or four times a day has also been much recommended, and James' powder, given in the same manner ; but in all inflammatory affections of the mucous membrane of the in- testine, the effect of antimonial preparations would appear to be rather questionable. II. The second indication, which is to quiet the general irrita- tion of the canal, will be chiefly answered by mucilaginous articles and opiates, particularly Dover's poAvder, 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 pe- riod of the disease, especially when the affection is extensive, by taking into the stomach as little as possible of either food or drink; as from-the morbid irritability of the parts, the mildest articles often produce great irritation. Suet, dissolved in milk, has been much recommended; and a favorite remedy in the time of Sir John Pringle was a conbination of yellow wax and Spanish soap, melt- ed together over a gentle fire, and then rubbed up with Avater. 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 membrane, after the force of the inflammatory symptoms has been subdued by the necessary means, various remedies appear to be useful, in differ- ent states and different stages of the disaase. In the earlier stages, benefit 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 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 dysenteric symptoms always cease. In the dysentery of tropical climates, calomel is given instill 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 pre- ♦ See Dewar on Dysentery DYSENTERY--TREATMENT. 251 sume to give an opinion, because I have had no experience; but when 1 have seen a similar practice attempted in the dysenteric af- fections of this country, it has appeared to be decidedly injurious; and when mercury is given, it appears that the small doses of cal- omel combined Avith Dover's poAvder, in the manner Avhich I have mentioned, is the form best adapted to the earlier stages of the dis- ease. In a more advanced stage, when the morbid secretion con- tinues after the inflammatory symptoms have been subdued, various remedies of a tonic and astringent nature appear to be useful,— such as, cusparia, lime'Avater, 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, espe- cially a strong decoction of cusparia with nitric acid and lauda- num ; and oxide of bismuth with cusparia and DoArer's poAvder. Charcoal has been strongly recommended, and, in one very severe case, in Avhich it was given in combination with Dover's powder, it appeared to Mr. Gillespie and myself to be decidedly useful. Ni- tric acid, combined Avith opiates, I conceive to be a remedy deserv- ing of much attention even in the earlier stages, after the necessa- ry evacuations. 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 sta- ges, mucilaginous articles, or thin arrow-root with an opiate, an in- fusion of tobacco, or an infusion of ipecacuan. After the first ur- gency of the inflammatory state has been subdued, 1 have seen decided benefit in relieving the tenesmus from injections of lime- water, at first diluted with equal parts of milk or thin arrow-root, and with the addition of an opiate. In the above observations, I have said nothing of the use of purgatives in this class of diseases, because I do not consider them as forming a regular or essential part of the treatment; but it comes to be a question of much interest, what is the principle to be kept in view in regard to the use of purgatives, and what are the cases to Avhich 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 re- tention of feces in the parts above. This state of the upper part of the bowels is to be considered, in such cases, as requiring, distinct attention, because, in a febrile and irritable slate of the system, it 252 CHRONIC DISEASES OF MUCOUS MEMBRANE. must prove an additional source of irritation, or may even pass into a state bordering upon ileus. It must, therefore, be counter- acted by the occasional use of the mildest laxatives, as castor oil, or small doses of the neutral salts. But by laxatives in such a case, I imagine we are to consider ourselves as only obviating bad effects from feculent accumulation in the parts above, rather than as acting upon the disease with which we are contending. By laxa- tives, indeed, the evacuations may become healthy, but these are brought down from the healthy parts above, and cannot be consid- ered as having any beneficial operation upon the part which is the primary seat of the disease. The spontaneous improvement of the evacuations, in connection with the resolution of the disease, is to be considered, I imagine, as an effect and a sign, rather than a cause of that resolution, and as a state which cannot be imitated or forced by the use of purgatives. In the earlier stages of this modification of the disease, indeed, it is highly necessary and proper to ascertain by the operation of some mild medicine, that there is no accumula- tion of feculent matter; but we have seen in the most satisfactory manner that the bowels may be entirely Avithout feculent matter, though the evacuations have consisted entirely of bloody mucous from an early period of the disease. In such cases as these, the use of purgatives 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 Avhich 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 experience of this eminent physician, the remedy ' least equivocal in its effects, and the most uniformly useful,' was blood- letting. The mercurial treatment was tried in all its forms, but often failed ; and it did not appear worthy of the same degree of confidence as in other climates. In some cases, the mouth could not be affected j in others, the worst description of mercurial mouth * Dublin Hospitable Reports, vol. iii. DYSENTERY--TREATMENT. 253 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 Avhich the disease was supposed to have passed into the ulcera- tive stage, mercury was injurious. Of the cases which were not accompanied by much pain or fever, many got well with a saline purgative, followed by two or three doses of Dover's powder ; and even of the more severe cases, attended with fever and tenderness of the abdomen, many recovered under the same remedies preceded by bloodletting. But in many cases, purgatives seemed greatly to aggravate all the sufferings of the patient. They often failed in producing any change in the appearance of the motions; while on the other hand, a large feculent loose stool was not unfrequently passed after a bleeding, by patients Avho, 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,—blood-letting, followed by calomel and opium, and this by the balsam of copaiva, with farina- ceous diet; but next to full bleeding, his chief reliance seems to be in opium; and on a review of his whole experience in the epidem- ic to which his valuable paper refers, he says, ' were the same cases again to be placed under my care, I Avould not hesitate to give opium in doses of four or five grains, as it was the opium chiefly that seemed to arrest the progress of the inflammation; and whatever, in such a case, procured respite to the patient from agony, some- times proved of permanent benefit.' The preceding observations were written, and ready to go to press, before I had an opportunity of seeing the second volume of Mr. Annesley's splendid work on the diseases of India. It gives me much satisfaction to find that they agree, in all the more essen- tial respects, with his observations in regard to dysentery. The point on Avhich 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 adapted to the dysentery of this country, is in the frequent or almost daily use of purgatives. I have already stated my opinion on this subject, and the grounds which induce me to believe that the use of purgatives in dysentery is a prac- tice requiring the utmost discretion, being 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 254 CHRONIC DISEASES OF MUCOUS MEMBRANE. cases produced no beneficial result, and in others greatly aggravated all the sufferings of the patient. The subject is one of the highest practical importance, and deserving to be investigated Avith the ut- most attention. Mr. Annesley begins the treatment of dysentery in a robust patient with free general and topical bleeding, and a large dose of calomel combined Avith 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 jallap and cream of tartar, and a purgative injection. The calomel and opium are also repeated after a few hours interval; and this treatment is assisted by warm fomentations, Avarm bath, and anodyne injections in very small bulk. These remedies are aftenvards repeated ac- cording to circumstances, Avith blistering on the abdomen if neces- sary ; and a purgative is generally given every morning. In the more advanced stages of the disease, when there is reason to be- lieve that ulceration has taken place, he trusts chiefly to blistering, anodyne injections, Dover's powder Avith camphor and catechu, nitric acid, and the external application to the abdomen of the nitro- muriatic solution. Mr. Annesley gives no countenance to the empirical and indis- criminate use of mercury, Avhich has become so much in fashion with some writers in all stages and all conditions of dysentery. He gives calomel Avith opium in the early stages, along with the neces- sary evacuations, but chiefly as a purgative. ' When given late in the disease Avith the intention of affecting the system, or Avhen its exhibition is continued with this intention for too long a period, it often seems to precipitate the malady to an unfavorable termination, by inducing or keeping up irritative fever, and lowering the powers of life.' In regard to the difficulty often experienced in affecting the system Avith mercury in the early stages, he states, that it is oc- casioned by the existence of active inflammation, and that the ap- pearance of mercurial action in these cases is often to be regarded as a sign rather than a cause of the resolution of the disease. In many instances, both of simple dysentery, and of dysentery com- bined with disease of the liver, he has seen the mercurial action take place in the fullest manner, and yet the disease Avas not only not arrested, but seemed to run its course more rapidly to an unfa- vorable termination. And even in the milder cases which got well under the constitutional effects of mercury, there was often a pro- TREATMENT. 255 tracted recovery from the diminished energy of the poAvers of life occasioned more by the mercurial action than by the disease. Since the publication of the first edition of this volume, I have found decided benefit, in several dysenteric affections, from the use of sulphur; and to several friends who have employed it at my suggestion, it has appeared to have very beneficial effects in various affections of the mucous membrane. It has generally been given in small doses, such as 10 grains, repeated three times a day, com- bined with small opiates, or with Dover's powder ; and in the chro- nic cases frequently with angustura. M. Mayer, in Hufeland's Jour- nal, has strongly recommended a nitrate of soda as of most remark- able efficacy in dysentery. It is probable also, that the internal use of borax might be useful in certain states of the disease. § //.— Treatment of the chronic cases. In the chronic form of the disease, the morbid conditions which we have chiefly to contend with, are either the chronic fungoid in- flammation, or ulceration. The treatment is extremely precarious, and but few of the cases comparitively do well. The remedies which appear to be most generally useful are the following; lime- water ; vegetable bitters and astringents, especially the cusparia and logAvood; preparations of iron; small quantities of mercury with opium especially calomel Avith Dover's powder, or small doses of calomel with opium and ipecacun; the resins, as turpentine, balsam of copaiva or tolu, with small opiates; sulphur with opium ; nitric acid; various combinations of these remedies with each other, as a strong decoction of cusparia with nitric acid and laud- anum. Repeated blistering on the abdomen is often very benefi- cial, also bandaging with a broad flannel roller, and tepid salt water bath. Sulphate of copper has lately been recommended by Dr. Elliotston in various protracted affections of the boAvels ; and in any trials of it which I have had an opportunity of making in this class of diseases, it appears to be a remedy deserving of much at- tention. It is given in doses, at first, of half a grain, combined with an equal quantity of opium, and is gradually increased, if ne- cessary, sometimes to the extent of gr. iii. Avith half a grain or a grain of opium, three times a-day. In the treatment of all the affections of this class, much de- 356 INFLAMMATION OF MUCOUS MEMBRANE. pends upon the most rigid attention to diet. Animal food in every form seems in general to be hurtful; and the greatest benefit re- sults from a diet strictly confined to farinaceous articles and milk. A modification of the disease appears to exist, affecting 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 medical treatment. The following case will illus- trate this modification of the disease, which in practice, is one of considerable interest. Case CXV.—A lady, aged 30, came under my care in spring, 1813, affected in the following manner. She had a remarkable tenderness of the inside of the lips, the tongue, and the throat; a constant discharge of saliva ; a burning uneasiness in the tongue, throat, breast, and stomach ; and great uneasiness in swallowing, and for sometime after it. She had a constant tendency to diarr- hoea, and a feeling as if food or drink did not remain in the stom- ach, but passed almost immediately through the bowels. There was some cough, with frequent pulse, great debility, and increasing emaciation. The throat appeared raw, and a little inflamed; the edges of the tongue and the inside of the under lip Were excoriated, and covered with small ulcers, having inflamed margins; there was also a painful excoriation about the anus and the labia. The complaint was of about three months standing, and had begun while she Avas in the puerperal state in England. A variety of treatment was employed Avithout benefit; she became emaciated and debilitated to the greatest degree; the diarrhoea became inces- sant, Avith much pain, and a feeling as if everything she swallowed passed through her immediately. She had no relief but from large opiates, and that relief Avas but slight and temporary. When the case appeared to be hopeless, she began to take a decoction of logwood (1 oz. to 1 lb.) a wineglass full four times a day, combined with a small opiate. From this time she recovered daily, and in two or three weeks was in perfect health. Affections of the mucous membrane of the bowels seem to oc- cur 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 vari&ble IN INFANTS. 257 appetite, Avith impaired digestion, and a variety of uneasy feelings about the boAvels, sometimes described as a rawness and tender- ness, and sometimes as a feeling -of heat, as if hot water were passing through them. A painful feeling of distention is often complained of, especially after meals, though no actual appearance of distention can be perceived. In some cases, the tongue is loaded; in others, there is a peculiar raw appearance of the tongue and throat; and sometimes the tongue has a peculiar red, dry, and glazed appearance. Along with these feelings the*e is occasionally a slight and protracted feverishness, but, in some cases, the pulse is not at all effected. The bowels are often tolerably natural, or easily regulated; but laxative medicine is in general uncertain in its effects, and is. apt to operate too violently. The motions are sometimes natural, but frequently they are mixed with mucus in a very concrete or tenacious state, assuming various forms, as irreg- ular crusts, like the crusts of aphthae, or masses of a rounded or tuburcular form, which are apt to be mistaken for worms. The af- fection is often extremely tedious and untractable ; and it is often difficult to say what treatment is most beneficial. The remedies deserving of attention are chiefly those already referred to, in re- gard to the diseases of the membrane, especially bismuth, lime water, cusparia, balsam of capaiva. Mercury in any form appears in general to be hurtful. Much depends upon diet; and the great- est benefit is often obtained from a regimen restricted entirely to farinaceous articles and milk. Stimulation, and friction of the abdo- men is often useful; also warm clothing and the tepid salt water bath. SECTION V OF THE INFLAMMATION OF THE MUCOUS MEMBRANE IN INFANTS, x 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 principles Avhich are applicable to it, do not djf 33 258 INFLAMMATION OF MUCOUS MEMBRANE fer from that already referred to in regard to adults, it is an affec- tion of so much practical importance, as to be deserving of sepa- rate description. The most important point in the investigation re- fers to the means of distinguishing the disease, in its early stages, from the ordinary 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 stages, 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 in- stances, pressure on the abdomen 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 advanc- ing rapidly to a fatal termination. 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 exceedingly in appearance, and I have never been able to satisfy myself that any reliance is to be placed upon them in ascertaining the disease. They sometimes consist chiefly of a reddish brown mucus, sometimes of a pale clay-colored matter, and sometimes of a dark watery fluid ; but in many cases they show little deviation from the healthy state, Avhile, in others, their appearance is evidently disguised or modified by articles of nour- ishment, which pass through nearly unchanged. The disease often goes on for sometime without exciting alarm, or being distinguished from an ordinary diarrhoea, until attention is strongly and suddenly directed to the dangerous nature of it, by the occurrence of consti- tutional symptoms. These consist in some cases, of a great degree of febrile oppression, Avith dry crusted tongue, thirst and vomiting ; in others, of a very sudden and rapid exhaustion of the vital pow- ers, Avhich is unexpected, and is not accounted for by the frequency of the evacuations ; and sometimes the first appearance of unfavor- able symptoms consists in the sudden occurrence of coma, with a peculiar hollow languid look of the eye, and a pale waxen aspect of the Avhole body, while the pulse perhaps continues of tolerable strength. These symptoms may appear while the disease has been IN INFANTS. 259 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 inconvenience. The causes of this affection are not well ascertained. It fre- quently occurs about the period of dentition, and in many cases ap- pears to be connected with Aveaning. The fatal terminations are either by a rapid and peculiar sinking of the vital poAvers or by coma. The appearances on dissection are nearly uniform. In va- rious parts of the inner surface of the intestine, especially the ileum, wefind 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 gen- eral 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 per- itonitis. In the cases which terminate by coma, effusion in the brain is met with, and this termination is often preceded by a re- markable diminution of the secretion of urine, amounting, in many cases, nearly to suppression. This termination seems to bear a considerable analogy to the Ischuria Renalis, Avhich usually termi- nates 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 favorably, Ave 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 combined with Dover's powder. In some cases the free use of digitalis seems to be extremely useful, also blistering on the abdomen; and, when the disease exhibits much activity, topical bleeding may be employed in the early stages. In the ad- vanced stages, when there is a tendency to sinking, wine must be given freely ; when there are threatenings of coma, blistering on the neck must be employed. From both these conditions infants often make most unexpected recoveries. When there is urgent vomiting, blistering on the epigastrium appears to be the most effectual remedy; considerable benefit in settling the_stomach is also obtained from small doses of the vegetable bitters and the ox- 260 INFLAMMATION OF MUCOUS MEMBRANE. ide of bismuth. The state of the teeth is to be attended to, and the gums are to be divided wherever they appear to be producing irri- tation. In the protracted boAvel complaints of infants, in which there Avas reason to suspect the existence of this affection in a chro- nic form, I have found nothing so useful as lime-water. The two following cases will be sufficient to illustrate the prin* cipal phenomena connected with this interesting and highly dan- gerous affection. Case CXVL—An infant, aged 6 months, (13th May, 1817,) had been affected for about a week with looseness of the bowels and occasional vomiting. The affection had been considered as the common bowel complaint of dentition, but the stools were scanty, offensive, and dark colored ; and though they were by no means fre- quent, 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 favorable appearances Avere of short continuance. On the evening of the 18th the diarr- hoea suddenly increased ; it was excited by everything that was taken into the stomach, and the articles that Avere taken seemed to pass through the bowels with great rapidity. On the morning of the 19th, she was pale and exhausted; and though the looseness Avas checked by opiate injections, every attempt to support her was in vain. She died in the afternoon, having lain through the day in a state resembling coma. Inspection.-^-The bowels were externally healthy, except some spots of superficial redness. On the inner surface of the small in* testines there were, in many places, irregular patches of inflamma- tion ; in other places there were circumscribed spots of a dull ash color, Avhich were sensibly elevated above the level of the sur- rounding parts, and were covered by minute ulcers, so as to give them a peculiar honeycomb appearance. On the external surface of the intestine, corresponding with many of these portions, there Avere defined spots of redness and increased vascularity; the mes- enteric glands were enlarged ; the other viscera were healthy. Case CXVII.—An infant, aged 7 months, soon after Aveaning was suddenly seized with vomiting and diarrhoea ; was oppressed, fretful and feverish; the motions Avere scanty, and varied in their DEATH FROM OTHER CAUSES. 261 appearance, being sometimes brownish, and sometimes pretty nat- ural. After a day or two the vomiting ceased ; the diarrhoea con- tinued, not severe nor frequent, but accompanied by much oppres- sion and feverishness, a brown fur on the tougue, and a remarkable dryness of the gums ; the motions varying in appearance as before, Various remedies Avere now employed with little benefit. After four or five days, the child became comatose; this was relieved by blistering on the neck, and a dose of calomel. The motions then became green, but were generally scanty and watery; the febrile state continued, with the fur on the tongue; the child sunk gradu- ally, with oppressed breathing, and died on the ninth day. Inspection.—The bowels were externally healthy, except spots of redness on various parts of the small intestine, which appeared deep-seated, as if shining through the peritoneal coat. At the parts corresponding with these spots, the mucous membrane was elevated into irregular patches of inflammation, and the inflammed surfaces were covered by very minute ulcers ; in the neighborhood of these portions the mesentery was unusually vascular. The colon was colapsed and externally healthy; its inner surface was covered in many places by very small vesicles, which were scarcely elevated above the surface of the membrane, but appeared as if shining through it, clear, transparent, and watery; they were most numer- ous in the caput coli, but were also observed through the whole course of the colon ; and they preserved the same character through the whole extent of it, without any appearance either of inflamma- tion or ulceration. SECTION VI. CASES SHOWING THE STATE OF THE MUCOUS MEMBRANE AFTER THE CESSATION OF THE SYMPTOMS, THE PA- TIENT'S DYING OF OTHER DISEASES. To the facts which have been related in connection Avith this in- teresting inquiry, I shall only add the following examples, calculated 262 CHRONIC DISEASES OF MUCOUS MEMBRANE. to show the state of the parts, when the symptoms had ceased, after long continuance, and the patients died of other diseases. The second showed a very remarkable and rather uncommon A'ariety of the'matter evacuated from the bowels. Case CXVIII.—A lady, aged 24, had been of a feeble and delicate habit from her early years, and from the age of sixteen, had been almost constantly in a more decided state of bad health. She was generally confined during the Avhole Avinter, with cough, pain in the bowels, and diarrhoea ; she got a little better during the summer, but was constantly more or less affected with diarrhoea, and occasional pain of the bowels, Avith variable appetite, bad diges- tion, 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 Avere fluid, and of a whitish color, and usually occurred four or five times every day; when at any time they Avere less frequent, she became much oppressed about the stomach, and extremely uneasy. She had frequently pain in the bowels; her appetite was bad, but the pulse was natural. In the winter, the same state of her bowels continued, and she had loud noisy cough without expectoration. In summer 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 hyosciamus. The bowels got into a natural state, the stools being consistent and healthy, and from this time there was no re- turn of diarrhoea; but her appetite and digestion continued very bad, and she made little improvement either in flesh or in strength. In the following winter her cough returned, at first Avithout expec- toration ; but afterwards she had pain in the breast, purulent expec- toration, and hectic fever; and died of phthisis in May, 1817, Avith- out any return of the complaint in the bowels. Inspection.—The lungs were extensively tubercular, Avith nu- merous vomicae. The lower half of the stomach was contracted and considerably thickened, and the pylorus was a little thickened, but not indurated. On the internal surface of the intestine there were many portions, several inches in extent, of a dark red color, and more vascular than the other parts ; and on many places there were, on the mucous membrane, small circumscribed smooth spots, Avhich had every appearance of the cicatrices of ulcers Avhich had healed. The other viscera Avere healthy. DEATH FROM OTRER CAUSES. 263 Case CXIX.—A lady, aged 18, had suffered for a year or more from a disordered state of the bowels, accompanied by a most re- markable : and unmanageable degree of tympanitic distention. When I saw her, along Avith Dr. Combe, in the summer of 1826, she was affected with a variety of hysterical symptoms, with much weakness, impaired appetite, and a very disordered state of the bow- els. Under a course of mild laxatives, combined with tonics, these symptoms gradually subsided; and when she returned to the coun- try in August, she was in very good health, except that the bowels required the frequent use of medicine and that she occasionally complained of headache, and of a feeling of heat in the epigastric region. In November the bowels again became more obstinate, and she was considerably annoyed with acidity. In the beginning of De- cember, her throat was covered with aphtha?, and she brought up from it considerable quantities of thick white matter; and about the same time, the evacuations from the bowels began to contain much viscid mucus, and afterwards portions of a Avhite 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 apthous state of the throat disappeared in the course of Decem- ber, and afterwards the tongue was only occasionally observed to be red and tender; but the other symptoms continued to recur from this time, Avith numerous variations, for six or seven months, dur- ing the greater part of Avhich 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 quantities of a substance, which sometimes appeared in the form of pure transparent jelly; at other times of a long fibrous stringy matter, and frequently of large pieces of firm, uniform, te- nacious membrane. These last were occasionally discharged in flat portions several inches in extent, and frequently formed distinct tubes; sometimes they were in masses resembling hytadids, and sometimes in membranous bags which enclosed healthy feces. The membranous crusts or tubes now mentioned were frequently four or five inches in extent, and sometimes portions of white matter re- sembling cream were observed in the evacuations. The discharges of these various matters frequently ceased for several days together, the motions then becoming quite natural. 264 CHRONIC DISEASES OF MUCOUS MEMBRANE. The re-appearance of the morbid discharges Avas generally preceded by constipation, and a sense of heat along the intestinal canal, 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 ap- pearance, but hard and lumpy. Her appetite was generally varia- ble, 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 ea- sily regulated by very mild medicines, and the evacuations were quite healthy. But from the middle of June, when the more deci- ded 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 expecto- ration, and occasional uneasiness in the left side of the thorax, where the respiration was very imperfect. The febrile paroxysms continued 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 char- acter ; and she died on the 9th. 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 disorganiza- tion, Avith much infiltration of puriform matter, and numerous small tubercles. In one place, 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 Avere several other small cavities which communicated with it. The right lung Avas healthy, except a small cavity at the upper part; the bronchial glands at the root of the lungs were much en- larged and tubercular. The viscera of the abdomen presented no appearance of disease, except the mucous membrane of the colon. DEATH FROM OTHER CAUSES. 265 Through its whole extent, it was thickly covered with small spots of a clear Avhite color, which were remarkably distinguished by their color from the mucous membrane surrounding them. Few of them Avere larger than the diameter of large pin heads, and, on minute examination, they were distinctly ascertained to be vesicles, very little elevated, but, Avhen punctured, discharging a small quan- tity of clear fluid. The whole surface of the membrane presented a very peculiar appearance, from the immense number of these spots with which it was covered, but the other coats were entirely healthy. In the mucous membrane of the caput coli, there were two distinct spots in a state of ulceration. The small intestine was healthy. In the preceding observations I have endeavored to give an outline of the pathology of the mucous membrane of the intestinal canal, in as far as, in the present state of our knowledge, the facts appear to be worthy of confidence; but it is well known, that, among the pathologists of France and' other parts of the continent of Europe, the subject has been made to assume a much more ex- tensive form. In the investigations of the writers Avhom I now re- fer to, inflammation of the gastro-intestinal membrane, in an acute, sub-acute, or chronic form, is considered as being the origin of a great variety of diseases, particularly of almost every modification of dyspeptic affections, and all the varieties of fever. This system has not been received to any extent by the pathologists of this coun- try ; and the grounds on which we differ from the eminent persons by whom it is supported are chiefly three, namely, in regard to the facts,—their generalization,—and their causation. I. We do not recognise the facts upon which this system is founded; because, according to it, many appearances are considered as indicating inflammation of the gastro-intestinal membrane, Avhich we believe to take place after death or immediately before it, and consequently not to be considered as indicating disease. The nature of these appearances has already been mentioned, as well as the grounds on which we conclude that they are not worthy of confidence in this pathological enquiry. They consist of livid, red, or brown spots on the membrane, portions showing a violet or rose 34 266 DISEASES OF MUCOUS MEMBRANE. color, enlarged vessels, varicose veins, slight extravasations of blood under the membrane, and various other appearances, consisting of mere change of color without any change in the organization of the part. Such appearances we now consider as fully ascertained to occur in a great extent in the bodies of persons who have died from execution or drowning, or from diseases not at all connected with the boAvels ; 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 enquiry, a large pro- portion of the appearances described by these writers, we admit that others are indicative of real and important disease : but we do not admit that these are uniform appearances in the diseases to which they refer. In a pathological point of view, for example, it is an important fact, that in a considerable proportion of the fatal cases of fever, inflammation or.ulceration is found in the gastro-intestinal membrane; but Ave 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 consid- ered as the cause of fever. III. But, even on the supposition that these appearances Avere met with in all the fatal cases of fever, the question still remains, whether they are the cause of fever or the effects of it; and upon this head, a very slight view of the facts will show that they are decidedly in favor of the supposition of these appearances being 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 they are often Avanting ; 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 period, 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 Avhich 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 Ave are warranted in con- cluding, that the affections of the gastro-intestinal membrane which are met with in connection with continued fever, are to be consid- ered either as incidental concomitants, or as effects of the disease, and as giving rise to peculiarities of symptoms in particular cases, CONCLUDING OBSERVATIONS. 267 but that they cannot, upon any principle of sound reasoning, be regarded as the cause of fever. The truth seems to be, that the morbid conditions observed in the gastro-intestinal membrane, in fever, or only a part of a series of changes Avhich take place in va- rious tissues of the body, especially in those forming surfaces, whether mucous, serous, or cuticular. We observe them vary re- markably in the skin. In one stage we find the cutis anserina with suspension of the natural exhalation; in another the dry pungent heat, often with deep redness; in a third, a morbid discharge in the form of clammy unhealthy perspiration ; in a fourth, a variety of spots, vesicles, papula?, petechia?, vibices, portions of erysipelas, and gangrene, and actual sloughing. These changes though more fa- miliar to us, are scarcely less remarkable than those which are ob- served in the gastro-intestinal membrane. They have accordingly been attended to as important phenomena in the history of the dis- ease ; but I am not aAvare that any one has proposed to consider them as the cause of fever. These observation apply to the general appearances of the mu- cous membrane, to which so much importance has been attached by the pathologists of the continent; but some of the later Avriters have taken rather a new view 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 attention as far as they consist of facts ; but we sus- pend our confidence when we are farther informed, that the dothi- nenterite is synonymous with the malignant fever of Sydenham, the hospital fever of Pringle, the typhus of Cullen, the putrid and pete- chial fever of other writers ; in short, that every variety of fever, continued, intermittent, and remittent, arises from the inflammation of these follicles. As the symptoms of the dothinenterite, they of course describe all the phenomena of continued and malignant fever, accompanied by a loose state of the bowels 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 follicles appear rather more prominent than natural, and slightly injected, especially in the upper part of the canal; as the disease advances, they be- come more prominent, with softening of the mucous membrane which covers and surrounds them ; and that, at a period still more advanced, this passes into ulceration. 268 DISEASES OF THE MUCOUS MEMBRANE. These observations are Avorthy of attention as facts ; but when, in describing the symptoms of the dothinenterite, all the usual symptoms of fever are detailed, with the addition of diarrhoea, and tenderness of the abdomen, the statement merely amounts to the fact, Avith which we are well acquainted, that when in a fatal case of fever, there has been tenderness of the abdomen Avith diarrhoea, we may expect to find disease of the mucous membrane or its fol- icles. When we are farther told, that this takes place in every case of fever, and consequently that fever in all its modifications depends upon the inflammation of these follicles, we hesitate alike about the doctrine and the generalization on which it is founded. This we do upon two grounds, namely, that, in many fatal cases, of fever, we cannot detect any disease of these follicles ; and, secondly, that, when we do find such disease, the degree of it, or the stage of its progress, bears no relation to the period of the fever, or the inten- sity 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 Avas draAvn out to the 21st day, with every symptom of the most severe form of typhus, the only morbid ap- pearances found in the mucous membrane were,—in some places a grey color; the crypts of Brunner, little developed; those of Peyer slightly enlarged, and a few of them presenting traces of erosion. In another patient, AA'ho lay with every bad symptom for twenty- eight days, the glands of Peyer offered some points which were red and denuded of their mucous membrane.; those of Brunner were almost all in their natural state, except a few which showed ulcerations, and a very small number which offered traces of me- lanism ; the mucous membrane of the great intestine was of a pale rose color, and appear thickened.* We must suspend our confi- dence, when we find a system, which professes to account for the whole phenomena of fever, founded upon such inadequate appear- ances as these. The fair conclusions from a view of the whole subject appear to be, that, in certain cases of continued fever, the gastro intestinal-membrane or its follicles become inflamed, pustu- lar, or ulcerated ; and that, as facts in the history of fever, these are worthy of much attention, but certainly do not Avarrant, in the slighest degree, any general deduction in regard to its nature or cause. ♦ See Landini sur la Dothinenterite.—Revue Medicale, lb26 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 detailed 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 observa- tions on it. There are, however, some points relating to the affec- tion, which present an interesting 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 mesentery most contiguous to the seat of the.ulcers. To what extent this connec- tion exists has not been investigated, but it is worthy of attention. In the progress of the affection there are some facts of considera- ble interest. In the earliest period at which we have an opportu- nity of examining the diseased glands, they present, when cut into, 270 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. a pale flesh color, 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 lose the flesh color, assuming first a kind of semi-transparency, and afterwards a firm opake Avhite structure, resembling the white tu- bercle of the 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 tubercular matter is the most abundant; and this afterwards appears to be gradually softened, degenerating into a soft cheesy matter,"or ill-conditioned suppura- tion, so familiar to us in diseases of this nature. When a gland in the first state of soft fleshy enlargement is plunged into boiling Avater, its color instantly changes to an opake Avhite or ash color; its texture becomes much firmer ; it contracts very much in its di- mensions ; and by a short boiling, it loses a great part of its weight, leaving a residium of an opake Avhite color and great firmness, having the appearance of concrete albumen. In the more advan- ced stages of the disease, the glands lose less and less by boiling ; and the opake white tubercular matter, Avhen it can be obtained pure, scarcely loses anything. In the first volume of the Medico- chirurgical Transactions of Edinburgh, I have mentioned some experiments which render it probable, that during these changes in the structure of the glands, there is a gradual deposition of albu- men, at first in a soft, afterwards in a concrete state; and that the peculiar character of glands in a state of tubercular disease, de- pends 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 modifica- tions occasionally occur in the state of the diseased mesenteric glands. I have mentioned a case in which they contained calcare- ous matter, and their cysts were so distended with a gaseous fluid, that they burst with a very sharp-explosion, Avhen slightly touched with a knife. A case occurred to Dr Kellie, in which the diseased glands Avere 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 frequent- ly combined Avith other affections of a scrofulous character, or with chronic peritonitis. But it is met with under other circumstances, and at advanced periods of life. I shall only add the folloAving example of this, which is rather a rare occurrence. DISEASE OF MESENTERIC GLANDS. 271 Case CXX—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 similar tumor was felt below the umbilicus ; and soon after a third betwixt the umbilicus and the region of the stomach. They were of large size, and somewhat painful on pressure. The functions of the stomach and bowels Avere little impaired ; but her general health soon began to suffer. The inguinal glands next began to swell, and increased to a great size; and chains of enlarged glands were traced from them under Poupart's ligament, and within the abdo- men. Enlargement then took place in the glands of the axilla, and on both sides of the neck. Finally, she had cough, with great ir- ritation about the trachae, fits of dyspnoea, hectic paroxysms, and progressive failure of strength; and she died, gradually exhausted after an illness of nearly two years. Inspection.—The abdominal tumors were entirely masses of diseased mesenteric glands, some of which were the size of large oranges, and of a firm Avhite tubercular character. There were chains of diseased glands running from Poupart's ligament by the side of the spine; but the abdominal viscera were otherwise healthy. Behind the trachae, and along the posterier mediastinum, there were large masses of diseased glands; and there were some tubercles in the lungs, but of no great extent. SECTION II. DISEASE OF THE OMENTUM. In the preceding cases several examples have occurred, in Avhich there was disease of the omentum complicated with disease of the neighboring organs. The following case, for which I am indebted to Dr. Storcr of Nottingham, shows uncombined disease of the omentum, and must be considered as a very uncommon af- fection. 272 PATHOLOGY OF INTESTINAL CANAL. —APPENDIX. Case CXXI.—A lady, aged GO, of a full habit, had complained for some months of prominence, weight, and habitual uneasiness in the front of the abdomen. In November, 1823, the complaint assumed an acute character, with severe pain, affected by respira- tion, and fever, but Avithout obstruction of the bowels. The pain Avas increased by pressure, and a soft diffused tumor was felt to oc- cupy the epigastric and umbilical regions, without and distention of the abdomen. The usual antiphlogistic treatment was now adopted, but with only partial and temporary benefit. After two or three weeks, the pain had become much less urgent; but she then passed into a state of low fever, with occasional delirium, and she died at the end of five weeks from the commencement of the acute attack. For the last week of her life, there Avas retention of urine, requiring the use of the catheter. Inspection.—The disease was found to be entirely in the omen- tum, which formed a thick, fleshy mass between three and four pounds in Aveight. It was of a dark color and soft consistence, and no disease Avas detected in any other organ. Another form of disease and of the omentum is described by Dr. Strambio, in the Annali di Med. It formed an immense tumor of the consistence of brain, and involving in the mass, the spleen, the left kidney, the ovaria, uterus and rectum. The other viscera were healthy. The disease was ascribed to an injury from a fall about a year before death. The symptoms were vomiting, with en- largement of the abdomen and febrile paroxysms. SECTION III. TYMPANITES. Tympanites has been usually distinguished into abdominalis and intestinalis. I have never seen such a disease as the tympan- ites abdominalis, except when air has esaped into the peritoneal cavity, in consequence of perforation of the intestine. Several ex- amples of this have been given. It often requires a great deal of TYMPANITES. 273 time and attention to discover the perforation, which may very often have escaped notice ; and in this manner, probably, has arisen the doctrine of tympanites abdominalis. The important division of tympanites is into two forms, which, for the s^ake of names, we may call acute and chronic. I. Acute tympanites, or that which occurs in connection with acute disease, we have seen taking place in various forms. In its relation to active abdominal inflammation, Ave have seen reason to believe, that it may occur at an early period, while the inflamma- tion 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 disorganization of the parts, marking a hopeless state of the disease; or that it may be left as an effect of the disease, from derangement of the muscular power, after the inflammation has been removed, and may, by attention, be entirely recovered from. In Case LXXIV, again, we have seen tympani- tes supervening upon diarrhoea, and assuming a very alarming aspect; and in Case LIII, we have seen it very rapidly fatal, and affecting the whole course of the canal, apparently connected with a general loss of its muscular power. The treatment adapted to this form of the disease has been mentioned in treating of the cases now referred to. It also takes place in connection with continued fever, and is in general rather an unfavorable symptom. In all cases of acute disease, tympanites requires to be watched with some anxiety; but Ave have seen that it may be recovered from, even under circumstances apparently the most alarming. II. Chronic tympanites is met with most frequently in females; and it often proves most untractable. When it is accompanied with any degree of wasting, and impaired general health, there is rea- son to suspect chronic peritonitis, especially if there should be any pain or tenderness of the abdomen. It also occurs in connection with chronic disease of the mucous membrane, as we have seen in Case CXIX, and it may be left as the effect of an acute attack, as in Case LXXIII. When it does not arise from such causes as these, the treatment must consist chiefly of attention to the gener- al health, Avith regular exercise, cold bath, and careful regulation of the bowels ; especially by small doses of aloes or rhubarb, com- bined with tonics and stimulants, as sulphate of iron, quinine, and the stimulating gums. Small doses of turpentine may often be 35 274 PATHOLOGY OE INTESTINAL CANAL.--APPENDIX. 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 tympanites, though assuming characters different from the ordinary cases. The abdgmen be- comes 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 organic disease; and has not unfrequently been mistaken for pregnancy, especially in females who have been married late in life. It is often in such cases ac- companied by suppression of the menses, and all the usual symp- toms of advancing pregnancy; and not a feAv examples have occur- red, in which every preparation was made for approaching accouche- ment, before the nature of the affection 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 of- ten assumes in a great measure the appearance of extensive organ- ic disease. I have had no opportunity of examining the parts in a case of this kind. In its early stages, the affection must consist en- tirely in a state of distention of the bowels, but the characters of it are very peculiar ; and it is 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 af- fections is, that, after continuing in a most extraordinary degree for a length of time, and resisting every remedy, they sometimes dis- appear spontaneously. In the Edinburgh Medical Essays, Dr. Monro has described the case of a young woman, whose abdomen became so enormously distended, that it often seemed in danger of bursting. This affection continued three months, and then disap- peared by a prodigious discharge of flatus both upwards and down- Avards. A remarkable distention sometimes takes place in circumscribed portions of the intestines, forming defined enlargements, Avith 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 super- ficial examination, such affections Avere mistaken for masses of or- ganic disease. I have described several cases in which this oc- TYMPANITES. 275 curred 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 gentleman from England consulted me resp'ecting 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, unyielding; but on laying him in the horizontal posture, and making pressure upon it, the whole swelling disappeared suddenly with a girgling noise. It ap- peared to be the caput coli in a singular state of distention. The affection had existed for a considerable time, and though he was subject to flatulence and indigestion, his general health was little impaired. In my treatise on the Affections of the Brain, I have described the case of a woman, who had swelling and hardness occupying the whole right side of the abdomen, and conveying the impression of an extensive mass of organic disease. But when she died, soon after, of an affection of the brain, no vestige of disease could be discovered in the abdomen. It appears that symptoms assuming the most alarming charac- ters, may arise from a merely distended state of the intestines, the nature of which has not been fully investigated. The following cases, for Avhich I am indebted to Dr. Cheyne of Dublin, will illus- trate this singular affection. Case CXXII.—A lady, aged 23, had been long affected with pain in the right hypochondrium, and a very confined state of the bowels, for Avhich a great variety of treatment was adopted with little benefit. In the autumn of 1822, the abdomen became greatly enlarged, tense, and painful. Some relief was obtained from topi- cal bleeding, blistering, and purgatives; but after a severe pulmon- ary attack in Avinter, the pain and weight were aggravated, and extended into the left side in the direction of the arch of the colon, with increased tenderness of the abdomen. In spring 1823, she Avas someAvhat improved, but in June and July,-there Avas again an increase of the abdominal pain, which became very severe in the course of the transverse colon, Avith obstinate costiveness, dry tongue and thirst. Some relief was again obtained from topical bleeding, purgatives, and enemata ; the latter bringing off frothy 276 PATHOLOGY OF INTESTINAL CANAL.—APPENDIX. discharges, and much flatus. In the beginning of winter 1823—4, she had two pulmonary attacks, after which the abdomen became again very tumid and painful. In April, 1824, she had pain in the right shoulder, pain and numbness of the right thigh and leg, and she often complained of a feeling as if scalding Avater were pass- ing along her right side. In June, the abdominal pain and tension being very great, a caustic issue was inserted on the right side of the linea alba ; purgatives were persevered in ; and she went to the country, where she remained during the summer and autumn, and improved considerably in strength. From this time her complaints continued to abate, and she has since enjoyed very tolerable health. The uterine functions had been, through the whole course of this affection, quite natural. A sister of this lady was affected in a similar manner, suffering most intense pain in the abdomen, and such "tumefaction that she was supposed to have ascites, and was several times on the point of being tapped. She died after protracted suffering, which continued for several years; and, on examination, the disease was found to consist entirely of an enlargement of the colon. A portion of it 44 inches in length is preserved; the largest circumference of which is 25 inches, the smallest 16. It was in many parts ulcerated. The existence of ulceration in this case gives reason to believe that the disease Avas originally connected with inflammatory action of a low chronic kind, which gradually destroyed the natural ac- tion of the part. But without any cause that can be traced of this nature, there appears to be a disease of the intestinal canal depend- ing upon a gradual loss of its muscular power, the cause of which eludes our researches. An interesting example is related by Dr. Parry, in the case of a medical gentleman who had been long lia- ble to dyspeptic eomplaints, great flatulence, and irregularity of his bowels. ^ After suffering, for a fortnight, pain in the bowels, with nausea and costiveness, he was seized with symptoms of ileus, accompanied with severe pain, which was most violent in the epi- gastrium and left hypochondrium. Under the usual treatment this attack subsided after several days ; but he continued from this time to be liable to similar attacks, which were accompanied by vomit- ing, obstinate costiveness, and severe pain\ with hardness and dis- tention in the epigastric and left hypochondriac regions. The bow- els were at all times unmanageable, and the motions thin, scanty, and not formed. The pulse was little affected. The matter vom- ARTERIAL HAEMORRHAGE FROM THE RECTUM. 277 ited at length became feculent, and he died with symptoms of peri- toneal inflammation, about six months after the commencement of these attacks. On inspection there Avere found marks of peritoni- tis with adhesions ; and the omentum was in a thickened and hard- ened condition. But the principal appearance was an enormous and uniform distention of the colon, the arch of which occupied en- tirely the epigastric and hypochondriac regions, so that the stomach and the liver were pressed upwards, high into the thorax. Its coats were in some places slightly thickened, and the peritoneum cov- ering of it was of a dark color, but there was no appearance of con- traction or obstruction in any part of its course. The enormous distention extended from its commencement to the sigmoid flexure, and it contained an immense quantity of feculent matter, partly solid and partly fluid. The sigmoid flexure and rectum were per- fectly healthy. The ileum was distended, and dark colored, but in a much less degree than the colon.* 1 have already alluded to the remarkable effects of galvanism in some obstinate affections of the bowels ; and I am indebted to the kindness of Dr. Cheyne for an additional illustration. A gen- tleman had been under the care of the most eminent physicians in England and Ireland for an obstinate state of the bowels, which was originally ascribed to haying slept in a newly painted room. From being of a full habit, he became greatly emaciated, and the complaint went on in this manner for about two years. Dr. Cheyne then recommended galvanism, which in about three weeks restored the natural action of the bowels, and he soon recovered perfect health. SECTION IV. ARTERIAL HJEMORRHAGE FROM THE RECTUM. I have seen a good many cases of arterial haemorrhage from the rectum, and they presented some facts worthy of being recorded^ The discharge is usually at first considered as haemorrhoidal, and ♦ Collections from the unpublished Medical Writings of Dr. Parry, vol. ii. 278 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. does not excite any apprehension, especially as the quantity of blood lost is often not great. But after some time, the patient begins to look pale, haggard, and exhausted; palpitation and breathlessness are excited by any exertion, frequently Avith 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 fre- quent, and is excited to the highest degree of frequency by very moderate exertions, perhaps by walking across a room. He becomes more and more exhausted, till he acquires all the appearance of a person sinking under the advanced stage of some deep-seated disease. During this time, he probably complains of nothing except extreme weakness ; and says he is sensible of no disease, except a degree of piles, Avhich bleed regularly, but in no great quantity. On examining the parts immediately after he has been at stool, or on making the extremity of the rectum protrude by means of a stimulating injec- tion, a small fungous mass is discovered Avithin 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 tenaculum, and tying it, so as to in- clude a part of the fungus. It is not necessary to go to the base of it, and in this manner much irritation is prevented, while the cure is equally effectual. The patient soon begins to recover strength, and it is astonishing with what rapidity every appearance of disease vanishes. It is difficult 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 haemorrhoids for a length of time, without any effect upon the general health. When the ligature does not entirely com- mand the" haemorrhage, the free application of the nitrate of 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; an d it Avould appear that in these cases the minute vessel is nearly at all times bleeding a little, and that the blood coagulates in the rectum, and accumulates, till such a quantity is collected as excites the patient to go to stool. This I think, does AN OBSCURE AFFECTION. 279 not take place with the dfscharge of haemorrhoids. The affection is also distinguished by the arterial color of the blood,—that which is haemorrhoidal being probably always venous. SECTION V OF A VERY OBSCURE AFFECTION, IN WHICH THE SYMP- TOMS ARE CHIEFLY REFERABLE TO THE BOWELS. The affection Avhich I refer to under this head, Avould appear to be connected with some morbid condition of the mucous membrane of the intestinal canal, the precise nature of which eludes our obser- vation. The patient is found thin, pale, and weak, with a withered look, a peculiar dry state of the skin, and a small weak pulse. His appetite is variable and capricious, and he feels uncomfortable after eating. The bowels are slow, though easily regulated ; and the evacuations are ahvays of a remarkably dark color, like dark mahogany, or almost black. The obscure nature of the affec- tion will appear most strikingly from the following case Avhich was fatal. Case CXXIII.—A lady, aged about 30, had been in bad health for four or five months; and when I saw her, was Avasted like a person in an advanced stage of phthisis. She had a small frequent pulse and bad appetite, but complained of nothing except some un- defined uneasiness in the abdomen. The bowels were slow, re- quiring the constant use of medicine; the motions Avere consistent and formed, but ahvays of the deep brown color of dark mahog- any or rose wood, and no treatment had any effect in correcting that color. The abdomen Avas collapsed, and nothing could be dis- covered by examination. Sometime after I saw her, she began to have uneasiness in her chest, with slight cough; she then became liable to fits of coma, in which she lay with her eyes open, but un- conscious of anything; 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. 280 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. 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 Avas throughout so thin, as to be transparent like goldbeater's leaf. On the mucous membrane there was in many places a tenacious mucus of a dark brown color, but no disease could be discovered in the membrane itself, and no mor- bid 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 mu- cous membrane interfering with digestion, and preventing the nour- ishment of the body. I have seen some other cases Avhich showed similar characters, and proved very tedious and unmanageable. The peculiar character in all of them was the remarkably dark color of the evacuations, which nothing had any effect in correcting. The last case that occurred to me seemed to derive most benefit from the sulphate of iron ; and this remedy, which in general makes the evacuations very dark or nearly black, made them in this case de- cidedly lighter than their usual color. Another seemed to derive benefit from small quantities of mercury. The patients had in general a peculiar emaciated Avithered aspect, with a dry state of the skin, a weak pulse, and a variable and capricious appetite; but no. actual disease could be discovered capable of accounting for their unhealthy appearance. SECTION VI. REMARKABLE ABSCESS COMMUNICATING WITH THE CAPUT COLI. Case CXXIV.—A young man, aged 19, on the evening of 16th September, 1827, was seized, after eating freely of pears, with pain of the bowels, accompanied with much vomiting and purging. These symptoms were relieved by the usual means, but were im DISEASE OF RECTUM--STRICTURE OF COLON. 281 mediately followed by fixed pain in the right iliac region, a little below and inwards of the superior spinous process of the ileum. At first nothing unusual was discovered by examination of the part; but after a few days, a deep-seated circumscribed swelling, about the size of an egg was felt; it Avas 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 Avas much fever Avith high delirium. General and topical bleeding, and all the other usual remedies, which were care- fully administered by Dr. Begbie. failed in giving any relief. Fever continued with high delirium; the swelling was still very tender to the touch, and there Avere frequent attacks of strong rigors. In the beginning of October, the swelling became more diffused and less painful, and an obscure feeling of fluctuation was discovered in it. ,On the 3d he was seized with severe diarrhoea, accompanied by a tympanitic state of the abdomen; the local affection then be- came less urgent, but the constitutional symptoms continued and as- sumed the characters of the advanced stage of low fever, and he died, gradually exhausted, on the 14th. Inspection.—Immediately above the caput coli, the omentum had contracted a very firm adhesion to the ascending colon and to the parieties of the abdomen; and in this manner was formed a circumscribed cavity, bounded by this portion of omentum, the pos- terior surface of the caput coli and the portion of peritoneum lin- ing the parietes at the part. This cavity contained a small quan- tity of ill-conditioned pus, and three or four bodies, which were found to be the seeds of fruit, covered by an earthy incrustation ; it communicated with the caput coli by a small irregular opening, and the mucous membrane around the opening was thickened and highly vascular. The cavity of the abscess was also found to ex- tend behind the peritoneum covering the iliac muscles, and upwards along the whole extent of the lumbar vertebrae. There is an obscurity in the pathology of this singular case ; and it seems difficult to say, Avhether the abscess had been origin- ally formed and had burst into the caput coli, or whether the per- forating 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 incrustation, in the cavity of the abscess, Avould appear to favor the latter supposi- tion. 36 282 PATHOLOGY OE INTESTINAL CANAL.--APPENDIX. SECTION VII. EXTENSIVE DISEASE OF THE RECTUM AND PROSTATE GLAND.—STRICTURE OF THE ARCH OF THE COLON, &c. Case CXXV.—A gentleman, aged 72, had been liable for fif- teen 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 ac- companied at each time by a desire to go to stool. This at last in- creased 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 fre- quent desire to pass urine continued, but it Avas passed without pain. On examination the prostate Avas 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 tu- mors 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 ap- pearance and rather fluid. He died, gradually exhausted, in July, 1827. Inspection.—The prostate Avas very much enlarged, and of a soft cheesy consistence, so that it broke down under slight com- pression. The coats of the rectum were much thickened, and it adhered extensively to the neighboring parts. The sigmoid flexure of the colon adhered to the brim of the pelvis. The blad- der was much thickened and contracted, but its internal surface was healthy. In the caput coli there was a small ulcer, and in the right side of the arch of the colon there Avas a thickened and contracted portion about an inch in extent, Avhich admitted only a small finger. The other parts of the colon, both above and below this contraction DISEASE OF RECTUM—STRICTURE OF COLON. 283 were distended Avith 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 umvorthy of attention consists in the masses of hard feces in the colon, assuming, in a great degree, the characters of glandular tumors, and some of them being even painful on pressure. It also illustrates in a striking manner that singular state of the bowels, in which fluid feces may be discharged regularly and freely, and 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. SECTION VIII EXTENSIVE DISEASE'OF THE BLADDER, AND COMMUNICA- TION BETWEEN IT AND THE INTESTINAL CANAL, AT THE EXTREMITY OF THE ILEUM. The following remarkable case, for which I am indebted to Dr. Hay, illustrates several points connected with the preceding in- quiries, particularly the translation of erysipelatous inflammation from the surface of the internal parts ; and the formation of a com- munication betwixt the intestine and the bladder. Case CXXVI.—A lady, aged 63, in the end of June, 1829, was seized with rheumatic symptoms, accompanied by an erythematic blush on the ankles. After 8 or 10 days these symptoms, disap- peared rather suddenly, and she was seized with dysuria and consid- erable uneasiness in the region of the bladder. On the following day (the 9th of July) there Avas complete retention of urine, with pain and distention of the abdomen, and continued vomiting; her pulse became extremely feeble and rapid, and the skin cold. On 284 PATHOLOGY OF INTESTINAL CANAL.--APPENDIX. the 10th the vomiting had subsided—the retention of urine contin- ued, requiring the regular use of the catheter, the urine being abundant in quantity and bloody. From this time she required the regular use of the catheter; the bloody tinge in the urine grad- ually diminished, and after 8 or 10 days ceased; but as this change took place, it became highly offensive, depositing purulent matter, and some portions of slough, and on several occasions, a quantity of fetid gas escaped through the catheter. The abdomen contin- ued much distended; and the motions were liquid, and generally very offensive. From the 15th to the 20th she seemed to rally a little in point of strength, but from that time sunk progressively, and died on the 28th. Urine, mixed with pus, was regularly draAvn off by the catheter until 36 hours before her death, from which time nothing but purulent matter seemed to be discharged from the bladder. Inspection.—The omentum adhered to the bladder and to the ascending colon. The caput coli was greatly enlarged, and the extremity of the ileum adhered to the posterior part of the bladdet. The bladder adhered extensively to all the parts within the pelvis, and in attempting to separate it, a large quantity of pus escaped. Its inner surface was sloughy, and shreds of its mucous coat were hanging into its cavity. An opening capable of transmitting a goose quill Avas found to exist betwixt the bladder and the portion of ileum which adhered to it. The left kidney Avas healthy ; the right was wasted, so as to leave only the"calyces and cellular tex- ture Avithout any of the glandular structure. PATHOLOGY OF THE LIVER. In a short dissertation on the pathology of the liver, my inten- tion is to do little more than attempt a slight outline of the morbid conditions to which that organ is liable, without entering minutely either upon the symptoms or the treatment. My reason for doing so is, that acute affections of the liver are comparatively rare in this country, so that I cannot speak of them from much personal observation; and that the chronic diseases are generally obscure in their symptoms, until they are detected by manual examination, and, in point of treatment, are in general beyond the reach of med- ical aid. I must at the same time confess my suspicion, that it has be- come a kind of fashion to refer symptoms to morbid conditions of the liver, without any good ground for considering them as being really connected with that organ. This is so common in the mod- ern phraseology of medicine, that it seems a very delicate task to start a doubt in regard to a doctrine so generally received. But, as a practical man, anxious to be guided by observation alone, there are three classes of facts which have appeared to me worthy of much attention in reference to this subject; namely, 1. That I fre- quently see such complaints get well under very mild treatment, as regulation o.f the bowels, and a little attention to diet; 2. That I have seen such patients put through long and ruinous course of 286 PATHOLOGY OF THE LIVER. mercury, Avithout any benefit, and afterAvards found the complaint rempved by a course of mild laxatives; and, 3- That I have known patients die of other diseases, while these alleged affections of the liver were going on, Avithout being able to discover in the liver, upon dissection, the smallest deviation from the healthy structure. I am ready to admit, that in such an organ as the liver there may be morbid actions Avhich do not leave any appearance that can be discoverd 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, Ave are certainly entitled to look for some trace of dis- ease, or else to do doubt whether the liver was really the seat of the disorder,—particularly if the symptoms were of such a kind as might Avith equal plausibility be referred to other sources, such as disordered conditions of the stomach or boAvels, especially the duo- denum or the arch of the colon. The structure of the liver, on a superficial examination, has a uniform appearance; but Avhen minutely examined, it is found to consist of two textures, which in certain states of disease can be clearly distinguished from each other. The one is a cellular or spongy texture or network, which appears to be of a yellowish white or ash color, and to possess comparatively little vascularity. The other is a substance of a red or reddish-brown color, contained in the cells of the former ; it is highly vascular, and is supposed to be capable of very rapid increase or diminution of its volume, in a manner almost resembling the erectile tissues. This however, is probably in some measure hypothetical, and it is probable, that the rapid changes in volume to which the liver appears to be liable, may be rather referred to the great vascularity of its structure, arising from the two distinct sets of blood-vessels which ramify through it in a manner quite peculiar to itself, namely, the hepatic artery and the vena porta?. A considerable part of the structure of the liver is also composed of the biliary vessels. In endeavoring to trace a slight outline of the actual morbid conditions of the liver, it is natural to arrange them into two class- es, namely the accute and chronic. There is, however, a difficulty in' this arrangement, because the two classes run so much into each other, that cases Avhich be^in with very acute symptoms, often INFLAMMATION OF THE LIVER. 287 become in their progress protracted and chronic. In using the terms, then, as a mere arbitrary division of the subject, I do it with the understanding, that, under the class of acute affections, I in- clude those Avhich 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 af- fection steals on in an obscure and insidious manner, perhaps only with dyspeptic symptoms,—or in which the affection of the liver is not ascertained till after protracted illness, or when the patient has died of another disease. This distinction is sufficiently correct for practical purposes; and an attempt at minute pathological ar- rangement on such a subject is often made at the expense of utility. In the following outline I mean to describe the liver disease of this country as they have occurred to myself, though with occasional reference to those of India, as they are described by the best prac- tical writers. SEC TION I. OF THE MORBID CONDITIONS OE THE LIVER, WHICH APPEAR TO BE CONNECTED WITH ACUTE DISEASE. § /.—Inflammation of the liver. The symptoms of inflammation of the liver seem to vary ex- ceedingly, according to the activity of the disease, and the part which°is the primary seat of it. There is generally pain in the right hypochondrium, increased by pressure, and frequently by in- spiration, with tension, considerable disturbance of the functions of the stomach, and often urgent vomiting. There is generally fever but this is often in a very slight degree ; there is sometimes jaun- dice, but this is often entirely wanting; and frequently there is pain extending to tfie 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 288 ACUTE DISEASES OF THE LIVER. accompanied by a higher degree of fever, than Avhen it is confined to the parenchymatous substance. When the upper surface of the liver is the chief seat of the disease, there is often cough, Avith symptoms closely resembling pneumonia; Avhen 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 ap- pear at all if the disease be chiefly in the convex surface. When the inflammation is seated in the substance of the liver, the symp- toms seem to admit of great variety, and are often very obscure,— the pain being frequently slight and dull, with very little fever; and it appears that the complaint may continue in this state for weeks or months, or may terminate more speedily by abscess or softening, though with very obscure symptoms to the last. The symptoms, however, attending inflammation of the substance of the liver are by no means uniformly obscure, for, in some of the fol- lowing cases, terminating by abscess, it will appear that they are of a very acute character. I have not seen inflammation confined to the peritoneal covering of the liver, except when combined with extensive and general 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 particu- larly described. 4. By passing into chronic disease. As some of the appearances, however, will be referred to under these heads, have not been absolutely ascertained to be terminations of inflammation of the liver, I shall not describe them under this arrangement; but, following the course which I have already pro- posed, I shall simply refer to them in the general investigation of the actual morbid conditions which we find in the liver after death. 1 BLACK CONDITION OF ITS SUBSTANCE. 289 $ //.—The mass of the liver more or less enlarged, especially on the right side ; externally of a very dark color, or nearly black; its substance, when cut into, also very dark colored, and giving out a large quantity of vpry dark blood. In other cases, the black color 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 de- scribed as connected with it are chiefly a febrile state, with anxious expression of the countenance, nausea, impaired appetite, and very bad digestion, pain, or a sense of weight and fulness in the region of the liver, and great oppression across the praecordia, often op- pressed breathing, headache, disturbed sleep, turbid urine, and a sallow color of the complexion. The disease has been called con- gestion, but this is merely a name accommodated to the appearance and explains nothing. It appears to be nearly allied to inflamma- tion, and there seems much reason to believe that this is to be con- sidered as inflammation of the substance of the liver, fatal in the inflammatory stage, or in a stage immediately succeeding the state of active inflammation. The following is the best marked case that I have seen of the appearance referred to under this section, and the morbid condition appeared to have been very superficial. Case CXXVIL—A gentleman, aged 28, (6th September, 1822,) was seized with vomiting, and for three days vomited every thing which he took into his stomach. There was an obscure uneasiness across the epigastric region ; the tongue was foul; the bowels Avere reported to have been easily regulated; the pulse from 120 to 130. The vomiting abated after three days, but returned after another day, though with less severity; then subsided again ; and in this manner were passed three days more, being six days from the com- mencement of the attack, without any other symptom. He Avas then seized with very deep jaundice, and I saw him foT the first time on the following day, 13th September. The jaundice was then very deep; pulse 120 and strong; no vomiting; no complaint 37 290 ACUTE DISEASES OF THE LIVER. of pain, even upon pressure ; tongue Avhite ; bowels open ; stools very dark. Blood-letting Avas now employed folloAved by the other usual remedies. For two days there was little change; the pulse continued at 120, but less strong; the boAvels open; the stools dark; the urine deeply tinged with bile. On the 10th and 17th, the pulse came doAvn, but very deep jaundice continued, Avith a look of much febrile oppression, but no complaint of pain ; the bowels were freely moved by repeated purgatives, and the motions showed no Avant of bile. On the 18th, he was seized with hiccup, which continued very troublesome through the whole day; the tongue as- sumed a parched and typhoid character; the pulse 108, and of good strength ; jaundice continuing very deep. He became from this time progressively worse, and died on the 20th. Inspection.—The liver was uniformly of a very dark color, al- most black, without any sensible increase of size. When cut into, it appeared that the black color Avas very superficial, the internal parts being tolerably healthy. The gall bladder was empty and flaccid; no obstruction could be discovered in any of the ducts; and no morbid appearance could be detected in any other organ. That this black condition of the substance of the liver is a state connected with inflammation, is rendered probable by an interesting case mentioned by Portal, in which it was combined with abscess. A gentleman, aged 50, Avas 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, Avith flocculent filaments floating in it. The liver was enormously enlarged; externally, it was of a deep red color, Avith pseudo-membranous deposition on its upper surface, and adhesion to the diaphragm ; internally, it was of a deep black color, and discharged, Avhen cut into, much black blood; and there were in various places vomicae, full of purulent matter.* The com- bination of this black condition of the substance of the liver with suppuration will also be found in Case CXXVIII. The earliest stage, perhaps, at Avhich the morbid appearances of the liver can possibly be seen, occurred in a remarkable case also * Portal,—Maladies du Foie. ABSCESS. 291 mentioned by Portal. A lady, aged 28, suffered a sudden cessa- tion of the menses from a violent mental emotion. She was imme- diately seized with severe vomiting, and complained of acute pain in the epigastric region, extending along the right hypochondrium. After a few hours, deep jaundice took place, with fever, distention of the abdomen, hiccup, and very difficult breathing; and she died on the following day. The liver 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 diaphragm was inflamed. The lungs were much gorged with blood. The other viscera Avere healthy. § III.—Abscess of the liver.* This must be considered as the result of inflammation of the substance of the liver, but the symptoms appear to vary exceedingly in activity,—in some cases being such as distinctly indicate active disease; in others, stealing on insidiously with little more than a feeling of weight and fulness ; and in many cases, most extensive abscesses have been met Avith, when the symptoms had been merely dyspeptic, or perhaps had been considered as hypochondrical. The following cases will exhibit the principal varieties of this affection as it occurs in this country. Case CXXVIII.—A gentleman, aged 22, (15th June, 1817,) was affected with pain across the epigastric region, increased by pressure, and accompanied by vomiting and frequent pulse. 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 Avas 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 jaundices. I saw him on the 20th. His pulse was then from 90 to 96, and soft: the bowels were open ; very deep jaundice con- tinued, but there was very little complaint of pain, except some un- easiness 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 110, without any other 292 ACUTE DISEASES OF THE LIVER. change in the symptoms. It subsided at night, but on the 23 was at 160 ; there was much febrile oppression, and very deep jaundice, with restlessness, slight pain upon pressure, and some tension in the region of the left lobe of the liver. The usual remedies were persevered in without any effect in controlling the disease. On the 24th, he continued in the same state, with an anxious febrile look, and died on the 25th. Inspection.—The left lobe of the liver contained several small abscesses, full of purulent matter; and there were also several ab- scesses in the right lobe in the part most contiguous to the left. In other respects, the Avhole substance of the liver, except a small part at the lower extremity of the great lobe, was very much softened and broken down, and of a very darker nearly black color. Both the hepatic duct and the ductus communis were obstructed by large calculi, and a larg% accumulation of bile appeared to have taken place in the substance of the liver, which flowed out freely when the ducts were laid open. The other viscera were healthy. Case CXXIX—A lady, aged 51 (23d October, 1816,) was af- fected with incessant vomiting, and severe pain in the region of the stomach, much increased by pressure, and extending downwards towards the umbilicus ; boAvels open ; pulse 84; the symptoms had continued 20 hours. She was treated by repeated blood-letting, blistering, full doses of calomel, &c. In the evening of the 24th, there was considerable relief of the pain, but it returned on the 25th with much severity : it was fixed in the region of the stomach, and Avas 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 re- turned Avith much severity, and continued with little abatement on the 27th and 28th. It was chiefly referred to a spot immediately beloAv the ensiform cartilage, and extended into the*region of the left lobe of the liver, where there Avere some tension and tender- ness on pressure. She Avas now free from vomiting; the bowels Avere quite open, and the motions dark colored ; the pulse varying from 100 to 120. She was now chiefly treated with calomel, digi- talis and blistering. On the 29th, the symptoms began to subside, ami in a short time, she Avas able to be out of bed, and stvined to ABSCESS. 293 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 vomiting, and oedema of the legs; pulse sometimes natural, and sometimes rather frequent. The pain recurred in paroxysms, which often ex- tended through the whole abdomen; and she was liable to attacks of vomiting, which continued severe for a day or two at a time, and then subsided ; her most permanent and uniform complaint was of constant and severe nausea ; and her general aspect was pale and exhausted, but without any appearance of jaundice. Some tension was felt in the region of the liver, but it was very obscure. With various remissions and aggravations of the symptoms now men- tioned, the case was protracted for four months, and she died grad- ually exhausted on the 27th of February. Inspection.—On the upper surface of the liver, towards the left side, there was an abscess, covered by little more than the perito- neal 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 ab- scesses in both kidneys. All the other viscera were healthy. Case CXXX.—A gentleman, aged 67, and previously enjoying good health, except frequent dyspepsia, had occasionally complained for some time of a pain in his right side, which affected him chiefly when he walked quickly. But he made little complaint, and was not confined to the house, until about three weeks before his death, when he had some irritation of his bowels, with kss of appetite, and an obscure uneasiness across the epigastric region. After another week he was confined to bed, his chief complaint being the frequent irritation 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 exhausted ; the pulse feeble, but little increased in frequency ; the bowels still troublesome, but kept in check by opiates. There was obscure uneasiness across the epigastric region, but without tenderness; and no 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 diffi- culty of swallowing, a great deal of hiccup, but no vomiting and no jaundice. From his exhausted state there was no room for ac- 294 ACUTE DISEASES OF THE LIVER. live treatment; he died gradually exhausted, a fortnight from the time Avhen he Avas first confined 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 puru- lent matter, the proper substance of the liver merely forming a very thin cyst around the cavity. At the cardiac orifice of the stomach there was evident inflammation of the mucous coat, with a deposition of flocculent matter; and this appearance extended alongthe whole course of the oesophagus, with much deposition of flocculent mat- ter in thin layers in different places. There were various adhe- sions of the intestines to each other; internally, the small intes- tine was healthy; but in the mucous coat of the colon, there Avas extensive ulceration, mixed with fungous elevations, which extended in a greater or less degree along the Avhole course of it, and even into the rectum- These examples will be sufficient to illustrate the remarkable diversity of symptoms Avhich 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 at- tention to the liver, as the seat of disease. In cases of this last kind, the affection, as Ave 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, with- out any acute symptoms. In both forms of the disease, the abscess is sometimes found of a most extraordinary size, occupying nearly the whole substance of the liver. A man, mentioned by Hasen- oehrl, had hapatitis, from which he Avas supposed to have entirely recovered, and he had returned to his usual occupations; but he soon after began to have febrile attacks, with progressive Avasting, 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 Avhen it was entirely evacuated, what remained seemed to be little more than the empty cyst of the abscess. In a similar case by Bonetus, there was found, in place of the liver, a great cyst, formed by its investing membrane in a thickened state and.full of a fluid like the Avashing of flesh. This man also lived six months from the period of an acute attack, and died gradually exhausted by diarrhoea, in Avhich he passed quanli- ABSCESS. 295 ties of a fluid resembling that which was contained in the cyst. I have the report of a case that occurred in Edinburgh, in which an abscess occupying the greater part of the liver, Avas found in the body of a man Avho died gradually worn out by complaints; which, almost to the time of his death, had been considered as hy- pochondrical. In a case by Annesley, an abscess of the liver con- tained 90 ounces of matter, and the parenchymatous substance of the right lobe was entirely destroyed. In other cases again the disease appears in the form of numer- ous small abscesses, having no communication with each other. In a case by Andral Avhich was fatal in thirteen days, the liver was beset Avith numerous small abscesses no larger than nuts, but each lined by a firm cyst of false membrane, the intervening substance being of a bright red color and softened. The symptoms were pain and tenderness in the region of the liA'er, with fever and j aun- dice. He found however, the same appearances in a man, who died Avith symptoms of peripneumony Avithout jaundice, and with- out any symptom referable to the liver. There Avere ten small ab- scesses in various parts of the liver, Avith a red and softened state of the intervening substance; the right lung was hepatized, with deposition of false membrane. Small cysts containing a thick pu- riform matter are sometimes found in chronic cases, and appear to be softened tubercles. When the parts which cover an abscess of the liver, form adhe- sions to the parietes of the abdomen, the abscess may burst exter- nally, or be opened, and may heal. In the same manner, by means of adhesions, the matter may be discharged into the stomach or the intestines, especially the colon. In a case by Malpighi the biliary duct was found to communicate Avith the cavity of an abscess. But the most remarkable course by which it sometimes finds an outlet is through the lungs, by means of adhesions formed both by the liver and the right lung to corresponding parts of the diaphragm. Numerous instances are on record in which this AA'as ascertained by dissection ; and not a few, in Avhich there was every reason to be- lieve that it had taken place though the cases terminated favorably. The following is the most remarkable example of this kind Avhich has occurred to me; and which, there seems every reason to consider, as being of the nature now referred to, from the total absence of pulmonary symptoms in the early stages, the tumefaction in the 296 ACUTE DISEASES OF THE LIVER- region of the liver, and the immense discharge which took place on the first appearance of expectoration. Case CXXXI.—A lady, aged about 40, had been affected for some months with uneasiness in the region of the liver, when, on the 5th of November, 1815, she was seized with violent pawn in that situation, accompanied with vomiting. By the usual remedies she was much relieved, but some degTee of uneasiness continued in the liver for several weeks; it then seemed to subside, but, after a short interval, returned with violence accompanied by vomiting and by fits resembling syncope. The pain was now so violent that for many nights together she was unable to lie down in bed ; these par- oxysms alternated with intervals of comparative ease, but, by the frequent repetition of them for nearly three months, her strength was very much reduced. The whole region of the liver was tense and tender to the touch, with evident enlargement; the pulse was sometimes small and frequent, and sometimes quite natural. In the end of December, she began to have cough, with some expec- toration, 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 thel5th she expectorated in the course of the day at least one pound, and about the same quantity on each of the two following days. The quantity then diminished consid- erably till the 25th, when she again brought up about a pound of matter, a*d the same quantity a few days after. During 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 dimin- ish 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. SIMPLE RAMOLLISSEMENT. 297 § IV—Simple ramollissement of the liver. This consists of a broken-down, friable, and softened state of a part of the substance of the liver, without any change of color. It is in general most remarkable on the convex surface, 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, leaving a ragged irregular surface below. The softened portion has commonly so far lost its consistence that the finger can be pushed through it with vfry little resistance; and in some cases the affected part is infiltrated with sanious or puriform fluid, not collected into abscess- es, but mixed irregularly through the substance of the softened part. This appearance we have every reason to consider as the result of inflammation. It is found in combination with abscess or other marks of inflammation, and I have very often observed it on the upper surface of the liver, in connection Avith extensive inflam- mation of the right lung. In these cases there was not in general any symptom indicating that the liver was a'ffected.. Mr. Annesley states, that this appearance is frequently met with in India in persons Avho have died rapid"ly from cholera or dysentery. ^ V.—The black ramollissemnt of the liver. I use this term simply to express the appearance, without im- plying any opinion in regard to the nature of this remarkable af- fection. It consists in a greater or less extent of the liver being reduced to a black mass of very little consistency, sometimes re- sembling a soft coagulum of venous blood, and occasionally accom- panied by a remarkable foetor. There is every Reason to believe that it is the result of inflammation, and that it is analogous to gan- grene. We have seen it complicated Avith abscess, and, in some observations by Andral, it was met Avith in cases in which fatal dis- ease of the liver supervened upon external injuries. It appears, hoAvever, to occur without any acute symptoms, for in a case by Boisment,* the symptoms were chiefly vomiting, with a slight yel- * Boisment.—Obs. sur quelques Maladies du Foie.—Archives Generales, torn, xvi, 38 298 ACUTF DISTASES OF THE LIVER. low tinge of the skin. The folloAA'ing is the best marked example of the affection which has occurred to me. Case CXXXII.—A lady, aged about 50, of a full habit and florid complexion, was suddenly seized in the beginning of June, 1821, Avith very deep jaundice, for which no cause could be traced. There was no pain, no tenderness, and no fulness in the region of the liver; the pulse was*natural, and rather Aveak; there was little appetite, and some nausea, but no other complaint. The boAvels were easily moved, and the motions were dark or broAvnish. 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 be- came more oppressed, with frequent complaint of nausea, and a feeling of languor; the tongue was white, but the pulse was natural. No other symptom was complained of, and nothing could be discovered in the region of the liver. On the 16th she began to have some vomiting, which occurred occasionally for three days, Avithout any other change in the symptoms, until the 19th, Avhen streaks of a black substance Avere observed in the matter which was vomited. The vomiting now became more and more urgent, with increase of* the quantity of this black matter, and she died gradually exhausted on the morning of the 21st. Inspection.—The liver was reduced to little more than a third of its natural size ; it was of a very dark or almost black color, and internally soft and disorganized, like a mass of coagulated blood. The gall bladder was empty and collapsed. The stomach and bowels contained a considerable quantity of black matter, similar to that which had been vomited, but Avere in other respects quite healthy. The appearance described under this head is probably a sequel to the condition described under § II.; and it appears to admit of various modifications. In a case by Boisment the tissue of the liver Avas infiltrated Avith dark blood; the substance, in other re- spects, Avas dark and friable, and beset Avith small friable tumors of a reddish brown color; in other places there were small cavities, containing a soft semi-liquid fluid like grumous blood. Little ac- count is given of the symptoms; but the case seems to have been protracted, and to have been accompanied, tOAvards the conclusion, by haematemesis, WHITE RAMQLLISSEMENT. 299 § VI.— The white or encephaloid ramollissement of the liver. The nature of this affection has been little investigated. I have placed it among the acute diseases on account of the degree of pain which occurred in the following case, which is the best exam- ple of it which I have met with. Case CXXXIII.—A gentleman, aged 65, in September, 1820, was seized, during a journey on horseback, Avith diarrhoea, the mo- tions 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 themonth, he Avas able to Avalk about a good deal Avithout appearing to suffer much uneasiness. On the 1st of October, there Avas increase of the pain, with fever, and the pain extended to the right shoulder. He Avas now largely bled and blistered, &c, and the acute symptoms were soon re- moved ; but he Avas never free from pain in his right side, and after some time he began to have cough, with copious mucous expectora- tion. 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 the pain in the right side continued. I saw him for the first time on the 11th of December ; he was then much emaciated, with some anasarca of the limbs ; there Avas still fixed pain in the re- gion 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 Aveak. The debility and dropsical symptoms in- creased progressively, and he died, 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 scarely exceeding the size of a split pea; internally, it Avas soft and of a white or ash color, very much resmbling the substance of the brain, and in many places almost of pulpy consistence; 300 CHRONIC DISEASES OF THE LIVER. scarcely the smallest portion could be discovered Avhich retained anything like the healthy appearance. There Avas considerable effusion in the abdomen ; the other viscera were healthy. $ VII.—Copious deposition of gelatinous matter of a soft consis- tence and a reddish color. This appearance is described by Portal as occurring both throughout the substauce of the liver arrd on its surface, raising the peritoneal coat into irregular soft tumors, accompanied with great enlargement of the liver. The case was of several months stand- ing, and Avas distinguished by pain in the epigastric region and vomiting, at first occasional, but becoming gradually more frequent; there Avas progressive Avasting, and at last dyspnoea and anasarca. $ VIII.—Remarkable distention of the biliary vessels. This occurred in a case by Boisment to such an extent as to give the liver the appearance of a large undulating cyst. The ap- pearance was found to depend upon a remarkable distension of all the biliary vessels, Avith dark colored bile, and was accompanied by Avasting of the proper substance of the liver. The affection seemed to depend upon a singular obstruction of the common duct by a membranous band which passed over it. SECTION II. OF THE CHRONIC AFFECTIONS OF THE LIVER. I have already stated, that by chronic affections of the liver I mean chiefly those in which the symptoms steal on in a slight and obscure manner, Avithout any complaint distinctly referable to the CHRONIC INFLAMMATION. 301 liver, until an advanced 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 condition of the liver is discovered only when the patient has died of some other disease. The distinction, I have already admitted, is entirely arbi- trary, but it seems to answer the purposes of practical utility in the division of the subject. The morbid changes of the liver Avhich come under this class appear to be chiefly referrable to the following heads:— $ /.—Chronic inflammation of the liver. This term is applied to a morbid condition of the liver Avhich often remains after an acute attack, and a corresponding condition may come on gradually Avithout any acute symptoms. The symp- toms are chiefly those of deranged functions. There is more or less pain or feeling of weight in the region of the liver, sometimes accompanied by a degree of tenderness; there are severe and un- tractable dyspeptic symptoms, wasting, and sometimes jaundice ; in other cases, pale evacuations without jaundice. There is generally a feeling of distention and oppression in the epigastrium and right hypochondrium, often vomiting, and pain, or a dragging sensation referred to the right shoulder. The bowels are generally slow, the tongue loaded, and the nights restless; there is commonly a leuco- phlegmatic aspect, often with febrile paroxysms tOAvards the eve- ning, and a peculiar burning sensation in the hands and feet. On examination, some degree of enlargement of the liver can often be discovered, but this is frequently wanting or very obscure; or the principal seat of the disease may be in the posterior parts, where it. cannot be discovered by examination. The morbid appearances in these cases usually consist of some degree of enlargement of the liver, especially of the right lobe ; the substance is generally dark colored or variegated in various ways, with streaks of a lighter color ; its consistence is frequently more dense than natural, but in other cases it is soft and friable j abscesses are met with in some cases, and in others tubercles. 302 CHRONIC DISEASES OF THE LIVER. ^ 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 descending as Ioav as the umbilicus, Avithout any remarkable change of its texture. It appears in some cases to be connected Avith a low and protracted inflammatory action; and in others to depend upon causes impeding the return of the blood from the liver towards the heart. In this manner the. liver is fre- quently found to be enlarged in connection Avith diseases of the heart. In a case by Andral, in Avhich the patient Avas liable to severe paroxysms of the symptoms arising from disease of the heart, the liver Avas distinctly felt to become enlarged during the paroxysm, and to subside again Avhen the attack was relieved by blood-letting. When this simple enlargement is of a more perma- nent kind, the symptoms seem to consist chiefly of derangements of the stomach, arising probably from the increased bulk of the liver ; in some cases there is jaundice, and in others dropsy ; but upon the Avhole, simple enlargement of the liver, Avithout any con- siderable change of its texture, must perhaps be considered as a rare affection in adults. The folloAving case will illustrate the ap- pearance, as it occurs in young persons of a scrofulous habit. Case CXXXIV—A boy, aged 11, in Avinter 1811 — 12, was seized with great enlargement of the glands under the jaw, his neck being completely beset Avith 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 im- paired in strength, with variable appetite and irregular attacks of fever. In the following summer, he Vvas affected Avith cough and dyspnoea, and it Avas now discovered that his liver Avas so much en- larged, that the edge of it Avas distinctly felt as low as the umbili- cus. He had a wasted and withered look, Avith cough, frequent pulse, enlargement of the abdomen, and anasarca of the legs; the latter increased to a prodigious degree, and he died after protracted suffering in October, 1813. Inspection.—The liver extended rather below the umbilicus, and so much into the left side as to fill the upper half of the abdo- SIMPLF ENLARGEMENT. 303 men. It AA'as a little paler than natural in its color, but in other respects Avas scarcely altered from the healthy structure. There Avas extensive disease of the mesenteric glands. The lungs were slightly tubercular, and there was a chain of enlarged glands, some of them as large as walnuts, extending behind the lungs from the bifurcation of the trachea to the diaphragm; some of these were of cartilaginous hardness, others contained thick purulent matter, and in others there were hard calcareous particles. There Avas consid- erable effusion in the abdomen. § III.—Tubera of the liver without other disease of its structure. These tubera presents externally a surface elevated into numer- ous irregular knobs, of a yellowish or ash color, and perhaps from two to three inches in diameter. Internally they exhibit a variety of textures—in some cases fibrous, in others, tubercular, or cheesy, and frequently there are cysts containing a viscid fluid. It appears that they produce marked symptoms only Avhen they are numer- ous, or accompanied by enlargement of the liver, or disease of its general structure; but that, Avhen 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 folloAV- ing example. Case CXXXV.—A gentheman, aged 80, had enjoyed uninter- rupted good health until a feAv weeks before his death, Avhen he became one day suddenly incoherent. This was removed by pur- gatives, and he had not shown any other symptom of disease, when one morning he was found dead in bed. Inspection.—No morbid appearance could be discovered to ac- count for his sudden death, except that all the cavities of the heart, the aorta, and the vena cava, Avere completely empty of blood. On the convex surface of the liver, there was a tumor about three inches in diameter, elevated into numerous irregular knobs ; on cutting into it, a cavity Avas exposed capable of holding about'oz. 8. and full of an opaque ash-colored fluid, which could be drawn out into strings. The liver in other respects was perfectly healthy. For a more particular account of these tubera, I refer to the de- scription and engravings of Dr. Farre. 304 CHRONIC DISEASES OF THE LIVER ^ IV.— The pale degeneration of the liver, consisting of change of color without remarkable alteration of texture. Under this head I mean to include a class of morbid changes of the liver of frequent occurrence, though presenting considerable varieties. The liver so affected has lost, in a greater or less degree, the healthy appearance, and has become of a paler color, Avithout any considerable alteration from the healthy texture. This change, in some cases, consists merely of a much paler shade of the nat- ural color ; in others, it is a dull Avhite or ash color, and frequently a uniform dull yellow, closely resembling the color of impure beeswax. The liver thus affected may be of the natural size, or it may be increased in size, or it may be diminished. The symptoms accompanying these changes have not been well investigated ; they are chiefly observed 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 derange- ment of the functions of the liver or the stomach. The most re- markable 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 dispersed through the substance of the liver ; but, in many cases, the whole liver is found changed into one uniform mass of this appearance, exactly resembling a mass of impure wax, and it seems to possess very little vascularity. A case is de- scribed by Clossy,*in Avhich the structure of the liver was wholly constituted of a congeries of little firm globules, ' like the vitella- rium of a laying hen ;' it occurred in a boy of 15, who had im- mense ascites. In a case by Boisment, these nodules were as large as peas, and the liver was diminished in size; the case was chronic with ascites. The French writers have a controversy whether the Cirrhose or*yellow degeneration of the liver be a neAv formation, or a hypertrophia of a yellow substance, which th'ey suppose to constitute a part of the structure of the liver in its healthy state. * Clossy.—Observations on some of the Diseases of the Parts of ihe Hu- man Body. PALE INDURATION. 305 No good can arise from such discussions, as it is impossible to de- cide them. § V.—Pale color of the liver with induration. The degree and aspect of the pale induration of the liver varies in different cases, from an appearance resembling a mass of tuber- cular lung, to that of true scirrhus, or to a texture in some places almost cartilaginous ; and, in some cases, there is a firm fibrous texture with a softer matter in the interstices. These morbid ap- pearances may be confined to portions of the liver, or the whole organ may be entirely changed from the healthy structure. The color of the diseased parts varies considerably ; the most common is a dull ash color, sometimes with a considerable tinge of yelloAV, The disease may be complicated Avith hard tubercles of various sizes, embedded in the substance of the liver, or spread over its sur- face under the peritoneal coat; or there may be thickening or tu- bercular disease of the peritoneal covering itself. A liver in this state of disease may be not at all altered in its size, or it may be much increased, or it may be very much dimin- ished. The symptoms, of course, will differ in some respects in connection with these varieties. The following cases will illus- trate the principal modifications. (A.) Pale indurated, liver almost cartilaginous, of the natural size. Case CXXXVI —A man, aged 45, in the beginning of May, 1813, was affected with severe pain in the region of the stomach, Avhich soon shifted into the right hypochondriac region among the loAver false ribs ; it was much increased by respiration ; there was some cough; pulse 120. In the course of two days and a half, he was bled to the extent of oz. 145 ; the symptoms then yielded, and soon after he went to the country.. But he did not recover sound health : he had some cough and dyspnoea, with much debil- ity ; after some time he became dropsical; the dropsical symptoms increased with pain in the right side, and he-died in the beginning of August. 306 CHRONIC DISEASES OF THE LIVER. Inspection.—There was extensive effusion in the abdomen. The liver was completely changed in its texture, being through its whole structure, of a dull white color, and very hard, in many m places almost cartilaginous. There was not the smallest portion of it that retained the healthy structure or color, but it was entirely of the natural size. The lungs and all the other viscera were healthy. There is every reason to believe, that in this important case the remarkable disease of the liver supervened upon the acute attack, which occurred three months before the patient's death; and there- fore, according to 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 inflamma- tory attack may lay the foundation for it. (B.) Pale indurated, liver with enlargement. Case CXXXVII.—A lady, aged 45, had long been liable to dyspeptic complaints; but she was often for a considerable time to- gether entirely free from them, so that no suspicion had been ever entertained of the presence of organic disease. She also frequently complained of pains in the back, neck, and shoulders, which had merely a rheumatic character. In autumn 1818, she went to Har- rowgate, and seemed to derive much benefit from the use of the water. In the following winter, she was again a good deal con- fined, complaining chiefly of wandering rheumatic pains, with bad appetite, very bad digestion, and a feeling of oppression across the region of the stomach. On examination, the liver was now found to be much enlarged and very hard, but without pain or tenderness. In January, 1819, she began to lose flesh and strength; the pulse became small and frequent, with difficulty of breathing, and effu- sion 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 mar- PALE INDURATION, WITH ENLARGEMENT. 307 gin formed an adhesion to the parietes of the abdomen. Inter- nally, it Avas entirely changed from the healthy structure, being of pale or ash color, 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 CXXXVIII.—A lady, aged 50, had for some time com- plained occasionally of an uneasy feeling across the epigastric re- gion, which chiefly impeded her in stooping. About three weeks before her death, she first consulted me on account of a disease of the mamma, and the affection of the liver was then ascertained only by accident; it filled the upper part of the 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 back, the margin of the ribs could not be traced ; but the bones of .the thorax and the surface of the tumor felt like one continued bony substance as low as the umbilicus. At this time her general health was little affect- ed ; but after a short time she had some vomiting of blood ; she was then confined to bed, and died after nine days, without any ur- gent complaint except occasional retching. Inspection.—The SAvelling consisted of an immense irregular enlargement of the liver ; it was variegated in its appearance, be- ing partly of a pale ash color, and partly of a dark reddish brown ; internally it was uniformly pale and hard in its texture. (C.) Pale indurated liver, with great diminution of size. Case CXXXIX— A man, aged 40, was first affected with pain in the right side, not increased by pressure, and not 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 pro- gressive emaciation, and at last general dropsy; and died, gradu- ally exhausted, after an illness of about 18 months. Inspection.—There was some effusion in the cavity of the pleura, but the lungs were quite sound. The liver was so remarkably di- 308 CHRONIC DISEASES OF THE LIVER. minished in size, as scarcely to exceed the bulk of the hand half- folded ; it was closely drawn up under the ribs, and adhered inti- mately to the diaphragm. Its surface was studded with numerous tubercles; internally it was of a pale color, and very hard in its tex- ture. Many cases are on record, in which the indurated liver was much diminished in size, but in few perhaps to the extent Avhich occurred in this case. A man mentioned by Andral, had weak- ness, loss of appetite, and pain of his loins and shoulders, Avhich 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 Avas of a scirrhus hardness ; its surface was covered with a kind of sandy matter. A man mentioned by Boulland,* had pain in the region of the liver, and very deep jaundice; he died the day after his admission into the Hotel Dieu, and nothing Avas known of his history except that the jaundice Avas of six weeks standing. The liver was found much diminished in size and indurated ; internally it presented a a variegated surface of gray and yellow, with numerous small por- tions of an orange color. In other cases, this state of disease has been marked merely by Avasting, with obscure dj'speptic symptoms, and at last dropsy, without any thing calculated to point out the liver as the seat of the disease. A remarkable peculiarity in Case CXXXIX, was the violence of the pectoral symptoms. This effect of certain diseases of the liver will be aftenvards more particularly referred to ; it seems to be occasioned by the irregular tuberculated state of the convex sur- face of the liver, keeping up a constant irritation of the diaphragm. § VI—Dark induration of the liver. The folloAving case will illustrate this modification of the dis- ease, which differs from the pale induration only in its pathological characters, the symptoms being the same- * Mem. de la Soc. Med. D'Emulation. Tom. ix. DARK INDURATION. 309 Case CXL.—A gentleman, aged about 60, in spring 1821, AA-as observed to look ill, and had a yellow tinge of his eyes, but Avithout any particular complaint till the middle of June, Avhen he became dropsical in his legs, and soon after in the abdomen ; pulse natural; breathing easy ; appetite tolerable ; urine scanty. Noth- ing 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 diure- tics with a little mercury, for sometime with very little effect; on the contrary, the distention of the abdomen seemed gradually to in- crease, Avith an evident fluctuation. He then used mercurial fric- tion over the abdomen, when the diuretics began to take effect: and in the end of July, there was much increase of urine, and the swellings were diminished. This favorable state continued till the 7th of August. On the morning of that day, as he was preparing to get up at his usual time, after a tolerable night, he became sud- denly livid in the face, and instantly expired. The only previous change in his symptoms had been,.that, for about two days before death, his appetite had been somewhat impaired, and his pulse, Avhich had been previously quite healthy, was occasionally ob- served to be slightly irregular. Inspection.—There was an effusion in the abdomen to the amount of about 10 lbs. The liver was entirely of the natural size, but very dark in the color, nearly black, and covered on the sur- face with small hard black tubercles. Internally, it was much indu- rated throughout, and of a very dark brown color, interspersed with streaks of deep yellow. The heart was remarkably soft and flac- cid, and all its cavities were empty ; there was extensive ossifica- tion 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 these affections vary according to the part of the liver which is the principal seat of the disease, as they consist chiefly of irritation of neighboring organs, particular- ly the stomach and the diaphragm. The disease in these cases 310 CHRONIC DISEASES OF THE LIVER. seems in some instances, to consist of a" tubercular affection of the peritoneal covering of the liver; in others, there appears to be an elevation of portions of the substance of the liver forming nodules or tumors of various sizes, which in their internal structure do not present anything remarkably morbid ; in others they consist of tu- bercular masses, partly imbedded in the substance. When the dis- ease is so situated as to irritate the stomach, Ave find protracted vom- iting, Avith gradual loss of strength ; but one of the most remarka- ble effects of it, Avhen the disease is so situated as to produce constant irritation of the diaphragm, is to prove fatal with protract- ed pulmonary complaints, without any symptom referable to the liver. The following case Avill illustrate this modification of the disease. Case CXLl.—A lady, aged 35, had severe cough with dys- pnoea, which was sometimes severe, especially in the night. There Avas occasional pain of the chest and sides, Avith frequent pulse, restless nights, febrile paroxysms and perspirations in the morning. There was considerable expectoration, Avhioh consisted chiefly of viscid mucus, but Avas frequently mixed with portions of a puriform character, and occasionally Avith blood. She was liable to period- ical fits of vomiting, which attacked her generally in the evening, and she frequently complained of pain, which was referred to the left side of the abdomen, about the region of the spleen; but no disease could be detected either there or in the liver. These com- plaints went on for upwards of two years, without materially in- juring her strength; but in the third year she 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 be- came less frequent, but she continued to suffer from most severe paroxysms of cough, with copious expectoration and fits of dys- pnoea. Inspection.—No morbid appearance could be detected in any part of the thorax. The spleen was enlarged and hard. On the convex surface of the liver there was a remarkable tumefaction pressing against the diaphragm, and pushing it upwards; and the surface of the tumefied part was stucffled with small hard tubercles. The liver was not in other respects diseased, and the other viscera were healthy. TUBERA, &tC. 311 Another case has been formerly described, showing the produc- tion of severe pectoral symptoms by jdisease on the surface of the liver; and various cases are on record, showing the same result from diseases of other organs, situated in the neighborhood of the diaphragm. In a case by Portal, similar symptoms appeared to arise from scirrhus of the pancreas, and in one by Bonetus, from disease of the spleen. In a case by Morgagni, there was a tumor, which weighed a pound, attached to the posterior part of the stom- ach. A young woman, mentioned by Lsennec, had cough, dys- pnoea, copious expectoration, hectic fever, and great wasting. After these symptoms had gone on for some time, and she was consid- ered as decidedly phthisical, she was seized with violent pain in the epigastrium, and soon after discharged by stool an immense quantity of hydatids; from that day she recovered rapidly, and was soon well. The production of severe pectoral complaints by disease of the liver, is also strikingly illustrated by the following case. § VIII.— Tubercular disease of the liver, with severe pectoral com- plaints and ulceration of the stomach. Case CXLII.—A Avoman, aged 30, for Avhose case I am in- debted to Dr. Huie, was affected with cough, copious expectoration of viscid mucus, night sweats, and great prostration of strength. Soon after she was first seen by Dr. Huie, (in November, 1824) she Avas seized with vomiting of a very dark matter resembling venous blood in a state of partial decomposition, and she dis- charged large quantities of a similar matter by stool. A hard move- able tUmor was discovered in the epigastric region, the size of a walnut, which was painful on pressure. Her strength now sunk rapidly, and she died on the 3d of December. The vomiting ceased several days before.death, but the cough continued severe and the matter expectorated was of a very dark color. The bow- els were obstinate, and the motions consisted entirely of a black pitchy matter, without any appearance of natural feces. Inspection.—The tumor that had been felt in the epigastrium was found to be a tubercle, the size of an egg, attached to the left lobe of the liver. It adhered firmly to the stomach, near the pylo- 312 CHRONIC DISEASES OF THE LIVER. rus: and on the internal surface of the stomach, at the place of the adhesion, there Avas an ulcer the size of a shilling ; this ulcer ap- peared to have been the source of the black discharge, a consider- able quantity of which was still found in the stomach and intestines. The coats of the stomach, along nearly the whole of the smaller arch, were much thickened and indurated, and the pylorus was considerably contracted in its aperture. The tubercle presented, when cut into, a variegated texture, partly a firm white tubercular matter, and partly a reddish substance resembing the structure of the liver: but the Avhite matter Avas the more abundant. There were four or five similar tumors, the size of walnuts, in various parts of the liver. The left extremity of the pancreas was of a soft cheesy consistence, and adhered to the stomach. The other abdominal viscera were healthy. After the most careful examina- tion, no disease could be discovered in the viscera of the thorax, except a few slight adhesions between the pleura costalis and pul- monalis, which were evidently of long standing. § iX.—Tubercules and tubera of various characters diffused through the substance of the liver, with disease of the interven- ing structure. The mixed masses of disease which I include under this head, seem to derive their character, in some instances, from new forma- tions imbedded in the substance of the liver, in others from morbid degeneration of portions of the liver itself. The appearances vary in different cases; in some there are portions or nodules of a true scirrhus character, in others tubercular or cheesy, in others of the consistence of the brain ; some portions are of a yellow color re- sembling the cirrhose, others of a dark brown or nearly black ap- pearance. These various states of disease may sometimes be traced in the same liver; they may be interspersed with portions in a tolerably healthy state, and they may be farther varied by the appearance of small cavities containing a glairy fluid, or by the presence of real hydatids. The liver Avhich 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 circumstance in the history of the affection is the slight and obscure symptoms with TUBERA, he. 313 which the disease may advance even to a prodigious degree of en- largement. I shall only add the following example. Case CXLIII.—A gentleman, aged 67, had been for many years dyspeptic, but without any affection of his general health till the spring of 1820, when he began to decline considerably in flesh and strengh, and complained chiefly of a feeling of oppression about his chest. He Avent to the country and improved considera- bly, but in May he became worse. His chief complaint was then of a fixed pain in the lower part of his back, with restless nights; he was able to take a good deal of exercise on horseback, but com- plained that, after riding, the pain in his back was increased. He came to Edinburgh in June. He was then a good deal fallen off in flesh and strength, and his pulse was a little frequent; but his appetite Avas good, and he made no complaint of his digestion ; his chief complaint Avas still of a fixed pain in the lower part of the back. On examination nothing was discovered in his back; but a mass of disease was felt in the abdomen, extending from the ribs to near the spine of the ileum chiefly on the left side. It was not at all pain- ful 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 Avas now a gradual failure of strength Avithout any urgent symptom. His appetite and digestion continued tolera- ble until eight or ten days before his death, when he began to have nausea with thirst, foul tongue, and impaired appetite ; and he died gradually exhausted in the beginning of August. His bowels had been throughout natural or easily regulated, and the motions quite natural. Inspection.—The whole liver was enormously enlarged, espec- ially the left lobe, which descended nearly to the spine of the ileum. Externally, it was of a very dark color, variegated with light ash- colored spots. Internally, it Avas composed chiefly of numerous round tubera, of the size of small oranges ; they were generally of a Avhite or ash color, some of them approaching to a scirrhus 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 Avhich retained the appearance of the proper structure of the liver, but they Avere of very small extent, dark colored, and of a soft consistence. 40 314 CHRONIC DISEASES OF THE LIVER. It appears that the form of disease which occurred in this case is sometimes much more rapid in its progress. A man mentioned by Andral, died with fever, vomiting, and pain in the right hypo- chondrium, having begun only about a month before to complain of some uneasiness in the region of the liver. The liver was much enlarged, and presented a mixed mass of disease, scirrhus, en- cephaloid and tubercular. § X.—Hydatids. Hydatids are of frequent occurrence in the liver, and are found either in cysts attached to its outer surface, or imbedded in its sub- stance. The cysts in which they are contained are sometimes lined with a thick coating of false membrane, and not unfrequently there are found in them portions of bone. A liver which contains hydatids may be enlarged and otherwise diseased, or it may be quite healthy except with respect to the cyst which is imbedded in it. There are no symptoms which mark the presence of hydatids in the liver, distinct from those of the other chronic affections, and they have been found where patients died of other diseases without any symptoms referable to the liver. § XI.—Large cysts containing watery matter confined under the peritoneal coat of the liver. These cysts may appear either upon the convex or concave sur- face of the liver. The following is the most remarkable example that has occurred to me. Case CXLIV.—A man, aged 32, was affected with an im- mense tumor of the abdomen, which filled the greater part of it, extending from the region of the liver considerably below the um- bilicus, and into the left side. At the upper part, near the ribs on the right side, there was as evident fluctuation ; this was most re- markable when he was in the erect posture; in the horizontal pos- ture it seemed as if the fluid retired under the ribs ; no fluctuation CYSTS FULL OF WATERY FLUID. 315 was perceived in any other part of the mass. His breathing was much oppressed and laborious," especially when he attempted to turn on the left side; he then seemed in danger of instant suffoca- tion, for several minutes gasping in the utmost agony before he re- covered his breath; similar attacks were produced by other causes, especially any bodily exertion. He was much emaciated; and the complaint was of about one year's standing. A puncture was made on the spot where the fluctuation was felt; clear serous fluid was drawn off to the amount of nine or ten pounds, and the open- ing continued to discharge freely for a good many days. By this evacuation, he was very much relieved, but his strength continued to sink, and he died about ten days after the operation. Inspection.—The liver was very little enlarged. The tumor was found to consist of an immense sac formed on the convex sur- face, under the peritoneal coat; it was of such a size that it had, on the one hand, pressed down the liver below the umbilicus, and on the other, had pressed the diaphragm upwards as high as the second rib. The right lung 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 years. This immense cyst adhered firmly to the posterior half of the diaphragm, but betwixt it and the anterior part of the diaphragm there was a distinct cyst, containing a watery fluid It was this which had been opened in the operation; the areat cyst was entire, and contained lb. 18 of transparent colorless fluid Its parietes were firm and dense, like the peritoneum very much thickened. In the bottom of this cyst there were found two sin-ular bodies, consisting of flat cakes of a soft gelatinous matter rolled up into solid cylinders ; when unrolled, they were about ten inches in diameter, and about one-eight of an inch in thickness and had the appearance of a deposition which had been separated from the inner surface of the cyst. The liver was not diseased in its structure, and the other viscera of the abdomen were healthy but remarkably displaced, the stomach being on the left side and the pylorus towards the left os ileum. A remarkable circumstance in this case was the uncommon firmness of the tumor, which imparted the idea of an immense mass of organic disease, without any fluctuation, except at the]^ which was opened. A case considerably similar occurred in the Infirm- 316 CHRONIC DISEASES OF THE LIVER. ary of Edinburgh many years ago, under the care of the late Dr. Gregory. It Avas supposed to be an immense enlargement of the liver j but one day the whole hardness suddenly disappeared, with a feeling to the patient of something bursting internally. Fluctuation then became evident, though none had been perceived before. The patient died next day, and it was found that this remarkable change had taken place by the cyst bursting into the cavity of the peritone- um. Mr. Annesley mentions a case in which there Avas attached to the concave surface of the liver a cyst containing a quart of Avatery fluid, with a hydatid floating in it. Dr. Hastings has de- scribed a similar case, in which a week before the death of the pa- tient nine pounds of fluid were drawn off from a cyst of this kind.* Mr. Brodie has described two cases Avhich were supposed to be of this nature, but Avhich Avere relieved by the evacuation of the fluid. In the one, a young lady of 20, the relief vvas permanent; the quantity of fluid evacuated was three pints. The other was an hospital case, a boy who was dismissed in good health after the evacuation of a pint and a half.f A cyst of this kind also occurred in a case described under a former part of our subject. (Case CIX.) The above outline, which was intended to be merely an enu- meration of the principal morbid conditions of the liver, has ex- tended to a greater length than I expected ; and I shall therefore allude but very briefly to what remains of the subject, namely, the treatment of these affections. I have already referred to a fact which I conceive to be of the utmost importance, and deserving the most serious attention of practical men. I allude to a prevailing doctrine, or rather prevailing phraseology, by which numerous symptoms are ascribed to disease of the liver upon very vague and inadequate grounds ; Avhile, in many of these cases, a little attention would show, that the affection is seated entirely in the stomach or boAvels, especially in the arch of the colon. The prevalence of this doctrine, and the indiscriminate employment of mercury, which has arisen from it, I must hold to be evils of no small magnitude, and the utmost attention and caution ought to be used before pro- nouncing a train of symptoms to be dependent upon the liver. ♦ Midland Medical and Surgical Reporter, No. V. t Medical Gazette No. XII. TREATMENT. 317 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 practioner will find himself constrained to use greater circumspection. The real diseases of the liver resolve themselves into two great •classes, the acute and the chronic. The acute affections are to be combated by the means adapted to other inflammatory diseases, namely, general and topical blood-letting, blistering and saline pur- gatives. In the less active cases, indicated by local pain and tender- ness, without constitutional disturbance, we rely chiefly upon re- peated topical bleeding, blistering, issues, free and continued purg- ing, and a careful regulation of diet. In both cases, when the ac- tivity 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 vari- ous forms which have been detailed in the preceding observations, it will probably be admitted that a large proportion of them are beyond the reach of any human means. The treatment of these ought to be entirely palliative, consisting of a careful regulation of the diet and the bowels, with mild tonics, &c. This I conceive to be a point of much practical importance, because these affections often exist for a long time without 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 shortened. In several cases of chronic affec- tions of the liver, accompanied by jaundice, I have seen very good effects from the external use of Iodine, in an ointment containing dr. ss to oz. I of axunge. In the preceding observations I shall probably be charged Avith attaching too little importance to mercury in the treatment of this class of diseases, and I am well aware of the delicate ground on which I tread, when I venture to express a doubt of its adaptation to all stages and all forms of diseases of the liver. In doing so I Avould be distinctly understood to express myself in regard only to the liver diseases of this country, having no experience of any 318 CHRONIC DISEASES OF THE LIVER. other; but in respect to these I have no hesitation in saying, that mercury is often used in an indiscriminate manner, and with very undefined notions as to a certain specific influence which it is be- lieved to exert over all the morbid conditions 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 sometimes ascribed to it in regard to its influence on the secretion of bile, and in those affections which are commonly called bilious. Upon the princi- ples of induction with regard to cause and effect, which are recog- nised in other sciences, it may be doubted whether all these max- ims can be right, but I will not take upon me to decide which of them is wrong. I leave the subject, therefore, with merely throw- ing out these doubts, the force of Avhich must be felt by every pa- thological inquirer; and with hazarding the opinion, that much of the prevailing doctrine on derangements of the liver requires to be revised, and perhaps corrected. There are certainly many parts of it, of which the pathologist must be alloAved to doubt, whether they are not at variance with the principles of philosophical inquiry. APPENDIX TO THE PATHOLOGY OF THE LIVER. SECTION I. HAEMORRHAGE FROM THE LIVER. A gentleman mentioned by Andral, previously in perfect health, on getting up one morning complained of some 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 inspection, much extravasated blood was found in the cavity of the abdomen, which appeared to have proceeded from a lacerated opening in the substance of the liver ; this led to a small cavity full of coagulated blood, and the haemorrhage was distinctly traced to the rupture of a branch of the vena porta?. SECTION II. RUPTURE OF THE LIVER BY EXTERNAL VIOLENCE. Case CXLV.—A man sitting carelessly upon the edge of a cart was thrown from it by a sudden jerk upon the road. He im- mediately got up and scrambled into the cart, which was still in 320 DEATH FROM A GALL STONE. motion, and he did not appear to a person Avho Avas along Avith him to have received any injury, but he soon became faint, and in a feAV minutes was dead. On inspection, the liver Avas found to have been ruptured through a gTeat part of the right lobe, and there was ex- tensive 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 sub- ject, having nothing of any interest 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 CXLVI.—A lady, aged 60, had been for several years liable to attacks of acute pain in the right hypochondriac region, Avhich generally continued in great severity for a few hours, and then subsided suddenly. On Wednesday, 14th January, 1824, she was seized with pain corresponding to her former attacks, but which did not subside as usual. It continued through the night, accompanied by frequent vomiting and constitutional disturbance. On the 15th there was fever, with frequent vomiting and obstinate costiveness, and the pain was more extended,—being referred tp 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 ex- pression of intense suffering. Her strength sunk, and she died on the morning of the 17th. Inspection.—Every part of the intestinal canal was perfectly healthy, except the upper part of the duodenum, where there was considerable appearance of inflammation, with remarkable soften- ing, so that it was very easily torn. A large irregular calculus DEATH FROM A GALL STONE. 321 was found sticking in the ductus communis, and the parts were so softened that it came through the side of the duct when it Avas very slightly handled. In the texture behind the duodenum there was considerable appearance of inflammation. No morbid appearance could be detected in any other organ. II. Perforation or rupture of the gall bladder, or one of its ducts, and escape of the bile into the peritoneal cavity. The immediate effect of this accident is rapid peritonitis, fatal in eighteen or twenty-four hours. The symptoms preceding it will depend upon its cause, and consequently may be either very ob- scure, or such as indicate great distention of the gall bladder, Avith obstruction of the bile in its passage out of it. The causes of the affection are chiefly referable to two classes. (1.) Obstruction of the common duct. This may take place rapidly by adhesive inflammation, or more slowly by gradual ob- literation. In the former case the symptoms are rapid, as in a man mentioned by Andral, who had acute pain, followed by jaun- dice, and a pyriform swelling rising up from under the margin of the ribs. On the fifth day he was suddenly attacked with peritoni- tis, 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 distended ; the rupture had taken place in the hepatic duct, and much bile Avas 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 Avere found much con- tracted. (2.) 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 pain in the abdomen and fever which had various remissions and aggravations. On the 37th day of the disease, he Avas suddenly seized Avith symptoms of the most violent peritonitis, and died on the following morning after suffering inexpressible agony. On inspection, there were found marks of most extensive peritonitis. The inner surface of the gall bladder presented numerous small circular ulcers from one to three lines in diameter; two of them had entirely perforated its coats, so as to allow the escape of the bile into the peritoneal cavity. 41 322 PATHOLOGY OF THE LIVER.--APPENDIX. 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 upon 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 necessary 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 consider as ascertained with some degree of precision. 1. We can have little doubt that the bile is often deficient in quantity, producing dyspeptic symptoms, with paleness of the stools. This seems to arise chiefly in connection with the pale de- generation of the liveT, especially when the organ is much dimin- ished in size; but in some of the extraordinary masses'of disease which have been described, showing almost every point of the liver altered from the healthy structure, there were no symptoms indi- cating 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 CXLIII. 2. 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 appearance of the bile which is found in the gall bladder. In some diseases of the liver, accordingly, we find 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 diges- tion ; but this subject is at present involved in much obscurity. JAUNDICE. 323 3. It is probable that the bile may be increased in quantity; but it must at the same time be admitted, that our prevailing notions on the subject are rather hypothetical than founded upon facts. The bile is a viscid fluid of a green color, and, when it is mixed with the usual contents of the intestinal canal, it imparts to them a bright yellow. When the motions became of a dull white or ash color, we judge with tolerable precision of the deficiency of bile; but I am not aware of any test by which we can judge with precision of its redundancy; and I must confess my suspicion, that the term bilious stools is often applied, in a very vague manner, to evacua- tions 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 sys- tematic 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 popular notion that the color of the feces is derived from the bile; but this doctrine seems rather to be taken for granted than proved.' # SECTION V PATHOLOGY OF JAUNDICE. Jaundice is produced by the absorption of bile into the circula- tion, 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 as- signed 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 con- * Mr. Tytlcr,—Calcutta Transactions, vol. iii. 324 PATHOLOGY OF THE LIVER.--APPENDIX. gestion. These and some others of the same kind must be per- haps considered rather as hypothesis framed to correspond Avith the facts, than as deductions from them, and therefore not entitled to much confidence. When, with a view to practical utility, we consider the circum- stances under which chiefly jaundice takes place, they seem to be referable to the folloAving heads. I. The passage of a gall stone. Jaundice takes place from this cause, when the calculus is a considerable time in passing, so as to produce an obstruction of some continuance in the duct; Avhen 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 prob- able that it varies in different cases. This form of the disease is in general distinguished by the vio- lence of the pain, but cases have occurred in which the disease was distinctly referred to this cause, while the symptoms had been severe vomiting and jaundice, with very little pain. This occurred in a woman, mentioned in the fifth volume of the Medical Reposi- tory, who was suddenly seized with jaundice accompanied by vom- ing, and died the same night in a state of coma. A calculus Avas found sticking in the gall duct, and the duct Avas ruptured. On the other hand, I have described a remarkable case in Avhich a calcu- lus impacted in the common duct was fatal in three days with symp- toms of inflammation and ileus, without jaundice. Several cases are on record in which large calculi, after pro- ducing jaundice, and the other symptoms indicative of having been impacted in the duct, have worked their way outwards, and have been extracted from an opening in the parietes. In a case of this kind mentioned by Dr. George Gregory, after the gall-stone was extracted, the ulcer healed up, the jaundice Avent off, and the patient, who had suffered excessively for several months, rapidly got Avell. 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 yelloAv fluid ; in a third, it dis- charged calculi at intervals. I have seen, along with Mr. Lizars, a man, about 50, who has had a biliary fistula discharging for nearly four years. The complaint began Avith pain in the region of the liver, accompanied by vomiting and jaundice. After these jaundice. 325 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 yelloAV color, and some small biliary calculi. This opening closed, but another soon took place, Avhich has continued to discharge ever since. The discharge varies in quantity, but is often so profuse as in a very short time to wet his clothes as far as his knee, and in the night to soak through his bed to a great extent. Mr. Lizars at one time collected, in the course of a visit not exceeding fifteen or twenty minutes, about four ounces of a fluid, Avhich, on chemical examination, exhibited all the properties of pure bile. The man has every appearance of good health, and, except the fistulous opening, there is no appearance of disease in the region of the liver. His appetite and digestion are good, his bowels are regular, and the evacuations of a natural ap- pearance. 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 Avay 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 to admit a full-sized finger, but without any other appearance of disease. It has been disputed whether biliary calculi are ever formed in the substance of the liver, or in the gall bladder only. But Mor- gagni 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 pro- duce 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 Avho has once suffered from a gall stone is ahvays 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 Avere 3646. They vary exceedingly in size. Hildanus mentions one which weighed eighteen drachms.; and I have men- tioned one which measured in its longer circumference four inches, and in its smaller three inches and a half. 326 PATHOLOGY OF THE LIVER.—APPENDIX. Biliary calculi seem in general to produce no inconvenience while they lodge in the gall bladder; but in some cases they ap- pear to produce considerable derangement of the stomach, and of the general health, without entering the duct, and consequently without producing either pain or jaundice. I have mentioned the case of a woman, who died gradually exhausted by daily vom- iting, Avhich had continued more than a year, and in whom no mor- bid appearance could be discovered, except that the gall bladder Avas 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 af- fection had continued for a year or more, he discharged some large biliary calculi, and speedily recovered perfect health. The passage of biliary calculi, when they are producing urgent symptoms, can be promoted only by opiates, Avarm bath, laxatives, and perhaps the tobacco injection. The only means likely to pre- vent the formation of them are probably regular exercise, and con- stant 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 imprisonment. II. Inflammatory affections of the liver. Jaundice appears to be often connected with an inflammatory condition of the liver, ex- isting in an obscure form, and often of small extent. It may be suspected when the disease is attended with pain or tenderness in the region of the liver, though Avithout fever, or any symptoms of inflammation in an active state. The cased of more decided in- flammation of the liver seem to be attended with jaundice only when the inflammation is seated chiefly on or near its concave sur- face ; but in Case CXXVII. we have seen very deep jaundice in a case rapidly fatal, in which the only morbid condition Avas a uni- form black color 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 extensive inflammation^ termin- ating by suppuration, Avithout jaundice, though in some of the cases nearly the Avhole 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 JAUNDICE. 327 deep jaundice in Case CXXXII; while there was no jaundice in connection with the very extensive encephaloid disease in Case CXXXIII. in which the symptoms were more acute than in the former case. It appears, however, that there is a state 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 lung. 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 surface. Bonetus relates a similar case in which the disease was in the lungs, the liver being merely paler than natural. There had been fever with convulsions, and death in 15 days. It is prob- able, therefore, that the liver may be affected, in a manner analagous to that now referred to, from other causes which in a great measure elude our observation. To this principle we may perhaps 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 ob- served in connection 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 haemorrhoidal discharge and other evacuations which had become habitual. Portal has seen it supervene upon suppression of leucorrhoea; and he also mentions a woman who had been long affected with a copi- ous and very fetid discharge from the arm-pits, and immediately became jaundiced, when she suppressed it by means of a prepara- tion of alum. When jaundice appears to be connected with any affection of the liver of an inflammatory character, it must of course be treated by the appropriate remedies,—as general or topical blood-letting, blistering, antiphlogistic regimen, and very free and continued purging. When the activity of the symptoms has been subdued by these means, benefit is often obtained from mercurial friction, and I think likewise from friction with Iodine. 328 PATHOLOGY OF THE LIVER--APPENDIX. III. There can be little doubt of the fact, that jaundice is often produced by affections of the bowels, though the precise manner in which it arises from such causes is not easily 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 show, that jaundice may arise from an inflammatory state of the mucous membrane of the duodenum, acting directly, by obstructing the mouth of the duct.* IV. A singular fact in the history of jaundice is afforded by those cases, in Avhich it is distinctly induced by passions of the mind. A woman mentioned by Hoffman was affected Avith jaun- dice every time that her mind was agitated; and a medical gentle- man, mentioned by Mr. Cooke, became jaundiced almost invariably when he had a dangerous case under his care.f The doctrine of spasm has been applied to such cases ; but it is time that we should discard this hypothesis, which is used to explain every thing that we do not understand, and content ourselves with the facts when we can really go no farther. Jaundice, however, even when arising from causes apparently transient, is never to be looked upon as free from danger. For many cases are on record in Avhich death took place in a very un- expected manner, and in which no morbid appearance could be dis- covered capable of accounting either for jaundice, or for the fatal event. Several years ago, I saw a Avoman who became suddenly jaundiced a day or tAvo after accouchement. The're was no other symptom, and no danger apprehended, until after two or three days she became comatose and died. There was very slight effu- sion 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 * Dublin Hospital Reports, vol. iii. t Cooke on Derangements of the Digestive Orsans. JAUNDICE. 329 a considerable quantity about the spinal cord. Another young man, mentioned by the same writer, was very much frightened by hav- ing a musket pointed at his breast. Next day he was jaundiced ; soon after delirious; then convulsed; and he died in twenty-four hours from the first appearance of-the delirum. No disease could be detected, except turgescence of the vessels on the surface of the brain. Dr. Marsh also mentions two cases in which jaundice came on suddenly during the use of mercury, and was fatal with delirium and coma. In some cases, however, in which jaundice comes on in this manner, and is suddenly fatal the chain of events that seem to lead to the fatal result is traced in a more distinct manner,—as in a lady mentioned by Portal, whose case was formerly referred to. After great agitation of mind, she was seized with suppression of the menses; this was speedily followed by very deep jaundice; and she died next day. The liver in this case showed marks of exten- sive disorganization. V. The cases of long-continued jaundice are generally refera- ble to two heads, namely, chronic disease of "the liver, or tumors, or other diseases of neighboring organs, compressing the duct. Of the former class, we have seen various examples under the head of diseases of the liver; and we have also seen, on the other hand, chronic diseases of the liver of most extraordinary extent, without any appearance of jaundice. Among causes of the second class, are enlargements of the spleen and pancreas; masses of disease attached to the pylorous ; thickening and induration of the coats of the duodenum, and tumors of various characters compressing the common duct. In the Journal de Progres, a case was men- tioned some time ago, which after continuing for several months, was found to be connected with a flat tumor the size of a crown piece, involving the coats of the duodenum and the mouth of the biliary duct. There is also reason to believe that old cases of jaundice are sometimes produced by contraction of the calibre of the com- mon duct, arising from chronic inflammation of the coats of the duct itself. In this outline, I have alluded only to those sources of jaundice " which may be considered as ascertained with some degree of cor- rectness. Others are mentioned, but are probably in a great meas: 42 330 PATHOLOGY OF THE LIVER.--APPENDIX. ure 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 jaundice; or whether the liver had not also received an injury at the time of the accident. The yellow tinge in jaundice is said to have been observed in all the fluids of the body, except the milk. But Dr. Marsh men- tions, that, in examining the body of a woman who died in the Lock Hospital of Dublin from protracted disease, connected with jaundice, the mamma? appeared full; and by moderate pressure, there were obtained from them several ounces of a yellow tena- cious fluid, having all the visible properties of pure bile. He also mentions a case related to him by Dr. Cheyne, of a lady affected with jaundice, whose linen was distinctly tinged by the exhalation from her skin. PATHOLOGY OF THE SPLEEN. The morbid conditions to which the spleen is liable appear to be chiefly the following: k § /.—Inflammation. Inflammation may be seated either in the substance or the peri- toneal coat of the spleen. Active inflammation of the substance of the spleen is rarely observed; but Portal found proofs of its exist- ence in a man who died of acute fever, with pain in the left side, cough, dyspnoea, and violent palpitation of the heart. The lungs were sound, but there was inflammation of the spleen and the left side of the diaphragm. In other cases, vomiting has occurred. It is probable that the symptoms are in general more acute when the inflammation is seated in the peritoneal coat, than when it is in the substance of the spleen. I have not seen this affection in the idio- pathic form; but I have repeatedly seen the spleen completely en- veloped in a thick and dense covering of false membrane, in con- nection Avith peritonitis, without any disease of its substance. In- flammatory action of the spleen seems to occur more frequently in a chronic form, and to terminate in some cases by suppuration, in others by a peculiar black degeneration or softening. In both cases, the disease is generally protracted, and the symptoms are often exceedingly obscure. 332 PATHOLOGY.OF THE SPLEEN. ^ 17.—Suppuration of the spleen. The following is the only case of suppuration of the spleen that has occurred to me. Case CXLVII.—A gentleman, aged 52, who had enjoyed pre- viously very good health, was affected in January, 1821, Avith 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- Avith- out any defined complaint except weakness. When closely ques- tioned, he sometimes mentioned an undefined uneasiness across the epigastric region, but it Avas slight and transient; his appetite was A'ariable and capricious, but, upon the Avhole, not bad, and he had no dyspeptic symptom ; his bowels were rather slow, but easily kept open; his breathing Avas natural; and every other function was in a healthy state, except that his pulse continued a little fre- quent, and that he Avas becoming progressively more Aveak and emaciated. In this manner, the complaint went on during the re- mainder of the Avinter; in the beginning of summer he went to the country, Avhere he made no improvement. He was now greatly reduced in flesh and strength; his pulse Avas from 96 to 100 and weak ; his nights were generally good, but sometimes feverish; his appetite Avas bad, but he still took a good deal of nourishment, 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 pro- gressively. On the 2d day 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 AAras somewhat enlarged, and in the centre of it there Avas an irregular cavity containing several ounces of purulent matter; the surrounding substance Avas soft and easily lacerated. The liver Avas pale, but otherwise healthy; the kidneys were pale, Avith a peculiar degeneration of some parts of them into a firm white matter. After the most careful examination, no ABSCESS. 333 appearance of disease could be detected in any other part of the body. From the commencement of his illness, this gentleman was under the care of Mr. William Wood, and in the progress of it he was occasionally seen by Dr. Thomson and myself; but we never could detect a symptom from which we could infer what vvas the seat of his disease. • * There are few cases on record of suppuration of the spleen, and the symptoms in general appear to be protracted and often obscure. A young man, mentioned by M. Jacquinelle, (Journal de Med. torn. 88,) had pain and fulness in the left hypochondrium, with palpitation of the heart, faintings, and progressive emaciation 5 and he died gradually exhausted, at the end of a year. A short time before his death, there was a cessation of pain, followed by discharge of very fetid and dark colored matter by stool. The heart was found enlarged, with dilatation of the aorta. The spleen was much enlarged, and contained an abscess which had burst into the colon. A similar case is mentioned by Grotanelli; and an- other, in which the abscess burst into the cavity of the abdomen, and A\ras fatal in three days, A man mentioned by the same wri- ter, 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 subsided, and he discharged much thick and fetid matter in his urine. This continued about three Aveeks; he then recovered good health, and had continued well for seven years, when the account was published. In a avo- man mentioned by Heide, who had long been affected with a swell- ing in the left hypochondrium, a tumor formed at the umbilicus Avhich discharged purulent matter ; after it bad discharged for a month she died hectic. A cavernous ulcer was found extending from the umbilicus, betwixt the peritoneum and the abdominal muscles, and forming a communication with an abscess of the spleen.* Abscess of the spleen may likewise burst into the stomach, as in a very interesting case mentioned by M. Cozef The patient had pain in the epigastric region, with a remarkable feeling of * Heide Ccnturia Observ. Med.—Obs. xiii. t Jour, de Med.— Tom. 82. 334 PATHOLOGY OF THE SPLEEN. pulsation at the stomach, which Avas increased by exercise, and by any excess in the diet; he had occasional vomiting, and slight un- easiness in breathing, Avas easily fatigued by exercise, and a sense of suffocation was induced by any exertion. On examination nothing could be discovered but a slight tension across the epigas- trium, and little change took place for ten or tAvelve 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 subsided, 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 puru- lent matter and clots of blood. The parietes of it Avere in general about six lines in thickness ; and it communicated, by a free open- ing, with the cavity of the stomach 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 mentioned in the Memoirs of the Academy of Sciences, it contained 30 lbs. of matter. In an- other case mentioned in the same work by M. L'Hermite, 8 lbs. of matter were drawn off by tapping. The patient died next day, and the spleen Avas 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. Ward- rope found the spleen entirely reduced to a cyst full of puriform fluid.* ^ III.—Ramollissement or black degeneration of the spleen. This I believe to be the result of a low degree of inflammatory action ; and it is found as the only morbid appearance, in cases in which the patients have died with obscure and protracted symptoms. The spleen so affected may be enlarged, or it may be of the nat- ural size; but the Avhole 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 casein which this affection occurs as the only morbid appearance. ♦ Notes to his edition of the works of Dr. Bailie RAMOLLISSEMENT. 335 Case CXLVIII.—A lady, aged 60, had been for several months affected with loss of appetite, dyspeptic symptoms, and occasional vomiting. I attended her for about a month before her death, during Avhich 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 natural. She did not complain of any pain, 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 discovered after the most careful examination, except in the spleen, which Avas of a very dark color, and the whole substance of it was broken down into a soft mass like grumous blood. Case CXLIX.—A gentleman, aged about 45, consulted me in summer 1827, on account of a deep-seated painful swelling in the left side. On examination, it was found to be exactly in the region of the spleen ; it Avas well defined, and very painful; and no cause could be assigned for it. His general health was considerably im- paired ; and the functions of the stomach were a good deal de- ranged. After a variety of treatment, he regained pretty good general health ; and the swelling was very much reduced. I then lost sight of him for a year, during which I learned that he en- joyed tolerable health, though he occasionally felt uneasiness in his side. He died died in August, 1828, after an illness of about three weeks, which had the characters of continued fever. I did not see him in this illness, but was present, at the examination of the body. Inspection.—The spleen was very much enlarged probably to at least ten or twelve times its natural size. When first taken out, it had a remarkably soft and fluctuating appearance, as if its perito- eal coat contained a large quantity of fluid. But on cutting into h, this appearance was found to be owing to its whole substance being reduced to a soft black mass, like grumous blood. The liv- er was of a remarkably dark green color, but without disease of its texture. The condition of the spleen here referred to has been taken notice of by various Avriters; some of them compare it to a bag of very fetid pitch, others to the lees of oil; some call it putrefaction, 336 PATHOLOGY OF THE SPLEEN. and others gangrene ; and upon the whole, there seems every reas- on for concluding it to be an affection Avhich may be fatal without any other disease. A lady, mentioned in Dr. Johnson's Journal, vol. iii., died at the end of a fortnight, without any other symptoms than nausea and frequent vomiting; the pulse and bowels being quite natural. On inspection, there was found some slight appearance of inflammation on the lower intestines; the spleen was very soft, and broken doAvn into a mass like coagulated blood. A man, men- tioned by Sennertus, had been affected for some weeks Avith loss of appetite and pain in the left side; he Avas then seized with discharge of blood by stool, and died in fifteen days. The pancreas Avas 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 spleen ] and in some, it has been found combined with evident marks of inflammation in the neigh- boring parts. This occurred in a case by Lossius; and, in two cases by Crendal, it was found connected with extensive peripneu- mony. I have likewise observed it in several cases in which there had been extensive inflammation of the lower part of the left lung. A gentleman whom I saw lately, had been for several months re- markably fallen off in flesh and strength, without any defined com- plaint which could account for the change in his appearance. He was at last seized with a large carbuncle on the side of his head, accompanied by considerable constitutional irritation, under which he sunk rather suddenly. The spleen was found remarkably soft without enlargement, and Avhen cut into, discharged from every part a thick fluid of a reddish brown color. The left extremity of the pancreas was indurated, and slightly tubercular. No other disease could be discovered, after the most minute examination. § IV.—Simple enlargement of the spleen. When simple enlargement of the spleen is seen at an early period, it is accompanied Avith a state of highly increased vascu- larity. In the older cases, the structure is sometimes of a bluish purple color, and breaking doAvn under slight pressure ; in others SIMPLE ENLARGEMENT. 337 it is hardened, though of the natural appearance ; and sometimes the spleen has been found of an enormous size, Avithout appearing to deviate in any degree from the healthy.structure. This occurred in a case mentioned in the Medical Commentaries, in which it Aveighed 11 lbs. 13 ounces. In other cases, again, the disease pre- sents a mixed character, resembling some of the chronic affec- tions of the liver ;—some parts being of a tolerably healthy ap- pearance, others indurated, approaching to scirrhus; and perhaps, there may be hydatids or cysts containing a thick matter like pus or softened tubercles. One of the most singular facts in the pathology of the spleen, is the very rapid manner in which enlargement of it takes place, and the equally rapid manner in which it subsides. Some of the cases of this kind Avhich I have seen, appeared so very extraordinary, that I suspected some fallacy, until I found similar cases described as of frequent' occurrence by Avriters on the diseases of India. Several years ago, I saw, along Avith Dr. Combe of Leith, a sea- man who had contracted ague in England a few weeks before, and had returned to Leith, with the disease going on in the usual man- ner. In the left hypochondrium, there was a firm defined tumor arising from beneath the margin of the ribs, and projecting down- wards several inches. We agreed that our first object was to arrest the fever by the usual means, leaving this remarkable tumor for future consideration; but on returning about a week after, I found that the fever had been easily arrested, and that the tumor was en- tirely gone. The simple enlargement of the spleen occurs chiefly as the re- sult of intermittent and remittent fevers ; but it is also said to occur from other causes, as in young women in connection with suppres- sion of the menses, and in persons more advanced in life from the suppression of long continued hsemorrhoidal discharge. It is also met with, especially m Avarm 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 gener- ally dark colored. They are said to be liable to haemorrhage from various parts of the body ; there is deranged digestion, with mus- cular debility ; and often a general unhealthy state of the system with a tendency to sloughing sores from slight causes. There is 43 338 PATHOLOGY OF THE SPLEEN. 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 men- tions that he has known individuals in Lincolnshire affected with it for twenty years, though they had generally a pale or yellowish aspect; * and Lieutaud mentions a spleen which weighed 32 lbs. in a woman who had had the disease in a greater or less degree for seventeen years. It is now generally admitted, that, in the treatment of enlarged spleen, mercury is uniformly and highly injurious, producing ■ mortification of the mouth, and rapid failure of strength. In the earlier stages, when there is any considerable degree of tenderness repeated topical bleeding should be employed, followed by blister- ing or a seton. In other respects, the chief reliance of those who have seen most of the disease, appears to be upon free and contin- ued purging, and especially purgatives combined with tonics. The spleen powder, and spleen mixture of Bengal, are combinations of rhubarb, jallap, scammony, and cream of tartar, with Colombo pow- der 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; t as the period which is generally required for reducing by this treatment a very considerable tumefaction of the spleen, if the case has been recent. Others employ nitric acid with regular aloetic purges. The natives of India employ the ac- tual cautery, and a combination of aloes, garlic and vinegar. They also employ aloes, combined with the sulphate of iron. It is probable that the external application of Iodine might be useful. During the present season, I have seen, with Dr. Hay and Dr. Macwhirter, a little boy, aged 3, who was sent here from India with a mass of disease in the left side of the abdomen, believed to be an enlargement of the spleen. It occupied the whole space frpm the ribs to the os ilium, and the apex of the tumor extended considerably to the right of the umbilicus. It was of a smooth uniform surface, and firm texture, somewhat moveable, and not painful on pressure. The child had a pale sickly aspect, with a small rapid pulse, and was liable to attacks of haemorrhage from * Dr. Crane, Edin. Med. Jour. April, 1823. t Calcutta Transactions, vol. iii. TUBERCLES. 339 the nose. The affection had a most unpromising appearance, but it has gradually subsided, and is now scarcely perceptible. The treatment consisted chiefly of the use of the sulphate of iron, of which he took at first gr. 1. three times a-day with 1-3 of a grain of aloes ; afterwards gr.ij. twice a-day. The aloes was after some time omitted, the state of the bowels rendering it unnecessary. y V.—Tubercles. Tubercles are of very frequent occurrence in the spleen,—gen- erally in combination with tubercular disease in other parts of the body; and it may be seen completely studded with them, even in the bodies of infants a few months old. In these cases, they are generally very small and in the solid state; but in more advanced life, they may attain a very considerable size, and by suppurating pass into numerous small abscesses. A woman, mentioned by Gro- tanelli, had nausea, bad appetite, occasional vomiting, some cough, and pain in the left side; she lost her color, and the abdomen became tumid. The vomiting increased, with a quick pulse and anasarca; and she died in five months. Considerable effusion was found in the abdomen; the spleen was enlarged and contained twenty tuber- cles full of thick purulent matter. § VI.—Pale induration of the spleen approaching to schirrhus. This appearance, I have not seen, but it is mentioned by Por- tal and Lieutaud. An indurated friable state of the spleen is also mentioned as occurring in India, in which it breaks down, when handled, like a piece of old cheese. A black induration with great enlargement is mentioned by Diemerbroeck. y VII—Hydatids. Hydatids are of frequent occurrence in the spleen; they may be imbedded in its substance, but I think are more commonly met 340 PATHOLOGY OF THE SPLEEN. with in cysts formed by its peritoneal coat. In one case of this kind, in Avhich there was immense swelling in the region of the spleen, I found the disease to consist entirely of a bag of hydatids covered by its peritoneal coat, the substance of the spleen being little altered from the natural appearance. y VIII.—Hcemorrhage from the spleen, and laceration by exter- nal violence. Case CL—A AVoman aged 20, was admitted into the Infirm- ary of Edinburgh, on 16th June, 1829, under the care of Dr Dun- can. Her complaints were chiefly of a rheumatic character, with considerable nausea, some fever, anxiety, and restlessness. She stated, that, a fortnight before, she had been suddenly seized with severe pain in the stomach, followed by nausea and vomiting, and that these symptoms continued to recur at intervals for a week. On the 17th, there was vomiting, with much anxiety and restless- ness, and she complained of pain on pressure in the left side be- neath the false ribs. On the 18th, she became low and cold, and died in the evening. Inspection.—A quantity of coagulated blood was found in the cavity of the abdomen, which was ascertained to have proceeded from a laceration of the spleen. That organ was of a paler color than natural, and its substance was soft and easily torn. There was a sacculated disease of the right ovarium: but no other ap- pearance of recent disease could be detected in any organ. A man, mentioned by Fournier, had suffered from quartan ague for several months, but was considered as convalescent, when he died suddenly after a hearty supper. The spleen was found en- larged and ruptured ; and there was much coagulated blood in the cavity of the abdomen. Several cases are on record of laceration of the spleen by ex- ternal violence; in some of them, death seems to have taken place from haemorrhage, in others from inflammation. Cases of the former kind are mentioned by Lieutaud and Tulpias. A man, mentioned by Dr. Chisholm, fell while carrying a burden, and struck his left side against a stone. He felt little uneasiness at \hc HEMORRHAGE. 341 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 muscu- lar 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 sphac- elated. Various other morbid conditions of the spleen are occasionally met with, but they are distinguished by no particular 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 gelatenous fluid; deposition of fatty 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 Avoman, Avhose case is quoted from the Sweedish Transactions, in Dr. Johnson's Journal for 1828, had, after exposure to cold, sup- pression 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 transformed into a grumous glutinous fluid, enveloping three boney concretions, one of which was two inches and a half in length. The liver was found in a state of atrophy. PATHOLOGY or THE PANCREAS. Facts are wanting upon this subject; but it appears that the morbid conditions to which the pancreas is liable, are chiefly the following: /.—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 symptoms do not appear to be very distinctly defined. There was in general pain, which was chiefly referred to the back, while in others it had more the appearance of colic; vomiting occurred in a few of the cases, but does not appear to have been a uniform symptom. Dr. Baillie found an abscess of the pancreas in a young man who had a good deal of pain in different parts of the abdomen, with spasms of the abdominal muscles, but did not complain of any fixed pain in the region of the pancreas ; there was 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 vvas found greatly en- larged, and contained a considerable abscess; the ductus communis was obliterated by the pressure. Portal found a complete suppura- ENLARGEMENT. 343 tion of the pancreas in a man who died suddenly after two or three attacks of vomiting, followed by syncope; he had previously suf- fered from a paroxysm of gout, from which he was supposed to be convalescent. Abscess of the pancreas is also mentioned by Tul- pius and Bartholinus. In two cases by the former, it was con- nected with quartan fever; and in a case of continued fever, in which there was much pain of the back, Guido Patin found an im- mense abscess occupying the whole of the pancreas. A sphacela- ted 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 sud- denly, having complained only of a feeling of internal coldness; and Portal found the pancreas softened and gangrenous in a man who died of obscure pain in the abdomen, accompanied by wast- ing, with occasional nausea and diarrhoea. A gentleman, mentioned by Dr. Parry was first affected with loss of appetite, and a painful feeling of distention after taking a small quantity either of food or drink. He then had vomiting of almost every thing that was taken, and complained of pain which extended along the sternum to the throat, and was felt also between the shoulders, with much flatulence, and a burning sensation in the breast and throat. He died, gradually exhausted, about two months after the commencement of the vomiting. On inspection, the principal appearance Avas an abscess, four inches in diameter, formed between the upper surface of the pancreas and the lower surface of the left lobe of the liver. The sides of the abscess were rugged and uneven, and it contained a thick curdy matter. The pancreas and the adjoining portion of the liver were hardened; and there was hardness with contraction of the oesophagus, extend- ing along its thoracic portion. II—Enlargement, with a mixed state of disease, partly consisting of induration, and partly of a softened state resembling the medulary sarcoma. Case CLI.—A lady, aged about 40, came to Edinburgh in May, 1829, affected with very deep jaundice, which was of several months standing. There was occasional uneasiness in the abdo- 344 PATHOLOGY OF THE PANCREAS. men, but it \Aras not severe; and the general health was little im- paired. No disease could be discovered in the region of the liver: in the centre of the abdomen, near the umbilicus, there Avas a slight feeling of knotty irregularity, but it was obscure, and could only be felt occasionally. I saw her along with Dr. Macwhirter, and a great variety of treatment was adopted Avithout benefit. She at length became dropsical, and returned to the country, Avhere she died, gradually exhausted, in August.—I am indebted to Mr. Syme of Kilmarnock, for the account of the morbid appearances. Inspection.—There was a gallon of fluid in the abdominal cavity. The gall bladder was very large, and was distended with very black bile. The liver Avas of a deeper color than natural, but otherwise sound. The Avhole of the peritonaeum A\-as some- what thickened. The pancreas was enlarged to the size of two fists, and embraced the ductus communis so firmly, that it was found impossible to pass a probe from the gall bladder into the in- testine. It Avas of a mixed texture, some portions being soft, re- sembling the medullary sercoma, and others of schirrous hardness. The other viscera Avere healthy. Case CLII.—A man, aged 56, had pain in the left hypochon- drium, extending into the back, with oppression at the stomach, indigestion, and gradual emaciation; and he died gradually ex- hausted after two years, without any other symptom, except that for a Aveek or two before his death, there was a considerable degree of jaundice. He never had any vomiting, and his boAvels were easily regulated. No disease could be discovered by examination during life, even after he became to the last degree emaciated. Inspection.—The stomach and the intestines were healthy; behind the stomach, in the seat of the pancreas, there Avas a morbid mass four or five inches in breadth, and somewhat less in thick- ness ; it was closely attached to the spine, and surrounded the aorta. It varied in its structure, some parts being of almost cartilaginous hardness, others soft and composed of alternate layers of yelloAvish and Avhite matter. The liver was somewhat enlarged and soft; the other organs were healthy. Case CLIII.—A young man, aged 16, in May, 1812, began to complain of pain in the region of the stomach, extending through to the back. It increased very gradually, but without confining SCIRRHUS INDURATION 345 him from his usual employment, until July, Avhen he began to be affected with vomiting, Avhich generally occurred two or three hours after dinner. At this time, he commonly retained his break- fast ; but, in September, when I saw him, he vomited everything. He was then much wasted ; and a large irregular tumor was dis* tinctly felt in the epigastrium, which was painful on pressure. He died, gradually exhausted, in the end of December; for 8 or 10 days before his death, the vomiting had ceased, and he was then affected with severe diarrhoea. Inspection.—.The pancreas was enlarged, so as to form a mass seven or eight inches long, five inches broad and three in thickness; and internally showing a mixed state of disease as in the former case. The stomach, the duodenum, and the arch of the colon, had formed adhesions to the mass; and the stomach seemed somewhat thickened in its coats ; the other viscera were healthy. Ill—Scirrhus induration, with little enlargement, Case CLIV.—A woman, aged about 40, had vomiting and slight uneasiness in the region of the stomach. The vomiting gradually increased in frequency, until she vomited almost every thing she took into her stomach ; and she died, without any other prominent symptom, after the vomiting had continued about a year. A remarkable circumstance in this case was, that, though she died with gradual and progressive loss of strength, there was no ema- ciation ; 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 scirrhus hardness, without much enlargement; no other morbid ap- pearance 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 vomit- ing; but there is also ground for believing, that a diseased state of the pancreas has a most important influence upon the functions of digestion and assimilation, and that it may produce in this manner many serious effects upon the system, while the local symptoms are so obscure as not to indicate what organ is the seat of the 44 346 PATHOLOGY OF THE PANCREAS. disease. I shall only add the following .remarkable example of this kind. Case CLV.—A gentleman, aged 35, died after an illness of about eighteen months duration, in which it was to the last impos- sible to say what organ was the seat of the disease. His complaints began with a febrile attack, which left him weak ; and from that time he Avas liable to dyspeptic symptoms, with variable • appetite, and undefined uneasiness in the epigastric region. He gradually lost flesh and strength, and when he consulted 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 color. 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 for- mer state; appetite variable and capricious ; bowels sometimes cos- tive and sometimes rather loose ; 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 emaciated appearance. In Feb- ruary he became rather Avofse, with some diarrhoea and scanty urine; but these symptoms soon subsided, and he afterwards com-1 plained chiefly of throbbing in the head and a constant noise in the left ear. When I saw him in the middle of April he Avas reduced to the last degree of paleness and debility, but his pulse was full, strong, and regular. He took a good deal of food, and complained of nothing except the painful pulsation in his left ear. The action Of the heart Avas 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 remarkably pale and void of blood; the heart was sound but remarkably empty. The pylorus Avas thickened and firmer than natural, and had con- tracted an adhesion to the pancreas. The pancreas was consider- ably enlarged, and of nearly cartilaginous hardnesss, except some spots, which were soft, Avith the appearance of the medullary sar- coma. No other disease could be detected in any part of the body. Many cases arc on record of chronic diseases of the pancreas, I..... SCIRRHOUS INDURATION. 347 exhibiting the same diversity of symptoms 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 com- plaints, without any urgent symptom. In eight, there was frer quent vomiting, with more or less pain in the epigastric region; and thirteen were fatal, with long continued pain Avithout vomiting. In some of these, the pain extended to the back ; and in others, it Avas much increased by taking food. In several, there were drop- sical symptoms ; and in three or four there was jaundice from the tumor compressing the biliary ducts. In the morbid appearances, also, there was great variety; the pancreas being in some of the cases much enlarged, in others, in a state of scirrhus 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 Avas hardness Avith littte 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, gradually 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 Avho 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, Avith a very irregular surface, and were found to be composed of carbonate of lime. ^ 0 NATIONAL LIBRARY OF NLM032068490