DISEASES OP THE ABDOMEN.
 
 / ON 
 
 i - 
 
 DISEASES OF THE ABDOMEN, 
 
 COMPRISING THOSE OF THE 
 
 STOMACH, AND OTHER PARTS OF THE ALIMENTARY 
 
 CANAL, (ESOPHAGUS, C^CUM, INTESTINES, 
 
 AND PERITONEUM. 
 
 ^ 
 
 BY 
 
 Sf O. HABERSHCW, M.D., LOOT)., 
 
 FELLOW OF THE ROTAL COLLEGE OF PHYSICIANS ; SENIOR PHYSICIAN TO, AND LATE LECTURER 
 ON THE PRINCIPLES AND PRACTICE OF MEDICINE AT OUY'S HOSPITAL, ETC. 
 
 WITH ILLUSTRATIONS. 
 
 SECOND AMERICAN 
 
 THIRD ENLARGED AND REVISED ENGLISH EDITION. 
 
 PHILADELPHIA: 
 
 NKY O. LEA. 
 
 1879.
 
 - A vuo 
 
 \V V I 4, o 
 \ 
 
 COLLINS, PRINTER.
 
 PREFACE. 
 
 DISEASES of the Stomach have, during the last few years, received 
 considerable attention, and our medical literature has been enriched 
 by the labors of Budd, Hand field Jones, Chambers, Brinton, Wilson 
 Fox, Leared, Fenwick, and others. Much, however, still remains to 
 be done; and whilst some of the facts contained in the present 
 volume will tend to confirm what is already known, other new ones 
 will be found, which, we trust, will repay an attentive perusal of its 
 pages. 
 
 The design in this work has been to illustrate the diseases treated 
 upon, by cases which have come under our personal observation, 
 with a few remarks upon them, and some general deductions. 
 During the period of my curatorship of the Museum at Guy's, and 
 of my demonstratorship of Morbid Anatomy for several years, very 
 numerous opportunities were presented of noticing diseases of the 
 stomach and intestines in their varied phases; and I would tender 
 sincere thanks to those of my colleagues who have permitted the 
 mention of instances under their care. Although I have sought 
 definitely to distinguish some classes of diseased conditions, I should 
 be very unwilling to regard them as entities superadded to the 
 human frame, but rather, to quote the words of Sir John Forbes, 
 "as new phases of vital manifestations." 
 
 Life may be considered as the resultant of certain forces, mani- 
 fested in the performance of functions, which are combined harmo- 
 niously for one purpose; it has received varied appellations, each 
 indicative of our inability to discover its real character ; thus we 
 have had vital force, power of growth, nutrition, development, 
 organization, nature, &c., each new observer considering himself 
 more clear-sighted than his predecessor, although he has merely 
 substituted one term for another. This living force is in close cor- 
 relative relation with other physical forces, and the fuller investiga- 
 tions of physiological science show that the same forces are in 
 operation, namely, gravitation, chemical action, &c., in the living
 
 VI PREFACE. 
 
 organism, as external to it; modified, it is true, by another force, 
 namely, life. And as in the science of physics generally, so in the 
 study of living phenomena, we must ever bear in mind that a like 
 cause always produces a like effect. Vague observation, and the 
 superficial remarks of some writers, would lead us to suppose, that, 
 in living phenomena, the same cause is followed, at first by one 
 effect, then by another; interpreting fixed realities by prejudice 
 rather than by reason. 
 
 Some phraseology is necessary to express our meaning and ideas, 
 and one great difficulty is overcome, if we can understand that the 
 same words convey to each the same thought. It may be con- 
 venient, as we have mentioned, to regard life as the resultant of 
 certain forces, and disease as a deviation from the normal direction. 
 If any of the forces which are in natural operation be modified in 
 intensity, a deviation is the result, and diseased action is produced, 
 the resultant being necessarily changed; still the tendency is such 
 that on the withdrawal of the modifying force, the normal course is 
 reassumed. Not only may it be natural force which has led to this 
 departure from the healthy state, but new force may be added, as 
 much as when the earth in its orbit is disturbed by the attraction of 
 some other celestial body. 
 
 In diseases, many sources of change arise modifying forces thus 
 syphilitic or miasmatic poison, small-pox, &c., alter the character of 
 every function; a new substance is added as much as in the voltaic 
 battery, when the fluid in one or other cell is changed by the ad- 
 mixture of any substance; this may be merely of the kind already 
 existing, or a foreign substance may have been introduced ; in any 
 case, the phenomena are modified. Such, to some extent, is the case 
 in pathological changes. These changes, produced by perverted 
 nutrition, or altered vital forces, are in many instances of such a 
 character, that no examination of the structure itself could discern 
 the state which had been produced; as fruitless would it be to search 
 in the nerve of a limb for the altered force which had led to spasm, 
 as to expect to find a telegraphic message by a microscopical exami- 
 nation of the wire, although the structure of both had been tran- 
 siently modified by the disturbance of the forces they transmitted. 
 If the character of the disturbance in disease is one, which, like a 
 polar force, reverts to its former condition, no trace can be found on 
 inspection, but, in many instances, obvious structural modifications 
 are the result. 
 
 Diseased action, however, as generally manifested, is the resultant, 
 not of one, but of several changes in the normal condition, and very
 
 PREFACE. vii 
 
 few persons are literally in perfect health. The living forces are 
 modified by hereditary tendency, as struma; to this, perhaps, is 
 added, syphilis, to that miasm; still further, sudden changes of tem- 
 perature, improper supply of nourishment, of heat, and light, may 
 be causes of disease ; each of these may act as fresh sources of devia- 
 tion from the normal healthy direction of living action, superadded 
 to the resultant production by the previous combination. 
 
 Some have supposed that acute disease quickly passes off, and 
 that with the subsidence of the more marked symptoms no trace is 
 left behind, but very generally this is not the case ; the attentive 
 study of pathology will soon convince us of the contrary ; new ex- 
 citing causes of disease arise, perhaps of a different character, but 
 the resultant (to revert to the previous phraseology of forces) is not 
 precisely the same, the former diseased state acts as a modifying 
 force. This course may be often repeated, and if the changes have 
 been such as to entail discomfort or weakness, chronic disease is said 
 to exist; but if without these, the patient generally passes for one 
 in sound health. It is the acumen of the practical physician that 
 detects the traces of previous morbid action, and he alone knows 
 how rightly to estimate the course likely to be assumed by any new 
 addition to a state widely diverse to that of health ; hence, also, the 
 variety of diseases by which the same organ is affected, the causes 
 are different and so of necessity their effect. 
 
 It is the province of medical science, rightly to estimate the 
 effects produced on vital action by any disturbing causes, and to 
 study their almost endless varieties; several general characters lead 
 us to group these effects into classes ; and although in this volume 
 we have spoken of diseased action as manifesting itself especially in 
 the alimentary canal in the changes described, and the symptoms 
 detailed, it will be found that these parts are in many cases only 
 affected in common with the whole economy, whilst in others, that 
 the special manifestation of morbid action is in the abdomen. 
 
 Numerous means are available for checking and modifying dis- 
 eased action, and we must protest against the ignorance of those who 
 regard the draught of medicine as the only important agent. The 
 skill of the physician is often most manifest in the suggestion of 
 hygienic measures which by many may be assumed as of trifling 
 moment ; and whilst it is perfectly true that many morbid conditions 
 cease after a time, or that the frame becomes so accustomed to per- 
 verted action that the balance of functions is apparently maintained 
 without cognizance on the part of the patient, still the aid of 
 medical science is most important. The first agents to which we
 
 Vlll PREFACE. 
 
 must refer are those which are in constant operation in the mainte- 
 nance of life in one state preservation of health, in another the 
 cause of disease as the character of the air breathed, whether 
 saturated with moisture, poisoned with miasm, or with the decom- 
 posing effluvia of crowded cities, as compared with that found in 
 more elevated situations, on the sea or its coasts, &c. ; so also with 
 reference to diet, to light, to clothing, to temperature ; to habits of 
 mental or bodily training or exercise ; the right use of all these is 
 not less important in the restoration to health, than in the mainte- 
 nance of it, and in both cases alike, is within the province of medical 
 science. 
 
 Too frequently medicine is taxed to obviate the disease whilst its 
 cause is pertinaciously adhered to. It is in vain to recommend to 
 the dyspeptic patient remedies which would certainly mitigate his 
 disease, whilst intense anxiety remains, and hurried, half-masticated 
 meals are taken at irregular hours and without due moderation 
 or, again, it is useless to direct means to relieve a disturbed brain, 
 whilst excitement is added to excitement, the senses stimulated by 
 light, noise, animated conversation, and active thought or to give 
 opium to check peritonitis, to quiet muscular movement, when the 
 patient is allowed to move from the recumbent position. 
 
 The consideration of the fundamental conditions of life demands 
 strict attention, not only as indicating the tendency vital action has 
 to assume its natural direction, but also in enabling us to use and 
 apply effective means for the removal of morbid processes ; and we 
 are at no great loss to understand the intellectual power and acumen 
 of those who, because everything is not known in the pathology 
 and treatment of disease, would contemptuously discard that which 
 is known and established. We deplore the ignorance of those who 
 know not the value of opium in peritonitis, &c., of iodide of potas- 
 sium in secondary syphilis, of purgatives and mercurials in hepatic 
 engorgement, of preparations of steel in many forms of anaemia, of 
 quinine and arsenic in intermittents; our object is not to confute 
 errors which arise from wilfully closing the eye to light already 
 attained, but to seek to add facts upon which science may safely 
 advance. 
 
 "We have generally divided the chapters according to the anato- 
 mical divisions, rather than in a strictly pathological manner. The 
 first chapter is on diseases of the Mouth and Throat, and the next 
 on those of the Pharynx, but I have not dwelt upon those maladies 
 which more especially come under the care of the Surgeon. The 
 chapter on disease of the (Esophagus contains many interesting
 
 PREFACE. ix 
 
 cases, some of them obscure in their pathology, and very insidious 
 in their origin ; some instances of ulceration, perforating the trachea 
 or bronchi, which we have described, have generally, and we believe 
 incorrectly, been considered as instances of cancerous disease. The 
 diseases of the stomach constitute the subject of the next section, 
 and have obtained from authors very considerable attention; we 
 believe that there are forms of ulceration, superficial and evanescent, 
 which leave scarcely more trace in the mucous membrane of the 
 stomach than the aphthous ulceration of the mucous membrane of 
 the mouth, whilst others are permanent, and are manifest after 
 death ; and indeed we find the same forms of diseased action in the 
 mouth as in the stomach; thus both are affected by inflammatory 
 congestion, perverted epithelial growth and secretion, sluggish con- 
 dition of the circulation, acute inflammatory disease, as well as by 
 fibroid and cancerous disease. Ulceration of the stomach is probably 
 a more common condition than is generally supposed, and in many 
 instances yields to judicious treatment; the instances we have 
 adduced show that there are several distinguishing marks by which 
 it may be known from cancer. Fibroid degeneration of the pylorus 
 has generally been considered as of a cancerous nature ; and whilst 
 we are unable to remove this almost certainly fatal form of disease, 
 we may, as in cancer, do much to mitigate the symptoms and to 
 prolong life. 
 
 In the so-called functional disease of the stomach, chemical re- 
 search has removed much that was obscure, and will do still more 
 to explain the pathological changes which are induced; the investi- 
 gation of the physiological connections of the pneumogastric nerve, 
 as well as of the sympathetic nerve and the branches of the semi- 
 lunar ganglia, will enable us more correctly to estimate the very 
 diverse symptoms produced in dyspepsia, many of which have their 
 origin in this source. The right estimate of such symptoms as pain 
 in the region of the stomach and vomiting are most important in 
 the diagnosis, and equally so in the treatment of gastric affections. 
 
 The chapter on the Duodenum presents us with instances of dis- 
 ease which closely simulate maladies of the pyloric extremity of the 
 stomach. 
 
 The next chapter is on Gastro-Enteritis and Enteritis, diseases in 
 which correct diagnosis is very important; in the latter class of 
 diseases especially, life may be easily sacrificed by time being thrown 
 away, and by improper treatment; in the former with judicious diet, 
 warmth, demulcents, &c., recovery generally takes place. Whilst 
 we strongly recommend, in many of these instances of gastro-ente-
 
 X PREFACE. 
 
 ritis, the avoidance of mercurials, the value of salines, as bicarbonate 
 and chlorate of potash, and carbonate of soda, are well known to 
 those who have carefully watched the effect that has followed their 
 administration. 
 
 In the chapter on Strumous Disease of the Intestine and Perito- 
 neum we have sought to show that these diseases are only part of a 
 general perverted nutrition, and that, in many instances, disease in 
 other organs is entirely obscured by the more marked affection of 
 the abdominal viscera; here, also, we should strongly urge the 
 avoidance of mercurial medicines and of drastic purgatives; the 
 lives of many delicate children are sacrificed by worm powders and 
 quack nostrums administered in these diseases. 
 
 The diseases of the Cascum and its Appendix are next dwelt upon. 
 We have shown that unusual freedom of the cascal attachments may 
 determine intestinal obstruction from rotatory movements of the 
 intestine; the symptoms and treatment of csecal distension and of 
 local enteritis are described, as well as the more serious consequences 
 of perforation of the appendix; we have given numerous instances 
 of these forms of affection, and their perusal will show the great 
 similarity in the symptoms and their general course. Dr. Burns, 
 in a valuable paper in the 'Medico-Chirurgical Transactions,' de- 
 scribed, several years ago, some of these affections. It would appear 
 that the symptoms of cancerous disease of the caecum are different 
 from simple csecal enteritis and perforation ; and that in many cases 
 we may discriminate the character of the complaint. It will be 
 found that treatment may do much to relieve and to assist the cure 
 of caecal disease ; the pain demands rest, and it is well after the acute 
 pain has subsided, still to maintain absolute repose for several days. 
 The bowels are often confined, but the use of purgatives generally 
 aggravates the disease without effecting the desired operation ; this 
 is better obtained by the application of warmth and by opium; 
 those remedies which diminish the enteric inflammation lead most 
 speedily to the subsidence of the morbid symptoms. 
 
 We have next pointed out the characters of the several forms of 
 Diarrhoea, but we are well aware that diarrhoea is merely a symptom 
 of very different conditions, and that in many instances it passes 
 almost imperceptibly into dysentery. 
 
 Dysentery and Catarrh of the Colon are the subjects afterwards 
 considered, and the instances we have adduced show that inflamma- 
 tion of the colon, of a most severe form, arises in our own country. 
 Most of the writers on this subject are those who have observed it 
 in its worst forms abroad or in Ireland. In some of the cases
 
 PREFACE. xi 
 
 typhoid fever was simulated; in others, perforation of the colon had 
 taken place; in one there was pyaemia and commencing suppuration 
 in the liver; in several chronic cases the secondary effects were 
 shown in producing contraction of the intestine, perforation, and 
 artificial anus, &c. ; as regards abscess in the liver, in one case the 
 abscess had dried and contracted; in another, fresh diseased action 
 was set up around it, and abscess in the brain was the result. We 
 must confess, that in some of the most severe forms all treatment is 
 ineffectual to cure, whilst it partially soothes and relieves; but in 
 the great majority of instances means may be used which effectually 
 combat the symptoms of disease. 
 
 We had intended to give some observations on Asiatic cholera, 
 but for several reasons have not done so ; first, because although 
 the disease manifests itself more apparently in the disturbed func- 
 tions of the alimentary canal, it has not been clearly shown that the 
 disease is really one affecting alone or even principally the abdomen ; 
 and secondly, all the facts known in reference to this disease are 
 better and more clearly given in the report drawn up by Dr. Baly 
 and Sir W. Gull. 
 
 In the chapter on Typhoid Fever, we have merely described the 
 condition of the abdominal affection, without entering into the gene- 
 ral question of fever, and its treatment ; in the latter, it is well to 
 guard against the danger of so freely administering opiates to check 
 diarrhoea as to lead to cerebral oppression, and excessive engorge- 
 ment of the lungs, from imperfect performance of the respiratory 
 function. 
 
 In the chapter on Colic I have cursorily spoken of the simpler forms 
 of the disease, and separated the more severe varieties of ileus- 
 internal strangulation, intussusception, and cancerous disease of the 
 colon. It will be found that whilst the latter conditions bear a 
 strong general resemblance in producing fatal constipation, they 
 may, in many instances, be distinguished the one from the other ; 
 intussusception closely simulates simple colic, but, in not a few in- 
 stances, it is accompanied by discharge of bloody mucus, or with 
 actual diarrhoea ; and this latter symptom sometime arises even with 
 cancerous disease of the sigmoid flexure. We have very strongly 
 urged the avoidance of drastic purgatives, calomel, colocynth, and 
 even milder purgatives, and as strongly recommended the free ad- 
 ministration of opium ; the cases detailed almost uniformly show 
 that, where purgatives were given, vomiting, pain, and distress were 
 increased, whilst these and other symptoms were, on the contrary, 
 relieved by opium. Opium, in such cases, appears to be the best
 
 Xll PREFACE. 
 
 means of procuring relief to the bowels, if an action be possible. In 
 the chapter on Worms, we have designedly been very brief in our 
 remarks. 
 
 The cases of Suppuration in the Abdominal Parietes, and of Per- 
 foration of the Intestine from Without, are an interesting series ; 
 many of them are obscure in their diagnosis, and different in their 
 course. Great care is required in watching the symptoms as they 
 become fully developed, and in avoiding the aggravation of them by 
 too active treatment. 
 
 The serous membrane of the intestines, the peritoneum, is so in- 
 timately connected with the morbid conditions of the alimentary 
 canal, that we have appended some remarks on its diseases. In 
 very many instances the serous membrane is implicated by direct 
 extension of disease ; in other cases, the peritoneal change is the 
 expression of a general morbid condition of the whole system ; in 
 addition to a chapter on Peritonitis, I have appended remarks on 
 Ascites, and also on Abdominal Tumors. 
 
 The cases I have recorded might have been given at greater length, 
 and on each one fuller remarks might have been made ; but the de- 
 sign of the work has been, in a very few words to point out the 
 peculiarities of each instance, embodying in more general deductions 
 the apparent conclusions derived from the whole. My desire is to 
 shed some light on the difficulties which often present themselves in 
 the daily practice of the profession, and to suggest means whereby 
 the alleviation of disease may be promoted. 
 
 The former editions of my work on ' Diseases of the Abdomen' 
 have been exhausted for several years, and I regret that so long a 
 time has elapsed in the preparation of the present edition. The 
 whole work has been carefully revised ; several chapters on impor- 
 tant subjects have been added ; and, I trust, that it will be found 
 helpful in clinical study, as well as in the treatment of disease. I 
 have derived valuable assistance from my friend and colleague, Dr. 
 Goodhart, both in examining the later records of the Guy's patho- 
 logical department, and also in the revision of the work. 
 
 70, BROOK STREET, 
 
 GROSVENOR SQUARE.
 
 TABLE OF CONTENTS. 
 
 CHAPTER I. 
 
 Introduction. Digestion and Indigestion contrasted; general remarks upon and 
 summary of the various Structures involved glandular, muscular, serous, con- 
 necting, nervous, vascular ; preliminary remarks upon Treatment ; the action 
 of Remedies modified by the condition of the recipient ; by the co-existence of 
 other independent Diseases The antagonism of Disease . . .1 7-25 
 
 CHAPTER II. 
 
 On Diseases of the Tongue and Mouth. Paralysis of the Tongue Deficient Epi- 
 thelium Irregular growth of the Papillae Stomatitis Thrush Ulcerative 
 Stomatitis Cancrum oris Glossitis, acute and chronic phthisical and syphi- 
 litic; Xeuralgia of the Tongue Spasm Ringworm Parotitis Tonsillitis, 
 acute and chronic (Edema Cancer Paralysis of the Soft Palate Bulbar 
 Paralysis . > 26-44 
 
 CHAPTER III. 
 
 On Diseases of the Pharynx. Spasm Inflammation, catarrhal, membranous, 
 phlegmonous Syphilitic ulceration Cancer Suppuration behind the Pharynx, 
 Cysts, and Pouches . . 45-52 
 
 CHAPTER IV. 
 
 On Diseases of the (Esophagus. Anatomical relations Diseases of the Mucous 
 Membrane Inflammation Ulceration Abscesses Cysts Warty Growths- 
 Muscular Spasm Paralysis Hypertrophy Dilatation Pouches Strictures 
 The effects of Corrosives Foreign bodies Hemorrhage in the Coats 
 Rupture Gastric Solution 53-112 
 
 CHAPTER V. 
 
 On Organic Disease of the Stomach. Post-mortem Solution Atrophy of the 
 Mucous Membrane Hypertrophy Mammillation Dilatation of Stomach 
 Hour-glass contraction Lardaceous Disease Inflammation Ulceration 
 Sloughing of the Mucous Membrane Fibroid Degeneration of the Pylorus- 
 Polypoid growths Cancer 113-208
 
 XIV TABLE OF CONTENTS. 
 
 CHAPTER VI. 
 
 On Functional Diseases of the Stomach. Forms of Dyspepsia, from altered condi- 
 tions of the Mucous Membrane and of the Gastric Juice Atonic Dyspepsia 
 Exhaustion of Cerebro- Spinal System of Nerves Dyspepsia in Chronic Disease 
 At different periods of life Excessive Secretion of Gastric Juice Irregular 
 Secretion Morbid Secretion Pyrosis Dyspepsia in Rheumatism and Gout ; 
 in Albuminuria Dyspepsia from altered Vascular Supply ; from the state of 
 the Nervous System ; from impeded movements of the Stomach ; from Fermen- 
 tation ; Haematemesis Pain and Vomiting as signs of Gastric Disease. 
 
 209-251 
 
 CHAPTER VII. 
 
 On Diseases of the Duodenum. Position of State of Secretion Malformation 
 Congestion, acute and chronic Duodenal Dyspepsia Inflammation Ulcera- 
 tion Cancerous Disease Mechanical Obstruction Hydatid Perforation 
 
 252-275 
 
 CHAPTER VIII. 
 
 On Muco- Enteritis and Enteritis. Varieties Pathological Changes Symptoms 
 Diagnosis Prognosis Treatment 276-288 
 
 CHAPTER IX. 
 
 On Strumous and Tubercular Disease of the Alimentary Canal. Lardaceous Dis- 
 ease. Various forms of Diarrhoea in Strumous Children Disease of Mesenteric 
 Glands Tubercles in the Peritoneum and Strumous Peritonitis Disease of 
 Intestine in Phthisis Lardaceous Disease 289-311 
 
 CHAPTER X. 
 
 On Diseases of the Caecum and Appendix Cceci. Changes in position Atrophy 
 Distension (Edema Congestion Typhlitis Ulceration Cancerous Disease 
 Trichocephalus Dispar. Appendix Increase of length Atrophy Dilata- 
 tion Concretions Results of Symptoms of Disease Diagnosis Prognosis 
 Causes Treatment Cases . .... 312-345 
 
 CHAPTER XI. 
 
 On Diarrhoea. Varieties of Bilious Catarrhal Dysenteric Choleraic Serous 
 Melaena Symptoms Causes Prognosis Diagnosis Treatment Cases 
 
 346-359 
 
 CHAPTER XII. 
 
 On Dysentery and Catarrhal Inflammation of the Colon. Morbid Anatomy of 
 Dysentery Sequelae Symptoms Causes Prognosis Diagnosis Treatment 
 Table of Cases Chronic Catarrh of the Colon 360-392
 
 TABLE OF CONTENTS. XV 
 
 CHAPTER XIII. 
 
 On Typhoid Disease of the Intestine. Changes in the Intestine Symptoms 
 Treatment Cases 393-397 
 
 CHAPTER XIV. 
 
 On Colic. Varieties Flatulent Colic Spasmodic Colic Colic from Food from 
 retained Secretions and Excretions Lead Colic Symptoms and Diagnosis 
 Treatment 398-406 
 
 CHAPTER XV. 
 
 On Constipation. Effects Causes Symptoms Diagnosis Treatment 407-420 
 
 CHAPTER XVI. 
 
 On Organic Obstruction, Internal Strangulation, Intussusception and Carcinoma 
 of Intestine. Classification of Causes Symptoms Diagnosis Treatment 
 Cases of 421-472 
 
 CHAPTER XVII. 
 
 On Suppuration of the Abdominal Parieties, Perforation of the Intestine from with- 
 out, and Abscess in the Abdominal Parieties, extending into the Intestine 
 Fecal Abscess. Causes of External Perforation Symptoms Treatment 
 Cases of 473-486 
 
 CHAPTER XVIII. 
 
 On Intestinal Worms. Varieties Symptoms Treatment . . . 487-494 
 
 CHAPTER XIX. 
 
 On Peritonitis. Pathological Changes Varieties Symptoms Chronic Peritonitis 
 Diagnosis Prognosis Causes Treatment Cases Loose Bodies in Perito- 
 
 O O 
 
 neum 495-515 
 
 CHAPTER XX. 
 
 On Ascites. Dropsy. Varieties Asthenic Mechanical Inflammatory Glandu- 
 lar Tubercular Cancerous Ovarian Symptoms Diagnosis Treatment 
 
 516-529 
 
 CHAPTER XXI. 
 
 On Abdominal 1 "umors. Abdominal Spaces Tumors found in each region Diag- 
 nostic Signs 530-537
 
 ON 
 
 DISEASES OF THE ALIMENTARY CANAL 
 
 CHAPTEE I. 
 
 INTRODUCTION 
 
 THE function of digestion is essentially connected with life and 
 health ; and slight deviations from its normal performance produce 
 suffering in a greater or less degree. He is, indeed, fortunate who 
 can pass through his daily duties without having the thoughts and 
 attention directed to those operations for the solution, absorption, 
 and assimilation of nourishment, which in health are completed 
 unconsciously, without attention, or sense of pain. If there be severe 
 derangement of the digestive functions, not only is the attention di- 
 rected to them, and discomfort entailed, but there is reaction upon 
 the higher capabilities of man's nature ; the energies of the brain are 
 enfeebled, the memory is defective, the will vacillates, and the intel- 
 lectual powers are less free to guide in daily duty, avocation, and 
 research. The strength and muscular movements are diminished, 
 and the enjoyment of life changes to daily suffering and anxiety. 
 Contrast the vigor of mind and body during health, with the enfeebled 
 energy of the dyspeptic and hypochondriac. In the former state 
 there is no impediment to the exercise of deep thought and labor, in 
 any sphere to which the mind may be directed ; the whole attention 
 in the latter is absorbed by those functions, which are at best only 
 subservient to the manly exercise of mind and will. 
 
 If the digestive process be altogether checked, and no new supply 
 of nourishment be absorbed and assimilated; if no restoration be 
 made to the waste entailed by the exercise of every function, life 
 must sooner or later cease ; and disease, in its ravages, presents few 
 spectacles more distressing to witness, than the gradual wasting of 
 the frame, and cessation of life itself, from the non-supply of food. 
 Thus the whole system sympathizes with disorder of the alimentary 
 canal. 
 
 A knowledge of the structure and functions of each part of the 
 
 digestive apparatus, is necessary for the right comprehension of its 
 
 diseases. The structures of the alimentary canal are various, and 
 
 their sympathies universal; but in health these are so combined as 
 
 2
 
 18 INTRODUCTION. 
 
 to form a beautiful and harmonious whole: thus, 1st, we find a mu- 
 cous membrane richly supplied with glands, lining the alimentary 
 canal throughout its course; these glands are for secretion and excre- 
 tion; the secretions from these act physically or chemically in the 
 digestive process, whilst the excretory glands separate noxious or 
 effete principles from the blood. 2d. Beneath the mucous is the 
 muscular coat, essential for the execution of the required movements, 
 and for the propulsion of the contents of the canal. 3d. The peri- 
 toneal or serous covering, which by its smoothness permits of the 
 movement of one portion of the intestine upon another, and allows 
 distension to take place. 4th. The binding tissues, which are found 
 between these previously mentioned tunics, and which support other 
 equally essential parts, namely, 5th, the bloodvessels and lymphatics ; 
 and, 6th, the nerves supplied by the sympathetic and cerebro-spinal. 
 As Abercrombie has remarked, in reference to diseases of the sto- 
 mach, so, also, it may be added, in reference to every part of the 
 alimentary canal; that for the proper performance of the function of 
 digestion, the mucous membrane must be in health, the secretions 
 normal, the supply of blood and of nervous energy such as is required, 
 and the movements free. It must, however, be borne in mind that 
 the alimentary canal contains substances which are, strictly speaking, 
 external to the living agency and beyond the control of animal life; 
 and that those chemical forces, which we lind in operation external 
 to the body, act in the same manner within the stomach and small 
 and large intestines: the food becomes dissolved when the same 
 solvents are provided, and other circumstances adapted, as to tempe- 
 rature, movements, &c., whether it be put in a phial or in the stomach. 
 The fermentation of its contents takes place in the stomach and canal, 
 as well as in any chemical receiver; and these facts have to be 
 remembered in the study, as well as in the treatment, of disease. 
 Chemical force is in operation throughout the whole animal economy ; 
 it is modified and controlled by the living power, or it is free to act alone. 
 
 Each of the parts which have been mentioned, may be alone dis- 
 eased, or all conjointly ; the symptoms arising from each are in some 
 cases distinct, in others we cannot separate the one from the other. 
 
 1st. The mucous membrane and its secretions. The derangement 
 of these constitutes, perhaps, the greater part of the milder ailments 
 of the alimentary canal. The symptoms vary according to the part 
 affected : in the stomach, producing some of the forms of dyspepsia ; 
 in the intestines, constipation, diarrhoea, &c. But, when the mucous 
 membrane alone is affected, it appears probable that pain is not pro- 
 duced, and this circumstance we must regard as a merciful arrange- 
 ment. The lining membrane is exposed to varied causes of irritation, 
 but we do not experience pain ; if such were the case, every portion 
 of undigested food might produce suffering ; in some cases severe 
 pain is found in indigestion, but this arises from an extreme sensi- 
 bility of the sympathetic and other nervous supply of the stomach, 
 &c., and, is not due to the mucous membrane alone. 
 
 Dr. Beaumont, in his observations on the stomach of Alexis, some- 
 times observed the mucous membrane dry, injected, and much irri-
 
 INTRODUCTION. 19 
 
 tated without the production of pain; so, also, I have observed 
 actual inflammation of the stomach, as found in cases of poisonin^ 
 by oxalic acid, by chloride of zinc, and even by arsenic, without pain 
 from first to last. 
 
 2d. The muscular coat we find so stimulated, that it rapidly con- 
 tracts, and impels onwards its contents ; or, it is so enfeebled as to 
 retain them; sometimes it is spasmodically contracted, or a-ain 
 dilated, as in the forms of colic and flatulent distension. These con- 
 ditions appear to be productive of pain, sometimes of a very intense 
 form as we find in the griping of colic, and in enteritis, &c. As long 
 as the peristaltic action is uniform, regular, and healthy, we are un- 
 conscious of the movement ; but as soon as it becomes irregular or 
 tumultuous, retarded or spasmodic, we are sensible of uneasiness, or 
 even of severe pain ; the muscular coat of the intestine is probably 
 excited to contraction by the direct stimulus of its contents, but the 
 harmony of its movements is due to the supply of nervous influence 
 which it receives. 
 
 3d. The peritoneal or serous investment also manifests its derange- 
 ment by pain ; and here, again, is a wise provision, for as its disorders 
 require rest, or rather an absence of movement of the coils of intes- 
 tine one upon another, and the pain of peritoneal disease is increased 
 by muscular exertion, so the patient becomes prompted to assume 
 that position, and to retain that state, which is the best suited for 
 the restoration from disease. The observant pathologist and physi- 
 cian know, practically, the importance of rest in the recumbent 
 position, and they follow the teaching of nature in their stringent 
 directions : by this means inflammation is localized, and when per- 
 forations of the intestine have taken place, the injury is limited and 
 life may be prolonged. 
 
 4th. The state of the investing or binding tissues ; and, 5th, the 
 supply of blood, are important considerations in the study of these 
 diseases of the intestine. The connective tissue, for instance, is in 
 some cases the seat of fatal malady, in constriction of the pylorus, 
 and in cancer. Still more does the supply of blood call for attention : 
 it may be in excess, as in active or passive hyperasmia; in pulmo- 
 nary, cardiac, and hepatic diseases the engorgement of the mucous 
 membrane leads to peculiar and characteristic symptoms; the rupture 
 of vessels, or ulceration into them, causes hemorrhage into the canal ; 
 and again, a scanty supply or depraved condition of blood prevents 
 the proper performance of digestioii, as after great hemorrhage, in 
 over-lactation, in purpura, scurvy, or in starvation. The appearance 
 of the blood discharged into the several portions of the canal greatly 
 differs ; thus, in disease of the stomach, it is generally ejected as 
 dark semi-coagulated blood ; sometimes, as in the latter stages of 
 cancer, as coffee ground substance ; or in the acute disease of the 
 stomach and duodenum, according to Dr. Fraser and others, as a 
 green fluid. If, however, blood be passed into the duodenum, and 
 discharged per rectum, it has a black and tarry character; and in 
 proportion as the source of the discharge is near or more distant 
 from the rectum, a sanguineous appearance is retained.
 
 20 INTRODUCTION. 
 
 (Hh. The state of the nervous supply is often lost sight of; this 
 is a most complicated system of nervous fibrils and ganglia, which 
 are intimately connected with the cerebro- spinal centres, and with 
 the ganglionic centres of other parts, as of the lungs, the heart, and 
 the uriuo-genital organs. Many of the signs of intestinal disease 
 arise from this cause, and they have been dwelt upon by various 
 authors. In the ' Guy's Hospital Reports' of 1856, I have described 
 some dissections and observations on this supply of nerves ; they 
 surround the vessels, are distributed with them, and reach every 
 part of the intestine. The sympathy of other organs in abdominal 
 disease is due to this supply. In indigestion, we find cephalalgia, 
 depression of spirits, impaired mental energy, disordered sensations 
 of general or special sense ; and all these arise from the connection 
 of the sympathetic and the cerebro-spinal nerves. So again, the 
 throbbing of the vessels, the excited or irregular action of the heart 
 in dyspepsia, proceed from the union of the cardiac ganglia with the 
 solar plexus of nerves. With the lungs, the kidneys, the uterus, we 
 notice similar sympathetic disturbance ; and oftentimes, in a most 
 marked manner, the skin is observed in close connection with the 
 internal mucous membrane ; this disorder of the alimentary canal 
 induces many forms of cutaneous eruption, as urticaria from partak- 
 ing of mussels ; or the more chronic diseases of psoriasis, eczema, c. 
 These sympathies may, however, be due to the vascular condition, 
 as well as to the nervous relation, of one structure with another. 
 This relationship of parts, however, sometimes acts in a reverse 
 direction ; the alimentary canal is affected secondarily, from disease 
 of other structures ; for example, vomiting is a symptom of disease 
 of the brain, of the kidney, and of the uterus. But beside these, 
 there appear to be symptoms of primary disease of the alimentary 
 canal, which are due directly to the sympathetic nerve. 1. A re- 
 markable depression of the pulse, which we often find in these dis- 
 eases of the abdomen, when the pulse becomes soft and compressible, 
 and often irregular. 2. A sense of sinking and exhaustion is one 
 of the most marked signs of abdominal disease ; and in some cases 
 this exhaustion leads to sudden death, not only in cases when a 
 person may have died from a blow on the epigastrium, but in other 
 instances. I remember the case of a man suffering from aneurism 
 of the descending aorta; he endured very severe pain, and the pulse 
 became much enfeebled ; in a few days he died with comparative 
 suddenness. On examination, an aneurism of the aorta was found 
 at the diaphragm ; it had led to absorption of the bodies of the 
 vertebrae, but there had been no extravasation of blood into the 
 peritoneum, the cellular tissue, nor into other parts. The aneurismal 
 sac was about four inches in length, and one and a half in height ; 
 it had pushed aside the pillars of the diaphragm, which were white 
 and degenerated ; the splanchnic nerves were stretched across the 
 sac, and the semi-lunar ganglion was pushed considerably forward 
 and pressed upon. I think we were justified in believing that in 
 this case the depression, and comparatively sudden death, were in 
 great measure due to the pressure on the great sympathetic nerve
 
 INTRODUCTION. 21 
 
 centre of the abdomen. I bave, also, often observed in cases of 
 gastritis from poisons, as arsenic, sulphuric acid, chloride of zinc, 
 oxalic acid, that the pulse becomes remarkably depressed; and 
 sometimes, where we might have been led, from the absence of pain 
 and other symptoms, to have given a favorable prognosis, the patient 
 has suddenly died. 
 
 The pneu mo-gastric nerve has an important influence on the 
 stomach. This was shown, in a marked degree, by the experiments 
 of Dr. Wilson Philip, who demonstrated the effect of section of the 
 pneumo-gastric nerve on digestion, in checking its progress : section 
 does not, however, completely prevent but only for a time checks the 
 secretion of gastric juice. The irritation of the gastric branches of 
 the pneumo-gastric sometimes leads to symptoms indicative of disturb- 
 ance of the pulmonary branches of the same nerve : cough may be 
 set up ; and it is probable that the converse takes place ; the pul- 
 monic branches may cause reflex influence on the stomachic branches, 
 and produce violent vomiting. In the 'Medical Times and Gazette,' 
 there is a very interesting paper by Mr. J. Hutchinson on the " Dys- 
 pepsia of Phthisis;" and many have found in the early stage of 
 phthisis that the power to digest food is impaired, the diminished 
 nutrition tending greatly to promote the formation of low organized 
 products in the lungs. 
 
 Not only do the signs of abdominal disease arise from the derange- 
 ment of the structures of the canal, and from changes in the secre- 
 tions and contents of the same, but the administration of remedies 
 is guided by similar considerations. Many may be led to the use 
 of means by mere empiricism, but the observations of Chambers, 
 Turnbull, Budd, Handfield Jones, Wilson Fox, Pavy, &c., suggest 
 a more scientific and correct treatment, by directing to the physio- 
 logical chemistry of digestion or to a more correct pathology. 
 
 Remedies may be classed in the following manner : 
 
 1. Those agents which are used to check fermentative and chemi- 
 cal action. 
 
 2. Those which remove offending or injurious materials, and ex- 
 creta. 
 
 3. Those which correct or improve the secretions from the mucous 
 membrane, or those poured into the canal. 
 
 4. Those which affect the muscular coat, and its movements. 
 
 5. Those which alter the state of the circulation and vessels or ab- 
 sorbents. 
 
 6. Those which act on the abdominal sympathetic nerve. 
 
 7. Those which promote the solution of food and the digestive 
 process. 
 
 Dr. Headland has directed attention, in his valuable essay on the 
 action of medicines, to their mode of operation, considering them 
 chemically or mechanically, prior to absorption ; then, after entering 
 the blood* as influencing either its constituents or the muscular or 
 nervous structures to which it is supplied ; and lastly, in their elimi- 
 nation from the body. These remarks forcibly apply to the action of 
 agents in the treatment of abdominal disease. It is, however, often
 
 22 INTRODUCTION. 
 
 lost sight of, that Avhilst the alimentary canal is the structure by 
 which remedies can be most easily made to enter the blood, and there 
 exert their curative influence, it may be in such a condition from 
 morbid changes, that no absorption can take place ; and the adminis- 
 tration of remedies by the stomach may become almost useless, as far 
 as regards their ultimate action after absorption. 
 
 1. Agents which are used to check fermentative action or chemi- 
 cal decomposition. 
 
 Chemical science has done much, and will do still more, to suggest 
 means of counteracting changes of this character. Dr. Turnbull has 
 dwelt, in his work, on the varied forms of fermentative action, and 
 has shown that some agents possess in this manner considerable 
 power: as carbolic acid, creasote, sulphurous acid and sulphites, char- 
 coal, so also alcohol, &c. We have had much to learn on this sub- 
 ject ; and it would well repay the labor of some one well versed in 
 chemical science to extend these researches. 
 
 2. As agents for the expulsion of injurious matters, or excreta, AVC 
 have the whole class of emetics, of laxatives, of purgatives, and the 
 different forms of enemata. 
 
 3. Other remedies change the character of the secretions from the 
 mucous membrane, for the mucus in the canal is sometimes of an irri- 
 tating character, and we may do much to change its state after secre- 
 tion, at the same time that we use means to prevent such abnormal 
 secretion from taking place : demulcents of the following kind, as milk, 
 arrowroot, gum acacia, linseed, sheath the mucous membrane ; whilst 
 lime water, chalk, solution of potash, carbonate of soda, lessen the 
 irritating character of the secretion. At the same time, to diminish 
 inflammatory congestion, other agents are called for, as ipecacuanha, 
 potash, soda, magnesia, and some of their salts, or mercurials, anti- 
 mony, &c. If the object is to correct secretions arising from an en- 
 feebled or relaxed state of the membrane, we have vegetable and 
 mineral astringents and tonics, mineral acids, &c. ; others stimulate 
 to greater secretion, when there is deficiency, as some irritants, ipe- 
 cacuanha, salt, capsicum, pepper, &c. 
 
 4. Among remedies which act on the muscular movements of the 
 intestine, I may enumerate the class of purgatives, magnesia, nux 
 vornica, and strychnia, as increasing peristaltic action ; and conium, 
 opium, henbane, as diminishing these intestinal movements. 
 
 5. The state of the vessels of the stomach is affected by remedies 
 which directly act upon the portal circulation ; thus, purgatives, 
 mercurials, &c., by unloading the bowels, relieve the tension of the 
 vessels. 
 
 (x Those which act on the sympathetic nerve, diminishing its 
 sensibility, are chloroform, hydrocyanic acid, opium, bismuth, oxide 
 and nitrate of silver ; those tending to increase its sensibility are 
 steel, quinine, vegetable and mineral tonics, alcohol, &c. 
 
 7. Remedies which promote the solution of food are hydrochloric 
 acid, nitro-hydrochloric acid; pepsine and several compounds which 
 contain it are regarded as powerful assistants to digestion. 
 
 These remedies are variously combined in the treatment of abdo-
 
 INTRODUCTION. 23 
 
 minal disease; and by combination their action is modified, or their 
 efficiency is increased; their presence may thus be better tolerated, 
 and their absorption be facilitated. 
 
 The dietetic regimen is one of the most important subjects in 
 diseases of the stomach and intestine; as in other visceral diseases 
 we cannot obtain rest of the affected organ, but we can shield it from 
 unnecessary irritation and fresh excitement. 
 
 It will, often, however, be found, that the state of the nervous 
 system modifies the effect of remedies. If a highly sensitive patient, 
 hysterical or hypochondriacal, be led to suppose that a medicine will 
 produce a certain effect, the mind is so directed and influenced, that 
 a powerful action may be produced; or, if a patient firmly believe 
 that a particular medicine or plan of treatment will do him injury, 
 we shall, in all probability, find that the symptoms are described as 
 greatly aggravated thereby, and no argument will remove this per- 
 suasion. Thus, in a patient who had suffered from hemiplegia, and 
 was in a nervous condition, but who could not be persuaded to dis- 
 continue medicine, two tablespoonfuls of spring water were followed 
 by violent purging, and when changed for a pill of bread the same 
 effect was produced; and nothing could induce her to take a second 
 pill. Sbe believed them to be powerfully aperient, and purging took 
 place. Hence a wide field is opened for the charlatan and the quack; 
 while the experienced practitioner often finds, that in many ailments 
 he will in vain prescribe remedial agents, unless he acquire the 
 confidence of the patient. 
 
 The connection of 'one disease with another is a subject of great 
 importance, and of much interest to the practical physician. We 
 rarely find that a patient has died free from all disease, except the 
 one which has been the immediate cause of death; such a case is, 
 indeed, exceptional. It may be that an acute inflammation of the 
 lungs has led to fatal results, whilst chronic disease may have been 
 going on in the abdomen, the heart, or the brain, perhaps quite in- 
 dependently, but having an important influence on the curability or 
 non-curability of the acute attack: chronic disease creeps along with 
 unobserved step, till some acute affection proves fatal. This relation 
 of disease is worthy of our consideration, in studying the affections 
 of the alimentary canal; and we may find that the diseased condi- 
 tions arrange themselves in the following manner: 
 
 1. They take place simultaneously in the same body, without any 
 connection, as mere coincidents. 
 
 2. The connection may be that of different manifestations of the 
 same disease in its progressive action, rather than a really different 
 diseased condition. 
 
 3. One disease may have important modifying or predisposing 
 influence upon another. 
 
 4. Several organs may be affected simultaneously by one exciting 
 cause. 
 
 5. One disease may be antagonistic to another: and, 
 
 6. Diseases or abnormal conditions are conservative, or preventive 
 from other maladies.
 
 24 INTRODUCTION. 
 
 I might enumerate many instances of these associations, in diseases 
 of the nervous system, or of the thoracic viscera, but must content 
 myself with a few illustrations from disease of the abdomen. 
 
 1. As instances of coincident disease we may mention the follow- 
 ing: A patient who had been employed in working lead, and was 
 affected with severe colic, was partially relieved; but he suddenly had 
 intense collapse, and died with all the symptoms of perforated intes- 
 tine. We found, on inspection, that there was in the stomach a 
 large chronic ulcer, and at its base a minute perforation, which had 
 extended into the peritoneal cavity. A child affected with chorea 
 was relieved by sulphate of zinc, and was about to go home, when it 
 was seized with severe dysentery during the time that cholera pre- 
 vailed; and the little patient died in three days. In another patient 
 who lately died under my care, affected with phthisis, we found a 
 large hydatid cyst close ito the kidney, in addition to advanced de- 
 generation of the lungs. These diseases could not be looked upon 
 as cause and effect, and were correctly regarded as coincidents. 
 
 2. As manifestations of the same disease in progressive action, and 
 which ought not to be considered as two but as one disease, we may 
 enumerate the sympathetic vomiting which we find in hydro- 
 cephalus, and in diseases of the kidney and uterus ; the diarrhoea in 
 albuminuria, which follows an anasarcous condition of the mucous 
 membrane; the constipation in diseased spine; and the extension of 
 strumous disease, one organ or viscus after another becoming affected, 
 as the intestine and the larynx in phthisis. So, again, the severe 
 neuralgic pain in the parietes of the abdomen,' simulating colic, but 
 arising from disease of the spine, may be only the early manifes- 
 tations of the spinal disease, though preceding its more marked indi- 
 cations by several months or years. Numerous instances might be 
 adduced in the progressive symptoms of spinal disease, or of valvular 
 disease of the heart, or of chronic disease of the lungs. 
 
 3. One disease predisposes to, or modifies another disease. Thus, 
 in affections of the lungs, of the heart, and of the liver, the circula- 
 tion through the vena portae may become exceedingly impeded, and 
 the whole of the mucous membrane engorged and turgid with blood ; 
 in this stage, a slight exciting cause will set up distressing flatulence 
 and distension of the abdomen; chronic catarrh of the mucous mem- 
 brane is produced, or hemorrhage, or ulceration. A patient in inci- 
 pient phthisis, with tubercles or slight ulceration in the mucous 
 membrane of the intestine, is exposed to cold and wet, to hardship 
 and miasm. and very severe diarrhoea or dysentery is set up ; whilst 
 his friend, who has had no such predisposing cause, escapes, though 
 exposed to the same exciting influence. 
 
 The instances which Dr. Budd has deduced, of abscess in the liver 
 following ulceration of some part of the tract of the canal which 
 supplies the vena portae, are also illustrations of one diseased state 
 exciting another; here it does not follow as a necessary sequence, or 
 a continuance of the same diseased action, but new morbid changes 
 are produced. 
 
 Again : a strumous subject, after recovery from typhoid fever,
 
 INTRODUCTION. 25 
 
 may become affected with tubercular disease of the intestine. The 
 previous exhaustion lias rendered the patient already of feeble 
 power, subject to another disease ; and the typhoid ulceration of the 
 intestine is sufficient to excite the manifestation of its action : these 
 are by no means rare occurrences. 
 
 A sailor was admitted into Guy's, a few years ago, with Asiatic 
 cholera. He died, and in his colon a large circumscribed ulcer was 
 found, about the size of a crown piece, and covered by a slough, 
 with adherent cherry-stones ; the presence of such irritation and in- 
 flammation in the colon would render him more amenable to an 
 attack of the disease, although it would not produce it. 
 
 A young man fell into the Thames, and afterwards was seized 
 with diarrhoea ; he was shortly attacked with typhoid fever, and 
 admitted into Guy's. He quickly died; the dysenteric diarrhoea 
 rendered the fever more severe in its character ; and perhaps was the 
 immediate cause of the fatal termination. 
 
 4. Two diseases sometimes arise from the same exciting cause, or 
 rather two organs become affected : thus, acute inflammation of the 
 colon sometimes comes on with pneumonia. Of these cases we shall 
 speak more fully in our remarks on dysentery. 
 
 5. Diseases are in some instances antagonistic. Cancerous disease 
 and struma appear to be in this relation ; or it may be that they are 
 so diverse in their mode of operation that they cannot exist together. 
 We sometimes find in cancerous disease of the abdomen that the 
 mesenteric glands are contracted, and calcareous, as the result of old 
 strumous change ; this evidently indicates that one mode of action 
 has given place to another of a different kind ; and the same kind of 
 deposit is occasionally found in the lung when cancerous disease has 
 proved fatal. 
 
 6. Disease may be conservative in its character. We have many 
 instances of this in the abdomen. A chronic ulcer of the stomach is 
 oftentimes prevented by adhesions from perforating the peritoneal 
 sac, so that the liver, or the pancreas, forms the base of the ulcer. 
 So, again, in ulceration of the ileum and colon, in disease of the 
 cascum, and in gall-stone, adhesions prevent extravasation, or limit 
 it after it has taken place. Many instances of this kind might be 
 adduced in which life has been prolonged by these adhesions. 
 
 These associations of disease have an important bearing on the 
 correct diagnosis, and still more on the prognosis, of disease ; they 
 may oftentimes serve to explain its intractable character, as well as 
 to account for the different effect of remedies under apparently similar 
 circumstances; and the complication of -disease should place us on 
 our guard in making close observation of every sign which presents 
 itself to us, and should, lead to a strict inquiry into the history of 
 the patient, and the previous ailments to which he may have been 
 subject.
 
 26 
 
 CHAPTER II. 
 
 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 THE unqualified acceptance of the commonly received opinion, 
 that the state of the tongue is a guide to the condition of the diges- 
 tive organs would lead us into many mistakes ; and it is therefore 
 important to know to what extent the appearances of the tongue 
 will serve us in the investigation of abdominal disease. It gives 
 valuable indications, 1st in regard to the general state of the whole 
 system, and 2dly as to the condition of particular parts or organs. 
 Thus the growth, or the state of nutrition of the body generally may 
 be seen in the condition of the epithelium of the tongue ; the furred 
 state of the surface may show a febrile condition of system ; and as 
 nutrition as a whole is checked it becomes dry and brown, and even 
 black ; or the alterations may be of a merely local character, as from 
 inflammatory disease of the mouth alone, or a partial fur may be due 
 to contact with a carious tooth, or there may be papillary hyper- 
 trophy from persistent local irritation. 
 
 But the tongue is a complex organ, and its morbid condition may 
 be connected with alterations in any one of its different structures ; 
 it is composed of several vessels and nerves ; it receives a large sup- 
 ply of vessels, and has a complex epithelial investment. 
 
 In reference to the muscular condition of the tongue we may find 
 that one side of the tonyue is wasted and paralyzed, whilst the other 
 side is plump and strong ; this state is found in paralysis of the hy- 
 poglossal nerves, it was well marked in a patient under my care in 
 Guy's Hospital some years ago ; the breast had been removed two 
 years previously for cancer, and disease of the brain subsequently 
 supervened, there was severe pain at the back of the head, and the 
 side of the tongue was irregularly flaccid and flabby, whilst the other 
 was strong and active. After death a small growth was found 
 directly implicating the origin of the ninth nerve. 1 Mr. Hilton 2 has 
 also drawn attention to the effect of disease implicating the second 
 or third divisions of the fifth nerve in producing furring of the side 
 of the tongue. 
 
 2d. One side of the tongue may be weakened as in ordinary 
 hemiplegia; the tongue is protruded to the opposite or weakened 
 side by the increased action of the sound side. 
 
 3d. The tongue is protruded slowly in cases of general weakness 
 and paralysis; or 
 
 1 An interesting case of this kind is published by Sir James Fagot in the ' Clin. 
 Soc. Trans.,' vol. iii, p. 238. A man, set. 27, injured the back of his head, and part 
 of the foramen magnum became necrosed, and coincidently half of the tongue wasted. 
 Recovery ensued on the removal of the bone. 
 
 * ' Rest and Pain,' p. 194 et seq.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 27 
 
 4th. The patient may be quite unable to move it from extreme 
 exhaustion. The organ remains at the floor of the mouth in a 
 powerless state. 
 
 5th. The opposite condition is found in cases of chorea, the tongue 
 is sharply protruded and as quickly drawn in, as if from spasmodic 
 action, reminding one of the movements of the tongue of the frog, 
 or of the chameleon. 
 
 6th. The tongue is sometimes pale and flabby, and indented with 
 the markings of the teeth, indicating its want of tone and muscular 
 contractility ; or we find it small and contracted, and the tip almost 
 drawn to a point, as in irritability of the nervous system. 
 
 In reference to the vascular condition, the tongue is pale in states 
 of ansemia, but, on the contrary, in hyperaemia it is red and injected, 
 a state which may be especially noticed at the tip and edges; it is 
 this condition which is found in irritable states of the intestinal 
 tract, and in enteric fever. The red and distinct appearance of the 
 papillae of the tongue, as observed in states of angina and scarlet 
 fever, indicate active hypergemia; whilst, in diseases of the lungs 
 and heart producing obstruction of the circulation and imperfect 
 aeration of the blood, the venous condition of the tongue induces a 
 passive hyperaemia or lividity. 
 
 The epithelium of the tongue undergoes constant change of waste 
 and repair; its growth may be checked as that of other cellular 
 structures, and it may be reproduced with great rapidity; it may be 
 scarcely developed at all, or when produced, degenerative changes 
 may quickly ensue. To these various changes in the epithelial coat 
 are due the different kinds of fur, and a furred tongue is generally 
 caused by the excessive formation of the epithelial coat, and the 
 consequent degeneration of the redundant cells. But although an 
 overgrown epithelium is the common anatomical basis of a furred 
 tongue, there may be considerable difference in the characteristics of 
 color and tlfickness, association with papillary enlargement, growth 
 of fungus, &c., serving to distinguish various states of systemic and 
 abdominal disease. 
 
 With regard to the causes of the changes of color noticed on the 
 tongue, but little is known beyond the fact that a brown or yellow 
 color is in great part caused by decomposition of epithelial growth 
 or of food, saliva, mucus, &c., in the mouth, and therefore may be 
 independent of any derangement of the viscera. 1 
 
 The white tongue of the febrile state, and the white creamy fur of 
 acute rheumatism, depend probably upon some alterations of the 
 secretions acting upon the epithelial coat. Allied to these is the so- 
 called strawberry tongue of scarlet fever differing only in the addi- 
 tional enlargement of the fungiform papillae and their projection from 
 the surface. This state has been said to be only part of a general 
 disease of stomach although always present in scarlet fever. 2 
 
 1 Wilson Fox states that a large proportion of the colored furs are produced by 
 slight hemorrhages from the gums. ' Dis. of Stomach,' p. 19. 
 
 2 Femvick, "On the Condition of the Stomach and Intestines in Scarlatina," ' Med.- 
 Chir. Trans.,' vol. xlvii, p. 210. In this paper Dr. Fenwick attempts to show that
 
 28 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 Browness of the tongue is found in states of exhaustion and is 
 sometimes denominated the "Typhoid" tongue; the fallacy of brown 
 discoloration, from coifee, tobacco, or liquorice, &c., must always be 
 borne in mind. The Mack tongue arises from a more complete state 
 of exhaustion, and still further degeneration; with it sordes are ob- 
 served on the gums and teeth, the surface becomes irregular and fis- 
 sured. The later stages of severe fever present us with this change. 
 
 We sometimes find deficient epithelial growth ; there is then a 
 scanty fur, and this is often associated with injection of the sub- 
 stance of the tongue ; there is weakness, with irritation of the 
 mucous membrane. In this state a "patchy" condition is often ob- 
 served, and when there is still further loss of power, with irritation, 
 a red beef-like tongue, which may assume a glazed appearance, is 
 found, as in the later stages of abdominal disease, and of phthisis, 
 &c., sometimes with aphthous secretion and with ulceration. The 
 tongue becomes sore, mastication is difficult, and deglutition painful. 
 In the condition that we shall presently have to notice as chronic 
 inflammation of the tongue, there is a red and glossy appearance ; 
 the whole of the mucous membrane appears raw and sore and oozing, 
 as if there were an eczematous state of the surface. 
 
 The irregular growth of the papillte of the tongue leads to warty 
 conditions which may be harmless, or the precursors of malignant 
 disease. The irritation of a decayed and roughened tooth, when 
 long continued, may give rise to excessive sprouting of the papillary 
 structures, and present appearances with difficulty distinguished 
 from cancerous disease. The morbid growth of epithelium, when 
 more general, gives rise to an appearance which has been called 
 " ichthyosis of the tongue." This condition is found not only on the 
 tongue but also on the inner surface of the lips and cheeks ; it con- 
 sists of milk-white patches, which have a tough appearance, and 
 sometimes are not at all unlike white leather. It is said to be in- 
 variably followed by cancer, though opinions differ as to its curability 
 in its earlier stages. All, however, are agreed as to its exceeding 
 intractability, and for this reason it is of interest to the physician, 
 for he will probably detect the disease in its earlier stages and when 
 it is more likely to be amenable to treatment. It was first recorded 
 by Hulke in 1864, and again accurately described by Bazin in 1868, 
 who called it buccal psoriasis. 1 It was considered by him as a squa- 
 mous affection of the buccal mucous membrane allied to arthritic 
 psoriasis ; 2 and he states that, although very intractable, an alkaline 
 treatment, local and general, has produced some cures. It is not 
 
 inflammation of the resophagus, the stomach, and the intestine usually accompanies 
 scarlatina ; that desquamation of the epithelium of these parts takes place ; that, 
 notwithstanding the anatomical changes in the stomach, the formation of pepshie is 
 not prevented ; and that in this disorder the condition of the mucous membrane is 
 similar to that of the skin. 
 
 ' For a very good account of this disease see a thesis by M. le Dr. Dobove, Paris, 
 1873; alsoFairlie Clarke, ' Med. Chir. Trans.,' 1874 ; H. Morris, 'Brit. Med. Journal,' 
 1874. 
 
 Sir James Paget also considers this to be connected with gout. " See Lectures on 
 the Surgical Aspect of Gout," 'Brit. Med. Journal,' vol. i, 1875, p. 737.
 
 OX DISEASES OF THE TOXGUE AND MOUTH. 29 
 
 unfrequently associated with syphilis, though it is not benefited by 
 anti-syphilitic remedies. 
 
 Stomatitis, or inflammation of the mucous membrane of the mouth, 
 is often present in young children, especially during weaning. The 
 gums become red, the mouth is hot, the tongue swollen andfurred r 
 with whitish covering and with red papillae observable through it! 
 There is a general febrile state ; the child becomes fretful, and its 
 sleep is disturbed. Other 'portions of the mucous membrane may be 
 affected at the same time and symptoms of diarrhoea may come on, 
 or severe irritation of the stomach, so that food is at once vomited 
 or the bowels acted on as soon as food is taken. This state quickly 
 leads to exhaustion and rapid emaciation ; and unless it is checked, 
 a fatal result may soon follow. It may be produced by cold, by 
 improper food, by inattention to proper hygienic measures, by im- 
 pure air. AVe shall have again to refer to this condition in speaking 
 of inflammation of the stomach. 
 
 As to the treatment of stomatitis, pure air and proper diet are 
 essential ; milk with lime water or asses' milk may be tried, and, if 
 absolutely necessary, a wet nurse procured. Much relief may, how- 
 ever, be afforded by medicine ; chlorate of potash should be given 
 internally, and it may be used as a wash to the rnouth ; or borax 
 with honey may be employed, and if the bowels are confined, a tea- 
 spoonful of castor oil, or small quantity of citrate of magnesia, or of 
 rhubarb and carbonate of soda, may be given. 
 
 This form of disease is, however, not confined to children, for in 
 adults we find that the mucous membrane of the whole mouth be- 
 comes inflamed, extending backwards to the tonsils and fauces, and 
 implicating the tongue. A person may be exposed to cold or wet 
 or to a fog, and be seized with soreness of the mouth and throat, 
 the mucous membrane becomes red and swollen, the tongue is en- 
 larged, and sometimes is so much swollen that it is protruded beyond 
 the teeth, the throat is reddened and swallowing is difficult. The 
 patient becomes very feverish, the temperature is raised, and there 
 is general distress. This is not a specific or contagious form of 
 malady, but appears to be due to shock from cold; sometimes the 
 whole mouth, at other times only the posterior fauces and the tonsils 
 are affected, and we then have acute tonsillitis, or a condition which 
 is with difficulty distinguished from true and contagious diphtheria. 
 Acute stomatitis, extremely severe in its onset, subsides after a few 
 days, with very little treatment beyond warmth and bland nutritious 
 diet ; it is well to act gently on the bowels and to administer saline 
 medicine, such as the citrate of potash and acetate of ammonia ; and, 
 if the circulation is depressed and the pulse compressible, then wine 
 and alcoholic stimulants are called for. 
 
 In stomatitis the follicles are sometimes especially affected, small 
 vesicles are observed, round, transparent, and elevated, and when 
 broken, leave an irregular gray surface, resembling a small ulcer; 
 this condition is spoken of as follicular stomatitis; 1 the mouth is pain- 
 
 1 Aphthae are considered by some as vesicules ; but according to Bohn, quoted by 
 Niemeyer, no fluid can at any time be obtained from them, and they are rather croup-
 
 30 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 ful and mastication interfered with. These vesicles occur on the 
 tongue, on its sides, its freenum, on the lips, &c. The constitutional 
 symptoms may be very slight, but there is generally interference 
 with digestion, and the condition is ascribed to that cause. Whether 
 this be the case or not, it is generally associated with faulty nutrition, 
 and may occur after any of the eruptive fevers. In the treatment it 
 is well to act gently on the bowels by saline aperients as carbonate 
 of magnesia, dilute acid with sulphate of magnesia, rhubarb with 
 magnesia, &c. Salines may also be advantageously given with bark ; 
 a chlorate of potash gargle should be used, and care be paid to the 
 diet, so as to avoid food that is likely to ferment, such as sugar, 
 acescent fruits, &c. The application of caustic, as nitrate of silver, 
 is often recommended; it relieves pain at the site of the ruptured 
 vesicles, but there is often an increase in the abraded surface, and 
 greater subsequent pain. If there be impaired general health, it is 
 very desirable that a change of air to a warm locality be tried. 
 
 The Thrush or Muguet is a peculiar form of disease of the mouth 
 occurring in some states of exhaustion and of chronic disease. It 
 consists in a white or pultaceous secretion, which is found either in 
 patches or is generally diffused upon the mucous membrane of the 
 tongue, the mouth and the pharynx ; the mucous membrane is red, 
 and there is tenderness of the surface and some pain on movement ; 
 the deep redness of the mucous membrane is hidden by the thick 
 white or aphthous covering; sometimes vesicles are present, and the 
 glands are enlarged, and the papilke congested ; there is distress and 
 febrile disturbance. The white patches increase in size and are re- 
 renewed after removal. This aphthous condition occurs in young 
 children and also in adults in exhausted states of the system, as in 
 the last stages of phthisis ; it is often looked upon as an indication of 
 the approach of a fatal termination. It is a disease which is said to 
 have its seat only on mucous surfaces which are covered by pave- 
 ment epithelium, 1 thus affecting only the mouth, fauces, and oesoph 
 agus, but it is frequently associated in the severer cases with well- 
 rnarked evidence of general derangement of the intestinal tract, and 
 it is common to have vomiting and purging with it. It is also in 
 children very commonly followed by an erythematous or eczematous 
 state of the buttocks and genitals. 2 Mastication is difficult, and in 
 the infant suction is painful. If the white deposit be examined by 
 the microscope it is found to consist of mucous cells, spherical cells, 
 epithelium, and sometimes the torula of the oidium albicaus. The 
 torula is not always present, and it is, on the other hand, sometimes 
 found when the condition of the mouth is only part of a general state. 
 
 ous exudations on the surface of the mucous membrane, and the disease is therefore 
 called croupous stomatitis (Nienieyer, vol. i, p. 421). Rindfleisch, however ('Path. 
 Histology,' vol. i, 354, Syd. Soc.), describes a vesicular condition due to serous 
 exudation in a membrane covered by scaly epithelium. These vesicles subsequently 
 rupture, and a small sore is formed. Thus the aphthous state may be considered as 
 the later stage of the vesicular. 
 
 1 Trousseau, 'Clinical Medicine,' Syd. Soc., vol. ii, p. 619. 
 
 2 Valleix, 'Clinique des Maladies des En fail ts nouveau -lie's.' Paris, 1838, chapitre 
 Sine.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 31 
 
 In the treatment of the disease, it is most important to improve 
 the general health and sustain the strength ; the mucous membrane 
 of the mouth should be cleansed by a dilute solution of the per- 
 manganate of potash, or of borax, or of chlorate of potash ; the sul- 
 phite or hyposulphite of soda may be employed, 3j to |j of water, 
 or astringent gargles of alum, catechu or oakbark. 
 
 In Ulcerated Stomatitis 1 we have a more severe affection, which 
 unless it be produced by mercurial salivation, is especially seen in 
 young children of from four to ten years of age. The gums become 
 red and swollen, and then ulcerate ; they quickly assume a gray and 
 sloughy appearance and the alveolar processes are exposed; they 
 readily bleed, and the ulceration extends from the gums to the 
 cheeks. The teeth become loosened and are lost; the submaxillary 
 glands are enlarged. The child, for the disease is more especially 
 observed in early life, is seen to be pale and cachectic, the mouth is 
 hot, and there is a general febrile state ; but, even severe forms of 
 ulcerative stomatitis are not usually associated with any marked 
 constitutional disturbance; children do not appear to be suffering 
 severely, and the pain during mastication, with swelling of the cheek 
 and with fetor and hemorrhage, are the prominent symptoms. The 
 cause of this severe disease may generally be traced to poor and 
 improper diet and to an impure atmosphere ; sometimes it is attri- 
 buted to mercurial medicine, but it may occur quite independently of 
 any such exciting cause ; it is more likely to occur after exanthems, 
 such as measles or scarlet fever, and it is a wise precaution never to 
 administer mercurial medicine to young children during the course 
 of or the convalescence from these diseases. In the treatment 
 nourishing diet and a pure air are most important ; stimulants are 
 advisable, if there be much prostration of strength. Chlorate of 
 potash should be used as a wash and also given internally, borax 
 dissolved in glycerine may be applied, or a solution of carbolic acid, 
 or of permanganate of potash, and cinchona bark or quinine should 
 be administered. If the ulceration assume a phagedeenic form and 
 spread rapidly, it is well to apply a strong solution of nitric acid to 
 the part. 
 
 In this absence of constitutional symptoms and also of rapid ex- 
 tension, ulcerative stomatitis differs from cancrum oris, which we 
 have presently to notice ; as far as the ulceration itself is concerned 
 nothing could have a more unhealthy aspect than the diseased 
 surface, though it is devoid of the livid redness, the angry tume- 
 faction and the ashy slough of the latter disease. The one, however, 
 is a purely local disease, the other is attended by the severest con- 
 stitutional symptoms. The two diseases bear a close analogy with 
 other so called sporadic and epidemic affections, with fatal and non- 
 fatal influenza or cholera. They thus have more than their own 
 
 1 The disease termed pseudomembranous stomatitis appears to correspond in part 
 to this form and in part to that known as follicular stomatitis. Ulcerative stomatitis 
 is also called diphtheritic stomatitis and cancrum oris by Nieineyer and other German 
 authors ; but since both terms are otherwise interpreted by English readers it appears 
 unadvisable to accept the altered nomenclature.
 
 32 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 share of interest, and have a bearing upon one of the vexed patholo- 
 gical questions of the day, viz., the relation of cryptogamic organisms 
 to the origin and extension of local inflammation and the causation 
 of febrile conditions. The more simple form of the disease has many 
 points in favor of origination in some local cause, such as fungus 
 growth, 1 while the more malignant type is also closely similar in its 
 onset, progress and result to severe septicoemic conditions, which are 
 thought by many to be associated with the development of vegeta- 
 ble organisms in the blood and tissues. No positive evidence, how- 
 ever, can be adduced from cases of ulcerative stomatitis, for no 
 adequate examination of the tissue bordering on the ulcerated part 
 can be made, and the mere scrapings from the sore, though often 
 containing fungus- spores, are of no value because similar results may 
 be obtained from the mouth of any healthy person. 
 
 In many patients suffering from early phthisis the edges of the 
 gums become red and slightly swollen; this was noticed some years 
 ago by Dr. Th. Thompson, and we find a similar but more spongy 
 condition in those who for many weeks are fed upon a diet destitute 
 of fruit or of vegetables. In the treatment of irritable conditions of 
 the stomach and other forms of disease the necessity of some vege- 
 table diet is often lost sight of, and the general health of the patient 
 suffers in consequence. This state is, in fact, the incipient stage of 
 the spongy and granulating gums seen in true scurvy, a state which 
 often leads to hemorrhage, and is one of very great diagnostic value ; 
 similar hemorrhage 2 occurs in the less severe condition of spongy 
 gums from mal-nutrition. The hemorrhage in purpura haemorrha- 
 gica is of an essentially different character. Whilst referring to the 
 state of the gums we may mention a change which is due to altera- 
 tion in the gum, a deposit in it, namely, the lead line in chronic 
 poisoning by that metal; 3 it is a granular deposit in the gum of the 
 sulphite of lead, from the decomposition of the lead absorbed into 
 the system by the sulphuretted hydrogen from decomposing food. 
 The black pigmental patches observed on the lips, gums, and tongue 
 in Addison's disease are, on the contrary, a more diffused pigmental 
 change in the substance of the mucous membrane. They are, how- 
 ever, sometimes present without any disease of the supra-renal cap- 
 sules. 4 
 
 Mercurial stomatitis hardly needs a separate description; it is an 
 ulcerative form of disease attended by profuse salivation. Regarded 
 merely as an ulcerative disease of the mouth it is best treated by the 
 remedies applicable to simple cases, and chlorate of potash is all that 
 is requisite, both given internally and used as a gargle. For profuse 
 
 1 A disease which seems to consist in a derangement of the alimentary canal, 
 accompanied by fever and the presence of vesicles on the mucous membrane of the 
 tongue and mouth, which rupture and leave superficial ulcerations, appears to have 
 been sometimes produced by the consumption of the milk of cows suffering from the 
 foot and mouth disease. ' Rep. Med. Officer of the Privy Council,' 1869, Dr. Thome. 
 
 2 " Hemorrhagic iSudamina," described by Pye-Smith, ' Virchow's Archiv,' vol. i, 
 p. 452. 
 
 " Dr. Hilton Fagge, in ' Med.-Chir. Trans,,' 1876, vol. lix, p. 327. 
 'Path. Trans.,' 1873, p. 94.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 33 
 
 salivation, however, belladonna has recently been recommended. 
 Heidenhain, 1 in some experiments on the influence of belladonna on 
 the salivary gland, has found that the fibres of the chorda tympani 
 which act upon the secreting gland-cells are paralyzed by its admin- 
 istration, and this has subsequently been corroborated in actual 
 practice. 2 Carbolic acid lotion will also be found to be of service in 
 checking ulcerative action. Gentle magnesian purgatives should be 
 given to remove the mercurial from the intestinal tract, and the 
 health should be invigorated by a nourishing diet and by fresh air. 
 
 Still more severe is gangrenous stomatitis, or cancrum oris ; it is 
 one of the most terrible forms of disease ever observed in young 
 children. It occurs more especially between the ages of two and 
 five ; the little patient, thin, weak, and cachectic, has some swelling 
 of the gums and mouth; on examination one cheek is found to be 
 especially affected, there is a hard and diffused swelling, and on the 
 inner side a dark ashy spot is recognizable; this is a minute slough, 
 and rapidly spreads in depth and in extent; it reaches to the external 
 surface, and the cheek becomes perforated. As the sloughing spreads 
 the cheek is more and more destroyed, and the whole cavity of the 
 mouth is laid open; a miserable condition is thus presented, the 
 alveoli are laid bare and seen from without, and a ghastly spectacle 
 is witnessed ; with this destruction of parts there is offensive smell 
 and breath, there is much constitutional exhaustion, and fatal bron- 
 chitis or pneumonia supervenes. Such patients are also liable to die 
 from pyaemia, since there is a great risk in all diffuse inflamma- 
 tions about the face of plugging of the facial vein (thrombosis), and 
 secondary infection of the lungs. The part appears to die from the 
 commencement. Unless the disease be very speedily arrested the 
 most disastrous results follow either in the destruction of the face or 
 in the death of the patient. The best plan of treatment is to destroy 
 the slough by strong nitric acid, and to apply carbolic acid lotion; 
 to use a stimulating and nourishing diet, port wine or brandy, milk, 
 eggs, and strong soup ; and as to medicine, bark or quinine with 
 dilute hydrochloric acid and chlorate of potash are the best remedies 
 to employ. 
 
 We have thus several forms of inflammation of the mouth of dif- 
 ferent degrees of severity, simple inflammation, or inflammation with 
 severe and phagedaenic ulceration, or lastly of a gangrenous character. 
 
 Inflammation of the tongue or glossitis is also a disease which varies 
 greatly in severity ; sometimes it is only an accompaniment of general 
 stomatitis, or of catarrhal inflammation, and the tongue is but slightly 
 swollen and injected, but at other times the whole substance is in- 
 volved. It is cedematous and so much swollen that it protrudes 
 beyond the teeth, and cannot even be retained between the lips; 
 there is profuse secretion of saliva, the respiration is obstructed, and 
 death may take place from apnoea. There is febrile disturbance, the 
 pulse is compressible and dicrotic; the patient is scarcely able to 
 
 1 ' Pfluger's Archiv,' vol. xl ; also Lauder Brunton, ' Lond. Med. Rev.,' i, 17. 
 
 2 Ebstein, 'Berliner Klinische Wochenscrift,' 1873. 
 
 3
 
 34 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 swallow, and there is dyspnoea with inability to lie down or to sleep 
 from the interference with free respiration ; under these circumstances 
 the mind becomes depressed, and the patient forbodes a disastrous 
 termination. 1 Acute glossitis has been known to occur in association 
 with granular kidneys. A man was admitted into Guy's Hospital 
 under Mr. Birkett's care in 1863 for glossitis ; the tongue filling up, 
 and protruding from the mouth. There was no apparent danger of 
 suffocation, but the symptoms increased during the night and he was 
 found dead in the morning. The post-mortem showed cystic and 
 granular kidneys, much swelling of the tongue, and oedema also of 
 the palate. This state of acute glossitis may also be caused by irri- 
 tant poisons, such as mercury, the dust of ipecacuanha, of croton oil 
 seeds, or it may be produced by catarrh and the exposure to fog and 
 damp. A case of this" kind was admitted under my care at Guy's 
 Hospital. A young man after exposure to cold was seized with 
 symptoms of catarrh and inflammation of the mouth ; the tongue 
 became swollen, there was profuse secretion of saliva, and the respi- 
 ration was interfered with ; the tongue never, however, became in- 
 ordinately enlarged, and although for two or three days the patient 
 was unable to sleep, the disease soon subsided without any untoward 
 symptom. This might be regarded as catarrhal glossitis. 
 
 In another case more recently a youth about sixteen years of age 
 was admitted under my care with acute inflammation of the tongue; 
 there was much swelling, and an incision was ordered to be made ; 
 the distress increased, and again an incision was made on the other 
 side ; a third time a deeper incision opened a large abscess near the 
 base of the tongue and extending towards the left tonsil. The 
 abscess was washed out with Condy's fluid, and there was speedy 
 relief to the severe distress, but several days were required for the 
 closure of the abscess. The patient left the hospital well. 
 
 Glossitis, although at first severe and distressing to the patient, 
 generally subsides in mild cases after a few days, and the tongue 
 regains its normal suppleness ; in other cases suppuration follows 
 and an abscess is formed, or chronic thickening of the organ may 
 supervene. 
 
 In the treatment of this disease ice may be applied to the tongue ; 
 it is refreshing to the patient and relieves the hyperaemia of the parts. 
 Saline medicines may be administered, such as the nitrate and citrate 
 of potash ; the bowels should be freely acted on, and if medicine can- 
 not be swallowed a castor oil or colocynth enema should be used. If, 
 however, the swelling of the tongue increase to such an extent as to 
 interfere with respiration, free incisions should be made in the organ, 
 and, if necessary, even tracheotomy should be performed. 
 
 Chronic inflammation of the tongue is a very troublesome form of 
 
 1 A case of suftglossitis is described by Mr. Holthouse in the ' Clinical Society's 
 Trans.,' vol. ii, p. 140, which appears to be a less severe state than that here described 
 as acute glossitis. A man of 31 was suddenly attacked by swelling of the tongue, 
 which formed a hard, solid lump, filling up the posterior part of the mouth from floor 
 to roof. He had much salivation and difficult deglutition, but no dyspnoea. It ap- 
 peared to be a solid oedema of the subglossal region. It lasted four days, and appeared 
 to be relieved by quinine, but not by incision.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 35 
 
 disease. I have especially seen it in women advanced in life ; in 
 many cases the age is between sixty and seventy. There is general 
 feebleness, but the especial complaint is of the tongue, which is 
 swollen and red, some parts being of a more deep color than others ; 
 the movements of the tongue and deglutition are painful, and there 
 is increase in the quantity of the saliva ; the health is not otherwise 
 much disturbed. In some instances the mucous membrane of the 
 nose is affected, and some have traced the disease in the mouth to 
 irritation commencing in the nose. Diseases of the teeth or jaws 
 may set up the mischief in the mouth, and the composition of the 
 setting of false teeth may be a source of irritation. An interesting 
 paper on this subject appeared in the ' Medical Press and Circular' 1 
 by the late Dr. Woodman. 
 
 The appearance of the tongue in these cases suggests the idea of a 
 local form of inflammation resembling eczema of the skin. In the 
 treatment it is most important to remove every source of irritation, 
 but treatment is very unsatisfactory. Demulcents should be used 
 such as mucilaginous drinks, with borax and chlorate of potash ; 
 tonics should be given, such as quinine and steel, and they are best 
 administered as pills ; but all these remedies are often quite unavail- 
 ing, and we find only very slight relief is afforded. The most sooth- 
 ing combination for local application I have found consists of small 
 doses of carbonate of soda with hydrocyanic acid in the emulsion of 
 sweet almonds. I have often thought of administering small doses 
 of arsenious acid, with the idea of the eczematous character of the 
 disease. Hypertrophy of the papillae of the tongue is often found to 
 be produced by some prolonged local irritation, as a roughened tooth, 
 etc., and the appearance may be a general or a local one ; in the latter 
 case, if warty in character, it is sometimes with great difficulty dis- 
 tinguished from epithelioma. The symptoms are pain during masti- 
 cation and deglutition, and in some cases, to use a patient's expression, 
 "an aching of the tongue itself." There is, however, no glandular 
 enlargement, the disease persists for a long period without spread- 
 ing, and there is less tendency to degenerative or ulcerative change. 
 
 Another very important condition requiring a short separate con- 
 sideration is the ulcerated state of the tongue found in phthisis. I 
 am not now alluding to the merely aphthous state observed in its 
 later stages, but to a condition which may be present even before 
 the disease in the lung is of sufficient advancement to enable it to be 
 detected by the stethoscope. Two cases of this kind have lately 
 been under my colleagues Mr. Forster and Mr. Bryant at Ohiy's Hos- 
 pital. In the one, a woman, there was sufficient chest complication 
 to make the diagnosis easy, though she only applied for treatment 
 on account of her tongue ; there was no evidence of syphilitic poison. 
 The other, a man, set, 50, had a swollen and ulcerated tongue, in one 
 or two places it was deeply excavated, in others fissured, in other 
 parts superficially ulcerated and coated with lymph. The whole 
 
 1 'Medical Press and Circular,' December 9, 1874.
 
 36 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 organ thus presented a swollen and livid red appearance, dotted over 
 with yellow lymph spots quite characteristic of the disease and sug- 
 gesting phthisis. The chest was examined carefully to corroborate 
 the diagnosis, and with the result of only finding some dulness and 
 doubtful tubular breathing at one apex, indicative of old disease, and 
 it seemed as if in this instance the features of the disease had failed 
 lor a diagnosis. The patient, however, died in less than a month 
 with extensively distributed and recent disease of the lungs. 1 
 
 With regard to syphilitic affections the simple forms of ulceration 
 frequently come before the physician generally as an irregular form 
 of ulceration, serpiginous and superficial, on the tongue, tonsils, and 
 fauces. Occasionally we meet with mucous patches and gummata, 
 which may be mistaken for abscesses or subacute glossitis. In chil- 
 dren, also, the subjects of congenital syphilis, an intractable form of 
 ulceration of the tonsil is occasionally found. It would be difficult 
 to single out any special characteristic as attaching to a syphilitic 
 ulcer on the tongue or fauces. As on the skin it has a tendency to 
 great irregularity of border, such as is seen in few other instances of 
 ulceration, and this, with other syphilitic traces elsewhere, which 
 will in most cases be present, must suffice for the diagnosis. The 
 fibroid growth in the tongue in syphilis is generally easy of recogni- 
 tion, and also the irregularly puckered and white condition of the 
 surface due to a similar disease. As to other diseases, Fairlie Clarke 2 
 mentions neuralgia of the tongue as occurring occasionally and being 
 exceedingly painful. As a rule this affection generally affects only 
 one side, and is due to teeth irritation or some gastric disturbance. 
 Faradization, and even excision of portions of the nerve, have been 
 recommended for its relief. 
 
 Spasm of the tongue is also described by Eomberg. 3 It is said to 
 be associated with hysteria, neuralgia, and meningitis. 
 
 Lastly, Paget 4 has described a condition of ringworm of the tongue, 
 a state due to the growth of a fungus in curved undulating lines on 
 the dorsum, and shortly described by Dr. Fairlie Clarke. M. Maurice 
 Raynaud 5 has also described patches on the tongue in character 
 exactly resembling those of tinea tonsurans. 
 
 It is not necessary for me to enter upon the consideration of such 
 diseases as congenital hypertrophy, hydatid diseases, hypertrophy of 
 one or more of the component tissues of the tongue, of fibroid 
 growths, or of cancer ; these are all strictly surgical, and are beyond 
 the limits of this work. 
 
 1 A somewhat similar case is reported by M. Trelat in the ' Archives Ge"nerales de 
 Med.,' January, 1870. 
 
 1 ' Diseases of the Tongue.' 
 
 3 ' Diseases of the Nervous System,' Syd. Soc. Trans. 
 
 4 It is thus given in Sir James's own words : "This patient, a heal thy gentleman, 
 had observed the disease more than a year. On his tongue there was a bare purplish- 
 pink patch over nearly half the right side. This patch was all bare, i. e., it had a 
 very thin cuticle and no fur ; but it was intersected by two curved lines, and at its 
 posterior boundary was a white ring. The curved lines were undulating, map-like, 
 looking as formed of low banks of heaped-up cuticle." Fairlie Clarke, ' Diseases of 
 the Tongue,' p. 88. 
 
 'Archiv. Ge'ne'rale's de Me"decine,' 1872.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 37 
 
 Inflammation of the parotid gland; parotitis ; cynanche parotidea. 
 
 The parotid is the largest of the salivary glands, and consists, not 
 only of glandular structure, but of loose binding tissues. 1st. The 
 disease occurs as a simple inflammation ; 2dly, as disease of a spe- 
 cific form, the mumps ; and 3dly, as a complication of typhus and 
 sometimes of other fevers. 1 The symptoms which usher 'in this dis- 
 ease are febrile disturbance, a sensation of stiffness about the lower 
 jaw, quickly followed by pain, especially during movement, and 
 swelling : the pain extends, not only along the jaw, but into the ear 
 and over the head ; the swelling is generally limited to one side, but 
 sometimes both glands are affected at the same time ; the skin is 
 tense, and there is an inflammatory blush. 
 
 The submaxillary and lingual glands may be also involved. The 
 febrile symptoms continue for three or four days, and then gradually 
 subside. In rare cases suppuration takes place in the cellular tissue 
 of the gland ; but this result is less frequent in simple parotitis than 
 in cases where the throat has been affected and suppuration has 
 extended in the course of the Eustachian tube, or has burrowed 
 amongst the muscles of the back of the neck. 
 
 Specific inflammation of the parotid or mumps is a contagious 
 form of disease, and is generally observed in children. The symp- 
 toms are at first severe, and there is considerable constitutional dis- 
 turbance ; the mammary gland in girls, or the testicle in males, occa- 
 sionally becomes sympathetically affected, and there are pain and 
 swelling in them : in other cases the nervous system becomes impli- 
 cated in a marked manner, and restlessness, insomnia, or even mani- 
 acal symptoms are produced. Again, the general mucous membrane 
 of the digestive tract may also be inflamed, and gastro-enteritic 
 symptoms result. 
 
 As a complication of typhus fever the enlargement of the parotid 
 gland is an unfavorable indication, and is sometimes associated with 
 sallowness or duskiness of the countenance ; this condition of the 
 parotid occurs in in the second week of typhus. 
 
 With the exception of the last class of cases the prognosis of in- 
 flammation of the parotid of a simple character is always favorable. 
 The diagnosis is only difficult when deep seated mischief about the 
 pharynx or Eustachian tube has taken place, and when the tissues 
 about the gland are only secondarily affected ; so also when disease 
 has extended from the mastoid cells or from the teeth. 
 
 The treatment consists in the application of warmth, in the use of 
 gentle saline aperients, effervescing draughts, and unstimulating diet. 
 Time is required, for the disease in most cases runs a definite course, 
 and cannot be obliterated by medical treatment. Convalescence may, 
 however, be promoted by the use of tonics, such as quinine and steel. 
 If there be excitement of the nervous system then bromide of po- 
 
 1 Virchow distinguishes two kinds of parotitis idiopathic and symptomatic. The 
 former being what is popularly termed " mumps, "only occasionally leads to abscess, 
 but not infrequently it shows a disposition to metastasis. The symptomatic form 
 results from severe disease, as typhus, &c. He regards both as a catarrh in which 
 the gland-cells take part in the diseased process.
 
 38 ON DISEASES OP THE TOXGUE AND MOUTH. 
 
 tassium, with chloral hydrate if there be sleeplessness, will be of 
 service. 
 
 The tonsils are the next structures that we have to notice ; they 
 are situated between the anterior and posterior pillars of the fauces 
 and immediately beneath the soft palate, and they become affected 
 by various morbid processes. 
 
 The tonsil is composed of several tissues, each of which must be 
 taken into consideration when speaking of the diseases attaching to 
 it. Externally, i. e., on its pharyngeal aspect, it is a rounded projec- 
 tion which is covered over by scaly epithelium and has many depres- 
 sions on its surface into which this scaly lining passes. Thus its 
 surface is studded with small pouches or follicles. Enclosed in this 
 external membrane are numerous lymphatic follicles arranged in 
 groups and with fibrous trabeculse, bloodvessels and lymphatics run- 
 ning between them. These various parts are not at all equally 
 affected in tonsillar disease; in one there is affection of the epithelial 
 surface, in another of the whole substance, and lastly the interstitial 
 stroma is involved. In each form, however, all the component struc- 
 tures of the glands participate, although the structural change is 
 predominant in one. 
 
 They may be classified in the following manner: 
 
 Catarrhal inflammations < / ' 
 
 | Chronic. 
 
 i ( Acute = Quinsy. 
 
 Parenchymatous < n , TT J , 
 
 J ( (Jhronic = Hypertrophy. 
 
 1. Acute catarrhal inflammations are characterized by general 
 swelling of the mucous membrane with injection and excess of 
 mucus, sometimes of glairy, sometimes of an inspissated character. 
 
 To this group belongs acute oedema, generally an extension of dis- 
 ease from the soft palate or the mouth. 
 
 Erysipelatous inflammation, acute catarrh, diphtheria. 
 
 2. Chronic catarrhal inflammations, attended by more or less thick- 
 ening of the mucous surface, although not of the whole gland, and 
 by plugging of the glandular crypts with effete epithelial products. 
 
 3. Acute parenchymatous inflammation, where the whole substance 
 of the gland is swollen and may rapidly suppurate Quinsy. 
 
 4. Chronic parenchymatous inflammation is a disease which is said 
 to be productive of true hypertrophy of the gland, but it is more 
 especially dependent upon fibrinous overgrowth of the interglandular 
 trabeculae, with enlargement of the vessels. 1 The whole gland is 
 enlarged and more solid than normal. This state is commonly known 
 as chronic enlargement of the tonsil. 
 
 In addition to these more common forms of disease the tonsils are 
 not uncommonly subject to ulceration similar to that seen in other 
 parts of the mouth in ulcerative and syphilitic stomatitis, and they 
 are occasionally the seat of severe forms of ulceration and sloughing, 
 
 1 :i Microscopic Examination of an Enlarged Tonsil," 'Path. Soc. Trans.,' vol. xix, 
 p. 211, showing it to be a true hypertrophy ; the Malpighian corpuscles were closely 
 packed, with very little stroma. Mr. W. J. Smith.
 
 ON DISEASES OF THE TONGUE AND MOUTH. 39 
 
 which are sometimes called phlegmonous inflammations, sometimes 
 diphtheritic, but which would appear to occur under a variety of 
 morbid states. This state is sometimes seen in severe forms of pneu- 
 monia, in typhoid fever, in dysentery; and it is of especial interest 
 to note that these severe affections of the fauces are to be found 
 more especially in association with sloughy or phlegmonous states of 
 intestine. 1 Besides these we also find strumous, syphilitic, and can- 
 cerous diseases. 
 
 (1.) In acute catarrh the tonsils and the mucous membrane become 
 oedematous and congested; the color of the mucous membrane is 
 changed, it is reddened, and the line of demarcation is sometimes as 
 denned as with erysipelas affecting the skin, the swelling may be so 
 great that the soft palate and the uvula are twice their natural size, 
 and the parts almost corne in contact the one with the other; in 
 erysipelatous inflammation the oedema is very marked and the color 
 is dusky; if, however, the oedema is passive and chronic the color is 
 less dark. The extent of the elongation of the uvula and its shape 
 are very different in the cases of passive oadema; sometimes the 
 extremity of the uvula is rounded and swollen, at other times elon- 
 gated, pointed, and a quarter to half an inch beyond its proper pro- 
 portions. It will then reach the tongue or the posterior portion of 
 the pharynx and produce violent dry retching or cough. 
 
 Sometimes in acute inflammation of the tonsil the secretion is 
 altered and thin white patches are observed on the gland, resembling 
 diphtheritic exudation, or there is a raised portion of the mucous 
 membrane, whitish in color, which leaves a raised irregular edge 
 and is often mistaken for an ulcer ; this condition is an acute one, 
 and subsides after three or four days, but it is not true diphtheria. 
 (2.) If the disease be less acute, the secretion is altered and a white 
 secretion appears in the crypts of the gland, as if the extremities of 
 the follicular ducts were distended ; this condition also is often mis- 
 taken for one of ulceration. With this follicular inflammation of the 
 tonsil the mucous membrane of the pharynx is also affected ; it be- 
 comes congested, the surface appears irregular and granular, the 
 veins are enlarged and sometimes lead to hemorrhage. It is this 
 condition that is sometimes called clergyman's sore throat, and it is 
 a state of chronic congestion with follicular inflammation. When 
 the glands behind the pharynx become enlarged, they may push for- 
 ward the mucous membrane on one or other side, so that the canal 
 appears narrowed and one-sided. (3.) If the whole gland is inflamed 
 and the parenchyma affected acute tonsillitis there is general 
 swelling of the gland ; the anterior fauces are greatly narrowed, and 
 the tonsils nearly meet. If suppuration ensue, the swelling is still 
 greater ; there is softening of the part, and fluctuation can be felt, 
 unless the affection be confined to the posterior region ; as the acute 
 disease subsides it oftens leaves chronic enlargement of the gland, 
 
 1 In reference to cases of this kind vide ' Path. Soc. Trans.,' vol. xxvi, p. 84, 
 "Acute Enteritis," by Dr. Goodhart , vol. xix, p. 217. "Sloughing of Tonsils," by 
 Dr. J. Osier Ward; vol. xi, p. 106, "Calculus from Tonsil," by Dr. Silt, for Dr. 
 Baker.
 
 40 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 (4), which is increased by each subsequent attack, especially in 
 weakly and strumous children. 
 
 The symptoms produced will vary according to the severity of the 
 attack ; in simple oedema, the febrile disturbance is often severe, the 
 temperature may suddenly become high, from 103 to 105, there is 
 much irritation, dysphagia, pain towards the ear on swallowing, the 
 tongue is furred and generally the whole mucous membrane of the 
 mouth is affected. If the uvula be elongated, then there is dry 
 cough and vomiting, and these symptoms are often especially observa- 
 ble in the morning ; patients are sometimes supposed to have severe 
 bronchitis, whereas the mischief is simply in the throat. 
 
 In erysipelatous inflammation, in which there is duskiness with 
 oedema, there is great prostration with the febrile symptoms and 
 more distress, the attack comes on suddenly, and if it extend to the 
 epiglottis and glosso-epiglottidean folds of mucous membrane these 
 parts become cedematous and dyspnoea of a dangerous character is 
 produced. In follicular inflammation the symptoms are more 
 chronic; there is hoarseness, cough, and much distress, but without 
 febrile symptoms. In acute inflammation of the tonsils, there is also 
 much febrile disturbance, with pain and distress, deglutition is difficult 
 and very painful, and food is sometimes rejected by the nares, or the 
 patient is unable even to swallow saliva ; he cannot sleep, for the 
 disease in the throat interferes with respiration ; the tongue is much 
 furred, it is swollen, and in fact the whole mucous membrane of the 
 mouth is involved ; the breath becomes offensive, and the gums 
 covered with concretion ; this condition may gradually subside, or 
 with increasing distress rigor comes on, and after a longer or shorter 
 interval the pus which has formed finds a free vent and there is 
 sudden relief to the urgent symptoms ; in some cases a fatal termina- 
 tion suddenly supervenes from suffocation or from exhaustion ; sup- 
 puration, however, in some cases reaches to the loose cellular tissue 
 external to the tonsil, and it may burrow among the muscles of the 
 neck ; ulceration also ensues, and there is then an excavation on the 
 surface of the tonsil sometimes extending into its substance. 
 
 In syphilitic and in strumous subjects this ulceration has a peculiar 
 and characteristic appearance, in the former having a somewhat 
 circular margin, serpiginous in outline, in the latter with irregularly 
 raised edges and extending in both cases to the soft palate, leading 
 to its destruction and often to perforation. In syphilitic ulceration 
 of the tonsil the disease sometimes extends to the soft palate, and a 
 circular red line of inflammation may be seen across the soft palate 
 after ulceration has ceased, the disease spreading in the same manner 
 as psoriasis of the skin. 
 
 In chronic hypertrophy of the tonsil the glands present an irregular 
 and pitted appearance ; the enlarged glands, when increased by a 
 sudden accession of acute disease, almost meet, and all the symptoms 
 of the acute disease may be produced. Very slight causes suffice to 
 produce this aggravation of symptoms when the tonsils are chroni- 
 cally affected, and what is often of great annoyance to the patient 
 the Eustachian tubes are pressed upon, and the sense of hearing is
 
 ON. DISEASES OF THE TONGUE AND MOUTH. 41 
 
 interfered with. In many instances, as the acute disease subsides, 
 the partial and temporary obstruction of the tube causes some deaf- 
 ness, but in chronic hypertrophy the deafness is more permanent. 
 Another consideration must be borne in mind, namely, that persistent 
 enlargement of the tonsil interferes with the voice, and with the 
 entrance of air into the lungs ; hence in children it is not unlikely to 
 interfere with growth and may lead to imperfect nutrition. 
 
 In investigating the causes of these inflammatory diseases of the 
 tonsil we find that strumous subjects manifest greater liability to 
 them, and also in such patients a recurrence of disease is very apt to 
 take place. Cold is the most common exciting cause, but there is a 
 greater tendency to disease of the tonsil, especially of an acute kind, 
 when the nervous system is exhausted and nutrition is impaired. 
 
 There is much difference of opinion amongst medical practitioners 
 as to the best mode of treating acute disease of the tonsils. The 
 application of warmth to the throat in the form of cotton wool 
 externally, or a hot linseed poultice, or the " wet pack" in the form 
 of a cloth wrung out of water, will often suffice to relieve the disease 
 without any other treatment. Stimulating liniments may be used, 
 such as the compound camphor liniment applied on lint or rubbed 
 in, or a mustard poultice may be used. 1 In the mouth itself ice is 
 often very grateful, but as a rule warmth is more pleasant. Lunar 
 caustic or nitrate of silver may be useful, if the disease is circum- 
 scribed ; but unfortunately, in most instances, the mischief is more 
 extensive and the relief thus afforded is only temporary, and in some 
 cases it aggravates the disease and increases ulcerative changes. It 
 is better to use glycerine of tannin alone, or diluted with water as a 
 gargle, or as a vapor with a spray apparatus ; solution of chlorate of 
 potash or of borax, may also be used, and if there be any tendency 
 to ulceration, a dilute solution of carbolic acid, gr. iv to 3j, is a good 
 remedy for vaporization. If there be much febrile excitement saline 
 effervescing medicines may be given, or the acetate of ammonia, or 
 dilute hydrochloric acid with chlorate of potash ; if there be weak- 
 ness, a frequent and irritable or compressible pulse, then the fluid 
 extract of cinchona bark or quinine should be used. In nearly all 
 these cases it is very important to sustain the patient by good nour- 
 ishment, such as milk, eggs, good soup, and wine or ardent spirits 
 may be required. The prostration of strength is often very great, 
 and the stimulant effect of alcohol is of great service. The applica- 
 tion of tincture of iron is a favorite remedy with some physicians, 
 especially if the disease be of a diphtheritic character, but more 
 soothing remedies are preferable. 
 
 In chronic disease of the tonsils with hypertrophy the application 
 of caustic tends to increase the flow of blood to the part, and in this 
 manner augments the disease ; the employment of solution of iodine 
 is objectionable for a similar reason ; but the long-continued appli- 
 
 1 Dr. S. H. Roberts strongly recommends the use of turpentine externally in ton- 
 sillitis, ' London Med. Record,' vol. i, p. 395, and Dr. Handfield Jones the internal use 
 of belladonna ' Lancet,' 1871, vol. i, p. 12.
 
 42 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 cation of nitrate of silver is still more objectionable, for it may be- 
 come absorbed and produce discoloration of the skin. This would 
 scarcely be regarded as possible, unless it had really occurred. A 
 lady, whom I saw in consultation for severe colic, was found to have 
 a peculiar indigo discoloration of the skin, and upon inquiry I learned 
 that a strong solution of nitrate of silver had at one time been pre- 
 scribed for enlarged tonsils ; this solution had been zealously applied 
 by the patient and her nurse for a period of two years, and with the 
 effect of producing discoloration of the skin. The constant employ- 
 ment of tannin, either dissolved in glycerine and used with a camel- 
 hair pencil, or as a gargle, or with a spray apparatus, is generally 
 sufficient to lessen the size of the glands. For a like purpose also a 
 strong solution of alum may be used. A residence at the sea-side 
 or in dry and bracing air, nourishing diet, the administration of cod- 
 liver oil with quinine and steel, will help to relieve the mal-nutrition 
 connected with hypertrophy of the tonsils, and to lessen the growth 
 of the glands themselves. In other cases iodide of potassium may 
 be given with iodine or the iodide of iron, and iodine may be painted 
 on the skin. It is, however, well not to employ iodine in too con- 
 centrated a form, for on a delicate cutaneous surface it produces 
 much irritation, pain, and even vesication ; the iodine may also be 
 used by inhalation. Excision of the tonsil should only be practised 
 after astringents and general remedies have been fully employed ; 
 but in young subjects it is especially important not to allow these 
 hypertrophied glands to remain, for the reasons already stated. 
 
 The hasty removal of the uvula, however, for -prolongation and 
 relaxation is very much to be deprecated ; other measures may 
 suffice, and its excision may interfere with the process of swallowing 
 and with the voice. 
 
 In oedema of the tonsils and soft palate the inhalation of soothing 
 remedies is grateful to the patient, and even simple steam is of much 
 benefit. Astringents may be similarly employed with advantage, 
 but if necessary the parts should be scarified or incisions made, and 
 this is the more necessary when the cedema extends to the epiglottis 
 and glosso-epiglottidean folds cases in which fatal dyspnoea some- 
 times supervenes. Such cases require to be watched very carefully, 
 for after sudden excitement perfect freedom of respiration may give 
 place to irregularity of breathing and to urgent dyspnoea, and the 
 immediate performance of tracheotomy may become necessary for 
 the preservation of life. 
 
 If the cedema be associated with asthenic or erysipelatous inflam- 
 mation stimulants, with good nourishment, are of great value. Beef 
 tea, with port wine or champagne, should be given frequently ; and 
 astringents, with the tincture of iron, are often of great use as local 
 applications. As regards other forms of medicine, perhaps bark, 
 with hydrochloric acid, is productive of the most benefit. When 
 abscess in the tonsil is present, the sooner it is opened the better ; if 
 it be left, the dyspnoea and distress increase, and the local mischief 
 becomes more extensive by burrowing among the loose tissue of the
 
 ON DISEASES OF THE TOXGUE AND MOUTH. 43 
 
 posterior pillars of the fauces. An abscess protruding into the fauces 
 may sometimes be opened by the pressure of a sharp finger nail. 
 
 Cancerous disease of the tonsil is a rare form of disease, and is 
 associated with enlargement of the cervical glands. In an obscure 
 case of this kind that I witnessed some years ago, nearly every fort- 
 night or three weeks swelling of the neck and extreme dysphagia 
 came on ; the cause was not apparent, but it was found after death 
 that cancerous disease of the glands had exerted pressure on the 
 pneumogastric nerve, and thereby caused the dysphagia and other 
 symptoms of disease. 1 
 
 Paralysis of the soft palate must also be mentioned in connection 
 with diseases of the tonsils and adjoining parts. In paralysis from 
 diseases of the brain, ordinary apoplexy with hemiplegia, the di- 
 minished power of the tongue and muscles of deglutition leads to 
 marked dysphagia ; sometimes also local growth of a syphilitic or 
 cancerous character exerts pressure on the hypoglossal and other 
 nerves, and leads to diminished power; this is especially observed in 
 that interesting class of cases designated labio-glosso-laryngeal paraly- 
 sis. The spinal accessory nerve is probably in these instances impli- 
 cated, the muscles of the face are weakened, so also the tongue, but 
 it is especially in the soft palate and in the muscles of the pharynx 
 that the loss of power is observed ; the soft palate remains powerless 
 and flaccid, and sensibility is lost. The attempt to swallow may be 
 followed by the passage of food into the larynx, and in a case of this 
 kind under my care in the clinical ward of Guy's in 187-4, recorded 
 in the ' Guy's Reports,' directions had been given to feed the patient 
 by the stomach-pump, but in the attempt to swallow milk a portion 
 passed into the larynx and greatly hastened a fatal termination. 
 Loss of power of the soft palate is also observed to follow diphtheria. 
 These latter cases slowly recover, so also where the weakness is 
 consequent upon the full use of bromide of potassium ; such patients 
 complain of inability to swallow, with weakness and mental inertia. 
 The voice is altered, especially so where the tongue is affected, as in 
 cases of labio-glossal laryngeal disease. 
 
 The treatment in these maladies necessarily varies according to 
 the nature of the case, but faradization is often of great value in 
 strengthening the muscles of the soft palate. The semi -paralyzed 
 condition of the palate found after the free use of bromide of potas- 
 sium soon disappears with a cessation of the remedy. We have 
 already referred to a similar condition of atrophy of the tongue de- 
 pendent upon disease of its nerves or of the central nervous centres 
 (see page 26). In progressive muscular atrophy the muscles of the 
 tongue share in the general disease, 8 and they may at times be found 
 
 1 A valuable collection of oases of primary disease of the tonsils is to be found in a 
 paper by Mr. Poland, "On Cancer of the Tonsil Glands," ' Medico-Chir. Review,' 
 1872, p. 477. Three cases of cancerous disease of the tonsil have recently occurred 
 in Guy's Hospital, and for a very interesting case with cancer of the spleen and lym- 
 phatic glands ses ' Path. Soc. Trans.,' vol. xx, p. 369, by Dr. Moxon. 
 
 2 'Archives Generates de Medeoine,' series 5, vol. i, p. 571, Cruveilhier.
 
 44 ON DISEASES OF THE TONGUE AND MOUTH. 
 
 wasted on one side or the other in consequence of disease in the 
 brain or at the origin of nerves. 
 
 Such, unhappily, do not admit of much treatment, but a case of 
 Sir James Paget's, already referred to, shows that unilateral wasting 
 of the tongue is quite remediable should it happen that the feause 
 which produces it can be removed. 1 
 
 1 For other cases see Hughlings Jackson, ' Lancet,' 1872, vol. ii, p. 770 ; Buzzard, 
 ' Clin. Soc. Trans.,' vol. v, p. 146; "Case of Unilateral Face Atrophy, dating from 
 an attack of Chorea."
 
 45 
 
 CHAPTER III. 
 
 ON DISEASES OF THE PHARYNX. 
 
 THE pharynx is continuous by the fauces with the mouth, by the 
 posterior nares with the cavities of the nose, by the Eustachian tubes 
 with the ears, by the superior opening of the larynx with the respi- 
 ratory organs, and by the commencement of the oesophagus with 
 the rest of the alimentary tract; and disease of any of these con- 
 tiguous parts may interfere with healthy pharyngeal action. The 
 mucous membrane of the pharynx is loosely connected with the 
 muscular coat, and important vessels, nerves, and numerous glands 
 are placed on the external aspect. The part is richly supplied with 
 nerves, from the pneumogastric, the glosso-pharyngeal and spinal 
 accessory nerves, and this abundant supply has an important bearing 
 upon some pathological conditions. 
 
 Spasmodic irritation. Any one who has repeatedly examined the 
 pharynx is well acquainted with the varying sensibility of the part, 
 and that great irritability may be consistent with ordinary health. 
 The most intense excitability with true spasm of the pharynx is 
 observed in hydrophobia. Cases of this kind are occasionally seen, 
 and I have witnessed three instances, two in young men, and a third 
 in a little girl. In the first case, some years ago, the pharynx pre- 
 sented a very peculiar appearance on inspection; its cavity appeared 
 more than twice its natural size; the constrictor muscles were re- 
 tracted to the utmost, and the fauces were exceedingly large from 
 the rigid contraction of the soft palate; the spasmodic condition of 
 the muscles rendered every part of the pharynx as dilated as possible, 
 whilst from similar muscular spasm the oesophagus was contracted. 
 The mucous membrane of these parts was injected and covered with 
 tenacious mucus. There was great congestion of the membranes of 
 the brain and spinal cord, and the lungs were in a similar state of 
 engorgement. The other viscera were healthy, but there was em- 
 physema of the cellular tissue of the neck. The symptoms during 
 life indicated extreme irritability of the nerves supplying the pha- 
 rynx, as indeed, of all the branches of the fifth and pneumogastric 
 nerves. 
 
 Inflammatory diseases of the pharynx may be of an an acute or 
 chronic catarrhal character, or the inflammation may be follicular, 
 membranous, or phleymonous. 
 
 The catarrhal states scarcely require a separate description, for the 
 mucous membrane is continuous with the tonsils and palate, and dis- 
 ease extends by continuity of tissue. This is also the case with diph- 
 theritic inflammations, and also in the exanthems, as scarlet fever 
 and smallpox, for in the former the mischief extends into the pharynx,
 
 46 ON DISEASES OF THE PHARYNX. 
 
 and in the latter pustules have been observed on the mucous mem- 
 brane of the fauces. In cedematous and erysipelatous states the 
 tonsils, palate, and pharynx are generally affected. In catarrhal in- 
 flammation of the throat the mucous membrane is red, injected, and 
 swollen, and dysphagia is a common symptom ; the movement of the 
 parts produces pain in the direction of the Eustachian tubes, and de- 
 glutition is difficult. 
 
 Chronic catarrh is characterized by thickening of the mucous mem- 
 brane, with redness and slight hoarseness ; there is occasional irrita- 
 tion, which is relieved by the expectoration of a small quantity of 
 mucus. This troublesome affection is usually described by the pa- 
 tient as a relaxed throat, and it is closely associated with foUicular 
 inflammation, with which many of the symptoms are identical. This 
 is a less severe condition, but is even more chronic; the mucous 
 membrane is red and granular ; the veins are enlarged and varicose, 
 the adjoining part being in a similar state ; irritable cough, hoarse- 
 ness, and dysphagia are induced. If with these symptoms the uvula 
 is relaxed, vomiting, especially in the morning, is easily induced. 
 Over-speaking, as with clergymen, may be the cause of this follicular 
 disease, and it is greatly relieved by astringents used as a gargle, or 
 with a spray apparatus, as alum, tannin, krameria; and sometimes 
 by stimulants, such as capsicum, guaiacum, &c. Tobacco produces 
 a relaxed condition of the mucous membrane and cough is a common 
 symptom of this state. The best remedy is to give up the exciting 
 cause. A somewhat similar, if not identical disease, is sometimes 
 found in delicate patients of a strumous tendency or with chronic 
 chest disease. It shows itself in such persons chiefly by an excess of 
 viscid mucus, slightly offensive, about the posterior nares and fauces, 
 and which is most troublesome in the morning. The efforts at clear- 
 ing the throat under such circumstances are often productive of 
 vomiting. The posterior aspect of the soft palate and posterior nares 
 appear to be equally implicated with the pharynx. 
 
 Membranous inflammation of the pharynx occurs in the form of 
 croupous or of diphtheritic disease, and although in true croup the 
 larynx is first affected, the disease may extend to the pharynx, whilst 
 in, diphtheria, in which the pharynx is first attacked, the mischief 
 often reaches the larynx ; still we regard the diseases as essentially 
 distinct. This opinion is, however, controverted by eminent physi- 
 cians, who maintain that the diseases are identical. The pathological 
 character, as well as the clinical history, is different in the two dis- 
 eases. In croup we have a false membrane consisting of epithelial 
 cells and inflammatory product, based upon a congested membrane ; 
 in diphtheria the membrane is also composed of cellular elements 
 and fibrinous material, exudatory in character, and the result of in- 
 flammatory change, but the morbid effusion is more adherent to the 
 structures beneath, and the subjacent tissues are often sloughing. 
 Some also assert that, the diphtheritic membrane is fungoid in char- 
 acter. In the fauces and tonsils the membrane has a yellowish color, 
 it is tough, and is adherent to the surface beneath, and its separation 
 leads to abrasion and to bleeding. The croupous membrane in the
 
 ON DISEASES OF THE PHAKYNX. 47 
 
 larynx is less consistent and less adherent to the tissues beneath. It 
 is not, however, that every membranous exudation in the fauces and 
 pharynx is diphtheria ; on the contrary, many acute diseases already 
 described have this character, and in general exhaustion of the system 
 the throat becomes injected, granular, and may have an inflammatory 
 exudation upon it. In true diphtheria there is, then, greater ten- 
 dency to slough, there is general prostration of strength, the urine 
 becomes albuminous, and there is a liability to subsequent paralysis. 
 In croup there may be slight albumen in the urine from inflamma- 
 tory congestion, but this is very different from the albuminuria in 
 diphtheria. 
 
 As to the general symptoms, there is febrile excitement, sudden 
 elevation of temperature, uneasiness in the throat, difficulty in 
 shallowing, and great prostration of strength ; if the disease extends 
 into the larynx, the interference with respiration becomes a sjmiptom 
 of the greatest importance, as death often takes place from apncea. 
 
 The extent of the diphtheritic disease is very different, at one 
 time being located merely upon the tonsils and soft palate, at another 
 extending into the fauc'es, and even reaching the oesophagus, or the 
 larynx, as we have just remarked; the extension into the larynx, 
 with its attendant serious symptoms, may corne on suddenly or 
 insidiously. 
 
 The treatment consists in relieving the local disease and in sustain- 
 ing the strength of the patient. Some advocate the application of 
 lunar caustic, others use the solution of perchloride of iron, but these 
 means are often ineffective, they can only be applied partially, and 
 it is better to soothe the mucous membrane by demulcents, by warm 
 applications, and by keeping the fauces as free and clean as possible 
 l>v washing with a dilute solution of the permanganate of potash. 
 Warm applications should be applied externally. Chlorate of potash 
 with bark are the best remedies internally, and a liberal supply of 
 nourishment in the form of milk, eggs, good soup, &c., port wine or 
 brandy should also be given. 
 
 If the glands in the neck or the cellular tissue in the course of 
 the Eustachian tube become affected, then warm applications are 
 necessary, and it is well to give quinine more freely as well as 
 stimulants. 
 
 In diphtheria, after the subsidence of the more urgent symptoms, 
 a peculiar form of paralysis is occasionally developed, and dysphagia 
 results from the loss of power of the pharyngeal muscles. This con- 
 dition is very fully dwelt upon by Maingault in his valuable treatise 
 on "Diphtheritic Paralysis." This author states that "the symptoms 
 of paralysis of the soft palate are a nasal voice, pain on deglutition, 
 difficulty or impossibility which the patients experience in exercising 
 suction, in distending the cheeks, in blowing with the mouth, and 
 in gargling ; and, on examining the throat, we find immobility of 
 the soft palate, a lengthened condition of it, numbness, absence of 
 pain, and a diminution or loss of special sensibility. These various 
 phenomena supervene a longer or shorter time after the acute affec- 
 tion of the throat has been cured; and when the pain having already
 
 48 ON DISEASES OF THE PHARYNX. 
 
 completely disappeared, and the deglutition having become easy, the 
 convalescence is apparently established." Maingault gives the fol- 
 lowing table to show the relative frequency of the different forms of 
 paralysis which come on after diphtheria : 
 
 Paralysis of the lower limbs . . . .13 
 
 General paralysis ...... 64 
 
 Paralysis of the soft palate . . . .70 
 
 Disordered sensibility without muscular weakness 8 
 Amaurosis ....... 39 
 
 Strabismus 10 
 
 Paralysis of the muscles of the neck and trunk . 9 
 Anaphrodisia ....... 8 
 
 Paralysis of the bladder 4 
 
 Paralysis of the rectum 6 
 
 He also adds, that "dysphagia never fails to come on whenever 
 diphtheria is followed by general paralysis." In the treatment of 
 these cases a very generous diet is necessary; and, if deglutition be 
 impossible, an oesophageal tube should be used ; electricity has been 
 found of great service, and tonic remedies, as quinine, steel, &c. ; 
 others speak very favorable of the efficacy of strychnia of nux 
 vomica. In very many instances recovery slowly takes place, but a 
 fatal result occasionally ensues from this complication of a disease 
 terribly fatal in its primary effect. Sir W. Gull 1 has recorded an 
 instance of this kind in a child aged 12 ; and he attributes these 
 forms of secondary paralysis to the extension of disease to the spinal 
 nerve centres. 2 In the young patient just referred to, drooping of 
 the head came on five weeks after the attack of diphtheria. The 
 child could utter no sound, and the diaphragm was unmoved in 
 respiration, indicating a loss of power in the phrenic nerves. Fear- 
 ful attacks of suffocative dyspnoea were produced when the head was 
 moved in particular situations, and in one of these paroxysms he 
 died. 
 
 Phlegmonous inflammation or diffuse suppuration is a very severe 
 form of disease, and is generally the result of erysipelas, of pyaemia, 
 sometimes of diphtheria and of scarlet fever. 3 The patient rapidly 
 passes into a typhoid condition, the dysphagia becomes extreme, the 
 respiration is impeded, and on examining the neck we find either 
 erysipelatous redness of the skin or a fulness and tenderness among 
 the infra-hyoid muscles, impeding the free movement of the parts 
 concerned in deglutition. The examination of the neck will gene- 
 rally enable us to distinguish the dyspnoea arising from this cause 
 from that produced by disease of the larynx or trachea, as well as 
 
 1 'Lancet,' July, 1858. 
 
 2 Some observations have lately been made in Germany which, so far as they go, 
 seem to corroborate this opinion. See " Letzerich on Diphtheritic Encephalitis," 
 'Virchow's Archives,' 1875, p. 419. 
 
 8 It is called by the German authors angina Ludovici, especially when it attacks 
 the neck.
 
 ON DISEASES OF THE PHARYNX. 49 
 
 from that consequent on pressure or injury of the nerves of respira- 
 tion. 
 
 Diffused inflammation of the cellular tissue may also be produced 
 by ulceration in the mucous membrane of the pharynx. 
 
 The following is an interesting case of diffused inflammation of the 
 throat : 
 
 CASE I Abraham S , aet. 36, a sailor of intemperate habits, was ad- 
 mitted into Guy's Hospital, October 13, 1847. On the 5th, whilst unloading 
 coals, he received a blow on the back of the hand, and on the following day 
 rigors ensued, with pain in the axilla, but the skin of the arm did not become 
 inflamed. On admission, on the 13th, he presented the appearance of a man 
 suffering from typhoid fever ; there was delirium at night, and the respiration 
 was much oppressed ; no fluctuation could be found under the pectoral mus- 
 cle, nor any suppuration detected in the neck ; the wound on the hand was 
 dry. Stimulants and opium were administered. On the loth the respiration 
 was difficult and labored, 42 per minute ; there was evident obstruction of the 
 larynx and some tenderness existed about it, but scarcely any swelling, and 
 neither fluctuation nor suppuration could be detected on very careful ex- 
 amination ; there was great difficulty in swallowing. On the 16th the respi- 
 ration and deglutition were somewhat easier, but the skin was clammy and 
 the tongue dry. He died on the following day, after vomiting some blood. 
 On inspection the whole of the cellular tissue surrounding the muscles of the 
 neck was found infiltrated with pus, but there was no suppuration below the 
 pectoral muscles. 
 
 CASE II. Diffused inflammation of the throat. Ulceration of the pharynx. 
 A woman admitted into Guy's, in May, 1847, set. 66, had sore throat with 
 pyrexia ; typhoid symptoms quickly followed and she died on the fifth day. 
 On inspection suppuration was found among the muscles of the neck, and 
 around the oesophagus as low as the root of the lung. In the pharynx there 
 were several superficial ulcers, and one opposite the arytenoid cartilage had 
 extended into the cellular tissue. 
 
 These diseases appear to be due to an erysipelatous form of inflam- 
 mation, and are generally so severe as to be beyond the reach of 
 remedial measures. Ammonia with stimulants should be freely 
 administered: quinine in full doses may be tried, or large doses of 
 the tincture of iron. The suppuration is not sufficiently localized to 
 admit of relief by incisions, nor can remedies be efficiently applied 
 to the mucous membranes of the throat. 1 
 
 Syphilitic ulceration is often observed in the throat; it attacks the 
 tonsils, the soft palate, the uvula, the posterior nares, and it extends 
 from these parts to the posterior wall or to the pillars of the fauces ; 
 when the ulceration extends from above it is well to raise the soft 
 palate, otherwise the ulceration may not be seen. If the mischief 
 
 1 Only three well-marked cases are to be found in the Guy's post-mortem records in 
 the last ten years. One in a male, set. 19, under my colleague Dr. Wilks, in whom 
 the whole pharynx was much swollen and sloughing ; the urine was albuminous ; 
 death occurred suddenly on the seventh day. The second case, under Dr. Fagge, 
 occurred six weeks after scarlatina. The sloughing process had laid bare the muscles 
 of the pharynx. The patient died of pysemia. The third was an interesting case on 
 account of the extensive ulceration of the bowel with which it was associated. A full 
 report of it is published in the Pathological Society ' Transactions' for 1875. 
 4
 
 50 ON DISEASES OF THE PHARYNX. 
 
 extend from the epiglottis the posterior part of the tongue is impli- 
 cated. The ulcerutiou is seen to be circular in form, and often ser- 
 piginous in character. The disease is sometimes located quite at 
 the commencement of the oesophagus, and is the cause of severe 
 dysphagia. 
 
 In the severe forms of secondary ulceration the perchloride of 
 mercury is a valuable remedy, given alone or with iodide of potas- 
 sium. Where there is chronic and tertiary disease the iodide is of 
 especial service. Tonics alone will not effectually relieve this form 
 of disease, quinine, nitric acid, steel, &c., may be used for weeks 
 without any beneficial effect, when the bichloride will relieve in a 
 very short time. In scrofulous subjects 1 the disease may attack the 
 soft palate or commence in the larynx. If the latter, it extends to 
 the laryngeal side of the epiglottis and reaches the edge. Dvsphagia 
 is very severe, and if the epiglottis is affected food may be rejected 
 even with violence through the nares. In phthisis this ulceration of 
 the pharynx is sometimes a most troublesome and distressing symp- 
 tom; and as the pneumogastric supplies both the epiglottis, the 
 lungs, and the stomach, irritation at the throat in swallowing, will 
 produce cough, violent retching, and vomiting. 2 
 
 Cancerous disease often attacks the commencement of the oesoph- 
 agus and the larynx at the cricoid cartilage. Diseases of this char- 
 acter extend from the larynx into the pharynx. They are insidious 
 in their commencement, and may be partially relieved by demulcent 
 and by soothing treatment. Epithelial cancer and medullary cancer 
 are the varieties most frequently met with ; if the dyspnoea be urgent, 
 life may be prolonged by the performance of tracheotomy, but little, 
 however, can be expected from the operation of cesophagotomy, were 
 such an operation feasible. 
 
 Suppuration behind the pharynx sometimes occurs in young chil- 
 dren and in disease of the vertebrae. The symptoms produced are 
 extreme dysphagia, febrile excitement, and exhaustion; the respira- 
 tion is, however, less impeded in these cases than in primary disease 
 of the larynx. If suppuration have taken place below the level of 
 the soft palate, a projecting tumor is observed on examination of the 
 throat. The diagnosis is then sufficiently clear; and, when it is pos- 
 sible, puncturing the abscess relieves the urgent symptoms. Ab- 
 scesses of this kind arise from disease of the vertebrae or from local 
 sources of irritation. Bleuland 3 mentions fatal dysphagia "a collec- 
 tione puris inter spinse vertebrarurn corpora atque inferiorem pha- 
 ryngis superioremque oesophagi partem," and Dr. Fleming 4 narrates 
 several interesting cases of the same kind. One of them took place 
 in a strumous child, -aged 11, in whom there was tenderness at the 
 central part of the cervical vertebrae; the tonsils were enlarged, the 
 
 1 A scrofulous angina of follicular origin is described by Isambert, ' Gazette Heb- 
 dom.,' p. 757, 1871. 
 
 2 Ulcerative angina sometimes complicates ulcerative stomatitis in soldiers. An 
 epidemic of this kind is recorded by Lubanski, ' Lyon M6dicale,' viii, p. 42(j. 
 
 3 Bleuland, ' De sana et inorbasa oesophagi structura.' 
 
 4 ' Dublin Quarterly Review.'
 
 ON DISEASES OF THE PHARYNX. 51 
 
 - - - - b v 
 
 voice was nasal and muffled, andthe muscles spasmodically contracted. 
 Those at the back of the neck were / rigid, and, in speaking, the con- 
 traction of the labial and nasal muscles produced a sort of tetanic 
 expression; the jaws could be separated a little, and the tongue could 
 be slightly protruded. The abscess was opened by a bistoury, and 
 the child recovered. A still more remarkable instance occurred in 
 an infant aged two months; there was peculiar snuffle, difficulty in 
 deglutition, so that the child could scarcely take the breast, with 
 occasional dyspnoea, and these symptoms were followed by convul- 
 sion and a semi-comatose state ; by pressure of the finger against the ' 
 swollen part in the pharynx the abscess ruptured; its contents were 
 discharged through the nose and the infant recovered. 
 
 Cysts or pouches are found especially at the posterior part of the 
 pharynx, and form cavities varying in size from that of a pea to a 
 pigeon's egg. They are probably the sequel of glandular disease 
 and suppuration, and do not lead to any symptom. The pharynx is 
 sometimes seen to be one-sided when examined through the mouth, 
 and this distortion is found in most cases to arise from enlarged 
 glands oa the outer side of the canal, or, again, the fauces may be 
 narrowed by adhesion of the posterior pillars to the sides of the 
 pharynx. 1 
 
 Cancerous disease in the pharynx is observed at the cormnencement, 
 when the disease is found to extend from the tongue or the fauces, 
 or it is situated at its termination in the oesophagus, near to the cri- 
 coid cartilage. Several instances of the latter form of the disease 
 are mentioned with diseases of the oesophagus, but the following is 
 one in which cancerous disease began in the soft palate and was asso- 
 ciated with phthisis. Epithelioma is the most common form of 
 malignant disease affecting this part, but both medullary and scir- 
 rhous disease are sometimes seen. 
 
 CASE III. Carcinoma of the Throat. Tubercular Pneumonia Martha 
 M , jet. 31, admitted December 5th, 1855, and died on the 20th. She was 
 a short woman, married, and had been confined fourteen months previously, 
 but since that time had not been well, having suffered from a slight cough. 
 For three weeks she had had difficulty in swallowing, and this had increased 
 to such an extent that she was, on admission, unable to swallow food, except 
 with extreme difficulty. She could, with much distressing pain, swallow- 
 solids, but fluids were at once regurgitated through the nose. She had suf- 
 fered from hunger, but still more from thirst, and she was extremely ema- 
 ciated. The glands at the angle of the jaw on the right side were much 
 enlarged, giving her emaciated countenance a miserable appearance. Her 
 voice was nasal, and she was extremely exhausted. She was too ill to allow 
 the chest to be examined, and died on the 20th. Her relatives, brother, &c., 
 died of phthisis. On removing the larynx and tongue the soft palate was 
 found to be about twice its natural thickness, irregularly tubercular, and 
 brawny ; the posterior pillars of the fauces were affected in a similar manner 
 (Preparation 1785 70 ). On the right side there was a communication from 
 
 1 In Virchow's 'Archives,' 50, 161, is a paper on warty turners of the pharynx. 
 For an interesting paper on post-pharyngeal abscess in children, see Bokai, ' Jahr- 
 buch. fur Kinderheilkunde,' Band x.
 
 52 ON DISEASES OF THE PHARYNX. 
 
 nO BU 
 
 theTfltyarrnx 1 5-nti> an irregular rarity, situated opposite or rather behind the 
 angle of tin; jaw, about two inches and a half in length, and half an inch in 
 breadth, and containing almost black tsloughy substance. The glands were 
 infiltrated with firm, cancerous product. The tissue of which the soft palate 
 was composed consisted of an immense number of nuclei. In the lungs, 
 there were firm adhesions at the apex of the right lung, the pleura being 
 semi-cartilaginous. In the remaining part of the lung numerous minute 
 tubercles were observed beneath the pleura, and at the lower lobe there were 
 also moderately firm adhesions. The left pleura was free. At the apex of 
 the right lung was an irregular vomica, capable of holding about two drachms 
 of fluid, with a smooth lining, and surrounded by iron-gray lung, with several 
 opaque tubercles. At the lower lobe a considerable portion of the lung WHS 
 red and consolidated ; and several lobules were infiltrated with pale yellow, 
 low organized deposit, which was breaking down in several parts, and pre- 
 cisely resembled the lung observed in cases of acute pulmonary phthisis. 
 There was considerable congestion of the bronchi, and they contained tena- 
 cious mucus. The left lung was congested, but was otherwise healthy. The 
 bronchial glands were black from pigment, and those quite at the base of the 
 neck were firm, white, and dense, consisting of nuclei resembling those in the 
 palate. In the lung, the tubercles presented none of these nuclei nor did 
 they consist of cancerous growths, but were composed of imperfectly deve- 
 loped nuclei, dark pigmental granules, and some nucleated cells. The tissue 
 of the thickened pleura consisted of fibrous tissue. The heart was exceed- 
 ingly small and destitute of fat ; its cavities contained moderately firm clot, 
 and the valves were healthy. The liver, and also the spleen, were healthy. 
 The stomach and the intestines were contracted and healthy, except the 
 rectum and sigmoid flexure, the mucous membranes of which were congested 
 in longitudinal stripes ; and numerous minute superficial ulcers were scattered 
 along these patches. 
 
 This case is' one of great interest in the connection of cancerous 
 disease of the pharynx with tubercular pneumonia, diseases rarely 
 conjoined, as they occur at different periods of life, and are consid- 
 ered to be antagonistic the one to the other. In advanced life, when 
 death has resulted from cancerous disease, we sometimes find the 
 remains of tubercular disease in the form of calcareous deposit at the 
 apex of the lung, or in wasted glands, but such cases are rare and 
 exceptional.
 
 53 
 
 CHAPTER IY. 
 
 ON DISEASES OF THE ffiSOPHAGUS. 
 
 IN the study of any local disease it is important to recognize the 
 tissues of which that part is composed, and to note the structures 
 with which it is in contact. Morbid processes extend to contiguous 
 parts, and the knowledge of the diseases of one organ may serve as 
 an important guide in the investigation of a neighboring one into 
 which the structures merge. In the last chapter we described the 
 diseases of the mouth and throat, and there is much similarity in 
 some of the tissues prolonged into the oesophagus; but whilst the 
 mucous membrane is covered by the same kind of scaly epithelium, 
 it is of a more simple character. It has a large number of conical 
 papillas, which project into the epithelial layer, but it is destitute of 
 the abundance of secreting follicles existing in the mouth and throat, 
 although some isolated submucous glands of an acinous character 
 may still be found. The mucous membrane is more free, and is 
 separated by a layer of connective tissue from the muscular coat, 
 which is composed of longitudinal and circular bands. With this 
 greater simplicity of structure there is associated less activity of 
 function, and di/ninished severity of disease; thus, some of the affec- 
 tions of the mouth and throat which are dependent upon abnormali- 
 ties of the secreting parts are entirely absent, whilst the greater 
 predominance of muscular action, which may be regarded as the 
 prominent function of the oesophagus, leads to alterations of muscular 
 energy and to obstruction of a functional or organic character. 
 
 The oesophagus extends from the fifth cervical to the ninth dorsal 
 vertebra, and it is in this region that auscultation, if of any practical 
 value, may be applied to the elucidation of its diseases. Inclining a 
 little to the left of the vertebral spine soon after its commencement, 
 the oesophagus gradually passes again to the median line, and after- 
 wards a second time to the left as it reaches its diaphragmatic ter- 
 mination in the stomach. The canal is narrowed at the latter part, 
 at the diaphragm, so also at its commencement behind the cricoid 
 cartilage of the larynx, and again at the root of the lung. It is in 
 relation in front with the trachea, with the arch of the aorta, the left 
 bronchus, and with the posterior surface of the heart (left auricle); 
 at its upper part, on either side, the recurrent laryngeal nerves are 
 placed between it and the trachea, and below, the pneumogastric 
 nerves descend in close contact with it. At the posterior part of 
 the oesophagus the nerves unite to form a plexus (plexus gulae), and 
 they also receive filaments from the cardiac nerves of the sympa- 
 thetic.
 
 54 ON DISEASES OF THE (ESOPHAGUS. 
 
 In the consideration of the diseases of the oesophagus we shall 
 describe 
 
 I. Diseases of the mucous membrane. 
 Inflammation. 
 
 Ulceration. 
 Abscesses and cysts. 
 Warty growths. 
 
 II. Alterations in the muscular coat. 
 Spasmodic contraction. 
 Paralysis. 
 
 Hypertrophy and dilatation -pouches. 
 
 III. Obstructions. 
 Internal. 
 
 From annular constriction. 
 From syphilis. 
 
 From ulceration and cicatrices. 
 From cancerous disease. 
 External. 
 
 From pressure of aneurismal or mediastinal tumors. 
 From disease of the glands. 
 
 From effusions into the pleura and pericardium, and from in- 
 flammation in the mediastinum. 
 From abnormal arrangement of vessels. 
 
 IV. The effects of corrosive poisons. 
 
 V. Foreign bodies producing obstruction. 
 
 VI. Hemorrhage and ecchymosis. 
 
 VII. Rupture. 
 
 VIII. Gastric solution. 
 
 The function of the oesophagus is of so simple a character, and the 
 transit of food over its mucous surface is so rapid, that it is less sub- 
 ject to organic disease than some other parts of the alimentary tract. 
 The process of swallowing is dependent in great part upon its func 
 tional integrity, and cannot indeed be said to be completed till the 
 food reaches the stomach ; hence it is that dysphagia becomes one of 
 the most prominent symptoms of disease, not only of the pharynx, 
 but also of the oesophagus. 
 
 In the diseases of the mouth, the tongue, and the fauces, which 
 we have already mentioned, there is an interference with the first 
 part of the act of deglutition, so also in morbid conditions of the 
 pharynx and also of the larynx ; but in the affections of the oeso- 
 phagus it is the latter portion of the process of swallowing that is 
 hindered. 
 
 I. Diseases of the mucous membrane. Acute inflammation of the 
 mucous membrane of the oesophagus is a very rare disease. It is 
 described by some authors, 1 and dysphagia is mentioned amongst its 
 
 1 Cases of diphtheritic inflammation extending to the oesophagus are to he found in 
 'Path. Soc. Trans.' Galen Blueland, ' DC sana et morhosa structura o-sophagi :' 
 Mondiere, ' Arch. Gen. de Med.,' torn, xxx ; 'Diet, de M6d. et de Chir. Pratique ;' 
 Copland, 'Med. Diet.'
 
 ON DISEASES OF THE (ESOPHAGUS. 55 
 
 symptoms. Excepting those cases in which irritant substances have 
 been swallowed, and others also of gastro-enteric inflammation in 
 children, we have only seen two instances in which acute oesopha- 
 gitis could be said to exist. One, a man, set. 38, had gangrene of the 
 penis associated with purpura and a diphtheritic state of the fauces. 
 The oesophagus was much thickened, its longitudinal ridges were 
 too distinct, and its color was of an inky black. The stomach was 
 much injected and the intestines throughout were in a state of acute 
 inflammation. The second case occurred in association with phthisis 
 in a boy, let. 10, who gave no history of dysphagia ; yet the oesopha- 
 gus throughout its whole length was yellow and shaggy, and in a 
 state precisely corresponding to that known in the urethra as stru- 
 mous disease. The larynx was in a like state. The stomach was 
 healthy. A similar case is recorded by Abercrombie, in which a 
 soft adventitious membrane could be traced from the pharynx to the 
 cardia, and the pharynx and epiglottis were covered with a similar 
 membrane. The patient, a gentleman, aet. 26, had swelling of the 
 side of the neck, hoarseness, some dyspnoea, dysphagia, and febrile 
 excitement, followed by typhoid prostration. The throat was red, 
 and aphthous crusts were observed on the mucous membrane. Death 
 took place in three weeks. 
 
 In case of acute inflammation of both the small and large intes- 
 tines of a diphtheritic character, admitted under my care into Guy's 
 Hospital, during 1855, the mouth was inflamed, and the pharynx 
 and tonsils were covered with a white film, spread upon an injected 
 mucous membrane. This white film consisted of a beautiful torula, 
 interlacing in all directions, constituting the "muyuet;" it extended 
 downwards to the commencement of the oesophagus, and some traces 
 of it were found in that canal. In this instance, the symptoms were 
 those of dysenteric diarrhoea, which had come on several months 
 before the woman's admission into Guy's, and had persisted without 
 any intermission for seven weeks. The disease was attributed to her 
 removal into a damp house. The patient was exceedingly prostrate ; 
 she had severe vomiting, and whenever she attempted to take food 
 retching and acute pain were produced. No medicines nor injections 
 had any effect in checking the diarrhoea, and she died on the third 
 day after admission. The mucous membrane of the oesophagus was, 
 perhaps, equally affected with that of the mouth and pharynx ; and, 
 indeed, it appeared that the whole tract of the alimentary canal from 
 the mouth to the rectum was inflamed. 1 
 
 It is probable, that in some of the cases of severe gastro-enteritis 
 in children, in whom the mouth as well as the intestine is evidently 
 inflamed, the whole of the alimentary tract is affected, and would 
 present before death a condition quite abnormal. At the close of 
 chronic disease, we find a similar condition of the pharynx, rendering 
 
 1 See dysentery, for a more full account of this case. Steffen (' Jahrb. fur Kinder- 
 heilkrank.,' vol. ii, p. 143) gives forty-four cases of disease of the cesophagiis in 
 children ; hypersemia, catarrh, and follicular ulceration were present several times, 
 as well as croup and diphtheria ; thrush was found twice, and when this existed a 
 similar state was also found in the stomach.
 
 56 ON DISEASES OF THE (ESOPHAGUS. 
 
 deglutition both painful and difficult; aphthous inflammation of the 
 mouth having extended into this part. In these conditions, I have 
 not seen any remedy followed by such beneficial effects as the chlo- 
 rate of potash, associated sometimes with borax and honey ; but 
 alone it often acts apparently in a most marked manner. This 
 remedy in stomatitis, introduced I believe by Hunt, was very ex- 
 tensively used by the late Dr. Golding-Bird, and subsequent observers 
 have confirmed the favorable opinion which he entertained. It ap- 
 pears to act partly by its local effect, and also as a saline after its 
 absorption into the system. 
 
 Ulceration is generally due to syphilis or to cancerous disease, but 
 it occasionally occurs without any evidence that it is due to either of 
 these diseases; still, whatever may be the cause of the ulceration of 
 the oesophagus, its close proximity to the trachea leads occasionally 
 to perforation of the latter and to consequent symptoms. 
 
 In the Museum at Guy's Hospital, there are several specimens 
 showing ulceration of the oesophagus, of a non-cancerous character, 
 extending into the trachea, and there is some obscurity as to their 
 correct pathology. 1 Difficulty of deglutition is the most prominent 
 symptom during life in these cases ; in some, dysphagia is gradually 
 developed, in others, deglutition suddenly becomes impossible. The 
 patients complain of pain at the sternum or between the shoulders; 
 and on attempting to swallow urgent dyspnoea comes on, with the 
 forcible ejection of food through the nares. The patients become 
 emaciated, and life is only prolonged for a short time by the use of 
 nutrient enemata. On inspection after death, the only disease found 
 has been a perforation of the oesophagus opening into the trachea; 
 the openings, two or three in number, extended over one or two 
 inches, their edges were smooth, and without any thickening; and in 
 several cases the opening into the trachea was smaller than that into 
 the oesophagus. The examination of these cases does not give any 
 evidence of cancerous disease ; nor do we find -other signs of disease, 
 either in the larynx or in the lungs; the early symptoms appear to 
 arise from the oesophagus, the difficulty in respiration following that 
 of deglutition. These facts appear to show that the disease has not 
 commenced either in the mucous membrane of the trachea nor in 
 disease of its cartilages; and we are led to suppose, either, that an 
 abscess has formed between the oesophagus and trachea, and led to 
 fistulous openings into those canals, or that ulceration has taken 
 place in the oesophagus, and gradually extended in depth through 
 the adjoining structures. It sometimes, however, happens that 
 ulceration extending into the oesophagus arises from diseases of the 
 trachial cartilages, and the following remarkable specimen is of that 
 kind: 
 
 CASE IV. Diseased . Cartilages of the Trachea. Ulceration of the (Eso- 
 phagus A carrier, aet. 42, at Hampton, came under the care of Mr. Hol- 
 leston and Mr. Jepson, in 1853, for crowing respiration, with abundant 
 expectoration, but no very urgent dyspnoea, nor difficulty in swallowing. He 
 
 1 Case by Dr. Peacock, ' Path. Soc. Trans.,' vol. xvii, 186.6, p. 119.
 
 ON DISEASES OF THE (ESOPHAGUS. 57 
 
 gradually sank ; but six months before his death he expectorated a portion of 
 ossified tracheal cartilage (Preparation 171 1 87 ), and six weeks later a second 
 portion. On inspection, at the commencement of the oesophagus, immediately 
 beneath the cricoid cartilage, a vertical opening, half an inch in length, with 
 smooth and rounded edges, was found to extend into the trachea ; there were 
 three other communications resembling fissures, merely separated from each 
 other by shreds of mucous membrane. The cartilages of the trachea were 
 ossified, and there was ulceration of the mucous membrane of the larynx at 
 the cricoid cartilage. The inferior lobe of the right lung was consolidated, 
 but no other part of the body was diseased ; and there was no trace of can- 
 cerous nor of strumous disease. 
 
 Dysphagia was almost absent, as far as can be learned, in this case, 
 and the symptoms were those indicative of disease commencing in 
 the larynx; thus differing remarkably from the cases presently to be 
 recorded, where dysphagia was the most prominent complaint of the 
 patient. It is probable that their pathology is also different. No 
 history of syphilis is given, but the expectoration of a portion of 
 diseased cartilage, six months before death, indicated the character 
 of the disease. 
 
 CASE V. Ulceration of the (Esophagus. Perforation of the Trachea 
 
 A married woman, set. 24, who had never enjoyed robust health, about a 
 year previous to her admission under Dr. Barlow's care, had enlarged glands 
 of the neck, which diminished under the use of iodine. Six months after- 
 wards she began to experience difficulty in swallowing, with pain in the chest, 
 uneasiness in the throat, and shortness of breath. These symptoms increased 
 in severity till admission, but a short time previously they had suddenly be- 
 come very much aggravated. She was much emaciated ; no swelling could 
 be found about the neck, nor any disease detected in the chest. She ex- 
 perienced the greatest difficulty in swallowing fluids, and food was at once 
 forcibly ejected. Mr. Hilton passed an oesophageal tube, and found that 
 when the patient breathed, air passed through the tube, indicating a com- 
 munication with the trachea. She was fed for six weeks entirely by injections. 
 On inspection, the trachea and oasophagus were found extensively diseased 
 from the level of the cricoid cartilage, nearly as far as the bifurcation of the 
 trachea, and the two canals communicated by three openings. The anterior 
 Avail of the oesophagus near its commencement was destroyed, with the ex- 
 ception of two slips of muscle, which still remained ; and at this part there 
 was an oval ulcerated opening passing into the trachea ; below this a small 
 portion of the calibre of the oesophagus was considerably contracted ; still 
 lower the oesophagus was again destroyed, and two more openings passed into 
 the trachea. At this latter part, the posterior wall of the oesophagus was 
 also destroyed, and the body of the last cervical vertebra was exposed ; so that 
 an abscess had been formed bounded by the cellular tissue of the trachea, by 
 the remains of the oesophagus, and by the muscle of the neck. The openings 
 into the trachea were oval, transverse, perfectly smooth, and covered with 
 mucous, and not the least thickening nor heterologous deposit could be de- 
 tected by careful examination, aided by the microscope. In the ovary, and 
 in an adhesion on the surface of the liver, there were slight strumous granu- 
 lar deposits ; the other viscera were healthy, and there was no evidence of 
 cancerous disease. There was difficulty in breathing, and Mr. Hilton per- 
 formed tracheotomy, but without any permanent advantage to the patient. 
 (See Preparation 1714', and drawing 264 24 .) The stomach was small, con-
 
 58 ON DISEASES OF THE (ESOPHAGUS. 
 
 tracted, and almost perpendicular ; it contained a small quantity of bilious- 
 looking alkaline mucus. The large intestine was dilated, and contained 
 healthy feces; the caecum contained some acid mucus; the rectum presented 
 several small ulcers, and was covered by a firmly adherent diphtheritic 
 deposit. 
 
 The following case occurred in Guy's, in the year 1840. There is 
 no history of the symptoms on record ; but the patient was a man 
 set. 33, and he died four days after admission. The post-mortem 
 inspection was as follows : 
 
 The body was exceedingly emaciated. Near the middle of the oesophagus 
 the mucous membrane, for about two inches, was of a very red color, and 
 irregular from ulceration; the canal was much contracted, and would have 
 scarcely admitted the end of the little finger. Below the stricture the 
 oesophagus was much dilated, and an abscess had formed behind it, containing 
 four ounces of a dark fluid of a sour odor ; there was a small sinus leading to 
 the abscess ; the mucous membrane, both above and below the diseased part, 
 was quite healthy ; there was no evidence of cancer in the affected part, nor 
 was any other organ diseased, except that the kidneys were found to be 
 granular. (See Preparation 1789 57 .) It was supposed that a corrosive 
 poison must have been taken, but of this there was no evidence. 
 
 An exceedingly interesting record will be found in the 'Patholo- 
 gical Transactions' for 1852, by Mr. ~W. Trotter. A young woman, 
 in St. Mary's Hospital, set. 25, had ulceration of the oesophagus, 
 which extended into the pericardium, and led to sudden syncope and 
 death. For three months she had had nausea, dysphagia, occasional 
 vomiting, and pain at the top of the sternum, and at the epigastrium. 
 Solids were swallowed with much difficulty. There was found, after 
 death, simple ulceration without contraction ; the ulcer had extended 
 from the bifurcation of the trachea nearly to the diaphragm, and had 
 perforated the pericardium. No other organ was diseased. 
 
 The last two cases were instances of simple ulceration below the 
 bifurcation of the trachea ; in the others the disease was above this 
 part ; still, they appear very similar in character, and the modifica- 
 tion in the symptoms arose from the difference of the structures 
 which were implicated. 
 
 There are many instances of pain at the upper part of the sternum 
 on swallowing, when no trace of pressure nor aneurism can be found; 
 and I have seen this sympton disappear under the use of tonics, 
 sometimes with iodide of potassium. The idea of cancerous growth 
 has been precluded, and it has been therefore a question whether 
 some abrasion of the mucous membrane, or slight ulceration, such 
 as we sometimes find in the pharynx, had not led to this complaint. 
 
 It is exceedingly difficult, during life, to decide as to the character 
 of these cases of simple ulceration : the emaciation, dysphagia, and 
 distress being the same as in cancerous disease. In all the cases 
 which have come within my notice, the age of the patient has been 
 very much less than in those instances in which cancer occurred. 
 This alone, however, is not sufficient to enable us to decide with 
 certainty as to the character of the disease.
 
 ON DISEASES OF THE (ESOPHAGUS. 59 
 
 The treatment is exceedingly unsatisfactory; the spasmodic con- 
 traction of the ulcerated part prevents the passage of cesophageal 
 tubes; no food can be swallowed, and the administration of nutrient 
 enemata prolongs life only for a few days or ^veeks. It is painful to 
 find, after death, that simple ulceration of the oesophagus, or a fistu- 
 lous communication with the trachea, is the only existing disease; 
 and that if food could have been introduced beyond this point, life 
 might have been prolonged. The operation of oesophagotomy is a 
 very difficult one, and in many of these cases, if performed, would 
 be quite ineffective, because the disease is- often situated at the root 
 of the lung, or behind the first bone of the sternum; in either case, 
 the operation could not be performed below the seat of stricture. 
 Now that it has been practically shown that the peritoneum may be 
 divided without fatal result, and without the terrible effect seen to 
 follow from ruptured viscera, the propriety of forming a gastric fistula 
 in some of these cases is worthy of very serious consideration. An 
 operation of this kind appears certainly warrantable, as it would 
 afford a chance of life to those who have only the prospect of certain 
 death. In the human subject, several cases of gastric fistula acci- 
 dentally produced have been recorded, and experimenters on animals 
 have purposely made such openings, under the influence of chloro- 
 form, without the production of severe peritonitis. Since the first 
 edition of this work was published, a gastric fistula has been made 
 in many cases, although as yet only in one or two instances with 
 success ; the first was upon a patient of my own, and I suggested the 
 operation to relieve the agonizing distress of starvation in a man 
 dying from cancerous occlusion of the oesophagus. (See cases of 
 cancer.) 
 
 Syphilitic ulceration so generally leads to more or less obstruction 
 that it may advantageously be left till we come to treat of stricture. 
 
 Abscesses. Local suppuration in the submucous tissue of the 
 oesophagus sometimes occurs and produces dysphagia, or rather the 
 regurgitation of food, as in cases of organic obstruction. Two such 
 are recorded in the Guy's post-mortem records; both were of small 
 size and of no real moment. They are rare and obscure in character, 
 and the febrile disturbance is not sufficiently distinctive of the nature 
 of the affection. Diseased glands may set up this local abscess, as 
 well as the annular stricture to which we have presently to refer. 
 
 Cysts in connection with the oesophagus rarely occur; but small 
 pouches dependent upon local dilatation of follicles may be found, 
 and occasionally a cyst is discovered full of mucus; a case of this 
 kind was observed at Guy's last year, in which the contents of the 
 sac were mucoid, but the swelling had not given rise to any symp- 
 toms. 
 
 Warty conditions of the lining membrane are of pathological rather 
 than of clinical import ; it has not been found that their presence has 
 caused serious obstruction, or that any symptom indicating their 
 existence was produced. They are for the most part small, and con- 
 sist of flat, grain-like projections from the surface, which may easily 
 be overlooked by a casual observer. These warty growths are not
 
 60 ON DISEASES OF THE (ESOPHAGUS. 
 
 uncommon; of thirteen cases recorded in our reports, they occurred 
 no less than eight times in association with heart disease; in one 
 instance the patient suffered from phthisis, in two from Bright's dis- 
 ease, and in one from some form of psoriasis. This large prepon- 
 derance in heart disease suggests that chronic congestion of the coats 
 of the oesophagus, from the disturbed circulation, acted as the predis- 
 posing cause; in other instances there is an abnormal tendency to the 
 growth of the papillary structures in this part. In the lower animals 
 a very remarkable condition of the kind has been found, especially 
 in oxen, the whole mucous surface being covered over with larger or 
 smaller pedunculated cauliflower excrescences, of very horny texture. 
 One of these cases is to be found in the Museum of Guy's Hospital, 
 a second in the Hunterian Museum of the Royal College of Surgeons, 
 and a third was in a man, whose case is published by Luschka. 1 
 These instances correspond to the papillary tumor of the pharynx 
 previously alluded to. 
 
 II. Another important class of cesophageal diseases includes affec- 
 tions of its muscular and external coat. All disordered muscular 
 action of the oesophagus produces dysphagia, but this important 
 symptom arises from various causes, which may be classified in the 
 following manner: dysphagia arising from 
 
 1. Diseases of the structures connected with the first part of the 
 act of deglutition, affecting the tongue, the tonsils, the fauces, &c. 
 
 2. Diseases of the pharynx. 
 
 These two groups include glossitis in its several forms tonsillitis, 
 scarlatinal and diphtheritic affections, acute inflammatory states of 
 the fauces, strumous, syphilitic, and cancerous ulceratious; these 
 have been already described. 
 
 3. Diseases of the larynx, as laryngitis and croup; ulcerations of 
 the epiglottis and laryngeal cartilages, whether strumous, syphilitic, 
 or cancerous; tracheal affections. 
 
 4. Inflammation and ulceration of the mucous layer. 
 
 5. Functional disorders of the muscular coat, especially cases of 
 spasmodic stricture of the oesophagus and pharynx. 
 
 6. Paralysis of the muscles of deglutition. 
 
 7. Organic stricture from annular constriction, from syphilitis, 
 from cicatrices, from cancerous disease. 
 
 8. . Obstruction by pressure from without. 
 
 9. Contraction as the effect of corrosive poisons. 
 
 10. Mechanical injury and foreign bodies in the passage. 
 Dysphagia from several of these causes has already been noticed, 
 
 and we shall now have to consider the same symptom under other 
 conditions of disease. Before, however, speaking of difficulty of 
 deglutition as due to a changed state of the muscular fibre, it may 
 be well to advert to those instances where it is produced by affec- 
 tions of the larynx and trachea. 
 
 1 'Virchow's Jahrbuch,' loc. cit.
 
 ON DISEASES OF THE (ESOPHAGUS. 61 
 
 Laryngeal Dysphagia.- In acute laryngitis and in croup, it is the 
 exception to find deglutition performed in the normal manner; and 
 sometimes, especially in laryngitis, dysphagia is an urgent symptom. 
 In these cases, however, the dyspnoea and cough are the earlier and 
 the more marked indications of disease. The epiglottis is found to 
 be injected and tumid, and the branches of the superior laryngeal 
 nerve are rendered intensely sensitive. This abnormal sensibility 
 affords an explanation of the dysphagia which is generally present, 
 even if the mischief do not spread directly to the pharynx. 
 
 Diseases of the laryngeal cartilages rarely extend to the pharynx, 
 unless the malady be of a cancerons character; more frequentlv, as 
 in necrosis, suppuration takes place among the muscles of the neck, 
 and chronic laryngitis of a most intractable form is produced. But 
 although dysphagia is not a prominent symptom of disease when 
 only the cartilages of the larynx are affected, the reverse is the case 
 when the fibre-cartilage, the epiglottis, is also implicated, whether 
 in syphilitic, in strumous, or in cancerous diseases. 
 
 In syphilis, both the glossal and laryngeal surfaces of the epiglottis 
 become involved, and sometimes nearly the whole of the fibro-car- 
 tilage is destroyed, leading to distressing dysphagia; and in phthisis 
 ulceration of the epiglottis is one of the most trying complications 
 of the complaint, the ulceration extending on its inner surface as far 
 as the margin, which becomes eroded and gradually destroyed, and 
 the contact of food with this irritated surface sometimes leads to the 
 instant rejection of it through the nares. In chronic phthisis I have 
 seen this condition attributed to organic disease of the O3sophagus 
 itself, on account of the extreme urgency of the dysphagia, and 
 because the food appeared to have passed below the pharynx before 
 it was forcibly ejected. It sometimes happens that solids are more 
 easily swallowed than fluids; and this is the case in some instances 
 where the dysphagia arises from disease of the larynx; a solid will 
 pass over the diseased epiglottis and fall beyond it, whilst a fluid 
 comes in close contact with it. 
 
 Laryngeal dysphagia is often greatly mitigated by the inhalation 
 of steam, or of the fumes from coniurn or stramonium. In less severe 
 cases astringent gargles, and in syphilitic ulceration the application 
 of a strong solution of nitrate of silver, afford relief by diminishing 
 the extreme sensibility of the diseased surface. Counter-irritation 
 may occasionally be applied with advantage, as the tincture of iodine, 
 hot fomentations, cantharides, &c. The improval of health by resi- 
 dence at the sea-coast, by cod-liver oil, by preparations of iodine, and 
 of steel, and by the use of such forms of nutritious diet as can be 
 taken by the patient, are the means most likely to be followed by 
 enduring benefit. 
 
 With this form of dysphagia may be associated those instances in 
 which inflammation of 'the trachea is the cause of the symptom, and 
 this has been described by Dr. Hyde Salter 1 as " Tracheal dysphagia." 
 The complication of a purely cesophageal disease has been referred 
 to a stretching of the inflamed tracheal surface during deglutition ; 
 
 > Dr. Hyde Salter, ' Lancet,' 1864, vol. ii.
 
 62 ON DISEASES OP THE (ESOPHAGUS. 
 
 but this would equally apply to inflamed and swollen bronchial 
 glands, in which condition no such symptom is produced ; and it is 
 more probable that this symptom is due to the reflex action of the 
 pneurnogastric nerve. Tracheal dysphagia is best treated by inha- 
 lations of soothing remedies, as steam, alone or with ipecacuanha, or 
 with hemlock juice, and by the internal administration of salines, 
 with ipecacuanha or antimony. 
 
 The affections which now come before us are connected with the 
 nervous supply of the part, and with the mental condition of the 
 patient ; they are spoken of as spasmodic dysphagia or spasmodic st r/<-l- 
 ure. In globus hystericus a sensation is produced as of a ball being 
 lodged in the throat, with a painful feeling of suffocation ; it comes on 
 suddenly after emotional excitement or distress, and is oftena symptom 
 of an attack of hysteria, in persons suffering from general debility, 
 and especially where there is disturbance of the uterine functions. 
 The supposed obstruction to the passage disappears when the attempt 
 is made to swallow food. In other cases the sense of cesophageal ob- 
 struction is due to flatulence and to distension of the stomach, and is 
 relieved by the removal of flatus. Again, in irritability of the heart 
 with exhaustion, we occasionally find the same sensation of obstruc- 
 tion and spasmodic choking. It would seern that in these latter cases 
 the recurrent nerve as well as the cesophageal branchesare implicated, 
 for there is greater and more sudden distress of breathing than in 
 simple flatulence. The condition here referred to is one quite dis- 
 tinct from angina pectoris, as well as from the severe dyspnoea of 
 organic disease of the heart and cardiac asthma. It is a curable state, 
 and one that ceases when strength is restored. It is found sometimes 
 in patients who have suffered from nienorrhagia or other causes of 
 exhaustion, and in whom the heart is free from organic disease, 
 although the vessels may be more rigid and atherornatous than in 
 earlier life. 
 
 In severe spinal disease there is also occasionally present a nervous 
 dysphagia, which aggravates the distress of the patient. Another 
 class of cases is connected w r ith mental disease ; for instance, a patient 
 may state that he cannot possibly swallow, that the throat is entirely 
 occluded ; but the malady is in the brain rather than in the gullet ; 
 no attempt is made to perform the act, and the passage of an oesopha- 
 geal bougie will prove that the fears are groundless. These cases 
 may be mistaken for true paralysis. "With great feebleness of mus- 
 cular power the will is unable to excite muscular action ; the muscles 
 of the pharynx appear to be paralyzed, because they are not stimu- 
 lated to healthy contraction, and hence deglutition cannot be per- 
 formed. This condition is very different from the disease of the soft 
 palate already referred to in connection with labio-glosso-laryngeal 
 paralysis. The following interesting case, which was admitted under 
 my care into Guy's Hospital in July, 1856, was a well-marked in- 
 stance of functional dysphagia from the state of the nervous system. 
 
 CASE VI. Dysphagia. Mania, A. B was an emaciated man, a2t, 60, of 
 a dingy and sallow appearance, a gas fitter, who had resided at Deptfbrd. 
 His wife stated, that for several years he had suffered from attacks of extreme
 
 OX DISEASES OF THE (ESOPHAGUS. 63 
 
 irritability ; but that his only complaint was of pain in the region of the trans- 
 verse colon. On the 18th July, he appeared to lose the power both of speak- 
 ing and swallowing, having previously said, " that he did not know what was 
 coming over him." On the 23d he was brought to Guy's Hospital ; he was 
 then prostrate and unable to stand, but could slowly move his legs and arms; 
 his countenance was not without intelligence, and he appeared to understand 
 questions slightly ; he could not protrude his tongue, which remained almost 
 motionless at the floor of the mouth and was dry on its surface ; fluids put into 
 the mouth were retained for a short time, and then ran out again at the an- 
 gles of the lips, but he could not be induced to attempt to swallow ; placing a 
 teaspoon at the back of the mouth excited some action of the muscles ; the 
 pupils were active, the right was rather larger than the left ; the pulse was 56, 
 and compressible ; the heart's action was very feeble ; the respiration was 
 normal 20 per minute, but the air could scarcely be heard to enter the chest. 
 The abdominal muscles were exceedingly rigid, but the abdomen was not dis- 
 tended. Half a drop of croton oil was placed on the back of the tongue, and 
 afterwards, a nutrient enema was administered. On the 24th, my colleague, 
 Mr. Cooper Forster, passed an oesophageal tube into the stomach without any 
 difficulty ; some beef tea thickened with arrowroot was in this way adminis- 
 tered ; the patient afterwards swallowed milk and beef tea, &c., with less diffi- 
 culty, and on the third day began to speak ; he rapidly improved. His mind, 
 however, was not in a clear state, for as soon as he was able to eat. he had 
 the idea that no other patient in the ward had any food. This case closely 
 resembles some of those found in lunatic asylums ; but this patient was unable 
 to make the attempt to swallow ; a condition which might easily have been 
 mistaken for paralysis of the muscles themselves. I have since learned that 
 after leaving the hospital he became violently maniacal. 
 
 A similar condition of nervous dysphagia is observed in hysteria, 
 and occurs in young women of an excitable character, who are suffer- 
 ing from leucorrhoea, or painful menstruation, and impaired diges- 
 tion. The same strong language is used by these patients to express 
 their inability to swallow, and they show the greatest unwillingness 
 even to make the attempt. A young woman about twenty-three 
 years of age, was thus reduced to the greatest prostration, resembling 
 a case of fever. On passing an cesophageal bougie, no obstruction 
 whatever was found ; she afterwards swallowed food in small quan- 
 tities, which was increased day by day until she took the usual 
 amount. Fright, terror, and cold are found to produce spasmodic 
 dysphagia, and we have seen instances of this kind after violent 
 storms of thunder and lightning; but in lesser degrees it is not un- 
 frequent in hysterical subjects. 
 
 Spasmodic stricture of the oesophagus is not limited to women, but 
 may come on suddenly in men, with a sense of extreme dysphagia, 
 almost without apparent cause, and continue for several days, so 
 that the attempt to take food is followed by extreme pain and dis- 
 tress, and the instant rejection of any portion that is swallowed. 
 This spasmodic obstruction of the oesophagus may be superadded to 
 partial narrowing of the tube, and be almost a constant condition for 
 many years, so that great care is required during the process of de- 
 glutition, which must be performed slowly. 
 
 In an instance of this kind, a gentleman found that if he swallowed
 
 04 ON DISEASES OF THE (ESOPHAGUS. 
 
 slowly, and took a deep inspiration at the close of the process, the 
 food passed the diaphragm into the stomach, as if the act of inspira- 
 tion enlarged the cesophageal opening in the diaphragm. 
 
 The following is a remarkable instance of spasmodic affection of 
 the oesophagus. 
 
 CASE VII. A gentleman, get. 65, had enjoyed good health till he was 
 thirty years of age without any difficulty in swallowing. One day whilst 
 taking food he suddenly felt something stick in his throat, and he believed he 
 would be choked. He became blue in the face, and the dyspnoea was great 
 and noisy. By a great effort he managed to force on the morsel of food ; but 
 for months afterwards he had the greatest difficulty in swallowing, and could 
 only take the smallest sips. He improved somewhat, but still had to take his 
 meals with great caution, so much so that he was quite unable to dine even 
 with his family, as he had to masticate over and over again, and he always 
 finished his meal with the feeling of thankfulness that one more was over with- 
 out a stoppage. He was worse at times, and anything cold seemed to excite 
 spasm and almost prevent deglutition ; warm substances were more easy to 
 swallow, and even capsicum lozenges assisted the process. He had never con- 
 sulted any one, and his condition, described almost in his own words, was 
 mentioned accidentally as explaining a meal of dry bread with gentian and 
 ammonia, which he was taking by sips. 
 
 Spasmodic stricture of the oesophagus is very irregular in its recur- 
 rence. 
 
 A patient, set. 75, with degeneration of the vessels and albuminuria, had a 
 peculiar condition of the pharynx. The uvula had been removed many years 
 previously, and the posterior pillars of the fauces were adherent to the poste- 
 rior part of the pharynx, so as almost to obliterate the opening of the pos- 
 terior nares. He, had neither headache nor cough, neither palpitation nor 
 dyspnosa, but every three or four days suddenly whilst at dinner flatulence 
 appeared to cause obstruction in the gullet, then sudden sickness came on 
 and the inability to swallow ; after a short time the passage became free and 
 he could swallow as usual. The peculiar condition of the pharynx in inter- 
 fering with the first part of the process of deglutition did not wholly account 
 for this dysphagia. 
 
 A young gentleman called upon me in great alarm, stating that he 
 had obstruction of the throat, and that he could not swallow. With- 
 out knowledge of the physiology of deglutition he had been making 
 incessant attempts to swallow during eighty miles of railway journey, 
 and the failure had only led to increased efforts, but of no avail be- 
 cause his saliva was exhausted ; a glass of water enabled him to 
 complete the act, and assured him of the absence of disease. 
 
 Abercrombie 1 gives the case of a lady, set. 40, in whom stricture 
 of the oesophagus was supposed to exist. The symptoms continued 
 for a year, and were entirely relieved by passing "an egg-shaped 
 silver ball attached to a handle of silver wire." 
 
 This state, however, is not limited to one sex. Mayo 2 mentions 
 a remarkable instance of spasmodic stricture of the oesophagus in a 
 
 1 Abercrombie on 'Diseases of the Stomach.' 
 
 2 Mayo, 'Outlines of Pathology.'
 
 OX DISEASES OF THE (ESOPHAGUS. '65 
 
 gentleman, set. 60, who had sudden obstruction of the oesophagus 
 whilst at dinner. It was relieved by the passage of a bougie. The 
 brother of the patient, who had suffered from gout, had had a similar 
 seizure. The same author narrates a case of spasmodic stricture in 
 a young man, produced by ulceration of the interior of the larynx. 
 It must be borne in mind also, that spasmodic contraction of the 
 oesophagus tends to increase the obstruction arising from organic 
 causes, so that the degrees of dysphagia in the same case may vary, 
 being modified by this spasmodic complication. 1 
 
 The general symptoms and history aid us in the diagnosis of these 
 diseases : thus, there is an absence of emaciation ; the attack comes 
 on suddenly after a slight cause, as from nervous shock or slight 
 catarrh; there is freedom from pain, but nervous excitement is 
 always present. 
 
 Hot fomentations, the use of fluid instead of solid food for a short 
 time, aperient or antispasmodic enemata, as of turpentine or rue, 
 will afford relief in these cases. Tonics are often of service, as the 
 compound iron mixture with decoction of aloes, or the compound 
 steel pill, with aloes and myrrh; so also quinine, zinc, valerian; 
 vegetable tonics may be used; and the shower bath, good air and 
 exercise, and cheerful occupation of the mind will greatly assist in 
 the restoration to health. 
 
 Bougies are often employed, but their use is not generally bene- 
 ficial, and may be detrimental by tending to perpetuate and aggra- 
 vate a state of spasmodic irritation and contraction; but in cases 
 where the muscles of the pharynx have lost their contractile power, 
 the direct introduction of food is absolutely reqiiired. In some 
 hysterical patients, the refusal to swallow arises from a disordered 
 will rather than from any disease in the oesophagus itself. 
 
 Hulke, under the term cesophagismus, 2 describes the case of a pale 
 emaciated boy, aet. 10, who had vomited both solid and fluid food 
 for four months immediately after swallowing. The ejecta were so 
 unaltered that it was thought they could not have passed into the 
 stomach, and a probang seemed to meet with obstruction a short 
 distance from the cardia. Before his illness he had been healthy 
 and stout. He was very excitable and his mother was hysterical; he 
 was quite cured by careful feeding and moral suasion. 
 
 Paralysis of the muscles of deglutition may be either functional 
 or due to organic disease of the nervous centres. 
 
 A good instance of the functional disease is found in diphtheritic 
 paralysis described on p. 48. When due to organic disease of the 
 brain the paralysis of the muscles of deglutition is generally observed 
 immediately to precede the paralysis of the respiratory muscles, and 
 
 1 See also Sir James Paget, ' Lancet,' Jan. 7th, 1871. He considers hysterical or 
 spasmodic stricture of the esophagus as the homologue in the pharynx or oesophagus 
 of that want of harmony hetween the organs of speech and respiration which produces 
 stammering, and that it is due to unruly contraction of certain fibres of the oesopha- 
 gus. The degree of contraction varies" in different cases, in some only compelling 
 them to take their meals apart, in others bringing about starvation and requiring 
 the use of enemata. 
 
 2 ' Clinical Soc. Trans.,' vol. vi, p. 52. 
 
 5
 
 66 ON DISEASES OF THE OESOPHAGUS. 
 
 is looked upon, correctly, as a common sign of approaching death. 
 The nervous centre of the function of swallowing is close to that of 
 respiration, and there is an intimate connection between them. 
 Where there is loss of the power of deglutition, the placing of fluid 
 in the mouth will be followed by its entrance into the larynx, or by 
 violent cough, or it may even hasten death. 
 
 We not urifrequently, however, observe, in cases of cerebral dis- 
 ease, when the muscles of the tongue are paralyzed, that the swal- 
 lowing, especially of solids, becomes exceedingly difficult. This 
 difficulty arises from the movements of the tongue being restrained, 
 for the bolus of food cannot be formed, nor pushed back into the 
 fauces; fluids are more easily swallowed, because more readily 
 brought within the action of the true muscles of deglutition. Under 
 such circumstances the introduction of nourishment by an elastic 
 tube has been the means of prolonging life; it is probable that the 
 muscular fibres of the oesophagus have diminished contractile power 
 in these cases. The most severe instances of .this condition are to 
 be found in glosso-laryngeal disease already referred to. 
 
 Another class of cases are those connected with mental disease, 
 some of which may easily be mistaken for true paralysis. With 
 great feebleness of muscular power, we may find that the will is 
 unable to excite muscular action; that the muscles of the pharynx 
 appear paralyzed, because they are not stimulated to healthy contrac- 
 tion, and hence deglutition cannot be performed. 
 
 Hypertrophy of the muscular coat requires no lengthened descrip- 
 tion, since it is invariably associated with obstruction in some part 
 of the tube ; for the obstruction is almost always caused by stricture, 
 which leads to the hypertrophy ; but there is a case in the Guy's 
 Post-mortem Records of a very much hypertrophied oesophagus 
 where the only explanation was a large heart with mitral imperfec- 
 tion. The muscular coat was especially thick opposite the enlarged 
 heart. 
 
 Dilatation of the (Esophagus. Pouch. Three forms of dilatation 
 of the coats of the oesophagus and pharynx are met with ; in the 1st 
 the canal is uniformly dilated ; in the 2d a pouch or bag is formed, 
 consisting of all the coats ; and, in the 3d, there is a hernial protru- 
 sion of the mucous membrane .penetrating through the muscular 
 coat. 
 
 The first is found occasionally present in organic occlusion of the 
 oesophagus, especially where it is of a non-malignant character, and 
 of slow formation. Mayo, in his ' Outlines of Pathology,' narrates 
 
 a remarkable instance of oesophageal dilatation. " Mary B , aet. 
 
 83, ill for ten years, was in a state of extreme debility and emaciation ; 
 the food was returned in three or four minutes mixed with mucus, 
 and death took place from inanition. The oesophagus from its junc- 
 tion with the pharynx, which was rather less capacious than usual, 
 was enlarged to an extraordinary degree of dilatation. The greatest 
 width that it attained exceeded two and a half inches when distended, 
 and occurred about four inches above the cardia. The tube then 
 narrowed more abruptly, so as to render the cardiac termination like
 
 ON DISEASES OF THE (ESOPHAGUS. 67 
 
 the pharyngeal of nearly the usual dimension. The structure of the 
 cardiac end for about an inch, and that of the pharyngeal end for 
 about an inch and a half, was healthy. Intermediately the lining 
 tunic was thickened and opaque ; the mucous membrane had the 
 appearance of having yielded or opened into flat shallow depressions, 
 which followed a longitudinal direction above, and below formed 
 irregular pits. At the depressed surfaces, the membrane had the 
 natural color; between them, it was opaque and whitish. The mus- 
 cular fibres were normal in color and thickness ; they had grown 
 with the expansion of the canal." 
 
 In vol. x of the ' Pathological Transactions' Dr. Barker has re- 
 corded an instance of dilatation of the oesophagus commencing two 
 inches below the rima, and forming an ovoid swelling the size of a 
 swan's egg in the posterior mediastinum. There was a strumous 
 deposit in the bronchial glands forming masses as large as the fist, 
 and firmly adhering to the front of the oesophagus and of the trachea, 
 and connected with fibrous tissue surrounding the origin of the great 
 vessels. There was also a perforating ulcer in the duodenum, com- 
 municating with a small abscess in the peritoneum. 
 
 As to the second form, consisting of a muscular pouch, Mr. C. "W. 
 Worthington, in vol. xxx of the "Trans, of the Eoyal Med. and Chir. 
 Society,' narrates an instance under his own care. A gentleman, aet. 
 60, three years before his death, suffered from slight dysphagia, which 
 gradually became extreme, with progressive emaciation, and for 
 three weeks he was sustained by injections. The oesophagus was 
 constricted at the commencement, so that an urethral bougie was 
 alone capable of being passed. Opposite the cricoid cartilage, be- 
 tween the trachea, the oesophagus, and the cervical vertebrae, was a 
 pouch three and a half inches in length, like the finger of a glove ; 
 two-thirds of it were covered by the muscular fibres of the constric- 
 tors ; the opening into the pouch was free. The mucous membrane 
 of the oesophagus at the constricted part was healthy. The same 
 author quotes from Sir Charles Bell an instance of Mr. Ludlow's of 
 a muscular pouch, between the oesophagus and vertebras, in a man 
 a3t. 60, who had dysphagia for five years; and also mentions from 
 Sir Charles Bell one of the third form of pouch, consisting only ot 
 mucous membrane protruded through the muscular layer. This last 
 form may be free from any symptom. A case of this kind recently 
 occurred' at Guy's Hospital : J. C , aet. 28, was brought in a dying 
 state with peritonitis from perforation of the ileum during typhoid 
 fever. At the commencement of the oesophagus was a pouch half 
 an inch in length, consisting of the mucous membrane, and very 
 slightly covered at the neck of the pouch by a few muscular bands ; 
 it was full of mucus. (Prep. 1784 72 .) 
 
 An interesting case of pouch-like dilatation of the lower part of 
 the pharynx in a man. aet. 63, who had suffered from dysphagia for 
 many years, is recorded in the 'Path. Soc. Trans.,' vol. xvii, p. Ml. 
 The upper part of the pharynx was enlarged, with the muscles hy- 
 pertrophied. At the lower border of the inferior constrictor of the
 
 68 ON DISEASES OF THE (ESOPHAGUS. 
 
 pharynx was a pouch of mucous membrane, the size of a bantam's 
 egg, projecting downwards behind the oesophagus. 
 
 Some of these oesophageal pouches are probably of congenital ori- 
 gin ; two interesting cases of congenital defect were brought before 
 the Pathological Society by Dr. Herbert Ilott, and are published in 
 the ' Transactions' for 1876. The oesophagus terminated in a thick 
 pouch on the posterior surface of the trachea, a little below the cri- 
 coid cartilage, and a probe could be passed from the stomach upwards 
 through the terminal portion of the oesophagus into the trachea, and 
 it is this state that is usually observed in malformation of the oeso- 
 phagus. 
 
 III. Organic obstruction of the oesophagus arises from conditions 
 which may be internal in their character or they may be produced 
 by external pressure. The former, internal, may be from annular 
 constriction, from syphilis, from ulceration and cicatrices, and from 
 cancerous disease. 
 
 External obstruction arises from pressure of aneurismal or medias- 
 tinal tumors, from disease of glands, from effusions into the pleura 
 and pericardium, and from inflammation in the mediastinum and ab- 
 normal arrangement of the vessels. 
 
 The history of the symptoms will alone enable us to distinguish 
 these cases from each other. In some of them, we may hope that 
 remedial means may be successfully used which have hitherto scarcely 
 been fairly tried; in other cases, it is evident that nothing can be 
 done for cure, but the pain and the severity of the symptoms may be 
 mitigated. 
 
 Annular constriction of the oesophagus consists in the formation of 
 inflammatory material in the submucous cellular tissue ; the new 
 tissue contracts, and becomes exceedingly dense, forming a firm con- 
 stricting band, whilst the tube above dilates, and this obstruction 
 increasing, at last the passage of food becomes impossible. 
 
 The cause of simple contraction of the oesophagus is very obscure ; 
 it generally occurs towards the lower part, and sometimes the history 
 shows that dysphagia had been present in early life. 1 Sir Everard 
 Home 2 also refers to instances in which difficult deglutition has been 
 present from infancy, or, as in a case recorded by Dr. Fagge 3 only 
 from middle life. 
 
 The oesophagus is developed by the formation of a groove in the 
 layers of the germinal membrane, and this groove is subsequently 
 converted into a tube. Interference with the process of develop- 
 ment may lead to irregularities in the size of the tube and occasion- 
 ally also to its complete obliteration, and in this way some cases of 
 simple narrowing of the oesophagus may be explained, as well as 
 those instances of rare occurrence in which the canal ends in a blind 
 extremity. 4 
 
 1 'Path. Soc. Trans.,' vol. xvii, p. 138. 
 
 2 ' Practical Observations on the Treatment of Stricture in the Urethra ami in the 
 (Esophagus.' 
 
 3 'Guy's Hospital Reports,' 3 ser., vol. xvii, p. 413. 
 Porro, 'Syd. Soc. Bien. Retr.,' 1871-2, p. 152.
 
 ON DISEASES OP THE 03SOPHAGUS. 69 
 
 In reference to congenital defect, we may mention that an obstruc- 
 tion sometimes exists at the upper part, and is due to a membranous 
 fold across the canal ;* but this is easily explicable when we remem- 
 ber that the pharynx is formed separately from tie oesophagus, and 
 afterwards opens into it. Any failure of perfect obliteration of the 
 intervening septum will lead to the condition referred to, and in a 
 similar manner, but more frequently, malformation is observed in 
 the rectum, which being developed on the same plan remains as a 
 blind pouch. 2 
 
 AHien the dysphagia has not appeared till late in life the con- 
 striction may still have been due to congenital defect, the compensa- 
 ting hypertrophy of the muscular coats having for a time overcome 
 the impediment. At length, failing to do so, or ordinary senile 
 changes leading to the degeneration of the muscular fibre, dilatation 
 of the canal and obstruction ensue. 
 
 Syphilitic stricture of the oesophagus is not a common disease, and 
 the pathological evidence of the existence of such a condition is still 
 imperfect. In the ' Dublin Quarterly Journal of Medical Science,' of 
 February, 1860, Mr. J. West described two cases of dysphagia occur- 
 ing in young girls where the symptoms gradually increased, and at 
 length led to a fatal result ; four inches down the oesophagus there 
 was a constriction arising from the formation of fibrous material in 
 the submucous tissue. Disorganization of the lungs had taken place. 
 Mr. .West believed that the disease in each case was of syphilitic 
 origin. The same author makes a further contribution on the same 
 subject, in the 'Lancet' for 1872, 3 supporting his previous views and 
 quoting from various authors. Reference to the post-mortem records 
 at Guy's Hospital gives three cases which were probably of a syphi- 
 litic character. 
 
 The first case was a woman, aet. 32, in whom a firm stricture was 
 located at the termination of the pharynx ; the second case was a 
 woman, eet. 43, pregnant at the time of her death. Around the 
 pharynx opposite the mucous folds of the glottis were irregular 
 excavated ulcers with thick margins. 
 
 The third case I give in more detail. 
 
 CASE VIII A man aet. 48, who was under my care in Guy's, had been 
 
 a tobacco-cutter by trade, and when seventeen years of age had rheumatic 
 fever. When twenty-seven he had syphilis ; he had been intemperate in his 
 habits. His illness commenced four months before admission into the hospital, 
 and it was attributed to cold. He experienced soreness of the throat, which 
 gradually became more severe and was accompanied with difficulty in 
 swallowing. The dysphagia soon became so extreme that he could only 
 swallow a small quantity of fluid food. Two months later he became affected 
 
 1 Crisp, 'Path. Soc. Trans.,' vol. xxiii, p. 128. 
 
 2 For some further information on this point and on that of oesophageal fistulse, their 
 origination in permanent conditions of the brachial clefts and the likelihood of the ex- 
 istence of a communication between the trachea and the oesophagus in such cases, 
 the reader is referred to the ' Surgical Diseases of Childhood' by Mr. Holmes. 
 
 3 "On Syphilitic Constriction of the (Esophagus and Pharynx," 'Lancet,' August 
 1st, 1872.
 
 70 OX DISEASES OF THE (ESOPHAGUS. 
 
 with severe pain on the right side of the neck ; the pain passed upwards in 
 the course of the lesser occipital nerve, cough also came on. He was pale 
 and had a cachectic appearance, and emaciated rapidly. His voice was weak, 
 but not hoarse. Thfcre was an enlarged rery hard gland, situated beneath 
 the right sterno-mastoid muscle; other smaller glands could also be felt. 
 The breath was offensive and the tongue furred. When deglutition was 
 attempted he experienced gieat pain, and only a very small quantity of food 
 passed down the oesophagus, and very frequently it was forcibly ejected 
 through the nares. There was no stridulous respiration, but the throat was 
 too sensitive to permit an examination to be made with the laryngoscope. 
 When the finger was introduced as far as the pharynx the epiglottis was 
 found to be free from disease, but beyond it at the posterior and lower part of 
 the pharynx a raised and hard swelling could be felt ; this was at the com- 
 mencement of the oesophagus opposite to the cricoid cartilage. There was 
 dulness at the apex of the lung on the right side, with bronchial breathing 
 and bronchophony. He was unable to take cod-liver oil, but the avoidance 
 of solid food afforded some relief. The dysphagia again increased, but was 
 relieved by the use of nutrient injections, thus allowing the throat to rest. 
 These injections were after a short time quite ineffective, and as the distress 
 and emaciation became extreme, gastrotomy was proposed. The patient 
 suffered from pain in the course of the descending branches of the cervical 
 nerves from the pressure of the enlarged glands in the neck. It was felt that 
 unless some relief was speedily afforded the patient would rapidly sink, and 
 on the 24th Mr. Bryant proceeded to open the stomach. For twenty-four 
 hours the stomach was allowed to rest and nutrient injections were given by 
 the rectum ; food in small quantity was then introduced into the stomach. 
 The patient was free from pain, and said that he felt better for the food. On 
 the 28th he became very prostrate and occasionally delirious ; food introduced 
 by the opening into the stomach flowed out, but nutrient injections were con- 
 tinued into the rectum as long as they could be borne. He died on the .'Sotli, 
 5^ days or 130 hours after the operation. On inspection, ten hours after 
 death, the wound in the parietes was perfectly united to the stomach, and 
 there was no peritonitis ; the serous membranes had become adherent. At 
 the commencement of the oesophagus and the termination of the pharynx was 
 an oval ulcer about two inches in length ; it was hard and its edges were 
 slightly raised and puckered ; its surface was granular, and it had extended 
 forwards to the larynx, leaving, however, a strip of healthy mucous mem- 
 brane. In the larynx on the left side was a small ulcer one-eighth of an 
 inch in diameter .on a raised base, and the thickening extended to the poste- 
 rior part of the left vocal cord. There were several glands in the neck filled 
 with yellow low organized deposit. The right pleura was adherent at the 
 upper part, and at the apex of the lung was a small irregular cavity bounded 
 by dense iron-gray deposit. The whole of the lower lobe of the right lung 
 was acutely diseased, consolidated, and in a state of red and gray hcpatiza- 
 tion. The left lung contained some softening patches of pneumonia, resem- 
 bling pytemic inflammation. The heart was atrophied ; the kidneys were 
 small, but healthy ; the colon contained fecal matter in its whole length, but 
 the small intestine was contracted. 
 
 The following instance was probably due to syphilitic disease; the 
 very gradual onset, thfc long duration, the partial recovery under 
 anti-syphilitic remedies, tended to support this opinion. 
 
 CASE IX A lady, aet. 40, for many years had suffered from water-brash, 
 
 and for six or seven years before death had had pain in the oesophagus on
 
 ON DISEASES OF THE (ESOPHAGUS. 71 
 
 swallowing. She stated that the food appeared to stop at the centre of the 
 (esophagus ; for two years she had suffered from the excessive discharge of 
 mucus and saliva, with thirst. These symptoms and the dysphagia were 
 relieved by the use of myrrh and aloes; the dysphagia, however, increased, 
 and a year before her death she was unable to swallow any solid food. In 
 May, 1874, she vomited an elongated clot the size of the finger. In July 
 dysphagia increased in severity, but her principal complaint was of flatulence 
 and the discharge of mucus. The mucous membrane of the throat was granu- 
 lar, the abdomen was contracted, and there was no pain at the region of the 
 stomach. Mr. Durham passed a bougie nearly into the stomach on July 
 13th, and a few days later a smaller one into the stomach. The size of the 
 bougie was increased, and soon afterwards the patient could swallow much 
 more easily. There was a suspicion, from the fact of her having had mis- 
 carriages and no living children, that the disease might be syphilitic in char- 
 acter, and perchloride of mercury with iodide of potassium were given. The 
 relief was considerable, and for several months she was in comfortable health. 
 During the spring of the following year the dysphagia returned, with the same 
 complaint of mucous secretion. She was urged to allow the former treatment 
 to be followed, but it was postponed till the June of 1875, when exhaustion 
 had become extreme, and she sank at the beginning of July. No inspection 
 was made. 
 
 The relief that was afforded by perchloride of mercury and iodide 
 of potassium, and the introduction of the bougie, as well as the very 
 gradual onset of the complaint, led us to suspect syphilitic disease 
 as the cause of the obstruction ; and, it is to be regretted, that the 
 same plan of treatment was not pursued when the symptoms re- 
 turned. 
 
 Three other cases of simple stricture are recorded in the 'Patholo- 
 logical Society's Transactions,' the ages of each being respectively 
 fifty-five, fifty four, and forty-four. In these cases, two males and 
 one female, tlie disease was in the middle or in the lower part of the 
 tube. Dr. Moxon mentions, that he has once met with syphilitic 
 gummata in the oesophagus. It is, however, probable that many 
 instances of syphilitic obstruction occur which are cured by the use 
 of perchloride of mercury and iodide of potassium; for it is well 
 known that these diseases affecting the pharynx as well as the 
 larynx, rapidly improve under treatment. Bougies may be of great 
 service in restoring the calibre of the canal, but great care must be 
 employed in their introduction; for disastrous consequences have 
 followed their injudicious use in cases of ulceration. 
 
 Whilst referring to syphilitic disease we may mention a specimen 
 in the Hunterian Museum of the Koyal College of Surgeons, in which 
 a gummatous tumor in the liver had pressed upon the oesophagus, 
 and had caused obstruction. 
 
 Another form of organic stricture is from the contraction of cica- 
 trices; some of these cases may be from old syphilitic disease, or they 
 may result from ulceration originating in other causes, as disease of 
 the bronchial glands. The most frequent cause is the contraction 
 consequent upon the action of corrosive poisons or hot liquids in 
 early life. Of thirty -five cases of stricture of the oesophagus met
 
 72 ON DISEASES OF THE (ESOPHAGUS. 
 
 with by Keller 1 in five years, all were traced to the action of caustic 
 potash. A case of cicatrix in the oesophagus was under my care 
 some time ago in a man, set. 62. He had had some oedema of the 
 arms, as if from venous obstruction. A cicatrix of an ulcer w;is 
 found in the upper part of the oesophagus. Its surface was hard 
 and puckered, and tough fibrous tissue was observed on the outer 
 side. These cases, like the instances of congenital stenosis already 
 recorded, survive for a considerable period. An instance is men- 
 tioned in the 'Lancet' of a gentleman who had swallowed sulphuric 
 acid when two years of age, and for thirty years did not require any 
 treatment. We shall again have to refer to these cases in speaking 
 of the action of poisons. 
 
 In recorded cases of annular stricture, the obstruction has gradu- 
 ally increased in severity, and unless we have a history of poison 
 having been taken, or of the discharge of pus from an abscess, we 
 know of no direct symptom by which this form of obstruction can 
 be distinguished from that arising from cancerous disease. The 
 passage of a bougie may reveal to us the presence and position of 
 the obstruction without indicating its true character, but the mucus 
 from the bougie should be examined, and this may sometimes guide 
 to a correct diagnosis. A further means of diagnosis and also of 
 treatment has lately been advocated in auscultation of the oesopha- 
 gus by Dr. Hamburger ('Wien Med. Jahrb.,' xv, 2) and Dr. Clifford 
 Allbutt ('Brit. Med. Journal,' Oct., 1875); others have also confirmed 
 the value of the suggestion, and I have no doubt that the passage of 
 fluid may be heard passing down the tube and impinging against a 
 definite obstruction. 
 
 In Cancerous Diseases of the (Esophagus and Pharynx the symp- 
 toms are very similar to those mentioned as occurring in ulceration 
 of the oesophagus ; the patients are generally beyond the middle 
 period of life, but it occurs at an earlier period- in women than in men, 
 and difficulty in swallowing, which gradually increases in severity, 
 is the most prominent symptom. In some instances, however, the 
 dysphagia does not become extreme till the extension of the cancer- 
 ous ulceratiou to the lungs, or to other structures, leads to symptoms 
 which almost mask the original disease ; vomiting, or rather regurgi- 
 tation of the food, is always present in a greater or less degree. The 
 commencement of the disease is often very insidious, and attributed 
 to indigestion; flatulence may be complained of, and this is often re- 
 garded by the patient as the cause of the food not reaching the stom- 
 ach. There is also pain at the sternum, in the back, and sometimes 
 in the upper part of the throat, of a dull or burning character ; but 
 its intensity varies greatly. The obstruction of the canal leads to 
 the regurgitation of the saliva, and as this fluid accumulates it at 
 length reaches the epiglottis and cough is then produced ; patients 
 often complain of these symptoms as their sole malady, and also of 
 
 1 This author states that most of these cases were in children from two to four 
 years of age ; 23 were cured, 3 improved, 4 remained under treatment, 5 died. They 
 were treated by bougies, and the duration of the treatment was from three months to 
 one year and a half. Keller, ' Schmidt's Jahrbuch.,' vol. 118, p. 35.
 
 OX DISEASES OF THE (ESOPHAGUS. 73 
 
 flatus regurgitated from the stomach. Dyspnoea comes on when the 
 trachea or bronchi are involved, and is occasionally associated with 
 loss of voice, especially in those cases in which the disease is situated 
 at the base of the pharynx, when it extends into the larynx. The 
 dysphagia and emaciation increase, and after six or seven months the 
 disease generally proves fatal. 
 
 In organic obstruction of the oesophagus, and especially in that of 
 a cancerous kind the dysphagia is very peculiar ; the patient hesi- 
 tates in making the attempt to swallow, he takes a considerable time, 
 as it were, to prepare the muscles of the pharynx for the effort, and 
 when the attempt is made, the food or fluid is at once rejected : and 
 sometimes severe suffocative cough is produced. 
 
 Mr. Travers 1 thus describes cancerous disease of the pharynx and 
 oesophagus: " Scirrhous strictures followed by ulceration and cancer- 
 ous fungus are met with in the pharynx and the top of the oesopha- 
 gus in elderly persons, chiefly females, in rny experience. They are 
 productive of constant nausea, dry burning sensation in the throat 
 and stomach; difficult breathing, frequent spasms, and alarms of suf- 
 focation, and excessively impeded deglutition; upon the gentlest in- 
 troduction of the finger or bougie, hemorrhage follows, which after- 
 wards becomes spontaneous. The patient has a faded sallow coun- 
 tenance, a disturbed circulation, and is emaciated to a skeleton." 
 
 Haematemesis is sometimes a symptom of cancer of the oesophagus. 
 Dr. Bristowe exhibited at the Pathological Society a specimen of 
 ulceration of the oesophagus, extending into enlarged veins, and caus- 
 ing fatal hemorrhage ; and in another instance recorded by him, the 
 superior intercostal artery was opened by cancerous ulceration. The 
 hemorrhage produced by the extension of cancerous ulceration is 
 occasionally repeated several times in the progress of the disease, it 
 indicates its progressive character, and is often the precursor of a 
 fatal result. Dr. Balding, at the same Society in 1857, showed an 
 ulcer of the oesophagus of doubtfully cancerous character, in which 
 a sloughing cavity connected with the oesophagus had also formed a 
 communication with the right subclavian artery. The walls of the 
 aorta are often partially injured, and in some cases perforated, thereby 
 leading to sudden and fatal hemorrhage. 
 
 Sometimes the lymphatic glands are enlarged in the neighborhood 
 of the cancerous mischief, and it is well always to examine the neck 
 and axilla for evidence of glandular disease. Pressure on the bronchi 
 from similar enlargement leads to greater distinctness of respiration in 
 one lung than in the other; this, however, is also a sign of aneurismal, 
 or, in fact, of any kind of tumor exerting direct pressure on adjoining 
 structures, and is only of corroborative value. 
 
 In cancerous obstruction of the oesophagus we do not generally 
 find much distension of the canal above the seat of the disease ; for 
 the ulcerated surface leads to excessive irritability, and food is very 
 quickly regurgitated ; or a state of spasmodic contraction equally 
 favors 'the instantaneous rejection of ingesta. Dr. Alderson, however, 
 
 i ' Med. Chir. Trans.,' vol. xv, p. 252.
 
 74 ON DISEASES OF THE (ESOPHAGUS. 
 
 in writing on Carcinoma of the (Esophagus, mentions that "imme- 
 diately after deglutition, there is a remarkable bulging out or pro- 
 trusion of the oesophagus above the strictured point ; it is, in fact, a 
 bag or pouch, which is formed by the effort of the patient to swallow 
 a larger quantity of food than the oesophagus, in its natural state, 
 can contain." In annular obstruction of a non-cancerous nature, the 
 canal becomes more enlarged and dilated ; the disease' is of a more 
 chronic character, and there is less sensibility of the surface than in 
 true cancer. Monro 1 mentions an instance in which as much ;is ;i 
 pint of fluid could be retained for ten minutes. This general dilata- 
 tion of the oesophagus above an obstruction must be distinguished 
 from pouches connected with the canal, and already mentioned. 
 
 Epithelial cancer is the most frequent form of disease, but medul- 
 lary and scirrhous cancer also occur, the latter being the more rare 
 of the two; adenoid tumors are also observed. In numerous in- 
 stances, the growth has presented modifications of epithelial scales ; 
 some cells had very large nuclei, other growths showed large nuclei 
 thickly set together, or brood cells. Papillae are sometimes observed 
 on the surface of the growth, covered by healthy squamous epithe- 
 lium, and containing capillaries filled with blood or leucocytes. 
 Other papillae closely resemble brood cells, their central portion con- 
 taining nuclei and nucleated cells, and surrounded by flattened scales 
 or cells resembling epithelium. It appears probable, that in some 
 cases degeneration of papillse may lead to the formation of these 
 clusters of cells, rather than endogenous growth or other methods. 
 The disease generally extends by mere contiguity of structure, in- 
 volving the adjoining bronchial glands at the root of the lungs, and 
 thereby encroaching upon the bronchi : pneumonia is thus frequently 
 set up, and if sloughing occur gangrene of the lung follows. I have 
 several times found the pneumo-gastric nerves destroyed on one or 
 both sides ; and this destruction of nerve supply induces congestion 
 of the lungs, which is followed by pneumonia, without actual exten- 
 sion of disease into the lung passages. 
 
 The glands and other viscera are less commonly implicated in 
 epithelial cancer, although cases occur in which cancerous elements 
 are discovered in other structures besides that primarily affected, as 
 in the liver, pancreas, stomach, suprarenal capsules, &c. In the liver, 
 lungs, and pancreas, cells of an epithelial character, and precisely 
 similar to those found in the ulcerated oesophagus, have been ob- 
 served. In the lungs cancerous tubercles may exist with pneumonic 
 deposit. Mr. H. Gray records a case of villous and epithelial cancer 
 at the termination of the pharynx, in the ' Pathological Transactions' 
 of 1855 ; and at the termination of the oesophagus colloid cancer has 
 been observed. 
 
 Sometimes the cancerous ulceration extends through the dia- 
 phragm after destroying the oesophagus. In a case of this kind a 
 large sloughing cavity was formed, bounded by the pancreas, spleen, 
 and diaphragm, and it communicated with the posterior mediastinum 
 
 1 Monro 'On Morbid Anatomy of the Gullet, Stomach, and Intestine.'
 
 ON DISEASES OP THE (ESOPHAGUS. 
 
 75 
 
 by an opening in the diaphragm. Immediately behind the pericar- 
 dium was a large sloughing cavity, presenting above the truncated 
 .oesophagus and pneumogastric nerves, and terminating below as just 
 described. It was surprising that the patient could have lived as 
 long as he did, but only three days before death he took a railway 
 journey, and was not at all aware of his perilous condition. In 
 another case there was a remarkable absence of pain, although food 
 was liable to be at once rejected. 
 
 Mondie"re, in ' Arch. Ge*n. de He'd.,' torn, xxx, mentions from 
 Keppelhont a case in which ulceration of the cardia aud oesophagus 
 communicated with an abscess of the liver; and also from Dr. 
 Anesaut, an instance of scirrhous ulceration of the inferior part of 
 the oesophagus, rendered fatal by extension to the spinal cord. 
 
 The fatal issue arises from several causes, but these may generally 
 be arranged into two divisions. 1st. Inanition, the dysphagia having 
 become complete ; and 2dly, from the extension of the disease to the 
 lung or the surrounding tissues. The character of the disease of the 
 lung deserves our especial attention. In only 12 instances out of 59 
 did death result from simple inanition, and even in these the lungs 
 were not altogether free from disease. In these cases the wasting 
 may produce mental disturbance or even delirium. 
 
 The mind is sometimes found to wander in consequence of the im- 
 perfect supply of nourishment to the brain, or septic changes take 
 place, and the blood is thereby rendered impure ; again, inflammation 
 of the lung may prevent the arterialization of the blood, and hence 
 the cerebral symptoms. 
 
 Pneumonia was found in 
 
 Gangrene of the lung in 
 
 Pleurisy in 
 
 Secondary cancer of other viscera 
 
 Inanition 
 
 Hemorrhage . 
 
 Local suppuration round growth 
 
 20 cases. 
 11 
 
 1 
 
 10 
 12 
 
 2 
 
 3 
 
 59 
 
 As to the causes of the pneumonia, 1st. The pressure upon or 
 destruction of the pneumogastric is followed by acute pneumonia on 
 the same side, or by gangrene ; as we observed in several cases men- 
 tioned in the annexed table. 2d. The pneumonia appears to result 
 from the extension of disease into the bronchi, setting up, if not 
 pneumonia, acute bronchitis or laryngitis. 3d. The sloughing of the 
 cancer is followed by septic changes in the blood, and consequent in- 
 flammation of the lungs. 4th. Cancerous growth or tubercles in the 
 lung acts as the cause of congestion and inflammation. 5th. Stru- 
 mous disease of the lung may already exist.
 
 76 
 
 ON DISEASES OF THE (ESOPHAGUS. 
 
 Table of Cases of Cancer of (Esophagus and Pharynx. 
 
 No. 
 
 Sex. 
 
 Age. 
 
 Seat. 
 
 1 
 
 M. 
 
 45 
 
 Upper part to root of lung 
 
 2 
 
 M. 
 
 50 
 
 An inch from trachoal bifur- 
 
 
 
 
 cation 
 
 3 
 
 M. 
 
 73 
 
 Opposite root of lung 
 
 4 
 
 F. 
 
 63 
 
 Whole length of tube 
 
 5 
 
 F. 
 
 32 
 
 Commencement 
 
 6 
 
 F. 
 
 38 
 
 At bifurcation of trachea 
 
 7 
 
 F. 
 
 54 
 
 At bifurcation 
 
 8 
 
 M. 
 
 45 
 
 Ditto 
 
 9 
 
 M. 
 
 66 
 
 Upper part ? 
 
 10 
 
 M. 
 
 49 
 
 Two inches above bifurcation 
 
 
 
 
 of trachea 
 
 11 
 
 M. 
 
 57 
 
 Cardiac end 
 
 12 
 
 M. 
 
 64 
 
 Bifurcation of trachea 
 
 13 
 
 M. 
 
 71 
 
 An inch above bifurcation 
 
 14 
 
 M. 
 
 63 
 
 At centre 
 
 15 
 
 F. 
 
 31 
 
 Pharynx and palate 
 
 16 
 
 M. 
 
 50 
 
 From commencement to bi- 
 
 
 
 
 furcation of trachea 
 
 17 
 
 M. 
 
 53 
 
 From three inches down, to 
 
 
 
 
 cardia 
 
 18 
 
 M. 
 
 45 
 
 Root of lung 
 
 19 
 
 M. 
 
 69 
 
 From cricoid to root of lung 
 
 20 
 
 M. 
 
 47 
 
 Above the root, behind ma- 
 
 
 
 
 nubrium 
 
 21 
 
 F. 
 
 60 
 
 Centre 
 
 22 
 
 M. 
 
 68 
 
 Pharynx 
 
 23 
 
 M. 
 
 45 
 
 Ditto 
 
 24 
 
 M. 
 
 49 
 
 Ditto 
 
 25 
 
 F. 
 
 30 
 
 Ditto 
 
 26 
 
 F. 
 
 57 
 
 Ditto 
 
 27 
 
 F. 
 
 35 
 
 Upper oesophagus 
 
 28 
 
 F. 
 
 60 
 
 Ditto 
 
 29 
 
 F. 
 
 
 
 Ditto 
 
 30 
 
 M. 
 
 71 
 
 From cricoid downwards 
 
 
 
 
 three inches 
 
 31 
 
 F. 
 
 43 
 
 Upper oesophagus 
 
 32 
 
 M. 
 
 52 
 
 Ditto 
 
 33 
 
 M. 
 
 39 
 
 Ditto 
 
 34 
 
 M. 
 
 48 
 
 Ditto 
 
 35 
 
 F. 
 
 35 
 
 Upper oesophagus, three 
 
 
 
 
 inches 
 
 36 
 
 M. 
 
 
 
 Long stricture from cricoid 
 
 Complications. 
 
 Sloughing pneumonia ; 
 involved. 
 
 pneumogastric 
 
 Communication with trachea ; pneumo- 
 nia ; granular kidneys. 
 
 Gangrene of lung ; cancer of thyroid and 
 cervical glands. 
 
 Cancer of stomach, liver, pancreas, and 
 lung ; chronic pneumoTiia ; destruction 
 of the pneumogastric nerve : disease of 
 semilunar ganglion ; granular kidneys. 
 
 Laryngitis ; death from apncea. 
 
 Trachea opened ; cancer of lung and 
 kidney. 
 
 Inanition. 
 
 Gangrene of lung. 
 
 Acute pleurisy ; granular kidneys. 
 
 Trachea perforated ; gangrene of lung. 
 
 Gangrene of lung. 
 
 Trachea opened ; pleuro-pneumonia. 
 
 Pneumonia; pneumogastric nerve in- 
 volved. 
 
 Pneumonia ; pneumogas tries involved ; 
 pericardium opened. 
 
 Struinous (caseous) pneumonia. 
 
 Pneumonia ; pneumogastric nerve in- 
 volved. 
 
 Left bronchus opened ; pneumogastric in- 
 volved ; extension of disease through 
 the diaphragm. 
 
 Pneumogastric nerves truncated ; slough- 
 ing extending into the lung and through 
 the diaphragm. 
 
 Acute and chronic pneumonia ; pneumo- 
 jastrics free. 
 
 Inanition ; slight lobular pneumonia ; 
 gastrotomy. 
 
 Perforation of the aorta ; fatal hemor- 
 rhage. 
 
 Sloughing lung. ^ 
 
 Pneumonia. 
 
 Hemorrhage ; dyspnoea. 
 
 Sloughing lung ; tracheotomy. 
 
 Local suppuration. 
 
 Local suppuration ; sudden death. 
 
 Inanition ; lobular pneumonia. 
 
 Secondary cancer of the bones. 
 
 Lobular pneumonia ; perforation of % tra- 
 chea. 
 
 Pneumonia. 
 
 Inanition ; gastrotomy. 
 
 Gangrene of lung ; secondary cancer of 
 serous membranes. 
 
 Perforation of trachea ; broncho-pneu- 
 monia ; cancer of lung. 
 
 three Mediastinal suppuration ; pleurisy ; peri- 
 carditis. 
 
 Perforation of trachea ; broncho-pneu- 
 monia.
 
 ON DISEASES OF THE (ESOPHAGUS. 
 
 77 
 
 No. 
 
 Sex 
 
 Afje 
 
 Seat. 
 
 Complications. 
 
 37 
 38 
 
 F. 
 F. 
 
 31 
 
 38 
 
 Ditto 
 Ditto 
 
 Pneumonia ; ulceration into trachea. 
 Broncho-pneumonia ; bronchi full of fetid 
 
 39 
 
 40 
 41 
 
 M. 
 
 M. 
 
 M. 
 
 65 
 
 59 
 
 70 
 
 Ditto 
 
 Ditto 
 Vlid oesophagus 
 
 pus. 
 Trachea perforated ; secondary cancer of 
 lung and kidney. 
 Cancer of kidney. 
 Inanition. 
 
 42 
 43 
 44 
 
 F. 
 P. 
 M. 
 
 30 
 58 
 70 
 
 Ditto 
 Ditto 
 Ditto 
 
 Inanition ; trachea opened. 
 Pneumonia ; bronchus opened. 
 Trachea perforated ; gastrotomy ; ex- 
 
 
 
 
 
 hausted. 
 
 45 
 
 M. 
 
 63 
 
 Pour inches at lower end 
 
 dancer of thyroid. 
 
 46 
 
 M. 
 
 93 
 
 Four inches from middle 
 downwards 
 
 Inanition ; left bronchus opened. 
 
 47 
 
 M. 
 
 61 
 
 Two inches below bifurcation 
 
 Cancer of bones, pleurae, liver. 
 
 
 
 
 of trachea 
 
 
 48 
 
 M. 
 
 47 
 
 Two inches below bifurcation 
 
 Gangrene of right lung; perforation of 
 
 
 
 
 
 pleura. 
 
 49 
 
 F. 
 
 51 
 
 Three inches long opposite 
 
 Sloughing lung. 
 
 
 
 
 bifurcation 
 
 
 50 
 
 M. 
 
 38 
 
 ^ower two inches 
 
 Cancer of liver. 
 
 51 
 
 M. 
 
 50 
 
 jower end 
 
 Extension to the right lung ; sloughing 
 
 
 
 
 
 pneumonia. 
 
 52 
 
 M. 
 
 73 
 
 Ditto 
 
 Cancer of lung, pericardium, kidneys. 
 
 53 
 54 
 55 
 
 M. 
 M. 
 M. 
 
 53 
 50 
 64 
 
 )itto 
 )itto 
 S T ear cardia 
 
 Cancer of liver ; gangrene of the lung. 
 Cancer of glands, lungs, liver. 
 
 56 
 
 F. 
 
 31 
 
 Jpper part 
 
 
 57 
 
 F. 
 
 42 
 
 )itto 
 
 
 58 
 
 M. 
 
 63 
 
 Vhole tube affected 
 
 
 59 
 
 M. 
 
 45 
 
 jower seven inches 
 
 
 60 
 
 M. 
 
 59 
 
 ""rom cricoid downwards 
 
 
 61 
 
 F. 
 
 64 
 
 )itto 
 
 
 62 
 
 M. 
 
 51 
 
 Jehind cricoid 
 
 
 63 
 
 M. 
 
 54 
 
 ^ear cardia 
 
 
 64 
 
 M. 
 
 55 
 
 Middle 
 
 
 65 
 
 M. 
 
 56 
 
 <"rom sixth tracheal ring 
 
 
 
 
 
 downwards 
 
 
 66 
 
 F. 
 
 60 
 
 Jifurcation of bronchi 
 
 Trachea perforated ; exhaustion. 
 
 67 
 
 M. 
 
 64 
 
 Jpper end 
 
 Hemorrhage. 
 
 68 
 
 M. 
 
 66 
 
 Cardia 
 
 Still alive when reported. 
 
 69 
 
 M. 
 
 47 
 
 Middle 
 
 Recurrent nerve implicated. 
 
 70 
 
 F. 
 
 54 
 
 Ditto 
 
 
 71 
 
 F. 
 
 42 
 
 )itto 
 
 Inanition. 
 
 72 
 
 M. 
 
 63 
 
 x)wer third 
 
 Bronchitis and inanition. 
 
 73 
 
 M. 
 
 30 
 
 Cardia 
 
 Inanition. 
 
 74 
 
 F. 
 
 33 
 
 Jpper end 
 
 Exhaustion ; trachea opened. 
 
 For other cases of gastrotomy in cancer of the oesophagus, see Durham, in ' Holmes's 
 System of Surgery.' 
 
 Of 85 cases collected from the 'Guy's Post-mortem Records,' the 
 'Pathological Society's Transactions,' and other sources, 59 cases 
 occurred in males, 26 in females. This proportion of rather more 
 than 2 to 1 of males over females closely agrees with that obtained 
 from a smaller number of cases in the previous edition of this work. 
 Crisp, 1 in" tabulating 21 other cases, gives a still larger preponderance 
 
 'Lancet,' vol ii, p. 628, 1873.
 
 78 
 
 ON DISEASES OF THE (ESOPHAGUS. 
 
 to the males affected. Richardson, 1 however, states, that both sexes 
 are affected equally, an assertion apparently founded on a very small 
 number of cases. The average age of 57 males gives 55^ years, 
 again closely agreeing with a former result, and also with that given 
 by Crisp. 
 
 Of 25 women, the average is 44J years. It thus appears quite 
 evident that women become affected with oesophageal cancer at a 
 much earlier date than men, the average being 11 years earlier. 
 This is quite borne out by examining individual cases ; thus, of the 
 females, 2 cases occurred at 30 ; 3 at 31 ; 6 more between 32 and 38; 
 or a total of 11 out of 25 under 40 years of age. 
 
 From 30 to 40 
 40 50 
 50 60 
 60 70 
 
 Of the males 
 
 30 
 
 38 to 40 
 45 50 
 50 60 
 60 70 
 70 75 
 
 11 
 4 
 
 25 
 
 1 
 5 
 
 14 
 
 14 
 
 19 
 
 4 
 
 57 
 
 The youngest patient I find recorded as having had cancer of the 
 oesophagus was aged 22, mentioned by Dr. Richardson in his paper 
 before the Medical Society ; 2 but the sex of this patient is not stated. 
 
 Chronic affections of the lung are interesting in relation to cancer; 
 the tubercles may be of a cancerous character, and set up chronic 
 pneumonia; or with true cancer in the oesophagus the lung may be 
 affected with ordinary strumous disease, and the most careful exami- 
 nation may fail to detect any trace of carcinornatous product in the 
 lung, the two diseases existing independently at the same time. 
 
 Again, the vomica may exist at the apex of the lung, evidently 
 of a chronic character, or with dense iron-gray lung tissue around it 
 aud calcareous degeneration. In another instance under my care 
 there was a vomica at the apex, and the history indicated that cough 
 had existed long prior to the dysphagia. There were evident signs 
 of phthisis in the flattened apex, loud bronchial and amphoric respi- 
 ration and bronchophony ; had there not been present the cancer of 
 the oesophagus, it would have been considered as an ordinary instance 
 of pneumonic phthisis. In the exhaustion which was consequent on 
 the obstruction of the oesophagus, the cough continued troublesome, 
 and a few days before death acute disease of the lung was set up, 
 arising, perhaps, at the time the cancerous growth began to disinte- 
 grate, or from atmospheric changes. 
 
 Among the 85 cases, the longest period which elapsed between 
 the commencement of dysphagia and death was about two years, 
 
 1 'Lancet,' p. 596. 
 
 Ibid., loc. cit.
 
 ON DISEASES OF THE (ESOPHAGUS. 79 
 
 several were three to seven months, and in two still less, the interval 
 being only five and seven weeks. 
 
 The diagnosis is sometimes obscure ; this has been mentioned in 
 reference to annular stricture, and perforating ulcer into the trachea. 
 Where we find chronic disease of the lung with dysphagia, the diao-. 
 nosis is much increased in difficulty, because, in ordinary phthisis, 
 the dysphagia is sometimes exceedingly severe. This remark ap- 
 plies especially to the bronchitic phthisis of advanced life. 
 
 Dysphagia with chronic emaciation is the prominent symptom 
 of cancerous disease, but sometimes the dysphagia is very slight, 
 and the sudden onset of acute secondary disease masks the primary 
 mischief; and, again, very extensive sloughing of the oesophagus 
 may render the rejection of food from the stomach almost impossible. 
 It is sometimes very difficult also to distinguish between cancerous 
 disease of the oesophagus and pressure upon the tube by aneurismal 
 or other tumors ; in the latter instances the dysphagia is less persist- 
 ent, and often varies according to the position of the patient, the 
 oesophagus falling away from an aneurismal tumor of the aorta as 
 the patient leans forward; paroxysms of dyspnoea are also frequently 
 present in cases of arterial disease. Flatulent distension of the 
 stomach and disease of the cardiac orifice may simulate disease of 
 the oesophagus itself. 
 
 The prognosis is in all these cases very unfavorable ; but in some, 
 after the avoidance of irritating and solid food, or after the use of 
 nutrient enemata for several days, the dysphagia becomes diminished 
 in a marked degree, the patient is able to partake of solid food, and 
 we may be led to take a more favorable view of the case than is 
 warranted by the nature of the malady. Two cases admitted into 
 Guy's Hospital with symptoms of cancerous disease of the oesophagus, 
 men about sixty years of age, with nearly complete dysphagia, were 
 so much relieved as to leave the hospital; when, however, we find 
 the disease extending into the respiratory passages, or into the large 
 vessels, we may fear a speedy and fatal termination. 
 
 These remarks suggest to us the proper mode of treatment. The 
 most bland and unirritating diet should be given, as milk, eggs, 
 jellies, soups, &c. Solid articles of food should be abstained from, 
 at least for a time, for the attempt to swallow solids produces dis- 
 tressing spasm of the oesophagus ; and if the dysphagia be very 
 severe, nutrient injections should be administered, so as to allow 
 complete rest to the diseased structures. Stimulants and cod-liver 
 oil afford partial relief, and check the progress of disease. 
 
 Solution of potash and iodide of potassium, with vegetable infu- 
 sions, afford relief in the earlier stages of the complaint ; so also, 
 nitric and hydrochloric acids, with morphia or opium. In advanced 
 cases, where there is extensive cancerous ulceration and excessive 
 irritability from exposure of the branches of the pneurnogastric, 
 internal remedies are of no avail, and nutrient injections are the only 
 means of prolonging life. 
 
 Opium in one form or other is the best remedy for the .secondary 
 pneumonic or bronchitic complications ; to give mercurials and anti-
 
 80 ON DISEASES OF THE (ESOPHAGUS. 
 
 mon j, &c., is to exhaust still more rapidly the already ebbing life of 
 the patient. 
 
 It is a question of great importance how far bougies may be used 
 with advantage in the treatment of cancerous obstruction of the 
 oesophagus and the trachea or bronchi, the occasional entire destruc- 
 tion of the canal, and the injury which sometimes results to the 
 walls of the aorta, are each of them serious objections to its use; 
 and I have very frequently seen instances in which a bougie would 
 certainly have passed into the bronchus, and led probably to speedy 
 death. In the earlier stages the bougie may usefully serve to indicate 
 the precise character and seat of the disease, and also dilate the nar- 
 rowed passage, but it should always be used with extreme caution. 
 The cauterization of stricture of the oesophagus was resorted to about 
 the close of the last century; and Sir Everard Home, in his 'Practi- 
 cal Observations on the Treatment of Strictures of the Urethra and 
 Oesophagus,' records several instances in which the use of caustic 
 bougies was followed by relief of the severe dysphagia. Simple 
 bougies have been more frequently used, often with benefit, though 
 sometimes, as I have just remarked, to the injury of the patient. A 
 case is mentioned by Mr. Fletcher, in his ' Medical and Surgical Ob- 
 servations,' in which perforation was produced at the termination of 
 the pharynx, and suppuration among the muscles of the neck fol- 
 lowed; on the other hand, when carefully employed, food may be 
 introduced into the stomach by oesophageal tubes in cases in which 
 spasmodic stricture prevents the passage even of the blandest fluids. 
 
 As an instance of the beneficial use of the bougie, I may refer to 
 the following case : 
 
 A patient recently under my care in Guy's Hospital, suffering 
 from severe dysphagia, complained of pain about the level of the 
 sternum. He was forty-three years of age, by trade a letter-carrier, 
 and for twelve months the symptoms of obstruction in the oesophagus 
 had troubled him; but he had not found that the symptoms had 
 generally much increased since the time when he first noticed them. 
 The dysphagia sometimes became greater, but it was always Avith 
 great difficulty that any portion of solid food could be swallowed. 
 He was a spare man ; no enlargement could be felt in the neck ; there 
 was no apparent obstruction in the pharynx, nor was there any evi- 
 dence of pulmonary, cardiac, or arterial disease. Several attempts 
 were made to pass bougies into the stomach, but without success; 
 they rested about the level of the sternum ; even an elastic catheter 
 could not be introduced beyond that point. After a fe\v days I re- 
 quested the patient to abstain altogether from food, and fed him for 
 one week entirely by nutrient enernata; at the end of that time a 
 large bougie could be easily passed into the stomach; the rest to the 
 canal had allowed the irritation and spasmodic constriction to sub- 
 side, and, although organic stricture still existed, solids could be more 
 easily swallowed. The bougie met with an obstruction, as before 
 said, about the level of the sternum, and about three inches below 
 the first a second obstruction occurred, indicating probably the upper 
 and lower limit of the diseased surface; and when the bougie reached
 
 ON DISEASES OF THE (ESOPHAGUS. 8t 
 
 the constriction the coughing of the patient enabled the instrument 
 to pass onwards. Cod-liver oil and a nourishing fluid diet were 
 given, and the patient left the hospital relieved. 
 
 Of the 74: cases the upper part of the tube was affected in 33, 
 though in several it was not confined to that part alone. In 30 
 the middle, or the part about the root of the lung, was chiefly 
 affected, and the cardiac end only in 10. It is to be borne in mind, 
 however, that the proportions which these numbers represent are 
 not, perhaps, quite correct, for it is by no means infrequent to find 
 disease extending from the cricoid region to the root of the lung, or 
 from the latter to the cardia, so that several inches of the tube are 
 affected, and this renders it difficult to decide upon the precise origin 
 of the disease. Two cases are recorded in which the whole length 
 of the oesophagus was affected. 
 
 It is not of much importance, however, to decide as to the precise 
 position in which the disease commences. It is sufficient for clinical 
 purposes to remember that the tube is liable to be affected in three 
 parts at its commencement, its middle, and its termination. In all 
 these it can be shown that the surface is subject to increased friction, 
 and that the liability of attack is in proportion to the amount of 
 irritation. At the upper part this irritation is greatest, for the tube 
 suddenly contracts from a large pouch into a somewhat narrow tube, 
 and the food is compressed so as to be moulded to the reduced size 
 of the canal. Subsequently it will pass along smoothly unless inter- 
 rupted by further obstruction, and this is likely to happen near the 
 root of the lung, at the bifurcation of the trachea, and again at the 
 cardiac end. Again, at the commencement the cartilaginous struc- 
 tures in front of the oesophagus, and the occasional swelling of the 
 bronchial glands, are causes of pressure which do not exist at the 
 lower part. 
 
 If the proportions be taken in the different sexes, however, they 
 are found to be somewhat altered, the ratio of affections of the upper 
 to those of the middle parts being as 19 to 20 in males, 14 to 8 in 
 females. 
 
 The trachea was perforated in 13 cases, and in the majority of 
 these the disease attacked the part at the root of the lung. It was 
 not always so, and it is to be remembered that cases of simple ulcera- 
 tion occasionally occur which lead to a communication between the 
 two passages. 
 
 CASE X. Cancerous Disease of Lower Third oj (Esophagus. Division 
 of Canal. Life prolonged by Use of Bougie. Death from Bronchitis 
 A. B_, set. 63, a farmer, who had led an active life, began to suffer from 
 impairment of his health nine months before his death. His appetite failed, 
 and he soon began to suffer from difficulty in swallowing. The food only 
 appeared to reach the throat, and was quickly rejected. He had an irritable 
 cough, and at the upper part of the right lung the respiration and voice were 
 bronchial, and the resonance 'on percussion was impaired. He rapidly lost 
 flesh. He expectorated a large quantity of glairy mucus, and it was evident 
 that the saliva filled the oesophagus above the obstruction, and when.it reached 
 the throat or epiglottis induced cough. Mr. Durham passed a bougie to the 
 6
 
 82 ON DISEASES OF THE (ESOPHAGUS. 
 
 seat of stricture, and found it at the lower third of the oesophagus. By the 
 use of fluid diet and soothing remedies partial relief was afforded, but the 
 obstruction soon became complete, and nothing could be swallowed for about 
 two months before death. Mr. Durham was, however, able to introduce a 
 small ocsophageal tube and to feed the patient, gradually increasing the si/e 
 of the tube ; fluid food with vegetable, and when necessary wine, were thus 
 introduced into the stomach night and morning. The patient gained strength, 
 and was able to go out for a drive. Unfortunately in one of'these excursions 
 he took cold ; the glands at the angle of the jaw and the parotid on the right 
 side became swollen, the skin at the part became erythematous and brawny, 
 suppuration followed, and an incision was made. The ocsophageal tube was 
 still introduced night and morning, but with more difficulty on account of 
 the inability to open the mouth freely. The tube had for some days had an 
 offensive smell when withdrawn, as if it had come into contact with sloughy 
 tissue, and the examination of the mucus showed cells, which were very sus- 
 picious as to their cancerous character. Bronchitis then came on, and mucous 
 crepitation was heard at both bases, and on the right side there was some 
 consolidation of the lung. The temperature rose to 101.2, respiration to 40 
 per minute, the pulse to 120. There was partial delirium, and in a few days 
 he sank. On inspection, broncho-pneumonia was found, especially in the 
 right lung; the lower third of the esophagus was affected with a sloughing 
 cancerous growth, which had divided all the coats of the oesophagus, and had 
 formed a sloughy cavity in the posterior mediastinum ; a small portion of the 
 oesophagus was left which had served to guide the bougie to the lower opening 
 of the oesophagus. If the life of the patient had been prolonged for a few 
 days the pleura would probably have been perforated. There was scarcely 
 any infiltration of the glands, and no direct extension into the lung. 
 
 Although in this case life was cut short by an attack of bronchitis 
 and erysipelatous inflammation of the glands of the neck, there can 
 be no doubt that the exhausted state of the nervous system rendered 
 the patient more susceptible to these attacks. The introduction of 
 the bougie, which was very skilfully effected by Mr. Durham with- 
 out pain to the patient, greatly relieved the distressing sense of thirst 
 and of exhaustion from which many suffer, and prolonged life for 
 several mopths. 
 
 CASE XI. Cancer of the (Esophagus. Sloughing Pneumonia ; the Pneu- 
 mogastric Nerve involved. James R , aet. 45, was admitted into Guy's 
 Hospital, November 21, 1854, under Sir Wm. Gull's care, and died Novem- 
 ber 30th. He was a married man, a laborer, and intemperate in his habits. 
 For nine weeks prior to his admission he had been unable to swallow food 
 with comfort, and he had suffered from severe pain at the lower part of the 
 sternum. From that time he lost much flesh ; and cough, with pain in his 
 side, came on. He vomited occasionally, and had burning pain at the ster- 
 num ; and there was a sense of nausea when he began to eat. On admission, 
 he had a cachectic, pale, and wretched appearance ; he was troubled with 
 cough, and the expectorated matters were exceedingly offensive. At the apex 
 of the left lung the respiration was coarse, at the base of the right lung there 
 were signs of consolidation ; the patient sank in a few days. The severe 
 pulmonary symptoms in this case completely masked the original disease of 
 the oesophagus ; for a short time it was believed that the case was one of 
 pneumonia with old disease of the lung, and that the burning pain at the 
 sternum, and vomiting, were the consequence of his former intemperate
 
 ON DISEASES OF THE (ESOPHAGUS. 83 
 
 habits. At the commencement of the oesophagus extensive ulceration was 
 found on inspection ; the ulcer was four or five inches in length, irregularly 
 tubercular on its surface, and several tubercles were situated^in the mucous 
 membrane, both above and below the ulceration. The disease extended as 
 low as the root of the lung, but the lungs themselves and the pleura were free 
 from cancerous disease. The tissue external to the oesophagus was exten- 
 sively infiltrated, especially on the right side, and some of the bronchial 
 glands were affected ; the right pneumogastric nerve extended through the 
 diseased structures. The lower part of the pneumogastric appeared wasted, 
 but it could not be traced satisfactorily throughout, having been divided in 
 the inspection. The right lung, at its lower lobe, was of a greenish color, 
 and it had a faint gangrenous odor ; it was infiltrated with dirty serum, and 
 was imperfectly consolidated. The bronchi were intensely congested. The 
 remaining parts of the lungs and the larynx were healthy. The heart, 
 stomach, liver, intestines, &c., were also healthy, and no cancerous disease 
 could be detected in any other part. 
 
 As to the character of the growth, it had the general and micro- 
 scopical appearance of epithelial cancer. There was no direct com- 
 munication between any of the large bronchi and the ulceration of 
 the oesophagus ; and it appeared probable that the right pneumo- 
 gastrio, becoming involved in the disease, had predisposed to the 
 pneumonic inflammation on the same side. The case prove fatal at 
 an earlier period than usual, for the patient died ten weeks from the 
 recorded commencement of difficulty in swallowing; and the diag- 
 nosis was rendered obscure by the extreme severity of the pulmonary 
 symptoms. 
 
 CASE XII. Cancer of the (Esophagus, of the drvical Glands, and of the 
 
 Thyroid Body. Gangrene of the Lung George E , aet. 73, was admitted 
 
 into Guy's Hospital, November, 1853, in an extremely emaciated state, and 
 died February, 1854. He was a table-cover maker, and in his early life had 
 been intemperate. Eight months before his admission he received a severe 
 fall, from which he never recovered ; and two months later he began to sufi\-r 
 great pain in eating solids, and he had occasional attacks of vomiting. These 
 attacks became more and more frequent, and latterly almost incessant. He 
 could not take solid food, and complained of intense pain at the cardiac ex- 
 tremity of the stomach. Mr. Callaway passed an cesophageal bougie, but 
 without meeting any obstruction in its passage. The vomiting diminished 
 soon after admission. The bowels became constipated, and continued to suf- 
 fer severe pain. He became gradually weaker, and on February 5th he 
 vomited a considerable quantity of dark-colored fluid; he died on the 13th. 
 At the central part of the oesophagus, opposite the root of the lung, there was 
 a large, irregular ulcer, two inches in length, which involved the whole of 
 the tube ; at the upper part was a raised circular margin, and a partially de- 
 tached ulcer of similar character, about half an inch in diameter. At the 
 root of the right lung there was a mass of sloughing tissue, which was infil- 
 trated with sanious fluid, and the adjoining lung was consolidated. At the 
 base of the left lung there was a circumscribed mass of pulmonary apoplexy 
 with pneumonia, and a vomica containing thin purulent fluid. The cervical 
 glands and the thyroid body were infiltrated with carcinomatous product, 
 white, and of a medullary character. The heart had undergone both fatty 
 and fibroid degeneration. In the peritoneum were old adhesions, and a gran-
 
 84 ON DISEASES OF THE (ESOPHAGUS. 
 
 ular condition of the surface of the liver. The kidneys were also granular 
 and contracted. 
 
 Although the oesophagus was extensively ulcerated in this case, 
 a bougie could easily be introduced, showing that spasmodic con- 
 traction was the principal cause of the obstruction and of the rejec- 
 tion of the food. In this instance also, the bougie might easily have 
 passed through the diseased walls of the oesophagus into the posterior 
 mediastinum, or into the pleura ; and, from a diagnostic point of 
 view, it might have led to the supposition that the disease was 
 in the stomach rather than in the oesophagus, on account of the 
 absence of obstruction to the passage. As we have previously stated, 
 great care must be exercised in the use of these instruments. 
 
 CASE XIII. Epithelial Cancer of the (Esophagus, Pancreas, Liver, and 
 Kidneys. 7 he Pneumogastric Serves involved. Granular Kidneys. Chronic 
 Pletiro-pneumonia, with Cancer. Fibrous Tumor in Uterus. Cancer of 
 Supra-renal Capsules and Semilunar Ganglion Jane B , aet. 63, was 
 admitted Aug. 23, 1855, under Dr. Addison's care. She had suffered for 
 nine months, and the first symptom was pain after swallowing ; no tumor 
 could then be felt, but cancerous disease was suspected. After admission, a 
 firm mass, at the scrobiculus cordis, about the size of a hen's egg, could be 
 felt; it was well defined, sensitive on pressure, and tolerably distinct pulsa- 
 tion could be perceived ; the food was at once regurgitated. She complained 
 much of flatulence, and at night regurgitated water into the mouth. At 
 first, vomiting several hours after food was the principal symptom. Soon 
 after admission the food was at once returned ; sometimes, however, it was 
 retained for several days. She took creasote three times a day, and opium 
 at night, with considerable relief for a short time. On December 8th I ex- 
 amined some of the water ejected from the mouth, but could not discover any 
 cancer cells nor sarcina. She varied much, sometimes the stomach being 
 excessively irritable and rejecting everything, at other times she was able to 
 take food. On December 19th the tumor had not increased in size. She 
 became more and more prostrate, and during the last month of her life suf- 
 fered severely. She died March 26th. On inspection the body was much 
 emaciated. There was extreme atrophy of the brain, notwithstanding the 
 absence of cerebral symptoms. Chest At the commencement of the oeso- 
 phagus the mucous membrane began to present an irregular granular appear- 
 ance, with one or two whitish tubercles about the size of pins' heads ; passing 
 downwards, these tubercles became more numerous, till nearly opposite the 
 root of the lung an ulcerated surface was i'ound, with a raised margin and 
 partially sloughing ; still lower in the canal than this ulcer the walls of the 
 oesophagus were completely destroyed for about three inches, and the side of 
 the right lung was in a sloughy condition ; posteriorly the pericardium 
 bounded this sloughy mass, and there was an opening, about the size of a 
 sixpence, extending through that membrane, opposite the left auricle, which 
 was slightly affected with granular cancerous growth at that part. Nearer to 
 the stomach the walls of the oesophagus were again continuous, but infiltrated 
 with cancerous product, and nearly in a sloughy condition. At the floor of 
 the cancerous ulcer were several branches of the pneumogastric exposed ; 
 the right nerve could be traced down to the ulcer, and several branches were 
 completely truncated ; another branch of the right nerve passed obliquely 
 across the ulcer to the opposite side, to join the left nerve. On the left side 
 a branch was also observed to be truncated, and another ran for about two
 
 ON DISEASES OF THE (ESOPHAGUS. 85 
 
 inches exposed in the sloughy tissue. The branches to the lungs were entire, 
 and were situated above the cancerous growth. The ulcer in the oesophagus 
 presented the elements of epithelial cancer. Cancerous tubercles of epithe- 
 lial nature were found in both lungs, with some iron-gray pneumonia at the 
 left apex. Abdomen In the stomach, near the cesophageal opening, was a 
 raised tubercular growth about half an inch in diameter ; it was ulcerated at its 
 apex ; its section showed that it principally involved the mucous membrane, 
 but was extending into the muscular coat beneath. Some large nucleated 
 cells were observed in the raised edges of the growth, and degenerated gastric 
 follicles ; some of the follicles were much enlarged, containing highly re- 
 fracting particles, others contained nuclei. The rest of the mucous mem- 
 brane and the pylorus were healthy. The head of the pancreas formed the 
 hard mass which had been felt at the scrobiculus cordis ; it was hard and 
 white, and microscopically epitheliomatous. The adjoining lymphatic glands 
 were intiltrated and adherent ; the lesser curvature of the stomach was also 
 adherent ; the rest of the pancreas was normal. On the adjoining surface of 
 the liver was an irregular tubercle, evidently produced by contact, and in the 
 substance were several other small tubercles, but consisting of the same epi- 
 thelial elements. On the right side the cancerous infiltration extended to 
 the right semi-lunar ganglion, which appeared to be infiltrated with cancer- 
 ous product, cancerous cells being observed among the ganglionic cells. 
 There were cancerous tubercles in both supra-renal capsules, but only involv- 
 ing a small portion of the organ. The kidneys were granular, very small, 
 and only four ounces in weight. The cavity of the uterus was occupied by two 
 soft polypi, and a large dense tumor, about three inches in diameter, was 
 found in its walls ; the tumor was dense and fibrous and calcareous, but did 
 not present any trace of cancerous elements. (See Preparation 1799 33 .) 
 
 In this case the diagnosis was obscure, on account of the food 
 being sometimes retained for several hours; and this symptom ap- 
 peared to indicate disease of the stomach rather than of the oesopha- 
 gus. A tumor could also be felt at the scrobiculus cordis; the 
 disease of the oesophagus was, however, too extensive to produce 
 obstruction, the walls of the lower part of the canal being entirely 
 destroyed ; the injury of the pneumogastric was very extensive, and 
 the exposure of its branches was probably the cause of the severe 
 pain from which the patient suffered. 
 
 CASE XIV. Epithelial Cancerous Tumor in the Pharynx, closing the 
 entrance into the (Esophagus. Effusion of False Membrane in the Larynx 
 
 and Trachea. Acute Bronchitis Charlotte W , jet. 32, was admitted 
 
 under Mr. Cock's care, February, 1856, and died March 6th. She had been 
 out of health for a year, but for three months she had experienced very great 
 difficulty in swallowing, and for several days it had become almost impossible 
 to swallow anything except a small quantity of fluid ; and the attempt now 
 led to regurgitation through the nares. The eifort of swallowing did not 
 produce urgent dyspnoea. Respiration on admission was easy and normal, 
 but there was slight hoarseness. On examining the chest, the respiration 
 was found to be less free at the right apex. At the left side of the neck, 
 below the angle of the jaw, was a prominent round tumor about one inch in 
 diameter; it could be partially separated from the structures beneath. Mr. 
 Cock attempted to pass a small bougie, but this was found to be quite impos- 
 sible. The tumor in the throat could neither be seen nor felt. A short time 
 before death very urgent dyspnoea came on, and she died from apnoea. At
 
 86 OX DISEASES OF THE (ESOPHAGUS. 
 
 the lower part of the pharynx, attached to the cricoid and arytenoid carti- 
 lages, or rather the mucous membrane opposed to llu-ni, were four round 
 tumors closely placed together, or rather one lohulated growth, extending as 
 high as tlie upper margin of the epiglottis, and quite occluding the opening 
 into the oesophagus. After removal, a probe could only be inserted by slowly 
 passing it round the growth. The soft palate was considerably thickened. 
 The inner surface of the epiglottis, of the larynx, and of the trachea, was 
 covered by a layer of easily separable false membrane ; the bronchi, especially 
 the larger ones, were full of tenacious mucus. The tumor in the neck was 
 soft, and of a pale yellow color. All other parts were noimal. On examin- 
 ing the growth from the pharynx, its base was found to consist of large 
 cancer cells, containing a large granular nucleus, and the cells were closely 
 arranged together. The growth in the neck had a similar structure. The 
 surface was not ulcerated, but presented epithelium, which was normal in 
 some parts. The appearance of the papilla- has been previously referred to; 
 some were in a normal condition ; in others, the central capillary was ob- 
 structed, and some w r ere still more degenerated, closely resembling brood 
 cells. (Prep. 1785 76 .) 
 
 The obstruction at the commencement of the oesophagus in this 
 case was mechanical, and the cause of death secondary laryngitis. 
 The diagnosis of tumor was easy, but it was found to be quite 
 impossible to pass any instrument beyond the growth. Many in- 
 stances of non-cancerous polypi are recorded, and some may be re- 
 moved by operation ; in this case the groAvth was too low to be 
 reached, and its character was less suited for operative interference. 
 
 CASE XV. Carcinoma of the (Esophagus, communicating u'ith the 
 Trachea. Cancer of the Lung and of the Kidney Catherine S , set. 38, 
 admitted under Dr. Barlow's care, April 9th, 185G, and died April 17th. Sin- 
 had been a servant in a family for twenty years, and began to suffer from 
 her present illness about six months before her death. On admission she 
 was in a state of great emaciation, and the dysphagia was extreme. The 
 attempt to swallow food was at once followed by the regurgitation of it 
 through the nose and mouth. The circulation was exceedingly feeble, and 
 Dr. Barlow feared lest gangrene might come on. She appeared to die from 
 exhaustion. The body was much emaciated. In the neck, on the left side, 
 was an enlarged cervical gland, about one inch in diameter, firmly adherent 
 to the oesophagus and to the trachea ; a smaller gland was situated on the 
 right side; the former tumor could be felt before the division of the skin. 
 The lungs did not collapse freely. On dividing the trachea an opening into 
 the oesophagus, somewhat oval in form, slightly pointed above and below, 
 and about one inch and a half long, was found immediately above the division 
 into the bronchi ; the edges of this opening were thickened and slightly irre- 
 gular. The corresponding part of the oesophagus in its whole circumference 
 presented a nodular surface for three inches in length. The edges were 
 raised and irregular, and the surface ulcerating, and there was slight vascular 
 turgescence of the mucous membrane. Several cervical glands which were 
 adherent to the oesophagus were infiltrated with cancerous deposit; they were 
 of a firm consistency, and were white in color, but in the centre yellow. 
 Other glands at the root of the lung were not all infiltrated. The bronchi 
 were intensely congested, and contained much dirty grumous fluid. The 
 lower lobes of the lungs were much congested, and the right contained beneath 
 the pleura a small mass, about half an inch long and a quarter of an inch
 
 ON DISEASES OF THE (ESOPHAGUS. 87 
 
 broad, composed of yellowish-white cancerous substance. The left renal vein 
 was filled with adherent clot, and its walls were considerably thickened. In 
 this kidney were several cysts, and a minute tubercle composed of elements 
 resembling the other cancerous structures. On examination of the oesopha- 
 geal ulcer a small quantity of juice from the section presented numerous 
 nuclei, mnd in the section some epithelial plates, cells with large nuclei, and 
 caudate cells. It also presented some elongated nuclei and fibres, some ot 
 which had a curved arrangement, inclosing nuclei and brood cells. The 
 raised edges of the ulcer were composed of masses of these nuclei and cells, 
 with some intervening elongated nuclei and fibres, and on the addition of 
 acetic acid some elastic coiled fibres were observed. The growth in the lun" 
 presented similar aggregations of nuclei. The cervicalglands were of a 
 much firmer texture, and much fibrous tissue was observed in them, forming 
 irregular interspaces, in which nuclei were found. The central portion's 
 were yellow, and contained highly refracting granules (degenerating cancer). 
 The great number of large nuclei resembled those found in medullary cancer, 
 and this case appeared to be almost intermediate between medullary and 
 epithelial disease. 
 
 CASE XVI. Cancer of the (Esophagus. Extension into the Lung. 
 Gangrene James S , aet. 57, was admitted under my care into Guy's 
 Hospital May 12th, 1858, and died June 4th. For many years he had been 
 a coachman, and temperate in his habits. In 1832 he had been ill for six 
 Aveeks with pain across the chest, and for many years he had had cough. 
 Eight weeks before admission, on attempting to eat, he felt that he was 
 unable to swallow, and from that time he could take no solid- food ; the food 
 seemed to pass as far as the scrobiculus cordis, and was then rejected. He 
 was a pale and emaciated man; the thoracic viscera were normal, the abdo- 
 men was supple, and no tumor could be detected, but pulsation was very 
 distinct at the scrobiculus cordis. The superficial epigastric veins were 
 slightly enlarged ; he complained of weakness and vertigo. On the 21st he 
 had gaseous eructations, which increased the dysphagia. On the 25th food 
 was instantly rejected, and the vomiting produced a " cutting" pain in the 
 epigastrium ; at other times the pain w r as of a dull character. When un- 
 mixed with food the rejected matters consisted of tenacious mucus. He died 
 June 4th. On inspection the termination of the oesophagus was diseased. 
 For the space of an inch there was cancerous deposit infiltrated into the 
 mucous and submucous tissues, as also into the muscular layer. The canal 
 was much contracted, so that a small probe only could be passed. On the 
 right side the growth was adherent to the lung ; the cancerous tissue was at 
 that part ulcerated, and communicated with the lung tissue, which was in a 
 sloughing state. The upper lobe of the right lung contained pneumonic de- 
 posit and several small cavities. The other viscera, and the lymphatic glands 
 were in a healthy state. The examination of the growth showed much firm 
 fibrous tissue, and some cells of epithelial cancer. 
 
 CASE XVII. Cancer of the (Esophagus. Pneumonia. The Pneiimo- 
 gastric Nerve involved John D , a3t. 71, was admitted into Guy's Hos- 
 pital, on January 26th, 1859. For two years he had been under observation, 
 and he had also previously been in the hospital. The difficulty in swallow- 
 ing, and the emaciation, had increased to an extreme degree, but he was able 
 to get some food down until two or three days before his death, when the 
 symptoms of pneumonia came on. On inspection, eleven hours after death, 
 the body was found to be much' wasted. The oesophagus was contracted one 
 inch above the bifurcation of the trachea, the walls were thickened, and there
 
 88 ON DISEASES OF THE (ESOPHAGUS. 
 
 was adventitious deposit effused in a circumscribed manner in the submuoous 
 cellular tissue. Some of the neighboring glands were slightly infiltrated. 
 There was pleuro-pneumonia of the left lung, the whole being gray and solid, 
 with a dark-colored gray fluid exuding from it ; but there was no sloughing. 
 The left pneumogastric . was involved in the diseased structure of the 
 oesophagus. The heart and liver were healthy ; so also the gall bladder and 
 the ducts. The kidneys were degenerated, only five ounces in weight, and 
 they contained a few cysts. The diseased cesophageal substance consisted of 
 fibrous and elastic tissue, squamous epithelium, large nuclei and cells in 
 considerable quantity, aggregated in clusters ; and some of these clusters of 
 cells were limited by membrane, as if forming part of a glandular structure. 
 
 CASE XVIII. Cancer of the (Esophagus. The left Pneumogastric in- 
 volved. Pneumonia William E , set. 50, was admitted July 30th, 1856, 
 under Mr. Callaway's care, and died September 18th. He had suffered from 
 dysphagia for six months, and could not swallow solids. He had cough, and 
 expectorated tenacious mucus. His cough and expectoration became worse, 
 and the lung tissue involved. During the last week of his life he swallowed 
 with more ease. The ulceration in the oesophagus extended from the cricoid 
 cartilage to the bifurcation of the trachea; the edge was well defined, raised, 
 and yellowish ; the central part was ulcerated, and the whole circumference 
 of the oesophagus involved ; in front, the cartilages of the trachea were exposed, 
 and immediately above the bifurcation was an opening about the size of a 
 sixpenny piece, with irregular serrated margins.. The ulceration extended 
 downwards and outwards, and was closely connected with the external surface 
 of the left bronchus ; it had involved the pneumogastric nerve on that side, 
 one of the larger branches of which was completely destroyed. Posteriori}', 
 the vertebras formed the boundary of the ulceration. The greater part of the 
 lower lobe of the left lung was in a state of gray hepatization, and towards 
 the apex there was some iron-gray hepatization, with whitish tubercles. These 
 tubercles appeared to be of a cancerous character. In the right lung was 
 another small mass of condensed lung. There was slight infiltration of the 
 adjoining bronchial glands. On microscopical examination both the ulcer 
 and bronchial glands were found to be epitheliomatous. 
 
 The more easy deglutition during the last week of life is possibly 
 explained by the extension of the ulcer having destroyed the whole 
 of the circumference of the oesophagus and also the nerves, and there- 
 by preventing any spasmodic obstruction. The pneumonia of the 
 left lung was no doubt accelerated by the injury to the nerve on that 
 side ; but it must be borne in mind that the cancerous growth ex- 
 tended to the left bronchus. 
 
 CASE XIX. Cancer of the (Esophagus. Communication with the left 
 Bronchus. The Pneumogastric involved. Old Vomica in the Lung. Exten- 
 sion of Disease through the Diaphragm. George W , aet. 53, was admitted, 
 under my care, September 3d, 1856; he was emaciated and gray; he had 
 been a blacksmith at Chatham, and on the day of admission came from the 
 North Foreland. Until six weeks before, he had enjoyed good health ; at 
 that time he experienced pain in swallowing food, especially solids, which 
 were almost at once rejected. He had pain across the sternum. On the 6th, 
 he became more prostrate ; the hiccough was distressing ; the motions were 
 black ; and he brought up brownish-colored blood ; he gradually sank, and 
 
 died on the 8th, at 2 A. M. (Esophagus Two or three inches from the 
 
 commencement of this canal were several small ulcerated surfaces, of a pale
 
 ON DISEASES OF THE (ESOPHAGUS. 89 
 
 yellowish color, with central depression ; an inch further the whole of the 
 walls of the oesophagus were destroyed, and the margin defined ; beyond this 
 part was an irregular flocculent gray tissue, floating out when placed in water; 
 it was formed upon a dense fibro-cartilaginous base, firmly adherent to the 
 trachea, aorta, and other tissues ; an inch from the left bronchus was a cir- 
 cular opening, about three-quarters of an inch in diameter, forming a com- 
 munication between the oesophagus and the bronchus ; the latter tube con- 
 tained a flocculent gray mass, which almost obstructed it. Some of the 
 bronchial glands were partially infiltrated. The pneumogastric nerve extended 
 into the dense tissue at the base of the ulceration, and some of its branches 
 were exposed at the floor of the ulcer. The destruction of the oesophagus 
 extended to the diaphragm, and the ulceration passed through it, so as to form 
 an irregular sloughing cavity below that muscle, bounded by the stomach, by 
 the cellular tissue, by the large vessels, and partly by the left lobe of the 
 liver. The cardiac opening into the stomach remained in its normal condi- 
 tion, and near it was a second opening from the abscess just mentioned. The 
 ulceration also extended into the liver. The branches of the sympathetic were 
 partially destroyed, but could not be satisfactorily dissected ; some of them were 
 very hard, but on microscopical examination, nerve fibre, apparently undegene- 
 rated, could be detected. The coronary artery of the stomach was obstructed by 
 clot ; some of the glands at the lesser curvature of the stomach were infiltrated. 
 The ulceration almost extended into the thoracic aorta; that vessel was exceed- 
 ingly diseased, from atheromatous and calcareous deposit, and in two parts had a 
 greenish appearance ; there seemed to be a minute communication beneath a 
 bony plate with the ulcer in the oesophagus, but no probe could be passed. On 
 examining the upper margin of the cesophageal ulcer, large cancer cells were 
 detected and some nuclei ; the surface of the flocculent growth consisted of 
 pointed processes filled with granules, sometimes several proceeding from one 
 trunk. The stomach was exceedingly contracted and of hour-glass form ; the 
 mucous membrane was healthy. The left lobe of the liver, which was some- 
 what enlarged, almost obscured the stomach ; the liver itself appeared healthy, 
 its weight was 3 Ibs. At the apex of the left lung was an old vomica, surrounded 
 by iron-gray lung and calcareous deposit ; its lining was smooth, and it was 
 capable of containing about Jss of fluid. The pleura, on the left side, was uni- 
 versally adherent ; on the right side it was partially so at the apex, The 
 right lung also contained a small vomica, but there were no tubercles in it ; a 
 small, white, dense tubercle was situated beneath the right pleura. The re- 
 maining part of the lungs was oedematous. The pericardium contained an 
 excess of fluid ; the heart and its valves were healthy ; the weight of the 
 heart was 9^ ounces. The kidneys were atrophied, and contained several cysts. 
 
 The pain at the sternum, the difficulty in swallowing solids, the 
 emaciation, the cachexia, the age, all indicated organic disease of 
 the oesophagus. The general bronchial rales pointed to some com- 
 munication having been set up; and this was believed to be proba- 
 ble. There was no pain at the scrobiculus cordis, nor was there any 
 apparent indication of the abscess which existed. The prostrate 
 condition of the patient had prevented the development of more 
 manifest peritonitis. 
 
 The disease had, probably, existed for a longer period than six 
 weeks, if we judge by the destruction of nearly the whole oesophagus, 
 and the firm character of the tissue which bounded it. It was evi- 
 dently cancerous, although no other parts except those in immediate
 
 90 ON DISEASES OF THE OESOPHAGUS. 
 
 contact were affected. But the villous and flocculent character of 
 the growth, with evident cancer cells at the margin of the liberation, 
 appeared to indicate that it somewhat differed from ordinary epi- 
 thelial cancer. The small vomica at the left apex was not diagnosed; 
 it had remained in a passive condition, but its association with can- 
 cerous disease was an exceedingly interesting phenomenon. It is 
 doubtful whether any blood oozed from the aorta, or whether that 
 effused was from the coronary artery of the stomach. 
 
 The stimulants and food probably passed into the cavities which 
 Lad been formed in the mediastinum, and tended rather to irritate 
 than to produce effectual benefit. . Nothing more, however, could 
 have been done, except, perhaps, by the use of nutrient injections ; 
 but as the patient could swallow fluids and retain them, these means 
 appeared scarcely to be called for. 
 
 CASE XX. Cancer of (Esophagus. Pneu mo gastric Nerves truncated. 
 Sloughing extending through the Lung and through the Diaphragm John 
 H , set. 45, was admitted into Guy's Hospital Februsiry 17th, and died 
 March 2, 1858. He was a tall, emaciated man, who had been ill for several 
 years. He had no dysphagia, but the food was generally rejected at once ; 
 sometimes, however, it was retained. He had no pain between the shoulders, 
 nor on pressure at the region of the stomach. He gradually sank, luajtcr. 
 tion. In the right lung the lobules were consolidated very generally, and 
 were infiltrated with offensive serum. At the root of the lung, below the 
 vessels, was a circumscribed slough communicating with the diseased oesopha- 
 gus. The left lung was affected in a similar manner, but in a less degree. 
 
 (Esophagiis At the root of the lung the tube was irregularly truncated, and 
 
 a large sloughing cavity was formed, bounded by the lungs; the cavity was 
 encroached upon anteriorly by the posterior surface of the pericardium. At 
 the lower part the diaphragm had sloughed ; and the sloughing cavity was 
 limited below by the pancereas, by the anterior surface of the stomach, and a 
 small portion of the liver. The pneumogastrics were both truncated. In 
 the stomach, at the cardiac orifice, there was an irregular infiltration of the 
 mucous membrane by cancerous product, and two openings extended into the 
 sloughing cavity before mentioned ; these openings were bevelled on their 
 inner aspects. The rest of the stomach was healthy. There was no glan- 
 dular enlargement, nor disease of the spleen, liver, intestines, etc. The peri- 
 cardium was adherent, the heart small, the valves healthy. 
 
 The physician who had the care of this case regarded it as one of 
 pyloric disease, on account of the remarkable absence of pain and 
 difficulty in swallowing, after the patient came under observation in 
 the hospital. This immunity probably arose from the manner in 
 which the oesophagus and its nerves were truncated. 
 
 CASE XXI. Medullary Cancer of the (Esophagus. Chronic Pneumonia. 
 Vomica. Acute Pneumonia William G , ret. GO, had been an attorney, 
 but he had become reduced in circumstances; for twelve months he had had 
 cough and shortness of breath, sometimes palpation of the heart, but no 
 haemoptysis; for twelve months also he had pain across the chest, but no ex- 
 pectoration ; his health continued tolerable till two months before I saw him, 
 when he first experienced difficulty in swallowing; this gradually increased 
 in severity, so that he was only able to swallow liquids, and that with con- 
 siderable pain. The pain was situated about the level of the third rib, at the
 
 ON DISEASES OF THE (ESOPHAGUS. 91 
 
 sternum, the sensation being as if a foreign body was retained at that part ; 
 the ability to swallow was occasionally relieved, but never completely so. 
 There was evidence of old disease at the apex of the right lung, and acute 
 bronchitis with it ; with these were associated tolerably clear evidence of 
 organic disease of the oesophagus, probably cancerous. In this condition he 
 was admitted into Guy's ; he was requested not to attempt to swallow, for 
 this effort produced spasmodic contraction of the oesophagus ; several nutrient 
 enemata were given. The following day he swallowed with greater facility, 
 and could take beef tea, eggs, and milk, with a little brandy ; his cough, 
 however, was more troublesome ; the sputum was purulent, nummulated, and, 
 on microscopical examination, presented no evidence of cancer cells, but 
 some curved elastic fibre, resembling lung structure, and large inflammatory 
 granule cells. After admission no food or milk was vomited. He continued 
 in the same state for some time, but gradually sank in about two months, 
 deatli being preceded by occasional delirium. On inspection, the lung was 
 found to be very firmly adherent to the right apex, and a thick dense layer 
 of fibrous tissue was with great difficulty separated ; the whole of the right 
 pleura was destroyed ; on making a section of the right lung, a small vomica 
 was found at the apex surrounded with iron-gray lung, the surface was 
 smooth ; the lower lobe was in a state of hepatization. The lower lobe of the 
 left lung was also pneumonic ; the pleura over it being covered with a thin 
 layer of lymph. Some of the bronchial glands' were slightly infiltrated with 
 cancer, but there was no evidence of cancer in the lungs. 
 
 In the oesophagus was an ovoid mass, about six inches in length and one 
 in thickness, attached at the root of the lung, and reaching nearly to the 
 cricoid cartilage; the canal was dilated; the mass was of a pale yellowish 
 color, and was softened in the centre; it was attached only to one side of the 
 tube, and no smaller tubercles were observed on the mucous membrane ; no 
 communication with the trachea or bronchi existed; the tumor consisted of 
 nuclei and nucleated cells resembling medullary cancer; none of the brood 
 cells usually found in epithelial cancer were observed. The pneumogastric 
 nerves were free, and the disease appeared to have commenced in the mucous 
 membrane. The heart was healthy ; so also the abdominal viscera ; the in- 
 testinal canal was much contracted, but contained solid feces. The liver 
 was slightly congested, and the gall bladder was much distended. 
 
 The existence of a disease so closely resembling pneumonic phthisis, 
 as that found in this case was very interesting, when we consider it 
 in connection with the cancerous disease of the oesophagus, and with 
 the age of the patient. It was my opinion, during life, that the 
 disease in the oesophagus had extended into the bronchi, but this 
 was not found on inspection. The only other disease which appeared 
 to be probable as a cause of the dysphagia was aneurism ; but the 
 persistence of the dysphagia in every position, and the absence of 
 other signs of aneurism, led me to believe that the obstruction was 
 of a cancerous character. If the patient had been much younger it 
 might easily have been supposed that the case was one of ordinary 
 phthisis, with severe ulceration about the larynx and epiglottis: we 
 had evidence of chronic disease of the lung, with acute disease; and 
 in phthisis the dysphagia is sometimes exceedingly severe and dis- 
 tressing; but the patient did not lose his voice, the food was never 
 regurgitated through the nose, nor did it produce spasmodic cough; 
 the obstruction was evidently below the epiglottis.
 
 92 ON DISEASES OF THE (ESOPHAGUS. 
 
 No attempt was made to explore the oesophagus with any bougie 
 or tube; the danger and discomfort which would have arisen from 
 it, did not warrant such an attempt being made. The use of nutrient 
 enemata, even for a single day, removed the very urgent dysphugia 
 which existed on his admission. The patient had previously tried 
 to swallow; till he found himself exhausted. 
 
 CASE XXII. Cancer of the (Esophagus. Artificial Opening made into 
 
 the Stomach Walter H , ret. 47, was admitted into Guy's Hospital October 
 
 8th, 1857, under my care. He had resided at Tunbridge Wells as a stable- 
 man, was of ordinary stature, light complexion, and moderately nourished. 
 He stated that for sixteen years he had had winter cough, but that he had 
 never had dropsy. On admission there was considerable dyspnoea; the lips 
 purplish; the pulse compressible, but regular; the chest was resonant on 
 percussion, and the respiratory murmur indistinct; distant prolonged expira- 
 tory murmur was everywhere audible, with some sibilant rale; the voice was 
 also indistinct, and tactile vibration diminished. The heart-sounds were regu- 
 lar and normal; the expectoration frothy and moderately abundant. The 
 abdomen was moderately full and rounded, and there was a small hard gland 
 felt about the anterior margin and upper part of the sterno-mnstoid muscle. 
 After he had been in the hospital for a short time, he began to complain of 
 severe pain in the throat during coughing; but, on carefully examining the 
 part, nothing could be perceived. In a few weeks pain was also produced 
 in swallowing, especially when solids were taken, and the cough continued 
 unrelieved. On December 14th, he continued to suffer severely, and became 
 more anaemic; the countenance was expressive of great distress, and the mind 
 irritable; deglutition had become very difficult, so that he could only take 
 fluid forms of food, and some stimulant. The cough also was very trouble- 
 some, producing very severe pain in the throat ; it was violent, and small 
 drops of blood were spirted out in the act of coughing ; the expectoration was 
 thin and watery. The chest continued resonant; respiration was very fee- 
 ble ; on the left side it was indistinct, and the expiratory murmur was pro- 
 longed ; the larynx was free in its movements. Nothing could be seen in the 
 throat, except slight oedema and redness towards the right side. The gland 
 at the angle of the jaw remained of the same size ; the pulse was compressi- 
 ble ; the tongue clean ; the bowels confined. Various means were tried, as 
 conium and carbonate of soda, with hydrocyanic acid, steel, etc. The bowels 
 were acted upon by colocynth and henbane, by magnesia mixture, or by injec- 
 tions. Counter-irritation was applied to the throat hot-water fomentation, 
 or cataplasm, blisters, &c. The inhalation of steam afforded some relief, but 
 still more the smoking of stramonium leaves. Tincture of aconite, applied 
 externally, was also of some benefit. Mr. Cooper Forster examined the throat 
 for me, but could not detect any cause of obstruction. The patient continued 
 during January and February without any improvement, the emaciation 
 increased, and both respiration and deglutition became more difficult, espe- 
 cially the latter. Morphia was occasionally given, and stramonium inhaled, 
 affording partial relief. On again examining the throat, Mr. Forster felt 
 below the epiglottis, towards the right side, a rounded tumor, which was evi- 
 dently obstructing the commencement of the oesophagus, and he believed that 
 its surface was ulcerated. The respiration, although noisy and accompanied 
 with a loud inspiratory sound, was not hurried, and sufficient a'r appeared to 
 enter the larynx. The propriety of performing tracheotomy was discussed, 
 but it was decided that no benefit was likely to accrue from it. The exami- 
 nation of the growth in the throat was followed by temporary relief, and the
 
 ON DISEASES OF THE (ESOPHAGUS. 93 
 
 patient was able, for three or four clays, to swallow solid food. The stramo- 
 nium and other remedies were continued, and nourishment was given in any 
 form that could be taken. On March 1st the emaciation was very much 
 increased. During inspiration a loud noise was produced in the throat ; and 
 this sound had for some weeks been increasing in intensity, so that he had 
 been unable to sleep for several nights, on account of the " roaring," as he 
 termed it. His voice had become more feeble, but the cough had almost 
 ceased ; he could only swallow fluids, and those very slowly ; his nourishment 
 latterly had consisted of milk and rum, with eggs. Deglutition was much 
 relieved for two or three days by two small blisters applied on either side of 
 the larynx ; but it again became so difficult that nutrient injections were 
 resorted to. These injections, by allowing the throat to rest, had enabled 
 him to swallow with more comfort. The pulse was very compressible and 
 
 small ; the bowels occasionally constipated. March 2d The respiration 
 
 became more difficult, and by the advice of Mr. Stocker tracheotomy was 
 performed. The incision was made as low as possible, but the trachea 
 appeared flattened from behind, and the patient could not bear the insertion 
 of the tracheal tube ; when it was attempted he appeared to be quite inca- 
 pable of breathing. The operation did not afford relief, and a deep-toned 
 rhonchus could be heard in the lungs. There was no congestion of the face ; 
 the pulse was very compressible ; the cough slight ; he was able to get down 
 his rum and milk, and some blanc-mange, &c. On the 9th he was breathing 
 more comfortably ; the opening in the throat was patent, and thin pus cov- 
 ered the red margins of the wound ; there was also less noise on inspiration. 
 24th. The emaciation and prostration of strength increased ; his bones 
 appeared barely covered with thin skin, and the face expressive of starvation. 
 He said " he was famished." He endeavored to relieve his distressing thirst 
 by moistening the mouth, but for four days he had not been able to swallow 
 a drop of fluid. The attempt to swallow at my request was preceded by much 
 hesitation and preparation, and was followed by a paroxysm of severe cough- 
 ing. The expectoration had changed in character, and had become muco- 
 purulent. On examining the chest sibilant rales were everywhere faintly 
 audible. There was no dulness on percussion, but preternatural resonance. 
 The voice was very feeble and scarcely audible ; the pulse slow and very 
 compressible ; the tongue clean ; the larynx was movable ; the gland at the 
 angle of the jaw had not enlarged ; the opening in the skin made during tra- 
 cheotomy remained open, and the skin was undermined, there being evidently 
 no power to repair the wound. The abdomen was exceedingly contracted, the 
 pulsation of the aorta being visible, and the arteries most distinctly traceable. 
 There was no evidence of enlargement of the liver, nor of disease of the 
 abdominal viscera. He complained of pain towards the right side, and tied a 
 handkerchief firmly around him to relieve the sense of hunger. The skin 
 was dry. He passed about a pint and a half of urine during the day. The 
 sleep was tolerable ; the mind clear and active. Nutrient injections of beef 
 tea, eggs, and rum, thickened, if possible, with flour, had been given, at tirst 
 four times and then six times a day. Milk also was ordered, and n^v of 
 tincture of opium were added to each injection. On the 25th he appeared to 
 be sinking, and the rectum ejected the enemata almost at once. His hands 
 were cold, but he complained of a sense of heat. 
 
 It now became a question whether life was to be allowed gradually 
 to die out, or an attempt to be made by any other means for the 
 introduction of food ; the patient appeared to have chronic bronchitis, 
 with epithelial cancer at the commencement of the oesophagus,
 
 94 OX DISEASES OP THE OESOPHAGUS. 
 
 possibly extending into tho trachea, and death threatened from 
 inanition. Three modes of relief suggested themselves 1st, the 
 forcible introduction of an oesophageal tube ; 2d, opening the 
 oesophagus in the neck ; and 3d, opening the stomach. In reference 
 to the first, there was evidence of a growth at the commencement of 
 the oesophagus ; and the trachea appeared partially compressed, as 
 shown in the operation of tracheotomy. The disease in the throat 
 was probably of the form of epithelial cancer, and the passage of a 
 bougie must have been constantly repeated. The great irritation 
 and coughing produced by attempting to swallow, showed that the 
 epiglottis was extensively ulcerated ; or, that there was a communi- 
 cation between the oesophagus and trachea, which would render the 
 passage of a bougie very dangerous. In some cases of cancer of the 
 oesophagus, a bougie has been passed into the pleura, and led to a 
 speedy death ; and probably the passage of a bougie could not have 
 been effected ; this decided against the first proceeding. As to the 
 second, namely, opening the oesophagus, since a very frequent seat 
 of cancer in that tube is opposite to the root of the lung, about the 
 third dorsal vertebra, and consequently beneath the position at which 
 the canal could be opened, the operation would have been very 
 formidable, dangerous, and even useless. The third proposition, 
 that of opening the stomach, appeared to be the only operation which 
 could possibly relieve the patient. 
 
 "Wounds of the stomach, as that of Alexis St. Martin, the cases 
 recorded by Mr. South and by Dr. Murchison, &c., showed that life 
 could be continued after a fistulous communication had been thus 
 made. The operations on the lower animals proved that it could be 
 performed with some probability of success ; such an operation 
 would give a chance of prolonged life, where death was otherwise 
 certain ; and where the peritoneum was healthy, there was less 
 danger than in abnormal conditions of that membrane. If life were 
 prolonged only for a short time, and food introduced, there would 
 be relief to the distressing thirst and the fearful sense of starvation: 
 and, lastly, it was evident that the patient was dying from inanition 
 rather than from the disease, nutrient enemata being refused. On 
 the other hand, however, I felt that the disease was probably of a 
 cancerous character, and would sooner or later terminate life ; that 
 the operation was a hazardous and uncertain one; and that life 
 might possibly be continued for a few days by a small portion of 
 the injection being retained. After carefully weighing these facts, I 
 asked the assistance of my colleague, Mr. Cooper Forster, and if he 
 considered the operation of opening the stomach through the anterior 
 abdominal parietes, for the purpose of introducing food, a feasible 
 and warrantable one, I decided that it should be attempted. The 
 operation was accordingly performed, and the stomach was opened 
 by an incision commencing at the extremity of the eighth rib, and 
 the edges were stitched to the wound. March 26th. The operation 
 took place about half-past 2 P. M., and was borne without a move- 
 ment on the part of the patient. The pulse, which before the opera- 
 tion was 62, and exceedingly compressible, rose to 116. Six drachms
 
 OX DISEASES OF THE (ESOPHAGUS. 95 
 
 of milk with part of an egg were introduced through an elastic tube 
 into the stomach. At twenty minutes past 3, about two ounces more 
 milk and egg were introduced ; the patient then complained of feel- 
 ing a sense of heat, but appeared comfortable. He was now removed 
 to bed. At 4 P. M. the pulse was 120 and still very feeble ; it was 
 decided to introduce every half hour, if the patient were awake, two 
 ounces of milk and egg, and every second time two drachms of rum 
 with it. At 9 P. M. he was comfortable ; there had been slight pain 
 in the left side ; the pulse was fuller, 124 ; the skin less parched ; 
 and he had slept occasionally for a short time. Messrs. Greenwood, 
 Gayleard, Owen, and Tuck, kindly volunteered to remain with him 
 iii rotation. During the night he had four hours' sleep, he passed 
 urine, and there were three slight watery evacuations from the 
 bowels. 27th. About 10 A.M. he coughed violently, and the con- 
 tents of the stomach were forcibly ejected through the wound. His 
 pulse continued 120. At 1 P.M. he was cheerful, his eyes more 
 bright, his voice stronger, the skin less parched, his tongue moist, 
 thirst and the sense of starvation relieved ; he had pain in the left 
 side ; the pulse 120, and very compressible ; his hands were cold, 
 feet and legs warm ; the coldness of the hands had been very marked 
 for several days. The operation had evidently mitigated his suffer- 
 ing. At 1.30 P. M. half an ounce of rum, with sugar, and an ounce 
 and a half of water, and fifteen minims of lemon -juice were given. 
 The stomach received it well, contracting upon the tube. He said 
 that it produced a comfortable sense of warmth throughout the abdo- 
 men. At 3.30 the pulse was firmer and fuller than at 1 o'clock, and 
 the hands warmer. Since the operation, during the twenty-four 
 hours, he had six eggs, beaten up in twelve ounces of milk, given in 
 small divided doses, with four ounces of rum. Milk and egg, or 
 beef tea thickened _ with flour, were ordered every half hour, and 
 occasionally half an ounce of rum, as just mentioned. At 8.30 P. M. 
 faintness came on, the face became cold and perspiring ; pulse 136, 
 and scarcely to be felt. The stomach appeared to have lost its power 
 of contracting on the food introduced. 
 
 Stimulants were ordered to be given repeatedly and freely, with 
 nourishment as before ; and two or three times, as a stimulant, KIXX 
 of tincture of sesquichloride of iron. During the night he was evi- 
 dently sinking, the pulse sometimes became scarcely perceptible, but 
 rallied after stimulants were introduced. On the 28th he slept for a 
 short time about 10 A. M., and expressed himself as comfortable, but 
 gradually became unconscious, and died at 10.45, rather more than 
 forty-four hours after the operation. 
 
 The inspection was made twenty-eight hours after death. The 
 body was extremely emaciated. The head was not examined. At 
 the lower part of the neck, immediately above the sternum, was the 
 wound made in tracheotomy, gaping and undermined, and on the 
 trachea a few drops of pus. At the left hypochondrium was the 
 opening made by the operation of gastrotomy also enlarged by the 
 plug which had been introduced a few hours before death. The 
 mouth and soft palate were healthy, also the epiglottis. At the
 
 96 ON DISEASES OF THE (ESOPHAGUS. 
 
 posterior surface of the cricoid cartilage there was a growth con- 
 nected with the mucous membrane, about a quarter of an inch in 
 elevation, and extending from side to side, soft and slightly injected ; 
 passing downwards, there was irregular ulceration, and towards the 
 trachea destruction of all the coats of the oesophagus; on either side 
 and below, the ulcer was bounded by a sharp undermined edge. 
 The cellular tissue of the trachea and its muscular fibres were de- 
 stroyed for about half an inch ; the mucous membrane was bare, and 
 perforated by a small opening about one-sixteenth of an inch in 
 diameter, so that fluid could pass from the oesophagus into the 
 trachea ; below the ulcerated surface in the oesophagus the canal was 
 much contracted by infiltration into the surface of the mucous mem- 
 brane ; the passage was so much diminished at this part that a probe 
 could only be passed after death, and it was probably quite im- 
 pervious to fluids during life. The constriction was situated at the 
 level of the first bone of the sternum. The rest of the oesophagus 
 was healthy. One or two glands in the neck were infiltrated and 
 diseased, but none of the mediastinal or other glands. The rima 
 glottidis was free ; the vocal cords and aryteno-epiglottidean folds 
 were quite healthy ; so also was the trachea. The bronchi contained 
 thick tenacious mucus. The pleura on the left side was healthy ; on 
 the right, there were general, but not firm adhesions. The lungs 
 were both much distended with air ; they were pale, emphysematous, 
 and covered the heart. At the right apex the lung-tissue was 
 puckered ; there were numerous lobules of iron-gray consolidation, 
 with intervening crepitant lung, but no disorganization. The lower 
 lobe of the right lung afforded a beautiful speciman of emphysema, 
 but there were numerous gray tubercles studded in small clusters ; 
 they were non-cancerous. The lower lobe of the left lung was much 
 congested, and one or two lobules were softened. and breaking down 
 from acute changes, which took place, probably, a very short time 
 before death. There was no enlargement of the bronchial glands. 
 In front of the surface of the heart was a small collection of pus, 
 only a few drops, apparently from the inflammation of a small gland. 
 The pericardium and heart were healthy ; the heart was contracted 
 and firm. On opening the abdomen, the intestines were found con- 
 tracted; the peritoneum was healthy ; no inflammation, as shoiun by 
 effusion of lymph, serum, or diminution of the normal smoothness, could 
 be detected. The stomach was partially distended ; it was situated 
 lower than usual, and its anterior surface was looped up to the 
 opening in the anterior abdominal parietes made by Mr. Forster at 
 the linea semilunaris. The mucous membrane of the stomach was 
 pale, slightly injected at the opening. On gently drawing aside the 
 stomach at the opening, the opposed serous surfaces were found 
 slightly adhering. The small intestine was healthy throughout, but 
 atrophied ; the food introduced had only passed four feet down the 
 intestine ; below that point the intestine was exceedingly small. 
 The lower part of the ileum was healthy. In the colon there was 
 several patches of congested mucous membrane. The gall-bladder 
 was distended, the liver healthy, so also the kidneys ; the spleen was
 
 
 OX DISEASES OF THE (ESOPHAGUS. 97 
 
 very small. There was no evidence of any cancerous disease affecting 
 any part except the oesophagus and one or two adjoining glands. 
 
 It is probable that chronic disease of the riglit apex had existed 
 for a long time, so also the emphysema of the lungs. Other miliary 
 tubercles were perhaps of recent deposition. The lobular consolida- 
 tion and congestion of some parts of the left lower lobe of the lung 
 were evidently only of very brief duration. As to the cause of the 
 cancerous disease we have no evidence; it was probably of about 
 six months' duration; its existence with chronic disease of the lung 
 is a fact of some pathological interest. The microscopical examina- 
 tion of the growth in the neck presented the form of cells commonly 
 observed in epithelial cancer. 
 
 In reference to the diagnosis in this case, it was evident at the 
 time of admission that the patient had chronic disease; he had had 
 cough for fifteen years; there was, however, no evidence of serious 
 obstruction to the heart or to the portal circulation ; the dysphagia 
 was then a new symptom. The examination of the chest did not 
 give any indication of phthisis, the respiration was exceedingly 
 feeble at the apices, but there was no dulness on percussion, and the 
 voice was diminished rather than increased in resonance; at the 
 bases the expiratory murmur was prolonged; it appeared probable 
 that there was no marked consolidation of the lung, but rather that 
 the feebleness of the respiratory act was due to emphysema. The 
 question arose, whether there was any pressure on the right bronchus, 
 but of this there was no proof; the respiration at the right base was 
 as strong as at the left, and there was no increase of resonance at 
 the right apex, though the respiration was less distinct. As to the 
 cause of the dysphagia, it was naturally suggested whether it was a 
 case of phthisis, in which the principal disease manifested itself in 
 the throat, by ulceration of the epiglottis. I have several times 
 observed in severe ulceration of the epiglottis very severe dys- 
 phagia; and the condition may be mistaken for obstructed oesopha- 
 gus. Few, however, would have had that idea in this case, for there 
 was wanting at the early stage the raucedo of phthisis; and the diffi- 
 culty in swallowing was evidently at a later stage of the process 
 than that produced by ulceration of the epiglottis: there the attempt, 
 to swallow is scarcely commenced before the food is ejected, often 
 through the nares; here, it passed beyond, there was no such ejec- 
 tion of food, but rather severe pain, and that extending to the ears. 
 The blood also which was spirted out during coughing was not as 
 we observe it in ulcerated larynx, but was evidently from the pha- 
 rynx. Subsequently a tumor could be felt at the commencement of 
 the oesophagus. The emaciation was not that of simple phthisis: 
 there we generally have a rounded abdomen, and often more or less 
 diarrhoea; here there was uniform constipation and collapsed abdo- 
 men. There was no evidence of syphilis to account for the affection 
 of the throat, nor of aneurism. It was presumed that the affection 
 of the pharynx and oesophagus was of the form of epithelial cancer; 
 the enlarged gland in the neck confirmed this idea, and there was 
 nothing to indicate any such disease of other viscera. As to the 
 7
 
 98 ON DISEASES OF THE (ESOPHAGUS. 
 
 prognosis, that was from the first unfavorable, but it was not for 
 several weeks anticipated that such serious disease of the throat 
 would present itself;' all idea was then given up of ultimate recovery. 
 In the treatment, the object was to relieve the irritation of the bronchi 
 and the engorgement of the portal system; and to strengthen the 
 patient, meat diet was given. The excreting organs and glands were 
 acted on by squill and blue pill, by purgatives, &c. The spasmodic 
 contraction of the bronchi was relieved by conium, alkalies, hydro- 
 cyanic acid, and stramonium. The pain produced by swallowing 
 and coughing was most distressing, and sometimes kept the patient 
 awake for several nights. Inhalation of steam afforded relief, so 
 also the smoking of the leaves of stramonium. The application, of 
 nitrate of silver aggravated the distress; but small blisters on either 
 side of the throat were productive of the greatest benefit; tincture 
 of aconite, also, applied externally was more palliative than chloro- 
 form; morphia administered internally produced transient compo- 
 sure; all these means, however, could not check the progress of the 
 disease. When it became necessary to resort to nutrient injections, 
 life was fast ebbing away. It may be a question as to what is most 
 effective in such cases; beef tea thickened with flour, an egg, and a 
 small quantity of rum were used. Sir W. Gull suggested the pro- 
 priety of using pepsine mixed with the fluid, and since the rectum 
 is incapable of rendering the aliment in a condition ready for absorp- 
 tion, it may be well deserving of trial. The longest period in which 
 I have known a patient nourished by injections alone, was in a case 
 mentioned by Dr. Barlow, in which for seventy days food was ad- 
 ministered only in this manner. In my patient the rectum much 
 more quickly refused injections. All other means of affording relief 
 being taken away, as stated in describing the case, I was brought 
 to the consideration of gastrotomy. I had previously ventured to 
 suggest this operation in impending starvation, in cases of perforation 
 or communication between the oesophagus and trachea, where deglu- 
 tition is sometimes impossible. Death in these cases sometimes 
 takes place simply from inanition. In this instance, it was well 
 known that there was incurable disease, and that any operation 
 which might be performed would only be palliative. It was sub- 
 mitted to the patient, that such an operation might be quickly fatal, 
 or prolong his life for a few weeks; even with such a slight hope he 
 most readily assented, so terrible was the sense of starvation and of 
 thirst. These symptoms were relieved, and the horrors of such a 
 death partially mitigated. In the treatment of the case after the 
 stomach had been opened, it might have been well to have repeated 
 nutrient injections by the rectum, and to have given food less fre- 
 quently, although the quantity introduced at each time was only 
 two ounces. There was fear lest the operation might suddenly ter- 
 minate the flickering flame of life, and lest no rallying should take 
 place; and afterwards, lest the sutures should give way, and thus 
 the contents of the stomach be freely extra vasa ted into the perito- 
 neum. After twenty-four hours, faintness came on; the patient was 
 evidently sinking, and any treatment would have been alike ineffec-
 
 ON DISEASES OF THE (ESOPHAGUS. 99 
 
 tive. Stimulants Avere given very freely, and at each time were 
 followed by a slight revival in the action of the heart. There ap- 
 peared to be nothing to call for the use of opium; at last, a small 
 quantity of tincture of iron was administered, as being one of the 
 most powerful stimulants. The consideration of the complete par- 
 ticulars of this case leads to the conviction, that if the operation had 
 been performed earlier more permanent benefit might have accrued. 
 It was done with a comparatively trifling addition to the sufferings* 
 of the patient; it was effected with ease, without collapse or perito- 
 nitis; and the thirst and sense of starvation were relieved in a degree 
 which were scarcely anticipated. In cases of equally advanced 
 starvation death has ensued as quickly; and it is probable that had 
 the operation not been performed, life would have terminated even 
 more speedily. The patient would certainly have been deprived of 
 the relief which for twenty-four hours he experienced. Under these 
 circumstances we should strongly urge a repetition of this operation, 
 if a favorable case were presented, but at an earlier period of the 
 disease. 
 
 Mr. Forster has a second time performed this operation on a child 
 for occlusion of the oesophagus from the action of caustic alkali ; 
 but so feeble had the child become that the stitches between the 
 coats of the stomach and the skin gave way, and extravasation took 
 place into the peritoneal cavity. 
 
 Since the publication of my former editions, the operation which 
 was attempted for the first time to relieve obstruction of the oeso- 
 phagus by opening the stomach has been performed many times, 
 and the following table shows in each instance the nature of the 
 case, the duration of the symptoms, the length of time that life 
 was prolonged after the operation, and the cause of death. 
 
 During the time that this work has been in the press, my col- 
 league, Mr. Howse, has ' in two cases successfully performed the 
 operation of opening the stomach ; in one case a man suffering from 
 extensive cancerous disease of the oasophagus survived a month ; 
 the patient was fed through the parietes, and death was occasioned 
 by the extension of the cancerous disease and by gangrenous pneu- 
 monia. The second case is still more recent (July, 1878), but the 
 patient is doing well, and the fistulous opening into the stomach is 
 well established. 
 
 Of seventeen cases, then, all proved fatal, the greater proportion 
 of them succumbing within a few hours, and only two surviving 
 the risk of the operation itself. One of Mr. Sydney Jones's cases 
 lived forty days and died of bronchitis. Another, under the care of 
 the same surgeon, lived thirteen days. One patient lived ten days 
 and died of septicaemia. Others only survived three or four days.
 
 100 
 
 ON DISEASES OF THE (ESOPHAGUS. 
 
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 ON DISEASES OF THE (ESOPHAGUS. 101 
 
 It must be noted, however, that 7 died of exhaustion, and these 
 only show that the operation was done too late. They tell very 
 little against the operation itself. In three others exhaustion had 
 probably as much to do with the fatal result as the peritonitis. One 
 patient died of broncho-pneumonia. 
 
 It is also worthy of note that in Mr. Durham's article on Gas- 
 trotomy, seven cases of the operation were performed for the ex- 
 traction of foreign bodies and these all recovered. 
 
 Professor Verneuil 1 records a successful case of gastrotomy per- 
 formed upon a young man aged seventeen, in whom the cesophageal 
 obstruction was due to the swallowing of caustic potash. The poTson 
 was taken on February 4th, and the stomach was opened on June 
 26th. In September he was convalescent. 
 
 CASE XXIII. Cancer of the (Esophagus. Sloughing. Perforation of 
 the Aorta. Sudden and fatal Hemorrhage Margaret H , aet. 60, was 
 admitted April 17th, 1861, under Dr. Wilks's care, in a prostrate condition ; 
 she made no special complaint, but appeared to be worn out from hard work, 
 rathsr than to be suffering from any positive disease. About a fortnight after 
 admission, she spat up a little blood ; but, on careful examination of the chest, 
 no disease could be detected. Two days before death she again spat up a 
 little blood, and appeared very prostrate. She rapidly sank. On inspection, 
 a circumscribed sloughing cancer was found in the centre of the oesophagus ; 
 the disease extended into the mediastinum, and involved the lung on the left 
 side. The sloughing had extended into the aorta ; the walls of the vessel 
 were perforated, and the stomach was distended with blood. It could not be 
 ascertained that she had ever suffered from dysphagia. 
 
 The diagnosis of this case was very obscure, and even when the 
 first oozing of blood came on it was supposed to have been poured 
 out from the lungs ; the hemorrhage from the aorta led to fatal 
 syncope ; the blood, however, passed downwards into the stomach, 
 and was not rejected by the mouth. The absence of the dysphagia 
 increased the obscurity of the symptom. 
 
 Among other diseases of the oesophagus we may mention polypus 
 and muscular tumors. 
 
 Polypus at the commencement of the (Esophagus. In the 'Medico- 
 Chirurgical Transactions' (vol. xxx), a case of this kind is recorded 
 by Dr. Arrowsmith. A lobulated growth, freely movable and about 
 the size of a walnut, was attached to the mucous membrane of the 
 oesophagus, and produced fatal dysphagia. The tumor was vascular 
 and homogeneous in structure. 
 
 Myomata of the oesophagus have been occasionally found, and an 
 interesting case of this kind is minutely described in the 'Trans. 
 Path. Soc.,' 1875, by my colleague Dr. Hilton Fagge. A large tumor, 
 two inches in length, was found about the centre of the oesophagus, 
 in a man aged thirty-eight. He died from bronchitis and emphy- 
 sema and an injury to the knee, but he did not suffer from any symp- 
 tom of oesophageal disease. 
 
 Obstruction of the (Esophagus from pressure of Aneurismal or other 
 Tumors. Tumors of a cancerous, strumous, or aneurismal character, 
 
 ' ' Gaz. des Hop.,' Oct. 28, 1876 ; ' Med. Times and Gazette,' Nov. 1876.
 
 102 ON DISEASES OF THE (ESOPHAGUS. 
 
 sometimes exert pressure upon the oesophagus, and cause dysphagia. 
 Cancerous and strumous diseases of the glands occur more frequently 
 in the anterior than in the posterior mediastinum, and in the former 
 situation they do not exert pressure upon the oesophagus ; but where 
 the root of the lung or the lower part of the neck is involved there 
 is closer proximity with the oesophagus, and pressure upon, or sup- 
 puration communicating with the canal may be the result. 
 
 The oesophagus is also in close contact with the aorta, and we 
 frequently find that dysphagia is one of the symptoms of aneurismal 
 disease of that vessel ; the dysphagia is, however, less severe and 
 constant than in direct constriction of the oesophagus. It is no un- 
 common thing to find death suddenly taking place from rupture of 
 the aneurism into the oesophagus; but a considerable time may 
 elapse, as in an instance recorded by Mr. S. Cooper, in which eight 
 weeks elapsed after the first rupture before the fatal hemorrhage 
 occurred; in other instances death follows from the condition of the 
 heart, or from pressure on the respiratory and laryngeal nerves, 
 producing fatal syncope or apnoea, even although the pressure on the 
 oesophagus may have been sufficient to produce sloughing. As to 
 other symptoms, they are pain at the sternum, at the side, between 
 the shoulders, and very frequently down the arm ; paroxysms of 
 dyspnoea often cause intense distress; and raucedo from pressure on 
 the laryngeal nerves is by no means unfrequent. The sounds of the 
 heart are frequently modified, and if any pressure be exerted on the 
 bronchus, it is manifested by the less free admission of air into the 
 lung on the side of the obstructed bronchus. The pain, dyspnoea, 
 and dysphagia, in some of these cases, are much relieved when the 
 patient bends the body forward, so as to remove the pressure from 
 the structures beneath. In an instance mentioned by Mr. Armiger, 
 in the ' Medico-Chirurgical Transactions' (vol. ii), the patient was 
 most easy on his knees and elbows. 
 
 The diagnosis is often very obscure ; the emaciation is not gene- 
 rally so great as we find in cancerous disease, but the paroxysms of 
 dyspnoea and pain are more marked and are exceedingly severe, 
 although the patient is at times able to swallow with ease. The 
 treatment is simply palliative ; yet much may be done for the com- 
 fort of the patient and the prolongation of life, by the regulation of 
 the diet, the avoidance of mental and physical excitement, and the 
 occasional use of sedatives and anti-spasmodics, as of morphia, chloric 
 ether, stramonium, &c., to relieve the paroxysms of dj^spnoea. A 
 word of caution must be given in reference to the use of bougies, for 
 I have seen several instances in which the attempt to pass a bougie 
 would have at once broken down the communication with the aneu- 
 rismal sac, and have led to sudden fatal hemorrhage. 
 
 CASE XXIV. Aneurism of the Aorta and Sloughing (Esophagus. James 
 F , set. 34, was admitted, November, 1855, and died in January, 1856 ; he 
 was a temperate man, married, and a laborer at Dartford. Six months before 
 his admission, after having been engaged a short time previously in carrying 
 very heavy weights, he experienced pain in the left breast; this pain became 
 much more severe, and also extended between his shoulders, but there was
 
 ON DISEASES OF THE (ESOPHAGUS. 103 
 
 no tenderness in the back. December 4th, the pain at the left nipple became 
 more fixed, and there was a slight systolic bruit. January 1st, it was noticed 
 that the radial pulse was weaker on the right side, and he was found to have 
 difficulty in swallowing solids. This dysphag'a increased in severity, and 
 his dyspnoea became more distressing. January 20th, he was unable to 
 swallow food ; his face was livid, dyspnoea urgent, and his pain severe. He 
 died on the 25th. On examining the chest, the lungs were emphysematous, 
 pale, but moderately collapsed. There was acute inflammation of the peri- 
 cardium, and considerable injection of the pleura on both sides. On turning 
 aside the lungs, an aneurismal tumor, about the size of a large orange, was 
 found at the termination of the arch of the aorta ; its walls were thin ; the 
 posterior part of the vessel was entirely destroyed, and communicated with a 
 cavity in front of the vertebrae, one of which was absorbed. There was 
 scarcely any fibrin in the sac. The aneurismal tumor had pressed upon the 
 oesophagus, and quite obliterated its canal ; the whole of its walls were of a 
 greenish color, very offensive, and in a sloughing condition. Still no per- 
 foration had taken place. Both bronchi were compressed. Two other 
 aneurismal tumors were found connected with the ascending and transverse 
 portions of the arch of the aorta. Other viscera were healthy. 
 
 CASE XXV. Aneurism of the Ascending Aorta Rupturing into the 
 
 Pericardium. Communication of the (Esophagus icith the Left Bronchus 
 
 Frederick K , get. 23, was admitted under Sir William Gull's care, January 
 23d, and died April 26th, 1856. He was a hawker, and had been living in 
 the Old Kent Road ; he had enjoyed good health till five months previously, 
 when he struck his chest against a box hanging from a crane ; a fortnight 
 afterwards he experienced pain at the part ; this gradually increased till three 
 weeks before admission, when he was obliged to give up work. On admission, 
 he complained of pain in the chest ; a distinct pulsation could be felt between 
 the second and third ribs on the right side, and a jar with the second sound 
 of the heart. There was pain at the seat of pulsation, and along the border 
 of the pectoralis major, and down the inner side of the arm. The pain con- 
 tinued severe, and a systolic bruit became audible at the seat of the tumor. 
 He could obtain no rest at night. On April 19th, he had difficulty in swal- 
 lowing, and this symptom increased in severity. On the 28th, after talking 
 witli his friends, he died very suddenly. On removing the sternum, an aneu- 
 rism of the ascending aorta was opened ; it had extended to the sternum oil 
 the right side. On opening the pericardium, it was discovered to be full of 
 blood, and a small irregular communication was found at its upper part with 
 the aorta. The heart was of normal size ; the left ventricle was not hyper- 
 trophied ; the valves were healthy. The ascending aorta formed an aneuris- 
 mal sac, about two inches and a half in diameter, principally on the right 
 side. The lung was adherent, and it was nearly perforated. The aneurism 
 extended as far as the origin of the left carotid ; below the left subclavian was 
 another small dilatation. At the centre of the oesophagus was a slough, and 
 an opening had been formed into the left bronchus ; there was no communi- 
 cation, however, with the aorta. The remaining viscera were healthy. 
 
 Although it appeared that the greater pressure from the aneurism 
 was on the right rather than on the left side, we can find no other 
 explanation for this sloughing condition of the oesophagus, and its 
 communication with the bronchus, beyond the pressure which all 
 these parts suffered from the distended aneurismal sac. 
 
 CASE XXVI. Aneurism. Pressure on the (Esophagus and on the Left
 
 104 OX DISEASES OF THE (ESOPHAGUS. 
 
 Bronchus. Difficulty in Deglutition, Sudden Death James F , jet. 
 about 40, was admitted, under Dr. Addison's care, August 24th, 1859, and 
 died September 24th, at f> P. M. He was a spare man, pale, but strongly 
 built ; for nine months he had suffered from pain at the sternum and between 
 the shoulders ; he had lost flesh ; and for several months had suffered from 
 difficulty in deglutition, so that on admission he was unable to take solid food ; 
 but fluids were easily swallowed. A few days after he had been in the hos- 
 pital, an attack of very urgent dyspnoea came on, but gradually subsided, 
 leaving the respiration easy and of ordinary frequency. Jn that state he 
 remained till the day of his death. The physical signs were obscure ; the 
 resonance on the left side was very slightly diminished ; the respiratory sounds 
 on that side were much less distinct than on the right ; and were accompanied 
 at the base with slight mucous rales; the voice was not increased in resonance. 
 Jso abnormal pulsation nor sound in the interscapular or sternal regions could 
 be heard. The heart sounds were normal as to rhythm; but the second sound 
 was "ringing ;" the pulse was compressible, more feeble on the left side. He 
 had no vomiting, neither was there any evidence of enlarged glands in the 
 neck, &c., nor had he any pain in the arm. On the 24th, after taking his 
 tea, he washed up the things for the nurse, and immed'ately afterwards he 
 was seen sitting on the edge of his bed, unable to speak, and scarcely able to 
 breathe. He never spoke afterwards, but died in about a quarter of an hour, 
 the heart continuing to beat after he had ceased to breathe. On inspection. 
 About one inch below the left subclavian artery an oval opening, with rounded 
 edges, led from the aorta, into a large aneurismal cavity about four inches in 
 diameter ; this cavity was bounded posteriorly by the vertebrae, which were 
 corroded; the tumor pressed upon the left bronchus, and upon the oesophagus, 
 and probably upon the thoracic duct. The lungs were healthy. The bronchi 
 on the left side were rather more congested than usual. The ascending aorta 
 and the arch were atheromatous ; the valves and the muscular fibre of the 
 heart were healthy ; the pericardium was normal, and no disease could be 
 found in any other part. 
 
 The sudden fatal apncea was due, probably, either to injury of the 
 laryngeal nerves and spasmodic action of the larynx ; or to sudden 
 distension and increased pressure on the bronchus. The diagnosis 
 was very obscure ; the symptoms were slight, and the interference 
 with the entrance of air into the left lung might have been regarded 
 as arising from a tumor in the mediastinum. 
 
 CASE XXVII. Dissecting Aneurism of the Aorta bursting into the (Esoph 
 af/us James H , jet. 38, had been losing flesh before admission, but origi- 
 nally had been a very muscular man. He had suffered from symptoms of 
 dysphagia, and there was crepitation at the base of one lung. The aortic 
 arch was found to be in a very diseased state. There were two true aneu- 
 risms, one, the size of a hazel-nut, would allow the tip of the finger to pass 
 into it, and was situated opposite the orifice of the left subclavian ; at the 
 posterior part of the aorta was a second as large as a plum ; this opened 
 straight into the oesophagus by a perforation capable of admitting three fingers, 
 and the blood had passed downwards in the coats of the oesophagus, separating 
 the mucous from the submucous coats as far as the stomach. The muscular 
 fibres were hypertrophied ; and the stomach and half the intestine were full 
 of blood. 
 
 Mediastinal tumors and enlarged ylands may cause obstruction.
 
 OX DISEASES OF THE (ESOPHAGUS. 105 
 
 These may be of variable nature. All primary mediastinal tumors 
 may be said to be lymphomata ; but other diseases occasionally 
 occur, and of these may be mentioned a fibrous growth of gumma- 
 tous nature, which has been found twice in our post-mortem series. 
 At other times some extension of cancer from the oesophagus may 
 lead to more complete obstruction, or hydatid tumors may occasion- 
 ally cause the same symptoms. 
 
 In a man set. -W, admitted with a large cancerous mass in the neck 
 on the left side, the growth evidently extended into the chest, and he 
 soon suffered from difficulty in breathing. The disease had passed 
 down the oesophagus beneath the mucous membrane, and it formed 
 a thick external layer; about the bifurcation of the trachea the whole 
 canal was involved. The bronchial glands, and also the kidneys, 
 were affected. The lungs were in an early stage of pneumonia. 
 
 Before concluding the subject of dysphagia, I must refer to its 
 occasional presence in pericarditis, and pleuro-pneumonia, as men- 
 tioned by Dr. Stokes, in his valuable work on ' Diseases of the Heart.' 
 Although very numerous instances of these diseases have come under 
 my observation, I do not remember ever having witnessed difficulty 
 in swallowing associated with the other symptoms of pericarditis ; 
 and even when the pericardium was found distended with 36 oz. ot 
 pus, and nearly filled the left side of the chest, this symptom was 
 not observed; in a patient recently under my care, extensive pleuritic 
 effusion was found with dysphagia, but careful investigation led me 
 to believe that the latter symptom had its origin in local disease. 
 Transient enlargement of the bronchial glands might, however, in- 
 duce the dysphagia in these cases, and, to quote the words of Dr. 
 Stokes, it may probably "be less the result of a mechanical condition, 
 such as pressure on the oesophagus, than of some excited irritability 
 either of that tube, or of parts immediately in contact with it." 
 
 .VII. Dysphagia from destruction of the mucous membrane by mechani- 
 cal or chemical agents. 
 
 Every year the lives of many children are destroyed by drinking 
 boiling water; vesication of the mouth, fauces, and pharynx is at 
 once produced; but generally, the instantaneous rejection of the 
 scalding fluid prevents any portion from being swallowed. The 
 margin of the epiglottis and the entrance of the larynx are, however, 
 often injured, and the sudden swelling of the mucous membrane of 
 the glottis by preventing the entrance of air into the lungs, leads to 
 a rapidly fatal result. 
 
 The prognosis after accidents of this kind in infants is very un- 
 favorable ; for, although the respiration may be apparently unimpeded 
 several hours after the injury, a slight increase of effusion of serum 
 into the swollen mucous membrane of the larynx leads to complete 
 occlusion of the already diminished rima, and causes death from 
 apnoea. The operation of tracheotomy has in not a few instances 
 saved life, but in many the supervention of acute disease of the 
 trachea and bronchi has proved quickly fatal. In several inspections 
 after death, the mucous membrane of the lower part of the oesoph- 
 agus and stomach have presented considerable congestion, showing
 
 106 ON DISEASES OF THE (ESOPHAGUS. 
 
 that some of the hot water Lad reached those parts; and in a case 
 of poisoning by corrosive sublimate, lymph was found in the oesoph- 
 agus. 
 
 The action of corrosive poisons may be divided into that which is 
 immediate or primary, and that which is remote or secondary. The 
 mucous membrane of the mouth, fauces, pharynx, and oesophagus, 
 becomes at once discolored by the chemical action of the poison, and 
 it assumes a yellowish-white or brown color, according to the strength 
 and character of the agent; if the poison be in a very concentrated 
 state, the membrane is charred and destroyed. The effusion of a 
 sero-alburninous fluid into the mucous membrane, or into the cellular 
 tissue, leads to considerable swelling; but, as with boiling water, the 
 epiglottis rarely escapes injury, and its margin often presents an 
 eroded and serrate appearance. The longitudinal rugae of the oesoph- 
 agus, especially near the stomach, are discolored or destroyed; shreds 
 of cesophageal membrane are sometimes ejected, and in one instance, 1 
 after strong sulphuric acid had been taken, a complete cast of the 
 oesophagus was thrown off. The stomach also is sometimes exten- 
 sively injured, its mucous membrane and coats being charred, or even 
 perforated, and the adjoining viscera similarly acted upon wherever 
 the poison comes in contact with them. If the patient survive the 
 immediate action of the poison, a fibro plastic product is effused into 
 the submucous tissue; thickening and contraction of the new product 
 takes place, and in this manner an annular constriction may arise. 
 
 Symptoms. The first symptom produced by taking corrosive 
 poison is severe pain of a burning character in the mouth and throat, 
 and along the whole tract of the oesophagus. When any portion has 
 been swallowed it is succeeded by vomiting of dark colored fluid, 
 containing blood ; extreme dysphagia quickly follows, and the act of 
 speaking is exceedingly painful; there is also sometimes urgent 
 dyspnoea. The lips are often injured by the contact of the poison, 
 the tongue is found to be swollen and injected, arid the mucous mem- 
 brane of the whole mouth is discolored, becoming yellowish-white or 
 brown, or completely charred; and the throat is in a similar condi- 
 tion. Cough and dyspnoea are distressing symptoms if the epiglottis 
 and larynx have been injured. Diarrhoea is occasionally present. 
 The patient has an anxious and dejected countenance ; the pulse is 
 compressible and feeble ; but the mind retains consciousness till death, 
 which may take place in a few hours. In other cases, it is often 
 remarkable how soon the injured mucous membrane of the mouth 
 and throat recover themselves; the vomiting subsides; the extreme 
 pain in the throat produced by swallowing or coughing disappears; 
 and in a few days the patient appears almost convalescent, and gives 
 hope of recovery. If only the mucous membrane of the stomach 
 be injured, there may be entire immunity from pain ; but the freedom 
 from pain is a very deceptive symptom, the patient often unexpect- 
 edly dies, from syncope or asthenia, although more generally the 
 subsequent contraction of the inflammatory product in the oesoph- 
 agus, stomach, or pylorus, leads to obstruction, slow emaciation, 
 
 1 Mayo's ' Outlines of Pathology.'
 
 OX DISEASES OF THE (ESOPHAGUS. 107 
 
 the regurgitation or vomiting of food, and a lingering death from 
 inanition. 
 
 The first effect of these poisonous agents is best combated by the 
 use of substances capable of neutralizing their chemical properties, 
 combined with oleaginous and demulcent drinks to shield the mucous 
 membrane. Opiates may be given to relieve pain, and as soon as 
 deglutition can be performed, bland and nutritious diet may be 
 allowed. 
 
 When secondary contraction of the oesophagus has taken place 
 the probability of relief is slight; fluid forms of nutriment adminis- 
 tered in a concentrated form, and injections of a similar kind may 
 prolong life. Dr. Cumin 1 succeeded in saving the life of a child by 
 the use of elastic catheters, after potash had been taken; and Mr. 
 Forster, 2 after the same poison, sought a like result, though less suc- 
 cessfully, by the formation of a gastric fistula. 
 
 CASE XXVIII. Poisoning by Sulphuric Acid. Death on the llth day 
 
 In an interesting case of poisoning by sulphuric acid, in October, 1855, in 
 which death did not take place until the eleventh day, the mouth and throat 
 were of a whitish color; at the posterior part of the mouth, there was con- 
 siderable injection of the mucous membrane, and on each side of the posterior 
 pillar of the fauces there were whitish loose patches of membrane. The 
 edge of the epiglottis was found minutely eroded, and the mucous membrane 
 of the oesophagus was pale and covered with yellow membranous flakes. The 
 prostration and collapse immediately following the reception of the poison 
 were accompanied by vomiting of grumous blood, but in less than twelve 
 hours the patient was able to swallow some milk and arrowroot ; and on the 
 fourth day appeared to take her food without difficulty. Death took place 
 from the sloughing condition of the mucous membrane of the stomach, com- 
 bined with inflammation of the duodenum, and of the whole tract of the 
 intestine. The ability to swallow in this case was restored in a very short 
 time, considering the fearful injuries which resulted to the whole of the 
 mucous membrane. (See more lull account of the state of the stomach in 
 our remarks on that viscus.) 
 
 Two instances admitted into Guy's Hospital in 1857, illustrate the 
 primary effects of poisons on the pharynx and oesophagus. They 
 are detailed in the Reports for 1859, by Dr. Wilks: 
 
 CASE XXIX. "Poisoning by Soap-Lees Charles T. C , set. a year 
 and a half, was admitted under Mr. Hilton, on September 4th, 1857, at six 
 o'clock in the evening. About an hour before, the child had drunk from a 
 cup about a mouthful of soap-lees ; some oil and mucilaginous fluids were 
 administered, and he was brought to the hospital. The child was then very 
 ill, and, in the course of an hour or two, some difficulty of breathing came on, 
 but this did not appear sufficiently extreme to warrant tracheotomy. The 
 most marked symptom after this was an intense heat of skin. The child died 
 at five o'clock on the following morning, twelve hours after swallowing the 
 fluid. 
 
 " Post-mortem appearances The mouth and tongue were slightly exco- 
 riated, and of a light brown color. The fauces, tonsils, and mucous membrane 
 of the pharynx had a slightly swollen appearance, and had a yellowish-brown 
 
 1 ' Transactions of the Medical and Chir. Soc. Edin.' 
 * 'Guy's Hcwpital Reports.'
 
 108 ON DISEASES OF THE 03SOPHAGUS. 
 
 hue. The whole of the oesophagus presented a similar condition, the mucous 
 membrane having a brownish color, particularly the longitudinal rugte. The 
 membrane was changed in character by the alkali, but was nowhere destroyed. 
 Tin' most pernicious effect had been produced at the very extremity of the 
 oesophagus, where the interior was of a dark-brown color; this terminated at 
 a defined line, the mucous membrane of the stomach immediately below being 
 quite unaffected. The stomach was contracted. It was found on opening it 
 to be quite empty; the ruga?, were well marked, and the whole mucous mem- 
 brane had a slightly pink hue, being more than usually injected. These 
 appearances were, however, so slight that, unless especially looked for, 
 they would probably have been disregarded. As before stated, the ter- 
 mination of the oesophagus was of a dark brown color, but this terminated 
 abruptly at its margin. Towards the pyloric end of the stomach, near 
 its greater curvature, there were a few rugae of a very dark color, produced, 
 no doubt, by the action of the alkali. The mucous membrane, thus altered, 
 was not at all soft, nor could it be stripped off; but, on the contrary, was hard, 
 and had a horny feel. The duodenum was healthy. The larynx, at its top, 
 was almost closed by the greatly swollen epiglottis, the enlargement being due 
 to an effusion of serum within it ; the glottis itself was only slightly swollen ; 
 and upon raising the epiglottis and looking into the larynx, the passage was 
 seen to be quite free; neither the vocal cords, nor any other part, having been 
 touched. The lungs showed some lobules in the first stage of inflammation. 
 The heart was healthy, and firmly contracted." 
 
 CASE XXX. " Poisoning by Sulphuric Acid. William V , ret. 56. 
 The patient's mind was not perfectly sound, and, therefore, the account he 
 gave of himself was received with some doubt. When he was admitted, on 
 the evening of October 28th, 1856, he walked up stairs to his bed, and did 
 not appear very ill, although he was dejected, and did not speak much. He 
 stated that he had been to a friend's house ; and there, by mistake, drank 
 about a dessert-spoonful of oil of vitriol. His mouth was of a brown color, 
 but not excoriated. Magnesia and milk were given him. On the following 
 day, and also on the third, he appeared depressed ; but he was not otherwise 
 ill, and it was thought, from the mildness of the symptoms, that he would 
 recover. On the fourth day, however, he died rather suddenly, or, at least, 
 unexpectedly. 
 
 " Post-mortem examination. The body was that of a strong, muscular 
 ,man. A yellow fluid, of acid reaction, ran from the mouth. The brain was 
 not quite healthy. The mucous membrane of the mouth was of a yellow 
 color, but when this yellow epithelial layer was removed, the mucous membrane 
 left was healthy. The front part of the tongue was also discolored, but not 
 the back. The ossophagus throughout was of a yellow color. The mucous 
 membrane was only affected in the most prominent ridges, but the walls of 
 the organ were swollen to three times their natural thickness. This was due 
 to a sero-albuminous exudation into the submucous tissue. The top of the 
 larynx was also slightly swollen in the same manner. The stomach appeared 
 natural externally, and was of usual size. Upon opening it, it was found to 
 contain about a pint of a bright yellow fluid. The mucous membrane was 
 especially affected at the pyloric half of the stomach. The fundus, in which 
 the fluid was found lying as usual, had only a yellow tint like the oesophagus, 
 and the mucous membrane was softened ; but, towards the middle of the 
 stomach, the whole of the pyloric half of the interior was of a black color, 
 and raised up in projecting masses or ridges, which were in a sloughing con- 
 dition, and would soon have been cast off. This black matter consisted of car-
 
 ON DISEASES OF THE (ESOPHAGUS. 109 
 
 bonized and decomposed mucous membrane, with blood within it. The whole 
 coats of the stomach were soft, and readily tore. The charring of the stomach 
 ended at the pylorus, but about two inches of the duodenum were of a purplish 
 color, ;md the rugae were blackened ; below this, the intestines, both small 
 and large, were unaffected. The small contained a yellow matter, similar to 
 that in the stomach. The contents of the stomach were not acid, nor was 
 any of the poison discoverable. The heart was healthy, and contained a firm, 
 decolorized fibrinous clot on the right side, not acid in its reaction." 
 
 The following case illustrates the secondary effect of a corrosive 
 poison in the thickening of the whole of the oesophagus and ob- 
 structed pylorus, which led to a fatal termination, in a man who died 
 three months after having taken an ounce of nitric acid. 
 
 CASE XXXI. Poisoning by Nitric Acid James T , aet. 24, was 
 admitted under Dr. Barlow's care, in March, 1852, in a state of extreme 
 emaciation ; more than two months previously he had taken about an ounce 
 of nitric acid, and had completely swallowed it before he discovered the fatal 
 mistake. The primary effects gradually subsided, but vomiting after food 
 increased, and he steadily lost flesh and strength; he vomited, with some 
 pain, all the food which he swallowed; the abdomen sometimes became ex- 
 tremely distended; the bowels had only been opened twice during the two 
 months preceding his admission; the tongue was injected. He lived eighteen 
 days after admission. On inspection, the epiglottis appeared healthy; the 
 mucous membrane of the whole of the oesophagus was thickened and readily 
 separated ; the submucous tissue and all the coats of the oesophagus were also 
 thickened ; the stomach was enormously distended, reaching to the anterior 
 superior spinous process of the pubes; the pylorus was obstructed, thickened, 
 and contracted ; the lungs and heart were healthy ; the liver was small, deep 
 in color, and the gall-bladder contained about siss of dark-colored bile; no 
 other viscus was diseased. 
 
 CASE XXXII. Poisoning by Nitric Acid. Recovery from the Primary 
 Effects. A young man, set. about 22, a hawker, whilst at his tea, on March 
 13th, took by mistake for vinegar, a mouthful of nitric acid, and swallowed 
 it. A severe burning pain in the mouth was at once produced, which ex- 
 tended to the epigastrium. A druggist prescribed an emetic ; vomiting then 
 came on, and he brought up about half a cupful of blood. The vomiting 
 continued through the night, and on the following day he was brought to 
 Guy's; the countenance was anxious; the mouth and tongue were stained of 
 a yellow color, the tongue enlarged and injected ; the throat was intensely 
 injected, and presented irregular shreds of whitish membrane upon it. He 
 was unable to swallow, and speaking produced cough and much distress in 
 the throat. He stated that he suffered pain in the throat and epigastrium 
 when retching came on, but not when quiet. He was a muscular man, and 
 in health at the time of the accident. Milk and eggs were given, and mag- 
 nesia mixture with tincture of opium n^v every four hours. On the 17th, 
 he was sitting up, taking food, and he stated that he felt much more com- 
 fortable; he had slight pain in the throat when he swallowed, but had no 
 other discomfort. The throat was still very much injected, and sloughy 
 mucous membrane was separating. In a few days he left the hospital, and 
 considered himself well. 
 
 The immediate effects of the poison were in a few days relieved, 
 and the dysphagia disappeared ; but after such severe injury to the 
 oesophagus we must look with great anxiety to the result, for thick-
 
 110 ON DISEASES OF THE (ESOPHAGUS. 
 
 ening of the coats and constriction may, and perhaps will, follow ; 
 in this case the acid probably reached the stomach, for pain was 
 produced at the scrobiculus cordis ; but there was no evidence that 
 serious injury had been done to that viscus. 
 
 We have already alluded to the great frequency of organic stric- 
 ture after corrosive poisons. 
 
 CASE XXXIII. Poisoning by Strong Solution of Ammonia The pa- 
 tient was sulmittetl under the care of my colleague. Dr. Pye-Smith. On in- 
 spection the mucous membrane of the mouth was red, and glazed with shreddy 
 mucus. The oesophagus was intensely red in its whole length, more especially 
 at its lower part, which was of a dark purple, and the color ceased abruptly 
 at the termination of the oesophagus in the stomach; at the upper part of the 
 oesophagus the mucous membrane was shreddy in longitudinal bands. The 
 stomach was injected over a circular patch, four inches in diameter, in the 
 position where the alkali would first impinge on the membrane ; at that part 
 the mucous membrane was thin, elsewhere thick, pale, and coated with thick 
 mucus. 
 
 Obstruction by foreign bodies does not generally come under the 
 cognizance of the physician, but he should bear in mind the possi- 
 bility of dysphagia arising from such a cause, and also that severe 
 and even fatal symptoms may result from the swallowing and lodg- 
 ment of sharp substances. Recorded cases seem to show that of all 
 things most commonly lodging in the oesophagus, plates of artificial 
 teeth are the most frequent. Such cases as these are to be found in 
 the medical journals. 1 That they should cause obstruction is by no 
 means to be wondered at. Still more remarkable, however, is the 
 fact that occasionally large substances may become impacted and 
 remain undiscovered for a length of time. 8 Other cases of dysphagia 
 arise, not unfrequently, from the lodgment of some pointed fragment 
 of food, it may probably be a fish bone. If these foreign bodies 
 remain they are by no means harmless. Cases are scattered through- 
 out medical literature in which the points of such sharp bodies have 
 perforated the oesophagus and aorta, and have led to fatal hemor- 
 rhage. It is well to remember, however, that many persons after 
 swallowing a bone may suppose that it is still in the throat when 
 they are only suffering from the effects of its passage, and a mere 
 abrasion on the surface of the mucous membrane will keep up the 
 sensation for many days. 
 
 The treatment of such cases may be left to the surgeon without 
 further consideration. 
 
 Eccliymosis. Hemorrhage from the oesophagus generally arises 
 from the rupture of aneurismal tumors, or from cancerous disease ; 
 but in cases of fatal purpura, we sometimes find the whole mucous 
 membrane covered by points of eft used blood, and blood is also 
 effused into the surrounding cellular tissue. The oesophagus, how- 
 ever, is affected only in common with the whole mucous surface of 
 the alimentary canal, as well as with other membranes and glaiid- 
 
 1 ' Lancet,' vol. i, 71 ; vol. ii, 73, &c. 
 
 * M. Duplay, ' Lancet,' 1847. Vol. ii, p. 849.
 
 ON DISEASES OF THE (ESOPHAGUS. Ill 
 
 structures. The oesophageal veins have been found to be varicose 
 in some cases of cirrhosis ; and in a case of hemorrhagic variola the 
 mucous membrane was found coated with blood. 
 
 The following case warrants the belief that rupture of the coats of 
 the cesophagus sometimes takes place during life : the specimen is in 
 the Museum of Guy's (No. 1799 46 ). 
 
 CASE XXXIV. Rupture of the (Esophagus M. C , set. 24, a cabinet 
 maker, of intemperate habits, attended a public supper in September, 1842 ; 
 during supper he felt sick, and left the table; he vomited slightly, and re- 
 turned home with assistance. He then took a dose of castor oil ; at two in 
 the morning he complained of severe pain across the epigastrium, and great 
 difficulty in breathing ; the abdominal muscles rigid, the respiration laborious ; 
 the patient was found sitting up in bed, leaning forwards on his hands ; his 
 countenance was anxious, the pulse soft, the bowels had not acted ; an emetic 
 of antimony and ipecacuanha was administered, but without effect ; at 7.30 
 A. M. there was less pain, but increased dyspnoea, and there was emphysema 
 of the face and throat. The stomach-pump was used, but without effect, and 
 he died at noon. On inspection a large rent was found in the cesophagus at 
 its lower part, filled with ingesta, which were also extravasated into the left 
 pleura ; the pleura also contained castor oil. The stomach and intestines 
 were exceedingly distended with flatus ; and the stomach partially dissolved 
 by gastric juice. The rent in the resophagus appears in the preparation to 
 extend into the stomach, but perhaps increased after death. 
 
 It is probable that the oesophagus was much dilated with food, 
 and that its coats were softened either by previous disease, or by 
 digestion from gastric juice regurgitated into it from the stomach, 
 and there remaining sufficiently long to corrode its walls. There is 
 no evidence that the stomach-pump increased the rent, for the castor 
 oil which was found in the pleura was taken several hours before 
 the stornach-pump was used; still, if it had been known that such a 
 rent had existed, this remedy would not have been applied ; the 
 severity of the symptoms suggested the probability that some 
 poisonous substance might have been taken with the food, and that 
 hence the emetic failed to act ; under such circumstances the use 
 of the stomach-purnp would have tended to relieve rather than 
 aggravate the symptoms. 
 
 Mayo quotes a case from Boerhaave of rupture of the cesophagus 
 after an emetic had been taken by a robust, but gouty man ; a rent 
 one and a half inches in length was found communicating with the 
 left pleura ; and the fatal result took place twelve hours after the 
 emetic had been administered. 
 
 In a patient admitted in July, 1874, under the care of my colleague, 
 Mr. Durham, for injury, by which the rib was fractured, the cesopha- 
 gus was lacerated for more than an inch in extent. 1 
 
 Gastric Solution. In studying the diseases of the oesophagus, 
 gastric solution of its lower extremity must be borne in mind. This 
 has been very clearly brought forward in the communications to the 
 'Guy's Reports,' by Mr. Wilkinson King, in the years 1842 and 
 
 1 For another case of rupture of the ossophagus after vomiting, in a man, aged 49, 
 see ' Lancet,' 1869, vol. ii, p. 337.
 
 112 ON DISEASES OF THE (ESOPHAGUS. 
 
 1843. It is exceedingly frequent to find the mucous membrane of 
 the oesophagus abruptly terminating at the cardiac extremity of the 
 stomach, from the solvent action of the gastric juice having extended 
 to that line ; but on opening the canal of the oesophagus itself for 
 several inches near its lower extremity, the upper margins of the 
 rugas are often found deprived of mucous membrane ; and long shreds 
 are observed on stretching out the tube, these portions having escaped 
 digestion. This solution extends into the mediastinum, as found in 
 cases mentioned in the communication just referred to, or into the 
 pleura itself, the contents of the stomach thus escaping into the left 
 pleural cavity, which is in closer relation with the oesophagus than 
 the right pleura. 
 
 Only two cases of this perforation of the oesophagus have occurred 
 at Guy's during the last few years, one in a case of fever, another of 
 hydrocephalus, so that it is a circumstance of unfrequent occurrence. 
 Mr. E. Canton, in the 'Lancet' of 1859, gives an instance of an infant, 
 set. 2 months, who died comatose, insensibility having come on two 
 hours after the ingestion of breast milk and soaked bread. An oval 
 opening, three-fourths of an inch in length, was found on the left 
 side of the oesophagus, the rent commencing a quarter of an inch 
 above the diaphragm. Its edges were thin, flocculent, and irregu- 
 larly fringed ; a second aperture also was found separated from the 
 other by a small strip of undissolved texture. The causes of gastric 
 solution are now more clearly understood than formerly. The posi- 
 tion of the body, the development of gases in the intestines pressing 
 upon the contents of the stomach, the non-contracted state of the 
 oesophagus itself, are causes which lead to the passage of the gastric 
 juice into the oesophagus. 'Sometimes, indeed, the pressure thus 
 produced forces the contents of the stomach into the pharynx, and 
 we find them gravitating into the trachea and bronchi.
 
 113 
 
 CHAPTER Y. 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 ALTHOUGH it is probable that every aberration of function is 
 marked by physical change, still very many of the local alterations 
 of structure are of a character so transient, and so completely beyond 
 the recognition of the senses, that \ve are compelled to separate 
 them from others in which the structure of a part is more evidently 
 modified. 
 
 A division of this kind is especially necessary in the study of dis- 
 eases of the stomach, for the larger number are of the kind in which 
 no structural lesion can be traced. The chemical, anatomical, and 
 physiological researches of late years have, however, diminished the 
 number of simple functional diseases and have greatly increased our 
 knowledge of those due to organic lesions. 
 
 We shall have to treat of the following abnormal conditions of the 
 stomach : 
 
 Solution by the action of the gastric juice. 
 
 Atrophy and hypertrophy of the mucous and muscular coats. 
 
 Dilatation of the stomach. 
 
 Inflammatory diseases 
 
 Catarrhal, diphtheritic, and suppurative inflammation. 
 Ulce ration. 
 
 Fibroid disease of the pylorus. 
 
 Cancer. 
 
 Post-mortem solution. The secretion poured into the stomach from 
 its numerous follicular glands has a very important function to per- 
 form in dissolving the nitrogenous portions of food. This secretion, 
 the gastric juice, is a clear, somewhat viscid fluid ; it has an acid re- 
 action, from the presence of hydrochloric or lactic acid, and it con- 
 tains an organic substance, pepsin, in small proportionate quantity. 
 By the mutual reaction of these agents on the organic animal prin- 
 ciples of ordinary food, assisted by the temperature of the body and 
 the churning movements of the stomach, the solution of the protein 
 compounds and of the gelatin and chondrin takes place, and a fluid 
 is formed containing peptone compounds, as they are called, and 
 which is discharged into the intestine through the pylor'c valve. 
 The solvent power of the gastric juice is of a simple chemical kind, 
 and it can be exerted external to the living organism when the 
 necessary conditions are carried out; it would act also upon the 
 structures of the viscus itself, even during life, but is prevented by 
 the protective covering of mucus and epithelium, constantly re- 
 newed by the living power of the part, and, as shown by my colleague 
 Dr. Pavy, by the circulation of alkaline blood in the minute capilla- 
 8
 
 114 ORGANIC DISEASES OF THE STOMACH. 
 
 ries of the membrane. After death, however, the chemical action is 
 unchecked, and the walls of the stomach are dissolved ; sometimes, 
 indeed, with great rapidity, and in every instance to some extent, so 
 that pathological researches are interfered with, and the appearance 
 of the stomach is necessarily modified. 
 
 John Hunter drew attention to post-mortem solution in connection 
 with diseases and injuries of the head, and T. Wilkinson King, of 
 Guy's, added definite facts in reference to the degrees and position of 
 the solution ; Dr. Budd, in his treatise on Diseases of the Stomach, 
 has still further and very fully elucidated the subject. The gelati- 
 nous softening which has been described by Andral, Cruveilhier, 
 &c., as occurring during life, is now generally believed to be a form 
 of this solution, and in this opinion I concur, although some talented 
 pathologists think differently. 
 
 It must be always borne in mind, that after death blood gravitates 
 into the most depending vessels, that exosmosis takes place, and 
 chemical action exerts its influence, unchecked and unmodified by 
 vital action. 
 
 The amount of gastric solution depends in part on the quantity of 
 gastric juice actually in the stomach at the time of death. Gastric 
 solution is especially manifest when sudden death occurs during the 
 process of digestion ; and it is shown still more as a sequence of 
 cerebral diseases, especially those of an inflammatory character, in 
 young subjects, the follicles having been stimulated to pour out 
 secretion at irregular times, and in excessive quantity. Time is re- 
 quired for the solution, and the action proceeds more rapidly in 
 summer than during the coldness of winter. The stomach is some- 
 times found completely perforated, although food may not have been 
 taken for several hours before death. 
 
 The simplest condition of this change is thinning and softening of 
 the mucous membrane, so that it is with great readiness detached; 
 if the bloodvessels be empty the membrane is pale, and it has a 
 semi-gelatinous appearance ; generally, however, the vessels contain 
 blood, which gravitates into the most depending vessels ; the haema- 
 tine exudes into the substance of the stomach itself, and greenish- 
 brown or almost black lines are formed in the course of the vessels, 
 over the whole of the dissolved part, from the action of the gastric 
 juice on the coloring matter of the blood. If the transudation have 
 taken place into the cavity of the stomach, a greenish-brown fluid 
 is produced by a similar action. This solution may be so slight that 
 it is only detected when we examine a section of the membrane with 
 the microscope, or the mucous membrane is exceedingly thinned, or 
 entirely destroyed ; the submucous and the muscular coats are then 
 dissolved, and at last the peritoneum is reached. The serous mem- 
 brane occasionally gives way, so that a ragged perforation is formed, 
 and the contents of the stomach transude into the peritoneal cavity. 
 The adjoining viscera then become acted upon, unless adhesions 
 exist which have obliterated the cavity, as we find in strumous peri- 
 tonitis. 
 
 The extent of the dissolved part is marked by a defined line,
 
 ORGANIC DISEASES OF THE STOMACH. 115 
 
 showing the level to which the solvent fluid has attained. This is 
 generally along the greater curvature; but sometimes, from the 
 position of the body, we find that the solution is greatest in the 
 region of the lesser curvature, or even that the duodenum is espe- 
 cially acted upon ; and this part of the intestine may be perforated 
 while the stomach is intact. Or from the evolution of gases, position 
 of the body, &c., the fluid is pressed into the oesophagus ; the mucous 
 membrane of that canal is dissolved, and sometimes all its coats per- 
 forated, so that the contents of the stomach are found in the pleural 
 cavity. 
 
 John Hunter attributed these effects to the fact that chemical action 
 is unchecked by the vital state of the parts ; but Dr. Bernard and 
 Dr. Pavy 1 have demonstrated that the gastric juice will act upon 
 living tissues, as shown by introducing a rabbit's ear and the leg of 
 a frog into a gastric fistula, thus proving the protective influence of 
 the gastric epithelium and mucus. These experiments, however, 
 are not conclusive, for the circulation could not be carried on in the 
 usual free manner, and the condition of the nervous system is not 
 sufficiently regarded. 
 
 When the anterior part is acted upon, Dr. Budd 2 explains the fact 
 by the small quantity of gastric juice, which was in the greater cur- 
 vature, being neutralized either by ammonia being evolved, or by the 
 exudation of alkaline serum from the blood, or from dropsical effu- 
 sion; whilst the small quantity on the anterior part has not been thus 
 neutralized. The action of the gastric juice, Dr. Budd states, may 
 be checked by alcoholic liquors, or by medicines administered before 
 death. We are not acquainted fully with the causes of the greater 
 gastric solution in some cases than in others, for, whilst agreeing with 
 the author just cited, that it is occasionally very manifest in cases of 
 phthisis, renal disease, typhoid fever, and cancer of the uterus, or 
 disease of organs in which the stomach is functionally disturbed, we 
 shall find an almost equal percentage of cases of solution when such 
 causes do not exist. It is certainly more manifest in children and in 
 inflammatory disease of the brain, and is generally more marked in 
 acute than in chronic disease. 
 
 Atrophy of the Mucous Membrane. Wasting of the mucous mem- 
 brane of the stomach takes place in common with that of other organs 
 and glands, and the subject has been elucidated by Dr. Handfield 
 Jones, whose microscopical investigations have directed particular 
 attention to the subject. 
 
 The mucous membrane of the stomach consists principally of small 
 glands or follicles, which open into minute pits on the surface, and 
 secrete the gastric juice, the most important solvent of food. Be- 
 tween the terminal extremities of the follicles clusters of lymph 
 cells are observed. The follicles rest on a stratum of connective tissue 
 of varying thickness, beneath which is a layer of non-striated muscu- 
 lar fibre. The delicate capillary branches of the bloodvessels, derived 
 
 1 'Guy's Reports,' vol. ii, third series, and ' Phil. Trans.' 
 
 2 ' Budd on the Stomach.'
 
 116 ORGANIC DISEASES OF THE STOMACH. 
 
 from the coronary, hepatic, and splenic arteries, extend between these 
 gastric follicles in nearly a straight course, and they form a beautiful 
 plexus of vessels around the minute crypts, and also beneath the 
 follicles themselves. These structures are easily observed under a 
 low magnifying power of the microscope, and in a portion of con- 
 gested membrane present a beautiful appearance. The sympathetic 
 nerve filaments are also seen at the base of the mucous membrane, 
 sometimes upon the capillary vessels, and at other times apparently 
 leaving them, forming a close plexus interspersed with numerous 
 ganglia in the submucous tissue ; filaments extend both to the peri- 
 toneal surface and to the mucous membrane. 
 
 The surface presents columnar epithelium and mucus, and the 
 follicles contain spheroidal epithelium and nuclei. As in every other 
 gland, these minute and simple ones appear to have varying degrees 
 of functional activity, and undergo degenerative changes. Thus in 
 many cases of fatal disease, with gradually increasing exhaustion, 
 only a small quantity of food is taken for many days before death, 
 whilst in other instances the appetite is maintained to the last ; we 
 consequently often observe, that in the one case, the follicles are full 
 of secreting cells and nuclei ; whilst in the other they are compara- 
 tively empty. 
 
 Microscopical investigation has done much to increase the knowl- 
 edge of pathology ; but with increase of microscopical power we must 
 add equal caution in removing all the causes liable to mislead us. 
 The mode which I have adopted in preparing sections, and which 
 will generally be found a successful one, is to stretch the membrane 
 over or between the fingers, and then, by means of Valentin's knife, 
 make a section of the required depth and thickness. This is after- 
 wards removed by scissors, and spread out in water by needle points. 
 I have examined with great care a considerable number of stomachs 
 from the post-mortem table of Guy's Hospital ; but it is not necessary 
 to mention the cases in which the membrane appeared in a healthy 
 condition. In many of these examinations I have observed appear- 
 ances precisely corresponding to the descriptions and drawings of Dr. 
 Handfield Jones ; but I think we must carefully consider that many 
 of these appearances may be produced, by the mode of making the 
 preparation, or by changes after death. I refer to wasting of the 
 follicles, nuclear deposit around them, and the development of cysts. 
 The gastric follicles change very rapidly after death, and in a short 
 space of time nothing can be observed but the termination of the 
 follicle itself upon the submucous areolar tissue, and above this an 
 irregular aggregation of granules and nuclei. The basement mem- 
 brane also rapidly becomes dissolved, and this condition will be found, 
 on microscopical examination, before the ordinary appearances of 
 gastric solution are observable in the stomach. The greater curva- 
 ture of the stomach is in this way generally too much changed to 
 allow us to place much dependence upon its microscopical examina- 
 tion ; and for this reason, it is evident that we have to avail ourselves 
 of portions of membrane above the line of solution. That from the 
 lesser curvature, however, and from the pyloric region, is less gene-
 
 ORGANIC DISEASES OF THE STOMACH. 117 
 
 rally dissolved by the gastric juice, and is also the part most subject 
 to morbid changes ; but the cardiac portion should also be examined 
 when possible. Not only does the membrane become dissolved, but 
 in some cases, by decomposition, it becomes emphysematous, and 
 presents minute vesicles and blebs, which occupy the substance of 
 the tissue ; or the appearance of the very minute emphysematous 
 vesicles in the mucous tissue may resemble the appearance of well- 
 defined cysts, surrounded by nuclei. This is one source of fallacy, 
 and another will be found in the fact, that nuclei are readily sepa- 
 rated from the follicles in the preparation of the section, and become 
 diffused between the structures. The contents of the follicles are 
 easily detached, and, by the action of acetic acid, of cold water, or by 
 mere pressure, a perfect cast of the follicles will be often extruded, 
 and project from the surface of the membrane. A third fallacy, 
 which may considerably mislead us, is the appearance of the mucous 
 coat, altered by the state of contraction of the submucous and mus- 
 cular coats beneath. The mucous coat will expand to the largest 
 amount of distension that the muscular coat allows. When the mus- 
 cular coat is contracted, the usual appearance of rugae is presented ; 
 but a further contraction produces a mamillated appearance of the 
 membrane. This may be sometimes observed, if we remove a por- 
 tion of healthy mucous membrane a short time after death and im- 
 merse it in cold water for a few hours, this state of mammillatiou is 
 then produced. A thickened, chronically-inflamed membrane will, 
 I believe, present true mammilation of the stomach ; but in that 
 artificially produced, the manner in which the fissures extend nearly 
 to the submucous cellular tissue, might lead us to attribute this 
 appearance to a morbid contraction of the membrane itself. Dr. 
 Hand field Jones gives, in his observations on the stomach, an origi- 
 nal and interesting account of the production of mammillation ; and 
 he attributes these depressions to wasting of the membrane, the 
 breaking up of nuclear masses, and to the contraction of the tissue 
 beneath. This opinion requires confirmation for, as far as my ob- 
 servations have gone, it would appear that mammillation is more 
 common than the existence or evidence of solitary glands or sepa- 
 rate nuclear deposits in the membrane ; and that this appearance of 
 simple mammillation may be easily produced artificially in a healthy 
 mucous membrane. A fourth fallacy may arise from the direction 
 of the section. The surface of the stomach being not that of a plane 
 membrane, and its follicles opening into crypts, an oblique section 
 may readily give the appearance of fibrous tissue abnormally de- 
 veloped, where such does not really exist. 
 
 The whole of the coats of the stomach are sometimes exceedingly 
 wasted, but in fatty degeneration or atrophy of the mucous mem- 
 brane this is not generally the case. There are several degrees of 
 this wasting or fatty change. Thus, sometimes the cells of the 
 follicles, instead of presenting a simple nucleus, contain a great 
 number of minute highly refracting particles, and almost resemble 
 an inflammatory granule cell, while the appearance of the stomach 
 itself is otherwise in a perfectly healthy condition ; although these
 
 118 ORGANIC DISEASES OF THE STOMACH. 
 
 cells are also found in other states, as in extreme congestion with 
 superficial ulceration, &c., they appear to indicate a diminution of 
 vital activity rather than an excess of it. At other times, the 
 stomach is found to be pale, and here and there studded with white 
 points, somewhat resembling solitary glands, but not at all elevated 
 above the surface. A horizontal section, in such a case, shows 
 around the crypts, at the whitened portion, minute highly refracting 
 granules and fatty particles ; and a vertical section presents a dark 
 border on the surface, consisting of the same elements ; these are 
 also sometimes observed, more or less distinctly beneath the follicles. 
 
 A more advanced condition of atrophy shows the follicles to be 
 entirely destitute of secreting cells, and only containing granules of 
 fat, or perhaps wholly destroyed, with irregular patches of pale 
 mucous membrane. The mucous membrane of the stomach also 
 undergoes lardaceous degeneration, in which the minute capillary 
 arterioles are infiltrated by amyloid material: this is an uncommon 
 condition, and only present with extensive lardaceous disease in other 
 organs. 
 
 Besides these forms and degrees of atrophy, which may be called 
 secondary, there are others which arise from chronic inflammation 
 of the membrane, in which the structure appears thickened, dense, 
 and the mere rudiments of gastric follicles remain. These may arise 
 from fibroid degeneration or cancerous disease slowly encroaching 
 upon the membrane adjoining it, and thus leading to atrophy and 
 degeneration. 
 
 The symptoms observed in some of the cases in which this fatty 
 change in the mucous membrane of the stomach existed, were a 
 sense of great prostration and exhaustion, with complete loss of 
 appetite. The tongue was clean, there was no pain, neither was 
 there thirst, nor vomiting, but an inability to take food ; in cases 
 where vomiting has sometimes taken place, it has possibly been from 
 other causes. This form of atrophy has been observed in phthisis, 
 in struma, in exhausting suppuration, and is often associated with a 
 fatty condition of the liver. 1 Wasting of the mucous membrane 
 may be the result of the action of corrosive poisons. 
 
 In a patient, set. 50, who died from extensive strumous disease, 
 the stomach was found to be flaccid ; its mucous membrane was 
 covered with a thick layer of mucus, and it presented, especially to- 
 wards the pyloric extremity, several opaque white patches, about a 
 quarter of an inch in circumference. These parts were found to 
 consist of degenerated mucous follicles. The follicles had their 
 usual outline, but were filled with minute fat-particles, and were 
 destitute of secreting cells. 
 
 In a case of poisoning by chloride of zinc, much wasting of the 
 mucous membrane of the stomach was observed, there was distension, 
 with gray lines of discoloration, and at the greater curvature an em- 
 physematous condition. 
 
 On the examination of the mucous membrane, above the emphyse- 
 
 1 Handfield Jones.
 
 ORGANIC DISEASES OF THE STOMACH. 119 
 
 matous line, the ends of gastric follicles were observed, but they 
 were not covered with the usual thickness of membrane. At the 
 pylorus the mucous membrane regained its usual thickness, but it 
 had a pitted margin, as at the circumference of an ulcer ; near to it 
 the membrane appeared thin, and presented numerous very minute, 
 transparent vesicles, which projected upon the surface of the mem- 
 brane, and appeared to consist of a cyst wall, containing fluid and 
 nuclei. The cysts, when ruptured, presented a halo of fluid and 
 granules around it. Other more minute cysts were found in the 
 substance of the membrane, particularly towards the greater curva- 
 ture. They were about l-30th to l-10th of an inch in diameter. 
 
 At first, it appeared that the development of cysts in this case 
 had taken place before death ; but the greater curvature presented 
 large blebs of air, and the smaller vesicles were, no doubt, of a similar 
 character. The separation of the elements of the membrane by the 
 development of gas had given rise to this deceptive cystic appearance. 
 I have observed a similar emphysematous condition of the mucous 
 membrane in some other cases, and it probably arises from rapid 
 decomposition taking place in connection with partial gastric solu- 
 tion, modified, perhaps, by a diseased condition of the membrane. 
 
 It occasionally happens that we find structures resembling solitary 
 glands of the intestine in the mucous membrane of the stomach. 
 Thus, a short time ago, in examining the stomach of a child who had 
 died from chorea, I found the whole membrane presenting numerous 
 whitish specks, which consisted of these structures imbedded in the 
 substance of the membrane. These are probably identical in struc- 
 ture with lymphoid tissue. 
 
 Hypertrophy. An apparent thinning of the mucous membrane of 
 the stomach is consequent on great dilatation of the viscus; and 
 conversely the lining membrane seems to be preternaturally thick- 
 ened when the stomach is contracted, and large rugae are formed by 
 the inversion of the mucous membrane; and, as we have before 
 remarked, simple contraction of the submucous tissues causes a mam- 
 millated appearance, resembling that produced by chronic change. 
 Still there are instances arising from chronic irritation and inflam- 
 mation, and from prolonged congestion, to which we shall have to 
 refer when speaking of catarrh, in which the mucous membrane is 
 both thickened and hypertrophied. In other cases, indeed, polypoid 
 masses are formed by the mucous membrane, and I have observed 
 large folds of this kind surrounding the pyloric orifice, without 
 evincing symptoms of disease during the life of the patient. Rind- 
 fleisch 1 considers that the mammillated state of the stomach is due 
 to the mucous membrane becoming, by the hypertrophy of its 
 glandular layer, too large for the muscular coat. Polypi became 
 developed from this overgrowth, and "in their interior, besides the 
 dilated tiibuli, true cysts are found scattered here and there ; these 
 are filled with watery fluid or with mucus. The interlobular con- 
 nective tissue, together with the Avails of the tubes themselves, forms 
 
 1 Rindfleisch, 'Pathological Histology,' vol. i, p. 419. New Syd. Soc.
 
 120 ORGANIC DISEASES OF THE STOMACH. 
 
 septa." Beside these polypoid elevations of the mucous membrane 
 pedunculated polypi are occasionally met with. 
 
 Mammillation of the stomach may thus be due to varied patholo- 
 gical conditions. 
 
 1. It may be artificially produced by simple contraction of the 
 muscular coat. 
 
 2. It may be due to hypertrophy of the glandular structure of the 
 mucous membrane. 
 
 3. To wasting and contraction of intertubular tissue (Haudfield 
 Jones). 
 
 4. Possibly to cystiform distension of the follicles. 
 
 The more marked hypertrophic changes which take place are 
 those connected with the muscular coat, when there is obstruction 
 at the pylorus; the muscular tissue then becomes stronger and 
 thicker, at first in the proximity of the obstruction ; the hypertrophy 
 gradually extends its area, reaching two or three inches, and even 
 over the whole stomach. This change is a preservative one, and it 
 tends, though with less and less efficiency, to force the dissolved 
 aliment through the diseased part; but at length the wasting conse- 
 quent on the system not receiving its proper supply of nutriment 
 becomes extreme, and the patient succumbs. 
 
 Dilatation of the Stomach. The distension of the stomach is due 
 to a relaxed condition of the muscular coat. The stomach in a 
 healthy state contracts npon its contents, and by its vermicular 
 action facilitates the movement and churning of the contents, by 
 which their thorough mixture with the gastric juice is promoted, 
 their solution accomplished, and the resulting fluid propelled on- 
 wards through the pyloric valve. It is at the pylorus that the 
 muscular fibre, especially the circular coat, has its fullest develop- 
 ment. When there is any obstruction at this part, particularly if 
 it be gradual in its origin, the muscular coat becomes proportionately 
 increased, so that the chymous fluid may be pushed through the 
 narrowed orifice. We have already adverted to this hypertrophy 
 of muscular fibre, but when the muscle is unable to overcome the 
 hindrance, then the ensuing dilatation becomes the more prominent 
 feature, and gradual distension ensues, till an enormous size is at- 
 tained, as we find in pyloric disease. 1 The muscular coat is, more- 
 over, closely connected with the nervous filaments of the pneumo- 
 gastric nerve, and also with the vaso-motor nerve. When, from 
 irritation of the nervous supply, irregular contraction takes place 
 we have spasmodic pain and, it may be, hour-glass contraction ; but, 
 when the nervous supply is weakened, the muscular coat is less able 
 to contract, and less competent to execute its usual movements; and 
 under such circumstances sudden great distension may so increase 
 that the muscular coat is unable to contract, the propelling power is 
 unequal to the work, the muscle is paralyzed from over-distension, 
 as is that of the urinary bladder also when over-stretched. 
 
 1 Bamberger quotes a case in which an inconceivable quantity of fluid (90 Ibs.) 
 filled the stomach. Virchow's 'Handb. der Spt-ciellen Path, und Ther.'
 
 ORGANIC DISEASES OF THE STOMACH. 121 
 
 Dilatation arises, therefore, from several causes. 1st. From ob- 
 struction. The distension may be from obstruction at the pylorus, 
 and this impediment at the outlet produces hypertrophy of the mus- 
 cular coat of the stomach. "We shall have to refer again to this 
 condition when describing organic disease at the pylorus, whether 
 fibroid or cancerous, or simple ulceration ; it is in this form of ob- 
 struction that the peristaltic movements in the stomach, as pointed 
 out by Sir William Gull, are especially recognized. They are seen 
 to pass from the left to the right, and when the walls of the abdo- 
 men are wasted, are easily observed. A small quantity of food or 
 water taken by the patient may serve to induce them. Spasmodic 
 contraction at the pylorus or pressure from abdominal diseases of 
 various kinds may also produce over-distension. 
 
 2d. From paralysis. Distension of the stomach may arise from 
 an exhausted state of the nervous supply of the pneumogastric, as 
 mentioned by Traube, 1 and also of the vaso-motor nerve. In these 
 instances no peristalsis is observed, for the muscle is weakened. 
 This form of distension is found in states of exhaustion, as from 
 long fasting, and in hysteria ; great distension takes place, with dis- 
 tress, breath lessness from pressure upon the diaphragm, and some- 
 times severe pain at the stomach, passing through to the spine. It 
 would seem that long continued vomiting may induce this form of 
 nervous exhaustion ; and a similar condition has been found in dis- 
 eases of the brain and the spinal cord, in typhus, cholera, and puer- 
 peral fever. Again, the fulness of the stomach in phthisis, and the 
 flaccid condition in which it is often found in this disease after death, 
 may be due to the paralysis or exhaustion of the pneumogastric ; 
 and in heart disease, in which chronic gastric catarrh is induced, the 
 flatulent distension of the stomach is promoted by a similar state of 
 nerve exhaustion. 
 
 The remarkable case recorded by Dr. Fagge 2 was perhaps due to 
 nervous exhaustion, for there was perforation of the duodenum and 
 an abscess behind the colon ; local suppuration in the neighborhood 
 of the stomach, such as empyema and purulent pericarditis, may 
 also affect the nervous supply, and thus favor distension. 
 
 3d. From the paralysis of simple over-distension. Distension of the 
 stomach may, however, suddenly take place and increase to such an 
 extent that the very distension itself is the cause of the paralysis. 
 Although not dependent upon any obstruction at the pylorus, the 
 result is the same in this case as in the first form ; but, since the 
 muscle is paralyzed, there is no visible peristaltic action. 
 
 This distension may be due to the formation of gas from indiges- 
 tible food, as mentioned by Dr. Hodgkin in his 'Anatomy of the 
 Mucous and Serous Membranes,' and severe dyspepsia may also pre- 
 cede it. The following table indicates the class of cases in which 
 distension occurs. It has been compiled from the post-mortem 
 records of Guy's Hospital during the last ten years, with the addition 
 of several other cases. 
 
 1 'Gesammelte Beitrage,' ii, 988. 
 
 2 'Gny's Hospital Eep.,' ser. iii, vol. xviii, p. 1.
 
 122 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 
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 Reaching below umbilicus 
 gas, 56 cubic inches 
 
 Distended to the size of a lu: 
 Much distended ; contents 1 
 
 Held two quarts 
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 liver were the only organs 
 the abdomen ; contents, a 
 
 mucus ; pylorus quite unc 
 Widely dilated 
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 Stomach "dilated" 
 Nothing seen but the stomac 
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 Enormously distended ; fillec 
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 Enormous dilatation 
 
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 ORGANIC DISEASES OF THE STOMACH. 123 
 
 Attention was drawn to distension of the stomach many years ago 
 by Sir William Gull in a case under his care, and of which the draw- 
 ing is in the Museum at Guy's Hospital, in which the stomach filled 
 the whole abdomen, and this distension appeared to be the cause 
 of death ; it has been well described by my colleague, Dr. Hilton 
 Fagge, in the communication previously alluded to. 
 
 The form of the abdomen is peculiar in this kind of distension, 
 being full in the left hypochondrium, but hollow in the epigastric 
 space, the curve of the upper portion of the stomach is dragged ob- 
 liquely downwards, and the pylorus is situated low down on the 
 right side, or even near the pubes. The greater curvature of the 
 stomach is seen to describe an arc from the left hypochondrium in 
 the direction of the pubes, following the curve of the abdomen. If 
 the pylorus be retained in its usual position the stomach may be 
 acutely bent, as in one of the cases described by Dr. Fagge. 
 
 If the distension be simply gaseous the peculiar form just described 
 is less marked, the epigastrium is more uniformly distended, and 
 the diaphragm is pressed upon. Fluid necessarily gravitates, and 
 thus the stomach gradually assumes a lower position. 
 
 The peculiar bulging of the stomach at the lower part of the abdo- 
 men may lead to the supposition that it consists of a distended uri- 
 nary bladder, or it may be mistaken for ascites, or hydatid tumor, 1 
 or distended colon; and whilst partially resonant on percussion it 
 may produce a splashing sound from the presence of fluid with air. 
 The symptoms produced by this state of distension are vomiting of 
 large quantities of fluid, of a grumous brown character, or watery- 
 acid mucus, or coffee-ground substance. The relief thus obtained is 
 often only partial, and in those instances where there is pyloric ob- 
 struction, the ejected fluids are often in a fermenting condition, with 
 a frothy, yeast-like surface, and the sarcina ventriculi of Goodsir 
 may be recognized ; in these cases also the peristaltic movement of 
 the' stomach is a sign of value. The peculiar form of the stomach, 
 the hollowness at the epigastrium, and the splashing sound produced 
 on percussion, are significant diagnostic signs. As to other general 
 symptoms there is distress, the eyes appear sunken, there is sense of 
 exhaustion, the pulse is compressible, and the bowels are generally 
 confined. "When the disease comes on acutely prostration is rapid, 
 and in a short time the disease may prove fatal. In other cases, 
 however, the disease may persist for many months. 
 
 The case described by" Sir William Gull was a remarkable one, for 
 the distension of the stomach was the only morbid condition, and 
 was quickly fatal. 
 
 In a patient lately under my care, a lady, aet. 60, the disease com- 
 menced after nervous shock. Stimulants were given to relieve this 
 state and produced subacute gastritis. Violent vomiting came on, 
 and with this some pain at the region of the duodenum or pylorus, 
 as if there was spasmodic contraction or ulceration. The sickness 
 soon subsided, but the bowels were confined, and the patient did not 
 
 ' Bamberger, loc. cit.
 
 124 ORGANIC DISEASES OF THE STOMACH. 
 
 gain strength. Gradually the fulness in the epigastric region passed 
 into the umbilical, and then into the hypogastric region, the epi- 
 gastric space becoming deeply hollowed. The distension had the 
 form of a large stomach, extending nearly to the pubes; an attack 
 of vomiting occasionally took place, but became less frequent, recur- 
 ring every three or four days, then once a week, and afterwards at 
 intervals of a fortnight or longer ; no pain was produced, but weak- 
 ness and constipation. No peristaltic movement could be recognized 
 in this case. 
 
 The symptoms continued for more than a year, and were greatly 
 relieved by treatment. The bowels were acted on by enemata, by 
 castor oil, by magnesia, &c. ; internally, remedies were employed to 
 check fermentative action, more especially hyposulphite of soda with 
 morphia, and they afforded great relief for a time. Steel, n ux vomica, 
 &c., were also used. The plan recommended by Kussmaul was tried, 
 namely, washing the stomach out with the stomach pump; but it 
 distressed the patient, and as there was no pain it was not repeated. 
 This plan, however, in some cases has afforded great relief. Friction, 
 and gentle manipulation of the stomach, is sometimes beneficial, and 
 the application of an electric current may induce more vigorous con- 
 traction of the muscular fibre. 1 Nutrient injections repeated several 
 times during the day were beneficial in the case just mentioned. 
 
 Mayer 2 and Pibram have stated that, from experiments on animals, 
 sudden distension of the stomach produces slowness of the pulse and 
 increase of arterial tension by contracting the vessels ; this statement, 
 if correct, may have an important bearing on the severity of the 
 abdominal symptoms, but it does not seem to be borne out by the 
 clinical sj^mptoms of patients suffering from flatulent distension, where 
 the pulse is feeble and compressible. 
 
 In the treatment of these cases, the plan advocated by Kussmaul 
 is worthy of trial, for it certainly speedily relieves gaseous distension, 
 and the removal of fluid from the stomach enables the viscus to 
 contract more readily. It is important to allow the stomach to rest, 
 and for a time nutrient injections only should be used. \Vhen food 
 is administered it is well to avoid those substances which are likely 
 to ferment, such as saccharine and farinaceous food; milk and light 
 soups may be taken. As to medicines, opium or morphia and alka- 
 lies may be given ; and, to check fermentation, carbolic acid -or the 
 hyposulphites; afterwards steel, quinine, and strychnia, may be used 
 to strengthen the muscular action. The local application of electri- 
 city is also beneficial. 
 
 Hour-ylass Contraction. The form of the stomach is sometimes 
 remarkably changed by the'state of the muscular coat, not only by 
 its uniform contraction, when it resembles a piece of intestine, or by 
 its distension, forming an enormous sac, but by irregular contraction, 
 when it assumes the shape of an hour-glass. This narrowing of the 
 
 1 Fiirstner has recently published some remarks on the use of the induced current 
 in dilatation of the stomach ; in three cases where the dilatation occurred in hysterical 
 females all were relieved. 'Berliner, Klin. Wochenschrift,' March 13th, 187(5. 
 
 * 'Centralblatt,' 13, 1873.
 
 ORGANIC DISEASES OF THE STOMACH. 125 
 
 stomach generally takes place about the centre, across the part that 
 is the subject of ulcerative action; in many instances the cicatrix of 
 an ulcer is found at the contracted part, but this is not always the 
 case. In an instance of cancerous disease of the sigmoid flexure of 
 the colon and duodenum, in which the liver also was involved, there 
 was a fibrous band between the lesser curvature of the stomach and 
 the liver, and the cicatrix of an ulcer. The stomach may also be 
 drawn down by an adherent state of the omentum. It is probable 
 that pain of a severe kind is sometimes due to this cause ; and when 
 recognized, narcotic remedies, with careful regulation of the diet, 
 are the only treatment likely to be of service. 
 
 Lardaceous Disease of the Stomach. The malnutrition which has 
 been called amyloid or lardaceous disease sometimes affects the coats 
 of the stomach: the stomach, however, is less subject to this change 
 than the intestine, and it is only affected in those instances in which 
 other viscera, as the liver, kidneys, spleen, &c., are extensively in- 
 volved. The mucous membrane appears thickened, and when iodine 
 is applied a brownish-red discoloration is produced. If a section of 
 the mucous membrane be made, the minute capillary arteries are 
 found to be thickened, and the nutrition of the mucous membrane 
 is changed. The diseases in which lardaceous disease is especially 
 observed are cases of chronic phthisis, and also old syphilis. In an 
 instance of elephantiasis Grgecorum with tubercular lung, the viscera, 
 and amongst them the stomach, were affected with lardaceous dis- 
 ease. In conditions of disease producing general exhaustion, it is 
 impossible to recognize this gastric change by any especial symp- 
 toms, nor does it call for treatment. 
 
 Inflammation of the Stomach. The instances of acute inflammation 
 of the stomach, which have come under my own observation, have 
 arisen from poisons, as alcohol, arsenic, oxalic acid, chloride of zinc, 
 sulphuric and nitric acids; in these there are two symptoms which 
 demand particular attention the absence of pain at the stomach, in 
 most instances, unless perforation have taken place, and the marked 
 prostration of strength, with depression of the pulse. 
 
 After irritant and corrosive poisons have been taken, burning 
 pain in the mouth and throat, charring of the mucous membrane, 
 vomiting, irritability of the stomach, purging of blood or of loose 
 fecal evacuations, are produced ; and according to the strength of 
 the fluid arid its action on the pharynx, oesophagus, and epiglottis, 
 there is dysphagia or dyspnoea. The vomiting is generally excessive 
 from the primary irritation of the poison, and the vomited matters 
 vary according to the character of the agent and the extent of its 
 chemical action. Subsequently, if the mucous membrane of the 
 stomach or oesophagus have been destroyed, and fibre-plastic exuda- 
 tion have taken place, contraction is the result, and narrowing of 
 the canal follows. The period during which food is retained is 
 according to the situation of the occlusion whether in the oesophagus 
 or at the pylorus ; in the former case, the food is at once regurgi- 
 tated ; in the latter, it may be retained for several hours. If the 
 absorption of nutriment be thus prevented, emaciation takes place,
 
 12G ORGANIC DISEASES OF THE STOMACH. 
 
 the whole frame becomes wasted to an extreme degree, and a fatal 
 issue follows in several weeks or months after the poison has been 
 swallowed. I must refer my readers to Dr. Taylor's valuable work 
 on ' Poisons' for an account of the distinctive symptoms produced 
 by the various corrosive and irritant poisons. 
 
 In a case of poisoning by alcohol, the appearance of the stomach 
 resulted from the irritant action of the poison ; but the morbid 
 change was of such a character, that unless especial attention had 
 been drawn to the part, it might very easily have been overlooked. 
 The stomach was minutely injected with arborescent vessels, and 
 the congestion was apparently the remains of an acute erythematous 
 inflammation. 
 
 In another case, in which sulphuric acid had been taken, the 
 patient survived for eleven days, the mucous membrane was left as 
 a detached slough. ' No pain was complained of, and death appeared 
 to result from syncope. 
 
 Absence of pain was also shown in a marked degree in a case of 
 poisoning by chloride of zinc, from Burnett's disinfecting fluid. 
 
 In another case, in which a woman had taken some oxalic acid, 
 the quantity of which, however, was not known, vomiting and pros- 
 tration were the only symptoms, and the patient gradually recovered ; 
 and in an instance of a case of poisoning by corrosive sublimate, 
 there was no pain at the stomach, except the tenderness resulting 
 from the violence of the vomiting, but only extreme irritability ; 
 afterwards, as the enteric inflammation increased in severity, with 
 tenesmus, &c., pain came on about the umbilicus, and generally in 
 the abdomen, but especially over the colon. The intensity of the 
 disease in the ascending colon and in the rectum was very manifest; 
 and it is remarkable how comparatively the small intestine escaped. 
 Depression of power, as shown by a very compressible pulse, was a 
 marked symptom throughout ; but after the fourth day on which 
 salivation was developed it became more evident, and the patient 
 quickly succumbed. The oesophagus was acutely diseased, and the 
 whole intestinal tract more or less congested. The suppression of 
 urine, and the coarse as well as the congested state of the kidneys, 
 were indicative of extreme irritation of those glands, but the whole 
 character of the blood seemed to be changed; it was fluid in its 
 character, the heart contained only a loose coagulum, and this con- 
 dition of the blood had probably an important influence in deter- 
 mining the intense congestion and the pneumonic state of the lower 
 lobes of the lungs. The patient died on the sixth day. 
 
 The prognosis in cases of acute inflammation of the stomach from 
 poisons is generally unfavorable, and care must be taken lest the 
 absence of pain and the clearness of the intellect mislead us as to 
 the injury done to the stomach. The action of the heart is often 
 exceedingly feeble, the pulse being perhaps scarcely perceptible ; 
 and this circumstance is the cause of the fatal syncope, which often 
 unexpectedly supervenes. 
 
 The treatment in acute inflammation of the stomach from poisons 
 consists 1st, in the removal of the poison ; 2dly, in counteracting the
 
 ORGANIC DISEASES OF THE STOMACH. 127 
 
 first effect by antidotes, and by protecting the mucous membrane by 
 means of oleaginous and demulcent substances ; 3dly, in diminishing 
 the pain by the use of opiate and anodyne agents : 4thly, in sustain" 
 ing the patient under the effect of the nervous shock and extreme 
 depression by means of bland nutriment, and sometimes by nutrient 
 and stimulating enernata ; 5thly, the secondary effects of contraction 
 of the oesophagus and pylorus may be mitigated by the use of fluid 
 food in a concentrated form, and several cases are recorded in which 
 the constriction of the oesophagus was relieved by bougies. Great 
 injury may be done by the too active interference of the attendant ; 
 depletion and mercurials, as well as powerful stimulants, generally 
 aggravate the mischief. 
 
 Acute Catarrhal Gastritis; Inflammatory Dyspepsia ; Subacute In- 
 flammation. Catarrh of the stomach takes place, probably, in an 
 acute form, and is the cause of some of the varieties of dyspepsia ; 
 but we are not cognizant of the conditions observed after death in- 
 dicative of this state, except that we sometimes observe intense con- 
 gestion with excess of mucous secretion. It very rarely happens 
 that any one can have the opportunities possessed by Dr. Beaumont, 
 of observing the appearance of the gastric mucous membrane during 
 life ; he found sometimes an erythematous condition, with deficient 
 gastric secretion, arising from irritating food or stimulants. These 
 cases of dyspepsia are no more functional in their character than 
 coryza or slight conjunctivitis. In ordinary catarrh, after exposure 
 to cold, we find there is generally partial, often complete, loss of- 
 appetite, and occasionally diarrhoea, the mucous membrane of the 
 stomach joining in the general condition. 
 
 In the dyspepsia just mentioned the symptoms are nausea or 
 vomiting increased by food, craving for cold drinks, injection of the 
 tongue, and enlargement of the papillae, with sometimes an abundant 
 yellowish-white fur, tenderness and uneasiness at the scrobiculus 
 cordis, pain extending to the back between the shoulder-blades, loss 
 of appetite, languor, headache, and an incapacity or unwillingness 
 for mental or physical exertion, an anxious care-worn countenance, 
 with a sunken condition of the eyes. Oftentimes there is slight 
 febrile disturbance, with a burning sensation at the palms of the 
 hands and soles of the feet ; the bowels become irritable or consti- 
 pated ; the urine is high-colored, and, with nitric acid, assumes a 
 deep-red color, or it deposits litbates abundantly. When vomiting 
 is severe, bright-green fluid and mucus are often ejected. This state, 
 in not a few instances, passes into a more chronic form of the disease, 
 which is often called chronic gastritis, a condition which is indicated 
 by soreness at the scrobiculus cordis ; by pain, which extends to the 
 spine; by sallowness of the complexion, and an anxious, distressed 
 countenance ; by injection of the tongue, which is sometimes like 
 raw beef, or has red patches upon it, as if deprived of epithelium ; 
 by a compressible pulse, and by emaciation. The pain at the stomach 
 is increased by food in every form. This disease is often very ob- 
 stinate, and persists month after month ; and although we have no 
 evidence of actual ulceration and destruction of the surface of the
 
 128 ORGANIC DISEASES OF THE STOMACH. 
 
 mucous membrane, still there is probably chronic inflammatory 
 change. The gums sometimes become spongy, and the mouth and 
 pharynx aphthous and painful ; vomiting also is occasionally a 
 troublesome s^ymptom, and diarrhoea may be present. Vomiting, 
 tenderness at the scrobiculus cordis, and the desire for cold drinks, 
 are the prominent symptoms of this inflammation of the mucous 
 membrane. 
 
 There is a predisposition to this form of disease in strumous sub- 
 jects ; but we must distinguish this affection from a sympathetic 
 irritation of the stomach, produced in the early stage of disease ot 
 the lungs and of the brain, and to which we shall have subsequently 
 to refer. And, we find towards the close of phthisis, of cirrhosis, of 
 strumous peritonitis, &c., a state arises, which although associated 
 with a general condition of exhaustion, closely simulates what we 
 have described as chronic gastritis: in these instances, however, the 
 small and large intestines are often implicated, and we find a flush 
 on one cheek, profuse perspirations at night, preceded by dry burn- 
 ing heat; the bowels are at one time confined, at another relaxed, 
 and the motions are very offensive in character. These symptoms 
 are often associated with great irritability of temper, fretfulness, and 
 sometimes with delirium. (See Gastro-enteritis.) 
 
 In the disease to which my late colleague, Dr. Addison, gave 
 especial attention towards the close of his life, " melasma supra 
 renale," irritability of the stomach and great prostration of strength 
 are the two most prominent symptoms; and so closely do the symp- 
 toms resemble those produced by poisons, and so frequent are the 
 traces of gastric irritation found after death, that it has often been 
 questioned how far these gastric symptoms, with bronzed discolora- 
 tion of the skin, are due to sympathetic disturbance, and how far 
 to disease of an inflammatory character. In instances of this kind 
 which have come under our notice superficial ulceration of the stom- 
 ach has been observed, in others arborescent injection of the capil- 
 liaries, with ecchymosis and an excess of tenacious mucus. 
 
 As to remedial measures, stimulants aggravate the malady; but 
 leeches may sometimes be applied in severe instances to the scro- 
 biculus cordis; whilst generally, cool drinks, soda water, or ice 
 mitigate the symptoms, and may be used with solution of potash and 
 demulcents, or with magnesia and opium. The carbonate or nitrate 
 of bismuth, with carbonate of soda and spirit of chloroform in almond 
 emulsion, is of great service in these conditions. If the bowels are 
 confined, saline aperients should be given, as the carbonate of mag- 
 nesia and soda, with lemon-juice or citric acid. Mercurial purgatives 
 are sometimes used, and have the advantage of thoroughly unload- 
 ing the bowels and of diminishing capillary and portal engorgement, 
 without increasing the irritability of the stomach; thus, calomel may 
 be given in doses of three to five grains, in combination with colo- 
 cynth, aloes, rhubarb, henbane, &c.; or blue pill or gray powder 
 may be administered in similar combination ; or, again, the calomel 
 may be decomposed by alkaline carbonates, as in the preparation of 
 soda with mercury in the Guy's Pharmacopoeia. It is well also to
 
 ORGANIC DISEASES OF THE STOMACH. 129 
 
 follow these mercurial purgatives with a warm aperient draught, so 
 as to produce a full and copious evacuation. To give mercurial 
 preparations, so as to affect the system generally, we think to be 
 positively injurious, and it is better when they can be altogether 
 dispensed with; saline aperients, followed by vegetable tonics, and 
 a bland, unstimulating diet, are generally sufficient. Local applica- 
 tions to the pit of the stomach are also useful in lessening the vomit- 
 ing and the pain, as mustard or linseed poultices, chloroform liniment, 
 with belladonna liniment, &c. Subsequently, if the appetite fail, and 
 the mucons membrane be relaxed, benefit accrues from the internal 
 administration of the dilute nitric or nitro-hydrochloric acids, with 
 vegetable infusions, as calumba, cascarilla, cusparia, or gentian. 
 
 In the more chronic forms the means best calculated to afford 
 relief are the giving of nourishment in small quantities, of a char- 
 acter which is easily digestible, and well masticated. Alkalies and 
 salines relieve the irritability and congested state of the mucous 
 membrane; for instance, solution of potash, the bicarbonate of potash 
 or soda, calcined or carbonate of magnesia, administered with almond 
 emulsion, with camphor mixture, or with any demulcent. If there 
 be neuralgic pain, it is well to add a few drops of dilute hydrocyanic 
 acid, tincture of henbane or conium, the solution of morphia or a 
 preparation of opium ; or to give the trisnitrate of bismuth, with 
 chloric ether. 
 
 In some cases I have seen very great benefit from the administra- 
 tion of lemon-juice ; the pain has subsided, and the toleration of food 
 and ability to digest it have~ considerably increased. It must be 
 borne in mind, in these cases, that whilst vegetable food appears to 
 be less easy of digestion, and often has to be prohibited, if months 
 are allowed to pass without its use the health fails on that account 
 alone, and increased cachexia is produced; the administration of 
 fruit, oranges, grapes, &c., is advisable ; the juice of a lemon may be 
 taken daily with relief to the pain and distress at the scrobiculus 
 cordis. 
 
 The application of leeches or blisters is often of service, and in 
 some cases I have known benefit derived from the introduction of a 
 seton at the pit of the stomach. 
 
 The action of the skin should be promoted ; and although sudden 
 and violent exercise is injurious and could not be borne, still, exercise 
 in the open air, and even horse exercise, is often very beneficial. A 
 change of air should, if possible, be made, especially from a damp 
 and relaxing situation to one of a more dry and bracing character. 
 
 Chronic Gastritis or Chronic Catarrh of the stomach and of the in- 
 testines, although it may arise from inflammation affecting the 
 gastro-intestinal tract in common with the pulmonary mucous mem- 
 brane, is more frequently observed as a consequence of congestive 
 disease of the portal system. The mucous membrane and sub- 
 mucous tissue become congested, often intensely so, or even ecchy- 
 mosed ; the membrane has a swollen, cedematous or granular appear- 
 ance, and is covered with a thick and tenacious layer of mucus. 
 This is sometimes found to be alkaline in its reaction, is with difficulty 
 9
 
 130 ORGANIC DISEASES OF THE STOMACH. 
 
 washed off by water, and consists of mucous corpuscles, nuclei, and 
 epithelium. 
 
 Thickening of the mucous and submucous membranes, and gray 
 discoloration from the deposition of pigmental granules from the 
 long-continued congestion of the capillaries, are the result of chronic 
 catarrh. The follicles of the stomach are found very distinct, and 
 filled with nuclei and cells, and there may be increase of the inter- 
 lobular lymphatic elements or nuclear overgrowth in the sheath of 
 the vessels. 
 
 The cause of this condition appears to be persistent congestion, 
 but it may also arise from long-continued excesses, and it has been 
 observed especially in tuberculosis, as well as in phthisis. Dr. Wil- 
 son Fox gives a total of 14 cases out of 36. Of 100 stomachs ex- 
 amined, 21 had acute catarrh, 19 chronic catarrh, and in 17 the two 
 states were combined. Other diseases which appear to predispose 
 to it are fevers, Bright's disease, peritonitis, and pneumonia. In 
 chronic bronchitis and emphysema, in valvular or obstructive dis- 
 ease of the heart, in cirrhosis of the liver, and in other conditions, 
 the vena portae, and its tributary branches, become over-filled with 
 blood, and consequently the capillary vessels from the mucous mem- 
 branes of the viscera also become surcharged ; altered secretion, and 
 the condition we have just described, is the consequence; thus, the 
 congestion is not limited to the stomach, but extends through the 
 whole of the tract of the alimentary canal, in both the small and 
 large intestines. 
 
 These conditions, then, are not in themselves primary, but are the 
 result of cardiac, pulmonary, or hepatic disease. Sooner or later, in 
 most cases, the signs indicative of gastric catarrh come on, pain at 
 the scrobiculus cordis increased by food, pain between the shoulders, 
 occasional vomiting, flatulence, oppression at the stomach, malaise, 
 constipation ; the flatulent distension after food becomes exceedingly 
 distressing, so that scarcely any can be taken with comfort, and solid 
 food is almost discarded. In some cases the pain takes the form of 
 a severe paroxysmal colic, returning day by day at a definite time. 
 
 An attack of haematemesis, or of bleeding from hemorrhoids, may 
 remove the congestion, and afford comfort to the patient, but the 
 symptoms are very quickly reproduced. The dyspnoea and palpita- 
 tion of heart disease, the cough and gasping for breath of chronic 
 bronchitis, engage the attention of the patient, and obscure the less 
 urgent symptoms of disease of the alimentary canal ; it is when the 
 former have been relieved that attention is directed to the abdomen. 
 This state of catarrh is often relieved by the same means which 
 mitigate the original disease. Emptying the portal system not only 
 diminishes the distension of the right side of the heart and of the 
 pulmonary vessels, but also the congestion, which is the direct cause 
 of the catarrh of the intestines. Purgatives, saline, hydragogue, or 
 mercurial, are generally used, and sometimes the more direct means 
 of relieving the vessels by the application of leeches to the anus. 
 The administration of mineral acids, with demulcents, expectorants,
 
 ORGANIC DISEASES OF THE STOMACH. 131 
 
 or tonics, according to the condition of the patient, affords great 
 relief; the preparations of steel may also be given with advantage. 
 
 Diphtheritic Inflammation of the Stomach. Acute inflammation of 
 the raucous membranes manifests itself by alteration in the secretion 
 and condition of all the parts composing them. The capillaries and 
 the blood within them, the formation of epithelium or mucous or of 
 other secretions, are modified, and the whole vital condition of the 
 part deviates from the healthy state. "' The more the conditions of 
 nutrition deviate from what is normal, the more will the material 
 effused from the vessels deviate from the normal type." 1 This is 
 exemplified in ordinary catarrh and bronchitis, as compared with 
 the effusion of false membrane in croup and laryngitis, and with the 
 sloughing which is occasionally seen in some severe cases of angina. 
 In these diseases the membrane becomes intensely red from conges- 
 tion of its capillaries, swollen from effusion of serum into its tissue, 
 hot and more highly sensitive, and its secretion is changed. If the 
 disease be slight, the mucus is altered in quantity rather than in 
 quality, or its cells are found to be exceedingly abundant and imper- 
 fect in their formation, or mere nuclei are produced. In croupous 
 inflammation, the secretion consists of a blastema, with greater or 
 less tendency to fibrillate, containing granules, nuclei, or variously 
 formed cells. It is more or less adherent to the membrane beneath, 
 though not incorporated with it. The larynx and trachea are most 
 frequently the subject of the disease, or perhaps still more, the 
 mucous membrane of the mouth pharynx, and nasal passages. 
 
 The real nature of the croupous inflammatory membrane, notwith- 
 standing all that has been written respecting it, still remains in some 
 obscurity. In common with other morbid products it is thought by 
 many to be of vegetable origin. We shall only state that wherever 
 it occurs it is from a membrane formed by epithelial and lymph or 
 pus cells welded together by a coagulated fibrinous material. This 
 opinion is considerably strengthened by the study of allied disease in 
 the alimentary canal. The mucous membrane of the bowel dis- 
 charges casts of coagulated mucus. The reason of the coagulability 
 of the effused material is probably not the same with all persons ; 
 in some it may be, that the intensity of the inflammation leads to 
 the effusion of an ordinary coagulable fibrin, in others that the char- 
 acter of the surface and the secretions with which the effusion comes 
 in contact may lead to coagulation which would not otherwise take 
 place. 
 
 The term diphtheritic inflammation was applied by Brejonneau to 
 a form of acute inflammation of the mouth and pharynx, accom- 
 panied with the effusion of a grayish false membrane in small len- 
 ticular or diffused patches, and followed by superficial or deeper 
 ulceration, the disease extending to the nasal mucous membrane ; 
 the same term is applied to similar disease affecting other organs. 
 
 Of late years, however, the term diphtheritic, as applied to inflam- 
 matory products, has come to have somewhat different significations 
 
 1 Paget, ' Surgical Path.'
 
 132 ORGANIC DISEASES OF THE STOMACH. 
 
 in English and German literature. The croupous inflammation of 
 German authors, though a term of much wider extension, includes 
 our diphtheritic inflammation ; and, any sloughing disease of a 
 mucous surface, where the whole thickness of the membrane sloughs, 
 would be the diphtheria of the German pathologists. We make this 
 distinction, though it is not adhered to by English writers, because 
 there are two forms of disease both in the throat and stomach which 
 correspond to the two varieties. Both in the throat and in the 
 stomach we occasionally find a sloughing form of disease, and we 
 also observe a membranous inflammation. 
 
 The stomach is less prone to acute inflammatory disease than either 
 the small or large intestine, and we rarely have an opportunity of 
 observing acute gastritis except as the result of irritant poisons. 
 Croupous or diphtheritic inflammation is still more rare, and the fol- 
 lowing case, although in many respects imperfect, is of considerable 
 interest ; the symptoms of disease of the stomach were not clearly 
 marked, but the patient was exhausted, and suffering from advanced 
 syphilitic necrosis of the bones of the nose, and was also the subject 
 of disease of the kidneys. 
 
 CASE XXXV. Syphilis. Diphtheritic Inflammation of the Stomach. 
 Diseased Kidneys. Necrosis of the Bones of the Nose Ann O , aet. 47, 
 was admitted, under Mr. Polland's care, Nov. 22, 1854, and died March 30th. 
 She had had syphilis many years previously, for which she had taken mercury, 
 and was admitted in a state of general cachexia, with necrosis of the bones of 
 the nose. In this condition she continued till a short time before death, 
 when she appeared more exhausted, and puffiness of the hands and face came 
 on. She appeared to die from exhaustion. 
 
 Inspection fourteen hours after death. The whole of the soft parts and 
 the bones of the nose as well as of the palate were destroyed. In the brain 
 there was serous effusion. The lungs and heart were healthy. The liver 
 was fatty and nodulated, and it contained small lardaceous masses. The 
 spleen was firm and waxy, and it also contained lardaceous matter ; its weight 
 was six ounces. The kidneys were much degenerated, presenting white de- 
 posit in the secreting structure, and the tubes contained highly refracting 
 granules (fat). 
 
 The stomach presented a very remarkable appearance ; it was of 
 normal size. The mucous membrane was intensely congested ; in 
 numerous parts were small patches of thin, yellowish, lymph-like 
 substance, which were very adherent, and were composed of mucous 
 cells, granules, granule cells, and some secreting cells. Other parts of 
 the mucous membrane were covered with tenacious mucus. There 
 was intense congestion of the capillaries of the mucous membrane, 
 the follicles of which were distended with granules and with secret- 
 ing cells. A dissolute life, and the impairment of general health 
 by syphilis and mercury, were the predisposing causes of this disease 
 of the stomach. 
 
 Of croupous inflammation of the stomach, Bamberger states " that 
 it is found in children with croupous exudation on other membranes, 
 and in adults it is secondary to typhus, pyaemia, puerperal fever,
 
 ORGANIC DISEASES OF THE STOMACH. 133 
 
 cholera, dysentery, or any acute exanthem." It is sometimes found 
 in children, too, after the administration of tartrate of antimony. 1 
 
 In a case of diphtheria, which was under the care of my colleague, 
 Dr. Pye Smith, in a child, aet. 4J, the palate, larynx, and trachea 
 were affected, and pneumonia was also produced. The oesophagus 
 was healthy, but in the stomach, within the radius of two and a half 
 inches from the cardiac orifice, were numerous small ulcers like 
 hemorrhagic erosions, and some of them were covered with a pellicle. 
 
 Dr. Fenwick has described acute inflammatory disease coming on in 
 the stomach after scarlet fever, and in a case of hemorrhagic small- 
 pox, which terminated fatally in Guy's Hospital under the care of 
 my colleague, Dr. Pavy, the mischief had extended into the stomach, 
 for not only the oesophagus, but the stomach and a great part of the 
 intestine, were lined with black pulpy fluid, which evidently con- 
 sisted of blood. 
 
 Of the other form, which is perhaps better termed phlegmonous 
 gastritis, the following case may be taken as a typical instance. 2 A 
 patient who died from gout, with granular kidneys, hypertrophy of 
 the heart, and phlegmonous colitis, had also acute disease of the stom- 
 ach. The stomach was thickened, and was rigid from inflamma- 
 tory infiltration ; the surface of the mucous membrane gave an alka- 
 line reaction to test paper ; the mucous membrane presented patches 
 of yellowish color, like fibrin ; these were adherent, and on removal 
 brought away some of the mucous membrane. He had suffered from 
 diarrhoea, and the intestine presented a curious state of its submucous 
 tissue ; there were projections like boils due to collections of pus be- 
 neath the mucous membrane ; the mucous surface was covered with 
 lymph ; in other parts ulcers appeared with ragged bases, some were 
 nearly healed ; the whole membrane was puckered, and the morbid 
 process had apparently gone on for some time. 
 
 Suppuration in the Coats of the Stomach. Local suppuration in the 
 walls of the stprnach is of exceedingly rare occurrence. The history 
 of the following case is imperfect in its details, but is sufficient to 
 show the general character and symptoms of such disease. It is 
 probable that the case was one of pyaemia. 
 
 CASE XXXVI. Elizabeth T -, aat. 40, was admitted May 2d, 1847, into 
 Guy's Hospital. She was a married woman, and a nurse. For a fortnight 
 she had suffered from pain in the limbs and back, and for a few days in the 
 stomach and chest. The abdominal tenderness subsequently increased. She 
 had anorexia and constant vomiting of a dark-colored, bitter fluid, with 
 intense thirst. Her death was preceded by restlessness and stupor. 
 
 Inspection twenty-four hours after death. The body was tolerably nour- 
 ished. The peritoneal cavity contained yellow, opaque, puriform secretion, 
 of uniform consistence, but of very offensive odor. At the pyloric third of 
 the greater curvature of the stomach was a firm mass, measuring four and a 
 half by three and a half inches. On opening the stomach, a small quantity 
 of greenish fluid escaped. The mucous membrane was dotted over its surface 
 with points of ecchymosis, and an irregular, dark-brown patch, about the size 
 
 1 Bamberger, loc. cit., p. 272. 
 
 2 'Path. Trans.,' 1875, Dr. Fagge.
 
 134 ORGANIC DISEASES OF THE STOMACH. 
 
 of a shilling, was found near the pylorus, at the centre of the thickened mass. 
 When the peritoneal and muscular coats were divided, there was found to he 
 a collection of pus in the stibmucous cellular tissue. The pus was semi-fluid. 
 The intestines were distended with gas ; but no disease could he found in the 
 mucous membrane, except a small polypus in the rectum. The liver \\;t.s 
 dark, congested, and lacerable. The spleen and kidneys were congested. 
 The uterus was full of menstrual blood. (Preparation 1802 85 .) 
 
 In a case of pyaemia, under the care of my colleague, Dr. Moxon, 
 with fistula of the rectum, two or three abscesses, as large as ha/,el 
 nuts, were found in the stomach between the muscular and mucous 
 coats. The serous and mucous coats were healthy, and no trace of 
 ulceration could be detected. 
 
 In addition to this form of local suppuration a diffuse form has 
 also been found in very rare cases, perhaps the best recorded instance 
 being that of my colleague, Dr. Hilton Fagge, in the ' Pathological 
 Society's Transactions' for 1875, p. 81. The case, as there detailed, 
 is that a gentleman, aat. 51, was taken with vomiting and retching 
 at 8 A.M. He had always a weak digestion, and for that reason, 
 during a late visit to Brighton, had taken but very sparingly of soup, 
 tea, and other light food. The pain was paroxysmal and very severe, 
 shooting up to the right shoulder. He became a little delirious, and 
 had frequent calls to evacuate his bowels without any feculent matter 
 passing, and he died quite suddenly at midnight. Barnberger, 1 in 
 his description of phlegmonous gastritis or inflammation of the sub- 
 mucous cellular tissue of the stomach, after describing it as com- 
 monly secondary to pyaemic aifections, and noting that Oppolzer had 
 seen it twice in puerperal fever, gives a somewhat similar case in a 
 young healthy soldier. The patient died after a few days of vomit- 
 ing, with violent pain of the stomach and high fever with delirium. 
 The stomach was infiltrated through its whole extent with pus, which 
 streamed out on every section. He remarks that a diagnosis in such 
 cases is hardly possible, by reason of the want of further recorded 
 cases. Dr. Moxon says of it, 2 " That though it is rare, Ackermau 
 has collected thirty cases, and that it is apt to set up pysemic ab 
 scesses in the liver." This, however, would hardly apply to the 
 diffused form so much as to the localized, for it would appear that 
 the former is too rapid in its course to have much time for the de- 
 velopment of secondary abscesses. 
 
 Ulceration of the. Ktomach. There are several forms of simple 
 ulceration observed in the stomach : 1st. Superficial ulceration, 
 affecting only the mucous membrane, which, although confined to 
 the surface, is associated with marked gastric symptoms. 2dly. Fol- 
 licular ulceration. And 3dly. Perforating ulcer, acute and chronic. 
 
 Long-continued congestion of the mucous membrane of the stom- 
 ach not only produces the state which we have described as chronic 
 catarrh, but is also followed by superficial ulceration, or as it is 
 termed hemorrhayic erosion ; but this destruction of the mucous 
 membrane is also the result of subacute inflammation. The mern- 
 
 1 Loc. cit., 266. s ' Path. Anat.,' Wilks and Moxon, p. 381.
 
 ORGANIC DISEASES OF THE STOMACH. 135 
 
 brane is generally found to be congested, especially at the rugae, and 
 the ulcers are situated at the lesser curvature, or in the neighborhood 
 of the pylorus. The ordinary size of these ulcers is about a quarter 
 of an inch in diameter ; they have irregular and sometimes rounded 
 edges ; as to color, they are minutely injected or pale, and in depth 
 they often reach to the submucous cellular tissue ; a single point of 
 ulceration may alone be observed, or several parts of the membrane 
 may be thus superficially destroyed. It has even been suggested 
 that several of these ulcers by uniting may lead to the larger per- 
 forating ulcer. The intervening tissue may either have a normal 
 appearance, or present arborescent and even general congestion, 
 whilst the submucous and muscular coats of the stomach remain free 
 from hypertrophic change, unless chronic irritation has existed. On 
 further and microscopical examination, the ulcerative process is 
 found to have irregularly destroyed the gastric follicles laterally ; 
 and the surface presents mucus-cells, nuclei, and epithelium. 
 
 The symptoms of superficial ulceration are sometimes of an acute 
 character ; vomiting, pain at the scrobiculus cordis, and between the 
 shoulders, tenderness at the epigastrium, pyrosis, injection of the 
 tongue at the tip and edges, loss of strength, and even great prostra- 
 tion, are the symptoms which have been observed in this disease ; 
 but in superficial ulceration other coincident diseases may exist ; as 
 disease of the supra-renal capsule, with long-continued indigestion, 
 phthisis, as in a case where there was great intemperance, and we 
 have also observed it with chorea. Great prostration of strength is 
 often a marked symptom, and a most interesting one, when it is 
 viewed in connection with the intimate union of the stomach with 
 the large plexuses and ganglia of the sympathetic nerve. The 
 association of some of these cases of superficial ulceration with 
 pyaemia, appears to show that a general diseased condition of the 
 blood predisposes to or excites this change. 
 
 In the class of cases associated with portal congestion, vomiting of 
 coffee-ground substance sometimes takes place before death, and fluid 
 of a similar kind is found in the stomach on post-mortem examina- 
 tion ; chronic congestion followed by ulceration leads to effusion of 
 blood, which gives rise to this red-colored vomited fluid. Obstruc- 
 tive disease of the heart and lungs, and any condition which inter- 
 feres with the free circulation of blood through the liver, predisposes 
 to this form of disease. This state of stomach is often associated 
 with chronic catarrh, and the symptoms before mentioned are gene- 
 rally present, an attack of hasmaternesis may afford great relief, but 
 the symptoms may be so masked by the primary disease that this 
 gastric ulceration is only recognized on the post-mortem table. 
 
 The following cases^ tabulated from the 'Guy's Post-mortem 
 Records,' indicate the frequent association of hemorrhagic erosion 
 with disease of the heart and lungs. 
 
 1. Cancer of rectum and liver ; oedema and gangrene of lungs. 
 
 2. Aortic disease ; dropsy ; pulmonary apoplexy. 
 
 3. Large white kidney with severe catarrh of stomach. 
 
 4. Ulcerative endocarditis; adherent pericardium.
 
 136 ORGANIC DISEASES OF THE STOMACH. 
 
 5. Disease of aortic and mitral valves. 
 
 6. Lardaceous viscera ; dropsy ; old syphilis. 
 
 7. Albuminuria ; hypertrophied heart. 
 
 8. Dilated heart ; imperfect ventricular septum ; dropsy. 
 
 9. Subacute aortitis ; retroverted valve and dilatation of the heart. 
 
 10. Dilated heart. 
 
 11. Aortitis; hypertrophy and dilatation of heart. 
 
 12. Bruised side ; polypi in the right side of the heart. 
 
 13. Purpura hemorrhagica. 
 
 14. Chronic bronchitis. 
 
 In the treatment of superficial ulceration the application of leeches, 
 or of a small blister to the scrobiculus cordis affords considerable 
 relief; nitrate of bismuth with conium, or with morphia, and hydro- 
 cyanic acid, soothes the irritated membrane, and diminishes pain. 
 Solution of potash, the bicarbonate of potash, or of soda, with ano- 
 dynes and demulcents, render the mucus less irritating, and thereby 
 diminish the congestion of the mucous membrane. Nitrate or oxide 
 of silver in small doses relieves the pain, and renders the stomach 
 more tolerant of food. Chloric ether also, with carbonate of soda, 
 and mucilage mixture or almond emulsion is often of great service. 
 
 Ice and cold water are exceedingly grateful to the patient, but 
 stimulants are not well borne, although on account of the prostra- 
 tion we ar often tempted to give them ; if they be absolutely called 
 for, they should be diluted and mixed with food, as wine with arrow- 
 root or jelly, or a small quantity of brandy with soda water. A 
 farinaceous diet is more suited to these cases than animal food, which 
 taxes in a greater degree the energies of the diseased membrane ; it 
 is well to allow three to four hours to intervene between each meal, 
 unless the stomach be very irritable, or the patient prostrate, when 
 small and often repeated quantities are to be preferred. 
 
 In some cases of anaemia, and chlorosis with leucorrhoea, steel may 
 be taken with advantage; it should be administered in the milder 
 forms, as the ammonio-citrate and tartrate, or in pills, as the corn- 
 pound steel pill with henbane and rhubarb, and always after a meal. 
 
 In the congestive forms of ulceration, purgatives relieve portal 
 congestion, and thus remove much distress; but their action is fol- 
 lowed by prostration, so that at last we are obliged to suspend them 
 altogether. Diuretics and diaphoretics also tend to a similar result ; 
 small depletions afford temporary relief, but are not called for unless 
 the respiration and the impeded action of the heart absolutely re- 
 quire them. 
 
 CASE XXX VII. Superficial Ulceration of Stomach. Diseased Supra- 
 renal Capsules John J , aet. 22, was admitted March 20th, and died on 
 the following day. He was a stonemason by trade, residing at Lambeth, and 
 during the winter had had pain in his stomach and vomiting. The vomited 
 matters consisted of watery fluid. On admission the extremities were cold 
 and he was almost pulseless, he had not diarrhoea but he had slight pain in 
 the hypogastric region. He rallied a little after admission, but vomiting of 
 bilious matter came on, and he appeared to die from syncope. 
 
 The inspection was made seventeen hours after death. The body was
 
 ORGANIC DISEASES OF THE STOMACH. 137 
 
 tolerably nourished, but the face was of a dingy hue, " Melasma Addisonii." 
 The brain and its membranes were normal. At the apices of the lungs 
 were lobules of iron-gray consolidated lung, with some calcareous deposit. 
 The right side of the heart was moderately distended ; the left was firmly 
 contracted. On carefully examining the stomach, the cardiac extremity pre- 
 sented post-mortem solution, but towards the lesser curvature the mucous 
 membrane was granular, and in several parts was destroyed by small patches 
 of ulceration. These were quite superficial and irregular. In other parts 
 above the line of solution there was aborescent injection. On microscopical 
 examination, mucous and granule cells were observed. In the small intes- 
 tine, Brunner's glands in the duodenum, and Peyer's and the solitary glands 
 in the ileum, were very distinct. The liver and spleen were healthy ; the 
 kidneys coarse. The supra-renal capsules were atrophied, being only forty- 
 nine grains in weight, and each was adherent to the surrounding parts by 
 dense fibrous tissue ; the left appeared irregular from contraction. The sec- 
 tion was pale, and presented fibrous tissue, fat, and cells. 
 
 There were evident symptoms of disease of the stomach in the 
 pyrosis, pain, and vomiting from which this man suffered. Discolora- 
 tion of the skin and the prostration of strength, which was very 
 remarkable, were typical signs of a condition which is now well 
 recognized as Addison's disease of the supra-renal capsules. 
 
 The connection of all these symptoms may be accounted for by the 
 fact that the pneumogastric nerve not only supplies the stomach, 
 and joins the large sympathetic ganglia of the solar plexus, but sends 
 a large branch to join the sympathetic nerve of the kidney and supra- 
 renal capsule, and this nerve is of considerable, size. The exhaustion, 
 collapse, fluttering pulse, present in many diseases of the abdomen, 
 and sometimes produced by blows on the epigastrium, as well as the 
 neuralgic pain in the side, with gastric irritation or ulceration, arise, 
 no doubt, from this cause, namely, the connection of the sympathetic 
 with the pneumogastric and spinal nerves. 
 
 CASE XXXVIII. Chorea. Endocarditis of the Mitral. Ulceration of 
 
 the Stomach Elizabeth C , aet. 18, was admitted March 28th, into Guy's 
 
 Hospital. For two weeks before death she had very severe chorea, with con- 
 stant jactitation, and sleeplessness ; gradual exhaustion supervened. The 
 mucous membrane of the stomach was softened and partially dissolved at the 
 greater curvature. Near the lesser curvature were several small congested 
 patches, in the centre of which the mucous membrane was destroyed. One 
 of these had the appearance of a cicatrix. 
 
 On microscopical examination, the follicles were found to be full 
 of granules, and cells containing highly refracting particles, some- 
 what resembling inflammatory cells. Similar cells, with mucus, 
 were present on the surface, and the capillaries of the mucous mem- 
 brane were much congested. The mucous membrane of the small 
 intestine was similarly congested. The condition of the stomach 
 appeared thus to indicate considerable irritation ; but the severe ner- 
 vous symptoms completely masked every other morbid state. 
 
 CASE XXXIX. Catarrh, and Superficial Ulceration of the Stomach. 
 
 Cystic Disease of the Ovary Ann A , set. 23, was admitted October, 1854. 
 
 She was a married woman, and, with the exception of ague several years
 
 138 ORGANIC DISEASES OF THE STOMACH. 
 
 previously, she had enjoyed good health. Nine months before admission, 
 after vomiting, which had latterly become habitual, she experienced pain in the 
 side, and the abdomen became swollen. The enlargement increased and sub- 
 sequently proved to be ovarian. After paracentesis the fluid re-collected, 
 and she was admitted in a very enfeebled condition. Vomiting came on, and 
 she gradually sank. 
 
 Inspection fifty-eight hours after death The peritoneum contained three 
 to four quarts of reddish fluid, and also a large cystiform tumor formed by the 
 right ovary. The stomach was large ; its rug* were reddened, and covered 
 with a thick layer of mucus. The mucous membrane was thin, and presented, 
 especially at the lesser curvature, numerous minute ulcers, which were found 
 to extend to the submucous cellular tissue, and on their surface numerous 
 spherical cells, containing highly refracting particles were observed. The 
 other parts of the intestine were much congested. The liver was fatty. 
 
 In this case the power of the patient was much reduced, and the 
 abdominal tumor had exerted considerable pressure on the vessels. 
 It appeared, however, that for some time before death, the mucous 
 membrane of the stomach had been in an irritated, if not inflamed 
 condition, as indicated by the repeated attacks of vomiting, before 
 any mechanical pressure was exerted upon the viscus. The earlier 
 attacks of vomiting were perhaps due to sympathy with the diseased 
 ovary. 
 
 Follicular Ulceration of the Stomach. Minute points of ulceration, 
 varying in size from one-sixteenth to one-fourth of an inch in 
 diameter, are sometimes found studding the whole surface of the 
 stomach. They do not extend deeper than the mucous membrane, 
 and are situated, not only at the lesser curvature, but over the 
 greater part of the stomach ; and they appear sufficiently distinct 
 from the more common superficial ulcer to warrant separate men- 
 tion. They may be associated with a similar condition throughout 
 the intestinal tract. Dr. Brinton thinks that there is no proof of 
 their origin in the gastric follicles, or in the lenticular glands if pre- 
 sent; and suggests the term punctate ulceration as being more 
 correct. 
 
 This form of ulceration has been observed in children with severe 
 gastric symptoms ; but it has been generally found after death when 
 no indication of disease of the stomach had previously existed, ex- 
 cepting, perhaps, the vomiting of coffee-ground substance. A draw- 
 ing, in the Museum of Guy's, 1 from an infant under the care of 
 Dr. Lever, shows the mucous membrane of the stomach intensely 
 congested, and covered with minute points of ulceration. The 
 microscopical appearance of these minute ulcers presents irregular 
 edges extending into the gastric follicles ; the base consists of the 
 submucous tissue, and on the surface are numerous cells, either 
 altered secreting cells, or inflammatory granule cells. There is no 
 proof that the disease originates in the solitary glands, but rather that 
 it is follicular in its character. These ulcers, in some cases, are pro- 
 bably formed a short time before death ; and are due in part to irri- 
 tating secretions, and to the depressed state of the nervous system. 
 
 1 Drawing No. 286' 5 .
 
 ORGANIC DISEASES OF THE STOMACH. 139 
 
 The disease is closely allied to the gastritis folliculosa of Cruveilhier, 
 or to what is called hemorrhagic erosion ; but the latter term is more 
 applicable to some of the forms of superficial ulceration with great 
 congestion. 
 
 In connection with the subject of follicular inflammation we may- 
 refer to an interesting case which occurred under the care of my 
 colleague, Dr. F. Taylor. In the stomach of an illegitimate child 
 aged 8 months, and who had died from syphilis, numerous whitish 
 round spots, about the size of "spangles," were observed. These 
 were at first believed to be ulcers, but on careful examination the 
 mucous membrane was found to be entire, but it could be easily re- 
 moved on the slightest pressure these spots extended to the sub- 
 serous tissue. There was also ulceration of the rectum. 
 
 In some fatal cases of hemorrhage from the stomach, a minute 
 ulcer, scarcely larger than those just described, has been found ; at 
 the base of which the branch of an artery has been observed con- 
 taining a small clot. 1 Sometimes there are seen numerous minute 
 specks, each containing a small clot. 
 
 Two cases,of this kind are recorded by Dr. Murchison in the 'Path. 
 Soc. Trans.,' vol. xxi, p. 162. The ulcers were such a^ might be 
 called hemorrhagic erosions, and occurred in spirit drinkers, and 
 both were fatal from hemorrhage. 
 
 CASE XL. Follicular Ulceratian of the Mucous Membrane of the Stomach, 
 trith Renal Anasarca and Diseased Heart Susan K , set. 67, was ad- 
 mitted into Guy's in June, 18o4. She had general anasarca, with albumi- 
 nous urine; the pulse was irregular; and there was dyspnoea, with palpitation 
 of the heart. A short time before death, vomiting of a dark-colored fluid 
 took place. 
 
 On Inspection, coarse congested kidneys were found, with a heart weighing 
 fifteen ounces, dilated and flaccid, and with some atheromatous deposit on the 
 mitral and aortic valves. There were several small fibrous tumors beneath 
 the peritoneum covering the uterus. In the stomach, above the line of gastric 
 solution, were numerous minute ulcerations, about the size of a pin's head, 
 studding over the whole of the w membrane, and without any thickening of the 
 submucous or muscular tissue. See Preparation, Museum, No. 1802 73 . 
 
 CASE XLI. Follicular Inflammation of the Stomach. Burn on the Leg. 
 Amputation. Abscess in the Lung and Spleen George H , aet. 15, was 
 admitted into Guy's Hospital April 20th, and died June 23d. He had 
 scalded the arm and leg with hot tar. The left leg was principally injured, 
 but was never disposed to heal, and the nerves became exposed ; the leg was 
 amputated on account of his prostrate condition and the severity of the pain 
 from which he suffered. 
 
 Inspection eight hours after death. The stump was sloughing, and the dry 
 bone projected. The left arm was oedematous. There was pytemic pneumonia 
 and minute abscesses in the heart and spleen. The diaphragm on both sides 
 was covered with purulent lymph. 
 
 The stomach contained coffee-ground fluid. Near the cardiac extremity 
 were numerous minute follicular ulcers ; but the gastric follicles for the most 
 part were found to be in a normal state. 
 
 ' Drawing No. 180r.
 
 140 ORGANIC DISEASES OF THE STOMACH. 
 
 Perforating Ulcer of the Stomach. The form of ulceration which 
 we have next to consider has been designated emphatically ulcer of 
 the stomach, by some also the chronic, and by others the perforating 
 ulcer. Some cases of the latter description are not of a chronic 
 character, and ought perhaps on that account to be considered a pa ft ; 
 many of those, however, which have extended over considerable 
 periods, terminate in perforation, so that we can scarcely separate! 
 the one from the other ; the term peforating is however meant to 
 imply a tendency to extend through the mucous, and also through 
 the muscular and peritoneal coats, although adhesions may prevent 
 sudden fatal peritonitis. 
 
 The perforating ulcer has probably in all cases been preceded by 
 some of the conditions previously described. The ulcers are situated 
 at the lesser curvature of the stomach, sometimes towards the ante- 
 rior, but more frequently towards the posterior aspect, and near the 
 pylorus ; they vary in size from a quarter of an inch to three inches, 
 or even more, in diameter, and are round, oval, or reniform, the 
 latter perhaps from the union of two ulcers. In the 'Dublin Hospital 
 Gazette,' Dr. Law mentions an instance in which an ulcer was six 
 inches in length in its long axis. Dr. Brinton, 1 in his investigations 
 on 'Ulcer of the Stomach,' states that in 43 per cent, the ulcer was 
 situated at the posterior surface, in 27 at the lesser curvature, in 16 
 at the pyloric extremity, in 6 on both the anterior and posterior sur- 
 faces, often in opposite positions, in 5 on the anterior surface, in 2 
 at the greater curvature, and in 2 in the cardiac pouch ; those on 
 the anterior surface being the most liable to lead to perforation and 
 peritonitis. 
 
 The edges of the chronic ulcer are rounded and elevated ; but in 
 those which are more emphatically termed the perforating ulcer the 
 edges are frequently neither raised nor injected, but merely present 
 a small punch-hole opening, perforating the peritoneal membrane. 
 The opening is rather larger on the mucous surface, but there is no 
 evidence of inflammatory action, and sometimes no adhesion what- 
 ever with adjoining viscera. More frequently, however, the edges 
 of an ulcer in the stomach are considerably thickened by the infil- 
 tration of fibrous tissue in the mucous and submucous coat; the 
 centre is therefore depressed, and a hollowed cavity is produced ; 
 and in many of these cases, also, the disease extends through the 
 muscular and even through the peritoneal coat. The opening in the 
 mucous membrane is' larger than that of the muscular, and the mus- 
 cular than the peritoneal coat, so that the ulcer has a bevelled ap- 
 pearance on its inner aspect. This fact has been adduced in support 
 of a theory as to the causation of the perforating ulcer, as we shall 
 see in discussing the pathology of the affection. If the peritoneum 
 ulcerate or slough before adhesions have formed, a round opening, 
 as if a punch-hole had been made, is observed to extend into the 
 serous sac, and leads to rapidly fatal peritonitis. If, however, adhe- 
 sions take place around the ulcer, its base is formed by the adjoining 
 
 1 Brinton on ' Diseases of the Stomach.'
 
 ORGANIC DISEASES OF THE STOMACH. 141 
 
 viscera, such as the pancreas, or the left lobe of the liver, or the 
 spleen. In these cases the base of the ulcer, or cicatrix, is of a 
 whitish color, and consists or fibrinous effusion, and is smooth, or it 
 has a minutely granular appearance ; the edges become exceedingly 
 firm, and are formed of dense fibrinous effusion into the mucous and 
 submucous tissues. Glandular mucous membrane is not re-formed 
 in these cicatrices. It is of some importance in explaining the fre- 
 quency of hemorrhage to remember, that the ulcer is most commonly 
 found on the posterior wall of the stomach, and therefore that the 
 floor of the ulcer is usually formed by the pancreas, and that pan- 
 creatic gland structure appears to have very little granulating power. 
 The lobules of the gland are frequently to be seen unobscured by 
 any new tissue at the base of the ulcer. The perforation into the 
 peritoneum is sometimes found at the edge of a large ulcer which 
 has been closed by adhesion, but which has given way at the side. 
 Adhesions also take place between the anterior surface of the stom- 
 ach and the abdominal parietes, so also with the parts in the lesser 
 omentum, with the glands, &c. When the liver is invaded, we find 
 that the adjoining hepatic tissue contains a considerable infiltration 
 of white fibrous tissue, and it is not very uncommon for suppuration 
 to extend round the base of the ulcer, and to invade some branch of 
 the portal vein, either by direct ulceration into it or by secondary 
 phlebitis, and this leads to secondary abscess in the liver. Ulcera- 
 tion occasionally leads to perforation of the coats of the adjoining 
 vessels either at an early stage, or when an ulcer has existed for 
 some time. Hemorrhages thus produced are sometimes rapidly fatal, 
 or they become checked for a time, and they often recur. Dr. Brinton 
 describes three varieties of this hemorrhage: 1st. From the exten- 
 sion of ulceration into the minute vessels of the mucous membrane 
 and submucous tissue, leading to a gradual discharge of blood, which 
 becomes mixed with the secretions; 2dly. Greater hemorrhage from 
 sudden congestion of the ulcerated surface ; and 3dly. Very profuse 
 bleeding from a large artery of the stomach. The hemorrhage from 
 the first two is never of any great severity, and we believe in fatal 
 hemorrhage from ulceration an open vessel can always be found by 
 careful search. The perforated vessel is often seen closed by a 
 small clot, or a drop of blood may be pressed from it, and in large 
 ulcers may be sometimes seen like a small papillary eminence. This 
 hemorrhage, however, is not limited to the gastric arteries, but takes 
 place from the arteries situated at the base of the ulcer, and belong- 
 ing to adjoining viscera ; thus, in one instance both the splenic artery 
 and the pancreatic were perforated ; and recently, we had an instance 
 in which the splenic artery alone was divided. (Preparation in the 
 Museum of Guy's Hospital.) Dr. Lee, quoting Cruveilhier, states 
 that ulceration into arteries and perforation take place more fre- 
 quently in secondary ulceration of a cicatrix than with primary 
 ulceration. Hemorrhage, however, often occurs at an early period 
 of the disease. 
 
 The form of the stomach may be greatly changed either by adhe- 
 sions external to the viscus, or by contraction of the walls of the
 
 142 ORGANIC DISEASES OF THE STOMACH. 
 
 ulcer. When the ulcer is situated in the centre, the cavity may 
 appear almost double, a form of hour-glass contraction. It is exceed- 
 ingly rare in simple ulceration, even when situated at the pyloric 
 extremity, for the whole circumference of ths part to be occupied 
 bv the ulcer or its cicatrix ; the side is irregularly puckered rather 
 than uniformly contracted. In some cases the ulcer is so large, and 
 the thickening so great, that the Avhole stomach becomes involved 
 in the inflammatory changes, and is greatly thickened, and conse- 
 quently very much contracted. The disease is then associated with 
 more than the usual emaciation, and the case will probably be mis- 
 taken for one of cancer at one or other orifice; though in cancerous 
 disease it is more common to find one or other orifice surrounded. 
 In another instance the part which, on opening the stomach, was 
 supposed to be the pylorus, was found to be a circular contraction 
 and a large ulcer, about an inch and a half from the pylorus, and 
 healthy mucous membrane intervened; but this was not simple ul- 
 ceration; there was cancerous product in the contracted omentum at 
 the part ; it was doubtful whether the cicatrix of an ulcer had been 
 followed by cancerous effusion in its neighborhood, and it is probable 
 that this is really the case in some instances. 1 The thickening of 
 the margins of the ulcer also encroaches upon the branches of the 
 pneumogastric, and leads to intense pain, violent vomiting, and death 
 from exhaustion. This implication of the nerve structure may pos- 
 sibly tend to the production of the anasmic state of so many of these 
 patients; the anaemia being thus a consequence, and not a cause of 
 ulcer. The second case related is of this character. The ulcer 
 sometimes, also, extends into the sac of the lesser omentum, and 
 may cause acute peritonitis, or form an abscess bounded by the spleen, 
 diaphragm, pancreas, and liver; or it communicates with the colon, 
 or even with the parietes ; these latter cases, however, are generally 
 of a cancerous character; 2 or the diaphragm itself is perforated, and 
 pleurisy and empyema are produced. 
 
 A remarkable instance occurred in Guy's, in 1845, under Dr. Bar- 
 low's care, the full report of which, by Dr. Wilks, is found in the 
 'Medical Gazette' for May, 1845, but I have given a brief abstract 
 of it. A secondary cavity, partially filled with air, had given rise 
 to the symptoms of pneumothorax. In another case which I have re- 
 corded, a sinuous ulcerated opening extended through the diaphragm 
 into a sloughing cavity of the lung. A communication sometimes 
 takes place from the colon, but this appears generally to extend from 
 
 1 With regard to cancer occurring after ulcer : it would appear that it does so in two 
 ways : 1, by a transformation of the simple sore into a cancerous one. It is by no 
 means uncommon to find evidence of a chronic ulcer and some part of it cancerous. 
 This corresponds to what is observed in other parts, and in the skin more especially, 
 where a chronic ulcer becomes epitheliomatous. But there is another method, viz., 
 where, as in the text, the sore still remains simple, but there is cancer in the neighbor- 
 hood. These cases, too, have their parallel in other parts, and we may mention the 
 breast, where chronic eczema and other states about the nipple are occasionally fol- 
 lowed, not by cancer of the breast, but by cancer of the axillary glands. Such cases 
 have been dwelt upon particularly by Sir James Pagct. 
 
 * See Dr. Murchison in ' Path. Trans.,' vol. viii, and Dr. W. T. Gairdner, in ' Edin. 
 Med. Journal,' 1855.
 
 ORGANIC DISEASES OF THE STOMACH. 143 
 
 the intestine to the stomach, rather than from the latter to the for- 
 mer; and the ulceration in these cases is found more generally at 
 the greater curvature. In a patient who died in 1847, there was an 
 ulcer opening from the colon into the greater curvature, and two 
 others from the greater curvature into the sac of the lesser omentum, 
 forming a large fecal abscess, which extended through into the lung. 
 Dr. H. Da vies narrates a case in the 'Pathological Transactions,' of 
 simple chronic ulcer extending into the colon. There had been dys- 
 pepsia and fecal vomiting, whenever the bowels were constipated. 
 The patient gradually sank.
 
 144 
 
 ORGANIC DISEASES OF THE STOMACH, 
 
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 146 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
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 ORGANIC DISEASES OF THE STOMACH. 147 
 
 Of these 65 cases, 37 occurred in males, 27 in Females. 
 Causes of Death. 
 
 Males. Females. 
 
 Hemorrhage ..... 8 5 
 
 Perforation ..... 12 14 
 
 Peritonitis (without perforation) 1 
 
 Various ...... 16 8 
 
 Not stated 1 
 
 37 28 
 
 Many facts of great interest have been brought forward in the 
 valuable papers of Dr. Brinton. As to sex, that ulceration of the 
 stomach is twice as frequent in females as in males; the reverse being 
 the case in cancer. In 654 cases he found 440 were females, and 
 214 males; and that in one out of every five cases more than one 
 ulcer was present; whilst in one out of every seven or eight cases 
 perforation took place. 
 
 In the consideration of the age of those who are the subjects of 
 this affection, the cases of cancer which have come under my own 
 immediate notice have been more advanced in life than those who 
 were the subjects of ulceration of the stomach. Dr. Brinton has 
 collected a large number of cases, and he shows that the ulcer gene 
 rally "affects the periods of middle and advancing life with a fre- 
 quency which gradually increases up to the extreme age allotted to 
 men." But the cases of ulcer in which perforation causing perito- 
 nitis happens "seem not only to select another period of life, but to 
 exhibit a marked contrast of age in the different sexes, the period of 
 life in which it is most liable to occur being quite a different epoch 
 in the male and in the female," in the female being between the 
 ages of 14 and 30, in the male from 50 to 60 ; the diminished risk of 
 the female at the latter periods of life rendering the total risk in the 
 same number of cases nearly equal. 
 
 The same author states that in the female one-half the instances 
 of perforation takes place between the ages of 14 and 20, whilst in 
 the male there is a constant proportion in each decade up to 50, 
 which diminishes but little up to 70. The complete average age 
 in the former, however, being 27 years, in the latter 42. Dr. Lees 1 
 mentions that he has seen perforation of the stomach from ulcer 
 " in a girl of 8, and a boy of 9 years of age." 
 
 As to the situation of perforating ulcer of the stomach, Dr. Brinton 
 gives the following as the relative situation in every 100 cases, but 
 the term perforation here must be remembered as being applicable 
 especially to those instances in which fatal peritonitis follows, not to 
 those in which adhesion renders extravasation impossible, as we so 
 often find in perforation on the posterior aspect. 
 
 1 Dr. Lees on " Diseases of the Stomach and Indigestion."
 
 148 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 In 100 ulcers on the posterior surface perforation occurred in 
 pyloric sac 
 middle 
 
 lesser curvature 
 anterior and poster or surface 
 cardiac extremity 
 anterior surface 
 
 2 
 
 10 
 13 
 
 18 
 28 
 40 
 85 
 
 Dr. Brinton has collected from varied sources 654 cases, but there 
 are several differences in our smaller number which are opposed to 
 some of his deductions. In reference to sex there are males 37, and 
 females 28. The total as previously given is 65, but in one the age 
 is not stated ; it was a case of multiple ulcer in an infant, and the 
 disease was of a different character, it has, therefore, been excluded. 
 
 Of the males : the mean age was 45, youngest 21, oldest 66. 
 " females " ' 40 20 " 76. 
 
 In the various decades the ages were as follows, bearing in mind that the males are 
 to the females as 35 to 28 
 
 7080 
 No. Per cent. 
 
 Males 
 Females 
 
 2030 
 
 No. Per cent. 
 6 17 
 8 23 
 
 3040 
 
 No. Per epnt. 
 9 26 
 9 26 
 
 4050 
 
 No. Per cent. 
 4 11 
 2 6 
 
 5060 
 
 No. Per cent. 
 9 26 
 6 17 
 
 6070 
 
 No. Per cent. 
 7 20 
 1 3 
 
 Of the males : 10 died from perforation the average age being 38 years. 
 " females 7 " " 23 " 
 
 That is to say taking males and females together 27 per cent, died 
 of perforation ; 28 per cent, of the males, 25 per cent of the females. 
 
 On the whole these facts corroborate those deducible from Dr. 
 Brinton's larger numbers, but in less striking proportions. In regard 
 to sex, however, this is not so, Dr. Brinton puts the proportion of 
 males to females as 1 to 2, and all who have written on the subject 
 agree with him. Bamberger gives a still larger preponderance to 
 the women, viz., 91 to 22. l In the numbers we give, the males are 
 in excess, viz., 35 males to 28. 
 
 There is, however, reason for supposing that these discrepancies 
 are to a large extent explained by the different sources whence the 
 figures are obtained. Some calculate the proportions from cases as 
 diagnosed during life ; others only from those which reach the post- 
 mortem room. This is seen from a perusal of the latest contribution 
 to the etiolgoy of gastric ulcer by Lebert. 2 Taking the several 
 statistics of this author we get 69 males to 183 females while the 
 fatal cases are 57 males to 41 females. Nor do we think this is alto- 
 gether accidental. It is sufficiently obvious that in hospital or pri- 
 vate practice women suffer more often than men from some of the 
 symptoms of gastric ulcer ; but it is probable, that if the actual 
 state of facts could be proved many of these would have to be re- 
 grouped as cases of gastralgia, subacute gastritis, or gastric catarrh. 
 
 The following table gives the percentage of deaths in the several 
 
 1 Loc., cit. p. 280. 
 
 * ' Die Krankheiten des Magens,' by H. Lebert. Tiibingen, 1878.
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 149 
 
 decades as given by Lebert on 198 post-mortems taken from various 
 sources, and that obtained by the analysis of our own cases. 
 
 Age in years. 
 10 to 20 
 
 20 
 90 
 40 
 50 
 
 30 
 40 
 50 
 60 
 70 
 80 
 
 Guy's Hosp. 
 
 22 
 28.5 
 
 9.5 
 24 
 13 
 
 3 
 
 The pathology of ulcer of the stomach is still involved in much 
 doubt and obscurity. Many theories have been suggested, and each 
 one has its supporters. 
 
 1st. Perforating ulcers are said to be of an inflammatory origin ; 
 the sequel in fact of chronic gastritis or the result, the coalescence of 
 several small ulcers to form a large one. 
 
 2d. They have been attributed by Rokitansky to congestion, ex- 
 travasation, and subsequent necrosis of tissue. 
 
 3d. Yirchow has supported an ernbolic theory. 
 
 4th. Some cases have been thought to prove that they are occa- 
 sionally due, and perhaps frequently so, to some deterioration of 
 nerve influence, or to some persistent local nervous irritation. 
 
 In considering the pathology of gastric ulcer, however, it is im- 
 portant to distinguish between the acute and chronic forms. The 
 determining cause is different ; the acute ulcer is rapid in its forma- 
 tion, and, therefore, it leads to perforation before adhesion has taken 
 place, and to peritonitis ; it has a peculiar appearance, and it occurs 
 at a definite period of life, especially in the female sex. The chronic 
 form is very insidious, it creeps on for years. Perforation into the 
 peritoneal cavity is more rare, because adhesions have formed, and 
 death from hemorrhage is more frequent. 
 
 It will be well to consider separately the causes which we have 
 enumerated. Of those mentioned the first can scarcely apply to the 
 acute perforating ulcer, for there are objections to that form being 
 considered as having essentially an inflammatory origin. The course 
 is too rapid to indicate an ordinary form of inflammation, and the 
 stomach in such cases does not show any evidence of it after death. 
 The ulcer is sharply defined and without a trace of thickening, and 
 the surrounding mucous membrane is more or less healthy. Neither 
 is a simple congestive origin satisfactorily substantiated. A local 
 congestion followed by infiltration of the coats of the stomach by 
 blood and subsequent necrosis of the tissues as a consequence, must 
 be due, either to a local intensification of a general gastritis, of which 
 there is no evidence in the majority of cases, or else to some local 
 venous stasis or arterial plugging. This, indeed, is Virchow's hypo- 
 thesis, 1 and it satisfactorily explains the occurrence of rapid ulcera- 
 tion. The experiments of Dr. Pavy, 2 which have been latterly 
 confirmed by Panum, show that the arrest of the circulation through 
 
 1 ' Virchow's Archiv,' xxv, p. 491. 
 
 4 ' Proceedings of the Royal Society.'
 
 150 ORGANIC DISEASES OF THE STOMACH. 
 
 any part of the stomach leads to digestion of that part by the gastric 
 juice in contact with it. 
 
 From the pathological changes in other structures we know that 
 embolism of the terminal vessels of any part leads to hyperaemia, to 
 extravasation of blood, and subsequent disintegration of the damaged 
 tissue. A venous stasis, would, of course, tend in the same direction. 
 The shape of the ulcer has been strongly dwelt upon as favoring the 
 embolic theory, and it has been pointed out by Virchow and others 
 that the so-called wedge or cone shape corresponds with the infarc- 
 tions of embolic origin. Still direct proof is wanting that embolism 
 or sufficient venous stasis is present in any number of cases to ac- 
 count for the frequency of ulcer ; and, moreover, it is not easy to 
 explain why embolism should take place in the gastric arteries and 
 not elsewhere, and why it should occur so frequently at a particular 
 age and in the female sex. An atheromatous state of the kidneys 
 has been suggested as the cause of the disturbance of the circulation 
 by Miiller, 1 but the examination of the coronary vessels does not 
 support this theory. We are led, therefore, to look to the 4th cause, 
 viz., some deteriorated state of nervous, supply, or some prolonged 
 local nervous irritation as the true origin of the acute perforating 
 ulcer. It is true that for this, again, there is no direct proof, not 
 perhaps so much as there may be for the embolic theory ; but the 
 sex, the age, the habit, the condition of the patients in whom it 
 occurs, all point towards the probability of a nervous origin, and 
 pathological processes in other organs and tissues, as the sloughing 
 of the cornea in paralysis of the fifth pair, are sufficient warranty 
 for entertaining the idea. 
 
 With regard to the chronic gastric ulcer, its appearance and the 
 changes around it favor the belief that it originates in chronic in- 
 flammatory disease. It may be set up in one or other of the various 
 ways that have been mentioned in connection with the acute form, 
 but we believe that while other causes may conduce towards its 
 occurrence, and while gastric solution may tend to its further exca- 
 vation, an inflammatory state is the best explanation of the appear- 
 ance of the ulcer. 
 
 The stomach is more fixed at the lesser curvature, in fact, this 
 part is almost stationary, for the stomach in its general expansion 
 and consequent movement turns upon this part as a centre, and it is 
 at the lesser curvature that ulceration generally takes place; the 
 nerves also are more freely distributed there. The normal distension 
 of the stomach takes place especially at the greater curvature, but 
 when the stomach is distended after removal, rupture always occurs 
 at the lesser curvature; and this fixity of position and the altered 
 nervous and vascular supply which result from distension may be 
 the determining cause of the position of the gastric ulcer. 
 
 The symptoms of chronic ulceration are, at first, those of ordinary 
 dyspepsia, and are often very obscure and imperfectly marked ; thus 
 slight uneasiness after food, and constipation, may be the only evi- 
 
 1 ' Wurzburg, Verhandlung, ' vi, p. 474.
 
 ORGANIC DISEASES OF THE STOMACH. 151 
 
 deuce of disease; afterwards the pain, witk tenderness' in the region 
 of the stomach, especially at^tbe scmbisuhis cprdisr a^ttraote More 
 attention from the patient ; the" pain' is "sometimes slight, at r other 
 times intense, and of a peculia'r gtiawrag character ; it is generally 
 'increased by food, and relieved by the ejection of it ; vomiting is, 
 therefore, generally present, and pyrosis or water-brash. Other 
 symptoms are pain between the shoulders, more or less of abdominal 
 uneasiness, constipation, emaciation, and a peculiar pallor and ca- 
 chexia. Hemorrhage and the ejection of blood by vomiting, hsema- 
 temesis, or its discharge by the bowels, or black stools, rnelasna, are 
 present in most cases at one or other stage of the disease. 
 
 The pain is not always of the same character, but may be con- 
 sidered as a symptom present in almost every case; it may be almost 
 constant, but generally undergoes degrees of exacerbation, being 
 increased by food ; the patient often states that pain comes on as 
 soon as the aliment reaches the stomach, and continues as long as it 
 is retained; sometimes it is so intense that the patient is completely 
 exhausted, as I have several times found when branches of the pneu- 
 mogastric nerve have been involved in the dense edges of a chronic 
 ulcer ; at other times it is so slight, that it only amounts to tender- 
 ness on pressure at the scrobiculus cordis. In a case recently under 
 my care, in which other signs of ulcer were present, the patient 
 stated that the pain, was sometimes relieved by firm pressure against 
 the back of a chair. Position has, in not a few instances, a marked 
 effect on the severity of pain, and I have several times seen the ob- 
 servation of Dr. Osborne 1 confirmed, that the influence of the posi- 
 tion of the patient on the pain serves as a guide to the seat of the 
 ulcer, according as the contents of the stomach gravitate towards or 
 away from the injured part ; thus in an ulcer of the posterior part of 
 the lesser curvature the patient has been most easy when leaning 
 forward and towards the left side ; and yet I have seen the pain con- 
 tinue whatever position has been assumed. In young women suffer 
 ing from well-marked ulceration of the stomach, with chlorosis, 
 neuralgic pain in the side may be present at the same time as tender- 
 ness and pain at the scrobiculus cordis, and, in these cases, we have 
 increase of pain during or prior to the menstrual periods. The pain 
 in the back is rarely absent in chronic ulcer of the stomach ; it is 
 generally less severe, and comes on later than the gastric pain, but 
 is sometimes complained of more urgently than that at the stomach 
 itself, the patient often stating that " the pain goes through to the 
 back." In speaking of the diagnostic value of pain, Dr. Lees states, 
 " the occurrence of pain will often be of great assistance in the diag- 
 nosis between simple ulcer and cancer ; for it is an important and 
 curious fact, that there is seldom pain in cancer of the stomach, 
 unless great obstruction of the pyloric orifice prevents the passage 
 of food out of this viscus." And again : " The mere fact of severe 
 pain constantly occurring after food, should lead you to diagnose 
 simple ulcer of the stomach rather than cancer. The pain, moreover, 
 
 1 ' Dublin Journal of Medical Science, 1st ser., vol. xxiv, p. 301.
 
 152 ORGANIC DISEASES OF THE STOMACH. 
 
 in simple ulcer, is often of a gnawing character, causing a sense of 
 siskenihg'ti&p^spipn^ jt is variable and remittent, sometimes being 
 very severe and then ceasing for days or even weeks ; but, in ma- 
 lignant disease, the pain, tliou^li imt often severe or lancinating, yet 
 is almost always constant after it has once commenced." Although 
 all observers will bear testimony to the general variability and 
 the gnawing character of the pain in ulcer of the stomach, still, in 
 some instances, as when branches of the pneurnogastric nerve have 
 been involved in the edges of the ulcer, or laid bare on its floor, the 
 pain is terribly constant. Again, in cancer of the pylorus, as in a 
 case to be presently mentioned, there was no pain acknowledged on 
 repeated questioning of the patient as to present symptoms or pre- 
 vious history ; and in other instances of cancer, when suffering is 
 very severe, the relief from pain is often very great on the avoidance 
 of solid and indigestible food, and during the use of anodyne reme- 
 dies. The dragging pain in the epigastric region, produced by adhe- 
 rent omental hernia, and the pain often present at the scrobiculus 
 cordis in chronic disease of the lungs and heart, must be remembered 
 as liable to simulate gastric ulcer, and to obscure the diagnosis. 
 
 The period at which vomiting takes place in ulceration of the stom- 
 ach is equally varied ; sometimes the food is at once rejected, in 
 other instances it is retained for many hours or days. In the case 
 previously alluded to, in which the thickened edge of the ulcer con- 
 tained a large branch of the pneumogastric nerve, the stomach almost 
 instantaneously rejected food, and the patient died exhausted, but 
 if the nerve be divided by ulceration or by sloughing the vomiting 
 may entirely cease. Fermentation and the development of the sar- 
 cina ventriculi of Goodsir 1 take place in some cases of chronic ulcer, 
 as well as in cancer and diseased pylorus. The sarcina can scarcely 
 be considered as a proof of obstruction, for its development occurs 
 without any impediment. 
 
 Vomiting, however, as a sign of gastric ulcer, must be regarded 
 with great care, since in so many instances it is purely synpathetic 
 in its origin. Pyrosis also is often present in disease of a less serious 
 character, and is among the signs of functional disturbance. 
 
 Chronic disease of the abdominal viscera is often marked by an 
 anxious and dejected countenance, with emaciation; in gastric ulcer 
 this appearance is present, and is associated with pallor, arising from 
 the impairment of general nutrition. 
 
 In cancerous disease, a careworn expression is found, with cachectic 
 sallowness ; and, in the anemia of chlorosis and amenorrhoea, there 
 is, in extreme cases, a waxen appearance, which is very peculiar ; so 
 also in the anasmia after considerable loss of blood. Again, in many 
 instances of struma and of glandular disease, pallor is present; but 
 in ulcer of the stomach the anxious countenance of abdominal disease, 
 conjoined with emaciation and pallor of imperfect nutrition, afforded 
 a very characteristic morbid expression, and as a symptom is rarely 
 absent. 
 
 1 Merismopodia ventriculi (Robin).
 
 ORGANIC DISEASES OF THE STOMACH. 153 
 
 As we have before said, hemorrhage takes place in most cases of 
 gastric ulcer ; vomiting of several pints or even quarts of blood may 
 be amongst the earliest symptoms of disease ; in other instances the 
 bleeding is slight, or entirely absent. It proved fatal in sixteen cases 
 of those which we have tabulated, or one in every four cases. The 
 first hemorrhage from the stomach is occasionally fatal ; in ordinary 
 cases the discharge of blood is preceded by a sense of weight and 
 coldness, followed by faintuess or actual syncope, and then rejection 
 of dark -colored blood takes place. The action of the gastric juice 
 confers this deepened color ; but if the effusion be very rapid, the 
 color is more bright ; a portion of blood passes onwards into the 
 duodenum and intestines, and if life is prolonged, so that it mav be 
 discharged per rectum, a black, tarry evacuation is the result. Some- 
 times, however, the whole of the blood is thus discharged, and there 
 is melaena without heematemesis ; but these symptoms are generally 
 combined. Instances have been recorded where sudden hemorrhage 
 into the stomach was followed by fatal syncope, without the discharge 
 of blood either by vomiting or purging ; more frequently the hemor- 
 rhage is oftentimes repeated. Some of the most severe cases of 
 hemorrhage are those in which the dense fibroid tissue of a chronic 
 ulcer prevents the retraction of a perforated vessel. 
 
 Unless hemorrhage, however, take place, we cannot with any 
 certainty diagnose ulceration of the stomach ; cachexia, emaciation, 
 pallor, pain, and vomiting, all arise without ulceration, in cases of 
 irastrodynia and irritability of the stomach, sympathetic or otherwise. 
 But hemorrhage is not in itself pathognomonic of ulceration ; it often 
 arises from overdistended capillaries in a gorged state of the portal 
 circulation, and in cancerous disease ; and although less frequent in 
 cancer than in simple ulceration, it does occasionally arise. Disease 
 of the oesophagus and aneurism sometimes produce the same symp- 
 tom. 
 
 The form of ulceration, however, which leads to the most disas- 
 trous termination, is that which tends to fatal perforation into the 
 peritoneal cavity. These instances often occur in young women af- 
 fected with chlorosis and amenorrhoea, or with painful menstruation; 
 the previous gastric symptoms are very slight, or altogether unno- 
 ticed, although there is generally impaired health, with leucorrhcea 
 or chlorosis, neuralgic pain in the side, and symptoms of hysteria. 
 The onset of the fatal attack is unexpected, and is generally after 
 slight muscular exertion, or after a full meal ; intense pain comes on, 
 followed by rapid prostration and collapse. The skin becomes cold 
 and clammy ; the pulse fails ; the pain in the abdomen becomes gen- 
 eral; tympanitis follows, and occasionally vomiting supervenes; 
 death ensues in from five to twenty-four hours, although life is some- 
 times prolonged for several days ; but, in rare cases, the patient re- 
 covers. The difference in the sexes with regard to the age at which 
 perforation is liable to occur is seen in the table. The average age 
 of males dying from perforation is thirty-eight, that of females only 
 twenty-three. 
 
 Abercrombie distinguishes three modes of fatal termination of
 
 154 ORGANIC DISEASES OF THE STOMACH. 
 
 ulcer of the stomach. 1, Gradual exhaustion ; 2, hemorrhage; and 3 
 perforation into the peritoneal cavity ; others may be mentioned, as 
 the extension of inflammation to adjoining viscera, as in the case 
 related in which mischief passed through the diaphragm into the 
 lung, and acute pleurisy was set up ; secondary suppuration in the 
 branches of the portal vein and pyaemia ; and the occurrence of pneu- 
 monia or bronchitis from nervous exhaustion. The disease, however, 
 sometimes remains in a passive condition, and the patient dies of 
 some other complaint. It is not very rare to find cicatrices in the 
 stomach ; and in those cases where there has been extensive destruc- 
 tion of surface, and of the muscular and peritoneal tissue, the ad- 
 joining viscera are found covered with a smooth fibrous tissue. 
 
 The duration of life after the development of symptoms of ulcer 
 of the stomach, as compared with cancer is generally very different. 
 Setting aside those cases in which perforation into the peritoneal sac 
 takes place, the ulcer is more curable aud extends over a longer 
 period ; it may be several years, and some have mentioned cases con- 
 tinuing for even twenty, and in one under my own observation the 
 symptoms were said to extend over forty years. I have several 
 times observed patients, men of middle life, suffering from severe gas- 
 tric symptoms, with sallow complexion, pain at the scrobiculus cordis, 
 vomiting of food, occasional hsernatemesis, loss of flesh, &c., who have 
 lost their symptoms under treatment and care, have regained flesh 
 and comfortable health, and had no return of symptoms for several 
 years. In cancer, after the well-marked symptoms have occurred, 
 we rarely find that a year passes, and frequently only three or four 
 months, before a fatal termination takes place ; and it is probable 
 that many cases of supposed cancer of the stomach, in which the 
 patient survived for many years, were really chronic ulceration. 
 
 Chronic Ulceration implicating branches of the Pneumo gastric. 
 
 CASE XLII. Chronic Ulcer of the Stomach. Phthisis. Branches of the 
 Pneitmogastric Nerves involved. Eliza B , set. 21, was admitted into 
 Guy's Hospital October 13, 1858. She had enjoyed good health till she was 
 fifteen years of age, when her health failed. She was then obliged to leave 
 her situation as a nursery-maid, on account of weakness, and pain in the chest. 
 At sixteen, menstruation commenced, and continued regularly till eighteen 
 months before admission, but from that time there had been amenorrhoea. 
 She was anaemic, emaciated, and had a dark areola around the eyes. The 
 respiratory murmur was feeble at the apices ; the heart sounds were normal. 
 She complained of pain frequently recurring in the hypochondriac and lumbar 
 regions ; of a feeling of distension and pain after taking food, and of a sensa- 
 tion as of a weight rolling when she turned on her right side, the left being 
 the side on which she could recline most easily. The appetite was bad, the 
 bowels were regularly open ; she slept but little ; the urine was normal. 
 Various remedies besides steel and cod-liver oil were given, and she left the 
 hospital for a short time, but was readmitted on March 16, 1859. She was 
 then extremely blanched, much emaciated, and had a dejected countenance. 
 She generally sat up in bed, inclining towards the left side, for it produced 
 pain to turn on the right side. There was no evidence of disease in the chest
 
 ORGANIC DISEASES OF THE STOMACH. 155 
 
 found after careful examination ; the respiration was 30 ; the chest was reso- 
 nant ; and the respiratory sounds were feeble, but otherwise healthy. She 
 had vague pain in all parts of the body, especially in the shoulder ; the spine 
 was tender everywhere, and unusually prominent from the wasting of the 
 muscles. The abdomen was rather distended, apparently from flatus. In 
 the epigastric region there was a hard swelling, tender on pressure, and tym- 
 panitic. When in great pain at this distended part, if compression was made, 
 the swelling disappeared, and the pain was relieved. On deeper pressure in 
 the epigastric region, a hard, resisting sensation was communicated. The 
 superficial abdominal veins were distinct. Opium, chloroform, chlorodyne, 
 cod-liver oil, etc., were administered, with partial relief. 
 
 On May oth she was transferred to my care, and was then greatly emaci- 
 ated ; she suffered constant severe pain in the epigastrium, and in the left 
 shoulder, and the pain was worse after taking food, which also produced 
 slight nausea. She had much flatulence, but no vomiting ; the bowels were 
 never acted upon without medicine or enema. The heart's action was rapid ; 
 the rythm regular ; the pulse, 120, was compressible. The abdomen was firm 
 and somewhat enlarged. The pain increased in severity, and sometimes be- 
 came of an agonizing character ; it was somewhat relieved by medicines, as 
 by opium, morphia, henbane, aconite, creasote, etc. The symptoms con- 
 tinued with varying severity till the end of July, but in August symptoms of 
 phthisis began to develop themselves ; the right side became dull, and indu- 
 bitable signs of disorganization at the apex were present. The patient began 
 to cough and expectorate, and became extremely emaciated. Scarcely any 
 nourishment was taken, but she lingered till October 10th. 
 
 On inspection, the right pleura was universally adherent ; the left partially 
 so. The right lung was extensively disorganized, and contained a large 
 cavity in the upper lobe, and much tubercular deposit in the lower. The 
 cavity was very large and ragged, and had apparently extended rapidly. 
 The left lung was nearly healthy, so also the heart. On opening the abdo- 
 men, the stomach was seen to be closely adherent to the left lobe ot the liver 
 at its under part. The stomach appeared to be thus hooked up in the cen- 
 tral part, and presented an hour-glass contraction. This adhesion of the 
 smaller curvature of the stomach and of the posterior surface of the liver was 
 so firm that it was impossible to separate the two organs. The liver also 
 contained much fibrous tissue. On attempting the removal of these viscera, 
 it was found that the pancreas also was closely involved in the adhesions. 
 By opening the stomach along its greater curvature, a large chronic ulcer 
 was found to be situated at the middle of the lesser curvature. It was 2^ 
 inches in length, and 2 in breadth, and had completely healed, there being 
 no sign of recent action about it. It had a raised, firm edge, and its floor was 
 formed by tough, fibrous tissue upon the liver and pancreas, the coats of the 
 stomach having been entirely destroyed at that part by the ulceration. The 
 pneumogastric nerves on both sides terminated in the fibrous tissue which 
 bounded the ulcer. The mucous membrane was elsewhere healthy. 
 
 The symptoms in this case advanced very slowly to a fatal termi- 
 nation, and nearly six years elapsed between the onset of the disease 
 and the death of the patient. There was no haematemesis at any 
 period, and the most prominent symptoms were anaemia, gradually 
 increasing emaciation, and pain in the left side, which became exceed- 
 ingly severe. The pain was at times agonizing, and was unrelieved 
 by any form of anodyne medicine ; the manner in which the branches 
 of the pneumogastric nerve were involved in the dense fibrous tissue
 
 156 ORGANIC DISEASES OF THE STOMACH. 
 
 at the edges of the ulcer afforded an explanation of the suffering. 
 The position of greatest ease, however, was that in which fluids grav- 
 itated from the ulcer, namely, the position assumed in leaning for- 
 wards and towards the left side, thus far confirming the statement of 
 Dr. Osborne. Vomiting was not a prominent sign of disease. For 
 some months the general symptoms were those of phthisis ; and, in 
 fact, towards the close, symptoms of affection of the lungs were rap- 
 idly developed. In reference to the etiology of the phthisis, it is an 
 interesting question whether irritation of the gastric branches of the 
 pneumogastric nerve had anything to do with the production of dis- 
 ease, at the termination of the pulmonary branches, or whether the 
 phthisical mischief was produced by the general impairment of nu- 
 trition. 
 
 CASE XLIII. Chronic Ulceration of the Stomach, involving the Pneumo- 
 gastric Nerve. Atrophy of the Left Lobe of the Liver. Death from Ex- 
 haustion E. S , set. 32, hud been a widow for nine years. Four years 
 before admission into Guy's Hospital she had an attack of hoc-matemesis, but 
 her health improved, and she continued in her situation as housemaid. Two 
 years later she had a similar attack, and, six months later, severe pain at the 
 region of the stomach came on. The pain continued for a few days, and was 
 much relieved by vomiting of blood. A similar attack came on after admis- 
 sion. Great weakness, with severe pain in the stomach, were the principal 
 symptoms ; the pain extended to the back, and was of a paroxysmal charac- 
 ter ; and food was very quickly rejected. At the epigastrium, fulness was 
 at h'rst felt, but afterwards a distinct tumor. The vomiting was uncontrolla- 
 ble, but sometimes subsided for several days. Vomiting of grumous fluid 
 then came on, and the pain at last became very severe ; she gradually sank. 
 
 Stomach presenting a chronic ulcer ; at Us upper margin the pnmunogastric nerve Is .shown 
 extending into dense fibrous ti-sue. The pancreas and the left lobe of the liver formed the base of 
 the ulcer ; the latter presented fibroid degeneration of its structure. 
 
 Inspection The body was much emaciated ; there was no marked disease 
 about the thoracic viscera ; the stomach was distended, and reached nearly 
 to the umbilicus. At the scrobiculus cordis the left lobe of the liver was 
 contracted, and adherent to the lesser curvature of the stomach, and it con- 
 stituted the tumor which had been felt during life. The stomach contained
 
 ORGANIC DISEASES OF THE STOMACH. 157 
 
 a considerable quantity of grumous fluid, and at the lesser curvature, about 
 half an inch from the pylorus, was an ulcer two inches and a half in diame- 
 ter, with raised everted edges of mucous membrane and dense fibrous tissue ; 
 the base of the ulcer was smooth, composed of an albuminous layer, and 
 formed by the pancreas and by the inferior surface of the left lobe of the liver. 
 The pylorus was not hypertrophied. The remaining part of the stomach 
 appeared healthy. On carefully dissecting the pneumogastric nerve along 
 the lesser curvature, it was found to pass to the margin of the ulcer, and its 
 fibres were incorporated with the dense fibrous tissue of which the raised 
 edges of the ulcer were composed. 
 
 The continued suffering, and the daily rejection of food, at length 
 completely exhausted the strength of the patient, and were the cause 
 of her death ; and although the pylorus was free from obstruction, 
 and no hypertrophic change was evident in the muscular coat of the 
 stomach after death, the symptoms were explained by the manner 
 in which the branches of the pneumogastric nerve were involved in 
 the dense edges of the ulcer. 
 
 The attack of haematemesis four years before admission into the 
 hospital, showed the chronic character of the disease; and as the 
 ulceration slowly extended into the surrounding vessels, the effu- 
 sions of blood were repeated ; but intervals of reparative action prob- 
 ably took place, for we find that there were periods during which the 
 more severe symptoms were relieved, and the character of the ulcer, 
 as shown by its general and microscopical appearances, warranted 
 such a conclusion. 
 
 The left lobe of the liver was small and atrophied, and its section 
 presented several large vessels surrounded by contractile tissue, with- 
 out any intervening gland-structure. Chronic change had extended 
 into this part of the gland, and the obliteration of the vessels had led 
 to the atrophy of the whole left lobe. 
 
 Ulceration icith Perforation. 
 
 CASE XLIV. Chronic Ulceration of the Stomach, with Painter's Colic. 
 
 Perforation George O , set. 28, was admitted into Guy's Hospital Feb. 
 
 22d, and died April 16th. He was a married man, of anaemic appearance, 
 but with dark hair. For ten years he had been a painter, but previously he 
 had employed himself as a publican, and he had then drank freely. Except 
 an attack of fever several years before, he had been in good health till nine 
 months before admission, when he was seized with colic, which came on with 
 vomiting, obstinate constipation, and severe griping pain at the umbilicus ; 
 from that time he lost flesh, and had constant pain in various parts of the 
 abdomen ; the bowels became constipated, and he suffered from pain between 
 the shoulders. A fortnight before admission he had haematemesis, and he 
 became very anaemic ; this condition persisted till his application at Guy's, 
 when the tongue was pale and the respiration easy; there was griping pain 
 also, in the abdomen, and constipation ; but the abdomen was supple, and no 
 disease could be detected on palpation. Compound Soap pill, gr. v., was 
 given every six hours. 
 
 On Feb. 29th Vomiting of grumous matter came on ; an enema was ad- 
 ministered, and an electo-galvanic current applied to the spine and abdomen ; 
 the galvanism produced some uneasiness.
 
 158 ORGANIC DISEASES OF THE STOMACH. 
 
 On March 3d. There was great pain in the abdomen, vomiting of grumous, 
 coffee-ground substance ; rapid prostration came on, and death took place in 
 a few hours. 
 
 Inspection, twenty-nine hours after death On opening the peritoneal 
 cavity it was found to contain a considerable quantity of gas ; and grumous 
 matter was extravasated from the stomach. Upon raising the left lobe of 
 the liver an opening, about the size of a pea, was observed in the lesser cur- 
 vature of the stomach; the mucous membrane was generally thickened, and 
 about half an inch from the pylorus, near the lesser curvature, was an oval 
 ulcer, about three inches by two in size, with raised and everted edges ; the 
 floor of the ulcer was formed by the pancreas, covered by white fibrous tissue ; 
 the opening before mentioned was at the anterior part of this ulcer. The 
 colon contained a large quantity of scybala. 
 
 There was considerable difficulty in the diagnosis of this case; the 
 evident indication of colic, in a painter of intemperate habits, ren- 
 dered the symptoms of ulceration of the stomach more than usually 
 obscure. The attack of hoematemesis might have been attributed 
 either to ulceration or congested portal circulation : but the vomiting 
 of coffee-grounds substance indicated the slow effusion of blood; and 
 it afforded a very characteristic symptom of chronic organic disease. 
 The immediate cause of the perforation was not apparent ; but, 
 although we could not affirm that the muscular contraction produced 
 by the galvinism was in any manner the cause of the suddenly fatal 
 issue, still, if the chronic ulcer of the stomach had been as prominently 
 before the mind as the lead colic, it is probable that the use of gal- 
 vanism would not have been directed. 
 
 CASK XLV. Perforating Ulcer of the Stomach with a second small 
 Chronic Ulcer in the same organ Harriet B , aet. 22, a single woman, a 
 milliner, who worked in the city, but resided at Bethnel Green, was stated 
 to have enjoyed good health, with the exception of occasional pain and other 
 uneasy sensations in the gastric region, but she had not any s ckness, and 
 she continued at work. The bowels were generally regular. On Friday, 
 Oct. 20th, after eating at about 3 P.M. a full meal of anchovies and bread, 
 she was seized with violent vomiting, followed by most intense pain, which 
 commenced in the left hypochondriac region, and gradually extended over 
 the abdomen. She said that the pain commenced by something giving way 
 in her side. When seen, about 9 P. M., she was in a state of great prostra- 
 tion, and she died at 11 A. M. on the 21st, twenty hours from the commence- 
 ment of the attack. 
 
 The body was well nourished. On opening the abdomen, the viscera were 
 found distended and covered with a coat of recent lymph, and with some 
 castor oil, which had been administered by the friends shortly after the 
 attack. In the stomach there were two ulcers, one with raised and rounded 
 edges, about half an inch in diameter, extending to the muscular coat, the 
 other about the same size, but with a smaller opening in the muscular, and 
 a round, smooth, small punch-hole opening perforating the peritoneal sac. 
 Both were situated at the lesser curvature, and the latter, in which was the 
 peritoneal perforation, was towards the posterior part. The remaining viscera 
 appeared healthy. 
 
 This case was peculiarly interesting: 1st, in presenting two ulcers 
 in the stomach, but in different stages, the one resembling ordinary
 
 ORGANIC DISEASES OF THE STOMACH. 159 
 
 chronic ulcer with thickened edges, the other having the appearance 
 of but slight action around it; 2d, in the early age of the patient, 
 twenty-two, and the slight character of the symptoms, namely pain 
 but no sickness ; although an ulcer existed in the stomach, dyspepsia 
 was the only precursor of the fatal perforation, and she considered 
 herself in good health, and continued at work ; 3d, in the sedentary 
 employment, constrained position, irregular meals, uncertain hours, 
 and probably only scanty fare, all tending to impair nutrition, and 
 act as causes of this fatal malady; 4th, in the occurrence of the per- 
 foration, as is usually the case, after a meal ; 5th, in the pain com- 
 mencing at the hypochondriac region, for this is not always the case, 
 and we cannot thereby ascertain at all times the seat of perforation : 
 sometimes, even, the position of the pain suggests caeca! instead of 
 gastric disease ; and 6thly, in showing the folly of at once giving a 
 purgative draught, for the castor oil was here found floating in the 
 peritoneal cavity. 
 
 CASE XL VI. Chronic Ulceration. Death from Perforation. A man, 
 set. 37, had been subject to dyspepsia, constipation, and general abdominal 
 uneasiness, but he had had no vomiting ; intense pain came on suddenly, 
 and he died in a few hours. 
 
 In the stomach a circular ulcer was found about the size of a five-shilling 
 piece, the edges were rounded, and the mucous membrane was more exten- 
 sively destroyed than the muscular ; the base of the ulcer was formed by the 
 pancreas and by condensed cellular tissue ; and quite at its upper margin, be- 
 low the left lobe of the liver, there was a small perforation, which had led 
 to general peritonitis. The microscopical examination of the ulcer showed 
 it to be of a simple inflammatory character. 
 
 The absence of hsematemesis, of vomiting, and of other symptoms 
 of gastric ulcer, except dyspepsia, was remarkable in this case, for the 
 ulcer was of large size, and was not of recent formation. 
 
 CASK XLVII. Chronic Ulcer of the Stomach. Perforation Mary 
 C , aet. 21, was admitted August 28th, 1858, about noon, and died in ten 
 minutes. She had been in a situation near the hospital, and had sutfered 
 from vomiting occasionally for five years, but had never had haematemesis. 
 
 Inspection was made about three hours after death. There was general 
 peritonitis. In the stomach there were two ulcers, each about three-eighths 
 of an inch in diameter ; both were situated at the lesser curvature, the one 
 at the anterior, the other at the posterior part of the stomach. Their edges 
 toward the stomach were thickened and bevelled ; the anterior one presented 
 a small punch-hole opening extending into the peritoneum, which had led to 
 the fatal peritonitis. The posterior one had also perforated all the coats, but 
 extravasation had been prevented by the adhesions. The other portions of 
 the mucous membrane of the stomach were healthy, presenting only slight 
 injection ; the remaining viscera were healthy. 
 
 In this case there had been evidence of disorder of stomach for 
 several years ; and the appearance of the ulcer also indicated chronic 
 action in its thickened edges, but there had been no vomiting of blood. 
 The ulcers on opposed surfaces of the stomach probably arose from 
 the two surfaces coming into contact.
 
 160 ORGANIC DISEASES OF THE STOMACH. 
 
 CASE XLVIII. Perforating Ulcer of the Stomach A servant girl, ret. 
 27, residing in the Borough, was suddenly seized with severe pain in the 
 abdomen ; collapse came on, and death followed in twenty-four hours. On 
 inspection a round ulcer was found on the anterior surface of the stomach ; 
 on the mucous surface it was half an inch in diameter, but on the peritoneal 
 only a quarter of an inch, and there was very little thickening. Its perfor- 
 ation into the peritoneum had set up fatal peritonitis. Other portions of 
 the mucous membrane of the stomach were partially dissolved. Remaining 
 viscera were healthy. 
 
 This was one of the instances in which there was very little indi- 
 cation of disease prior to the fatal attack, and the appearance of the 
 stomach after death showed an absence of thickening, and of chronic 
 action. 
 
 CASE XLIX A remarkable case, in which an ulcer of the stomach ex- 
 isted, and in which perforation was apparently produced by the straining 
 consequent on violent vomiting, occurred under the care of Sir William Gull 
 in a hospital patient in I860. A young man, aet. 21, was seized three weeks 
 before his heath with griping pain in the abdomen, followed by intense pain 
 and obstinate constipation. There was severe vomiting. Two bands were 
 found in the peritoneum passing upwards from the caecum, one to the trans- 
 verse colon, strangulating the intestines which had slipped beneath it, the 
 other passed to the pelvis. 
 
 In the stomach, about one-third from the oesophagus towards the pylorus 
 and an inch from the lesser curvature, was an ulcer, which had perforated the 
 peritoneum and had set up intense peritonitis. The opening through the serous 
 membrane was smaller than that in the mucous membrane. There was no 
 thickening of the edges of the ulcer. 
 
 CASE L. Chronic Ulcer of the Stomach. Perforation of all the coats 
 except the Peritoneal. Fatal Peritonitis (Reported by Mi\ A. W. A. 
 Evans.) William M , aet. 29, a policeman, was admitted into Guy's Hos- 
 pital, October 28th, 1859, under Dr. Addison's care. He had been in the 
 police force for six weeks, when he was seized with pain about the scorbi- 
 culus cordis, with vomiting, which came on about an hour after food had 
 been taken. There was pain also at the right shoulder, and a little blood 
 was found in the vomited matter, but no sarcinae. He had suffered habitually 
 from constipation. Three years previously he had had a similar attack, 
 from which, however, he recovered in three months. He afterwards enjoyed 
 good health, although he had vague and intermittent pains in the epigastrium. 
 He was a tall, sallow, and anaemic man, and on admission suffered from rather 
 severe pain at the epigastric region, but nothing could be felt on tactile ex- 
 amination. He stated that he had passed dark-colored stools ; the tongue 
 was large and white ; the pulse 88. Magnesia mixture, with hydrocyanic 
 acid, was prescribed three times a day. A castor-oil injection was admin- 
 istered at night, and beef tea and arrowroot allowed. A small blister was 
 afterwards applied to the scrobiculus cordis, and ^ij of sherry wine, with two 
 eggs, etc., were ordered. On November 2d nitrate of bismuth was given, 
 with mucilage mixture. The bowels then became constipated, and the mag- 
 nesia mixture was repeated with dilute hydrocyanic acid, tincture of opium, 
 and of lavender. On the 4th he passed a black evacuation, but the consti- 
 pation continued. On the 14th gr. xv of colocynth and calomel were given, 
 and a castor-oil injection administered, which acted very freely on the bowels. 
 On the 16th, severe pain came on in the abdomen; he became collapsed,
 
 ORGANIC DISEASES OF THE STOMACH. 161 
 
 and had vomiting, with excessive tenderness of the abdomen ; a grain of 
 opium was then given every six hours; hut on the 17th he was evidently- 
 sinking, and died at 9 P. M. On inspection the peritoneum was found to be 
 universally inflamed, and the intestines were glued together by recent lymph ; 
 older adhesions were found between the stomach and the parietes at the supe- 
 rior part of the abdomen. The stomach was slightly hour-glass in form ; and 
 about one and a half inches from the pylorus on its posterior aspect was a 
 chronic ulcer ; all the coats were destroyed, and the pancreas formed the 
 base of the ulcer, which was two inches in diameter. The mucous coat was 
 more extensively destroyed than the muscular. A smaller ulcer, directed 
 anteriorly, united with the posterior and larger one, its base was formed by 
 delicate fibro-cellular tissue and peritoneum ; this thinned, almost perforated 
 portion, was a quarter of an inch in diameter, and at its centre was a trans- 
 parent spot, only one-eighth of an inch across ; water, however, did not 
 exude. The perforation was not complete, but there was no doubt that suffi- 
 cient transudation had taken place to produce the fatal peritonitis. The 
 thoracic and other viscera were healthy. 
 
 The condition of the ulcers in the stomach was peculiar; two ulcers 
 had become united, but the posterior portion was of older formation, 
 and had a firm base of pancreatic tissue; not so, however, the ante- 
 rior one ; its base consisted of fibro-cellular tissue and peritoneum, 
 but the serous membrane was still entire. In typhoid ulceration of 
 the intestines we have several times observed peritonitis produced 
 when the peritoneum remained entire, transudation having taken 
 place without complete perforation, and it is probable that a similar 
 occurrence ensued in this instance. The case illustrates, also, the 
 caution that should be used in the administration of purgative medi- 
 cines. 
 
 Chronic Ulceration leading to Abscess. 
 
 CASE LI. Perforation of the Stomach. Local Suppuration in the Peri- 
 toneum. Pleuro-pneumonia. M. A. B , set. 33, was admitted into Guy's 
 Hospital, under my care, September 20th, 1860. She was tall and stout, 
 and stated that till the 18th she had enjoyed good health ; at 2 A. M. of that 
 day she had been seized with severe pain in the left side, which continued 
 till admission. 
 
 On the 21st she was in less pain, and the countenance was less distressed ; 
 the tongue had white fur on it, and was rather dry ; deep inspiration pro- 
 duced severe pain in the left side, but no friction sound could be heard ; air 
 entered the lower lobe of the left lung very imperfectly; and, in fact, respi- 
 ration was scarcely audible either in front or behind on the left side. There 
 was no abnormal sound with the heart ; the pulse was compressible, and 
 the skin hot. The resident medical officer had ordered gr. xv of colocynth 
 and calomel, and pills twice a day, containing calomel, antimony, and opium. 
 
 On the 22d she still complained of severe pain in the side ; there was dul- 
 ness at the base of the left lung, and scarcely any air entered that lung ; the 
 skin was hot ; the tongue was dry and furred ; the pulse was compressible ; 
 the bowels were opened freely. She was ordered to be cupped on the left 
 side to |vj ; to take soap and opium gr. v every night ; and acetate of ammo- 
 nia three times a day. 
 
 On the 24th the pain in the side was much less severe, but she was still 
 very ill, complaining of tenderness of the abdomen ; the tongue had a whitish 
 11
 
 162 ORGANIC DISEASES OF THE STOMACH. 
 
 fur. The abdomen was supple, not tympanitic, but there was tenderness at. 
 the lower part. She stated that in the previous week, immediately after 
 menstruation, she had been exposed to cold, and that then the pain came on. 
 Carbonate of ammonia was given three times a day, and the opium pill con- 
 tinued. 
 
 On the 25th she complained of an offensive taste in the mouth, and of in- 
 creased pain in the left hypochondriac region, but she bore considerable 
 pressure without aggravation of her suffering ; the tongue was furred ; the 
 mouth was clammy ; the pulse compressible, and slightly excited. She very 
 much desired to have soda water, and was ordered effervescing mixture, with 
 carbonate of magnesia, gr. x, every four hours, and wine ^vj. 
 
 On the 29th she was still distressed with an offensive ta*te in the mouth ; 
 the tongue was furred ; there was no tenderness of the abdomen, nor distress 
 in breathing. Opium was given night and morning, and soda water occa- 
 sionally. 
 
 On the 30th she was seized with eructation, and vomiting of thin offensive 
 pus, to use the words of the sister of the ward, as if an abscess had broken ; 
 she became exceedingly prostrate, and died on the 2d October at 9.50 A. M. 
 
 Inspection on the same day at 2.30 P. M. The pleura was adherent at 
 the lower lobes of both lungs, which were in a state of lobular inflammation. 
 The heart was healthy. The liver was pale, and it extended nearly to the 
 crest of the ilium ; it was very fatty, and weighed 6 Ibs. On the left side 
 there was a large abscess in the peritoneum bounded by the spleen, the left 
 lobe of the liver, and the stomach. The walls of the abscess were covered with 
 a layer of greenish-yellow lymph, and the abscess contained about two pints 
 of gray offensive pus. The abscess communicated with the stomach by a 
 small punch-hole perforation, situated about the middle of the lesser curva- 
 ture of the stomach on the anterior aspect. The edges of the ulcer were 
 bevelled internally, but they were not thickened. The mucous membrane of 
 the stomach was thickened and ecchymosed in patches ; there was some con- 
 traction of the mucous membrane of the stomach opposite the ulcer over the 
 pancreas, as if from the cicatrix of a former ulcer. The kidneys were pale ; 
 the intestines and ovaries were healthy. 
 
 The diagnosis of this case was obscure : on admission, there ap- 
 peared to be diaphragmatic pleurisy, but afterwards it was evident 
 that the disease was below, riot above, the diaphragm. There was 
 an absence of the ordinary signs of peritonitis, namely, tenderness 
 and distension of the abdomen ; still, there was pain of moderate 
 degree in the lower part of the abdomen, especially on the left side. 
 There cannot indeed be a greater proof of the absence of the ordi- 
 nary signs of peritonitis than that a gentleman of great experience 
 ordered, in rny absence, free purgatives of colocynth and calomel. 
 The patient was very restless, but her principal complaint was of 
 the offensive taste in the mouth, and she incessantly begged to have 
 soda water. The adhesions had localized the inflammation, and 
 there was none of the collapse which marks perforation into the 
 general cavity of the peritoneum. For several days the suppuration 
 increased in the abscess, but it evidently communicated with the 
 stomach, and the decomposition of its contents led to the offensive 
 character of the breath which distressed the patient so much. It is 
 probable that the pneumonia arose from pyaemia ; and it did not 
 come on till a short time before death. The sudden discharge of
 
 ORGANIC DISEASES OF THE STOMACH. 163 
 
 pus only a few hours before death indicated the rupture of an abscess ; 
 but it was even then very doubtful whether it proceeded from a 
 thoracic or abdominal source. 
 
 CASE LII. Chronic Ulceration of the Stomach, extending to the Dia- 
 phragm, and simulating Pneiimothorax. Barbara , aet. 39, was a married 
 woman, who for eighteen months had suffered from symptoms of dyspepsia or 
 chronic gastritis, from pain between the shoulders and at the epigastrium, 
 and from vomiting. Two days before admission she was seized with intense 
 pain in the left side and shoulder, and she had urgent dyspnoea. On ex-ami- 
 nation at the base of the left lung there was resonance, amphoric breathing 
 metallic tinkling, and segophony. She died twenty days alter the attack of 
 dyspnoea. 
 
 Dr. Barlow's diagnosis was confirmed ; there was pleurisy on the 
 left side, and a large peritoneal abscess, which communicated by two 
 openings with the lesser curvature of the stomach one near the 
 O3sophagus, capable of admitting the middle finger, and another, 
 smaller, near the anterior wall. The abscess was bounded bv the 
 ribs, spleen, liver, and diaphragm, and by inflammatory adhesions in 
 a partially sloughing condition. The pleura in this case was not 
 perforated, so that the symptoms of pneumothorax were produced 
 by the air in the peritoneal abscess. 
 
 The post-mortem examination in the following remarkable case is 
 here introduced as an illustration! of perforation of the stomach, 
 associated with perforation of the colon, as well as of the diaphragm. 
 The disease, however, in the colon appeared to be of the longest 
 duration, and to have led to the formation of the fecal abscess, whilst 
 the perforation of the stomach was, perhaps, secondary, and from the 
 external to the internal surface. 
 
 CASE LIII. Fecal Abscess, connected with the Stomach, the Lung, the 
 
 Spleen, and the Transverse Colon Ellen R , aet. 25, was admitted in July, 
 
 and died August 5th, 1847. History not known, except that she had fecal 
 vomiting. 
 
 On inspection the left lung was found adherent by old adhesions ; a vomica 
 was found in the upper lobe, and gray hepatization existed at its lower part. 
 
 Abdomen The intestines were matted together by old adhesions; the liver 
 
 also was adherent to the stomach. On the left side was an abscess of some 
 extent, bounded in front and to the outer side by the ribs, to the inner side 
 by the stomach and by the spleen, below by the transverse arch of the colon, 
 above by the diaphragm and right lung. This abscess communicated with the 
 chest by an opening through the diaphragm, and was there bounded by the 
 lower surface of the right lung and thickened pleura. It communicated also 
 by two separate openings with the greater curvature of the stomach, and by 
 one opening with the transverse colon ; it was filled with partially coagulated 
 blood ; the upper portion of the spleen was found sloughing in the cavity of 
 the abscess. The stomach also, and the transverse colon contained each of 
 them a considerable quantity of blood. The openings in the stomach were 
 round holes, having tolerably smooth edges, and the mucous coat, was not 
 thickened ; the peritoneal coat appeared as if it had been ruptured. There 
 were several ulcers in the transverse colon which communicated with the 
 abscess, and the bowel was thickened around them. The liver was large and
 
 164 ORGANIC DISEASES OF THE STOMACH. 
 
 fatty. Some of the mesenteric glands were calcareous. The contents of the 
 pelvis were all bound together by old adhesions, and there was a considerable 
 quantity of recent lymph at this part. Between the rectum and the bladder 
 was an abscess communicating with the rectum ; there were several other 
 ulcers in the rectum, and the whole mucous membrane was intensely injected 
 and of a deep purple color. There was strumous ulceration of the mucous 
 membrane of the uterus. 
 
 CASE LIV. Chronic Ulcer of the Stomach. Peritoneal Abscess. Per- 
 foration of the Diaphragm. Empyema J. F. L , set. G4, a basket maker 
 
 by trade, was admitted into Guy's Hospital, under Sir William Gull's care, 
 May 14th, 18GO. He had inflammation of the lungs when thirty years of age, 
 and a year afterwards he had rheumatic fever. Seven years before admis- 
 sion he had a blow by a capstan, which threw him into the hold of the vessel, 
 and from that time he had always suffered pain on taking cold. Seventeen 
 or eighteen months previous to admission he had also noticed a swelling at 
 the epigastric and umbilical regions, and he had nausea and vomiting after 
 taking food, but no blood was vomited. Severe tearing pain at the stomach 
 was produced by retching, and he also experienced at those times a burning 
 sensation, which lasted for twenty-four hours. The swelling had not increased, 
 but had extended more generally over the abdomen ; and for a few days the 
 pain had reached the loins. For two weeks he had felt severe pain above 
 the crest of the ileum on each side ; it came on after attempting to work, and 
 it passed up each side behind the clavicle. The painful part began to swell, 
 and continued swollen for two days, but the swelling afterwards disappeared. 
 From the commencement of his illness he stated that he had had a sense of 
 tearing whenever he lifted his left arm ; and he had frequently felt severe pain 
 below the last rib on the left side ; the pain was also felt in the lumbar region. 
 He had suffered much from flatulence, but not from sickness ; the bowels 
 were generally constipated. He was a spare man, with an anxious expres- 
 sion. The chest on admission was normal. The liver could be felt in the 
 epigastric region ; the spleen was also enlarged. The abdomen was increased 
 in size ; it was tender and tympanitic ; but no fluctuation could be felt. The 
 urine was not albuminous, its sp. gr. was 1020. He was ordered iodide of 
 potassium with the bicarbonate of potash. On the 19th the pain in the 
 abdomen was aggravated so that he could scarcely bear the pressure of the 
 bedclothes; the bowels were confined. Half a grain of opium was given 
 twice a day, and a simple injection was administered. During the afternoon 
 of the same day intense pain came on, and extended from the crest of the 
 ileum to the side of the thorax. On the 20th he seemed to be in severe pain, 
 and he suffered from great dyspnoea ; the face was pallid ; there was an anxious 
 expression of countenance ; and he had slight cough and scanty expectoration ; 
 the abdominal muscles did not move ; the base of the left lung was dull, both 
 anteriorly and posteriorly, and there was an absence of any respiratory sound ; 
 but there were tactile vibration and vocal resonance. The abdomen was 
 tense ; the skin was hot, but the extremities cold ; and he complained of great 
 thirst. On the 21st there was still great pain on the left side of the chest ; the 
 left side was dull on percussion except at the apex posteriorly; there was an 
 entire absence of respiratory murmur and vocal resonance at the base of the left 
 lung, but passing upwards the breathing became bronchial, and higher still 
 it became amphoric, with almost an aegophonic voice and great resonance on 
 coughing. The heart sounds were distinct on the right side of the sternum, 
 and the dulness extended as far as that part. On the right side generally the 
 respiration was puerile, and accompanied with bronchial rales ; the pulse was
 
 ORGANIC DISEASES OF THE STOMACH. 165 
 
 104 ; the tongue moist and furred ; the bowels were open ; there was no 
 appetite, but there was great thirst, and the breath was sweet. A blister was 
 applied ; acetate of potash with nitric ether and compound tincture of cam- 
 phor were prescribed, and four ounces of gin, afterwards increased to eight, 
 were ordered. The patient, however, rapidly sank, and died the following 
 day at half-past four. On inspection the abdomen was enlarged. The left 
 pleura was full of pus, and was lined with a flocculent membrane ; the heart 
 wa> pushed over beyond the median line, and the left lung was compressed. 
 The right pleura and lung were healthy, so also the pericardium and the 
 heart. On opening the abdomen the left lobe of the liver was found to be 
 adherent at the scrobiculus cordis by firm tissue, and it had formed the hard 
 mass felt during lite ; the peritoneum generally was healthy. On drawing 
 down the stomach, and removing the left lobe of the liver, a large abscess 
 was found between the stomach and the diaphragm, and it contained nearly 
 a pint of pus. The abscess was bounded by the liver in front and on the 
 right, by the spleen on the left, and by the pancreas posteriorly. In the 
 diaphragm was a small opening about the size of a crow-quill, and thus a 
 communication had been formed between the abscess in the abdomen and the 
 pleura. At the lesser curvature of the stonjach, and on its posterior aspect, 
 was a chronic ulcer two and a half inches long, bounded behind by dense cica- 
 trized tissue on the pancreas, but no perforation could be detected. The liver 
 was fatty, the other viscera were healthy. 
 
 Sir W. Gull correctly diagnosed this case as one of chronic disease 
 of the stomach, leading to perforation of the diaphragm, and causing 
 the fatal attack of pleurisy. The swelling at the epigastric region, 
 accompanied with nausea, vomiting, and "tearing pain," were strongly 
 indicative of gastric disease ; but it was very doubtful whether the 
 malady was of a cancerous character. It was doubtful, also, whether 
 the blow he received from a capstan had anything to do with his 
 subsequent disease. Chronic ulceration took place, perforation of 
 the walls of the stomach followed ; but the mischief was localized by 
 adhesions ; suppuration then took place, beneath the diaphragm ; 
 this muscle at last itself became perforated, and intense pleurisy was 
 at once set up by the extravasation of pus into the pleural cavity. 
 
 CASE LV. Chronic Ulceration of the Stomach. Perforation. A Sinus 
 extending into the Left Lung. Gangrene. Empyema. Second Chronic 
 
 Ulcer Eliz. F , aet. 36, had been treated as an out-patient for dyspepsia, 
 
 and it was supposed that ulceration of the stomach existed ; the prominent 
 symptom was vomiting of coffee-ground matter. After admission into the 
 hospital she became extremely low and emaciated, and gradually sank. It 
 was then believed that she had cancerous disease. She died October 13th, 
 and was examined twenty-six hours after death. 
 
 Chest The left pleura contained purulent effusion. The lower lobe of 
 
 the left lung was pneumonic and adherent to the diaphragm ; a vertical sec- 
 tion of this lobe exhibited an excavation, filled with dark-gray and tenacious 
 matter, which exhaled a gangrenous odor. The cavity was traversed by 
 pulmonary vessels, which, when placed under water, had a curious flocculent 
 appearance ; a sinus passed from this cavity, through several fistulous open- 
 ings in the diaphragm, into the stomach. The heart and pericardium were 
 normal, except that the foramen ovale was open. In the abdomen there were 
 chronic and vascular adhesions between the viscera and parietes, more particu- 
 larly about the right hepatic lobe ; the liver was situated unusually low in
 
 166 ORGANIC DISEASES OF THE STOMACH. 
 
 the abdomen. The small intestine appeared perfectly healthy ; the kidneys 
 were coarse and their tunics adherent. The liver and gall-bladder were 
 healthy. 
 
 On opening the stomach, along the greater curvature, an aperture of a 
 circular figure was discovered in its walls, the circumference of which, with 
 the exception of a small aperture at its upper border, was very firmly adhe- 
 rent to the under surface of the left lobe of the liver. This appearance, the 
 remains of old ulceration, was situated in the region of the lesser curvature 
 of the stomach. From the perforation in the ulcerated walls of the stomach 
 a sinus passed upwards, bounded upon the left by the spleen, on the right by 
 the left lobe of the liver, and behind by the pancreas and small omentum ; 
 above, it extended to the diaphragm, which was perforated by several fora- 
 mina, and the sinus communicated with a cavity in the inferior lobe of the 
 left lung; the surfaces of the organs bounding this sinus were tinged with a 
 dark-gray hue. The opening from the ulcer in the stomach was valvular, 
 and was situated under its superior border. The stomach contained dark, 
 almost black, thick, viscid fluid ; there was also a second chronic ulcer near 
 the pyloric extremity of the stomach. 
 
 The diagnosis of this case was obscure ; the earlier symptoms 
 indicated ulceration of the stomach, but the unusual prostration led 
 to the idea that the disease was of a cancerous character. The dis- 
 ease commenced in the stomach, and the ulcer at the lesser curva- 
 ture led to perforation ; the aperture, however, was at the posterior 
 aspect, and it was also surrounded by adhesions, so that it passed 
 into the structures between the diaphragm and the stomach without 
 leading to general peritonitis. Circumscribed suppuration then took 
 place, and ulceration extended through the diaphragm. Here, also, 
 adhesions between the pleural surface of the lower lobe of the left 
 lung and that of the diaphragm, prevented acute pleurisy being at 
 once produced ; the lung tissue was perforated, and a slough cavity 
 was formed. The pleura subsequently became acutely diseased, and 
 effusion of pus took place in the non-adherent part of the serous 
 membrane. The gangrene of the lung and the ernpyema led to the 
 excessive prostration in this case. A second ulcer was found in the 
 stomach. 
 
 Chronic Ulceration with Hemorrhage. 
 
 CASE LVI. Chronic Ulceration of the Stomach. Fatal Hemorrliage. 
 Perforation of the Splenic and of the Pancreatic Arteries Charlotte T , 
 a3t. 55, was admitted into Guy's Hospital, March 4th, 1857, and died March 
 5th, at 9.40 P. M. 
 
 She had previously been admitted under Dr. Oldham's care, in a very 
 blanched condition, complaining of severe pain in the left side ; she had had 
 no vomiting nor spitting of blood, and her appetite had failed ; whilst in the 
 hospital, however, she took food well. She was in a week's time transferred 
 to Dr. Wilks's care, and was then evidently suffering from internal hemor- 
 rhage ; she had great pain and uneasiness in the left side, with nausea, but 
 did not vomit. During the night she vomited a cupful of blood, and shortly 
 afterwards died. She had been a char-woman and of intemperate habits, 
 and six years before death she had vomited blood.
 
 ORGANIC DISEASES OF THE STOMACH. 167 
 
 On inspection, the pleura was found adherent, and the lungs healthy. The 
 left ventricle was contracted and empty, as in death from loss of blood. 
 
 In the abdomen the peritoneum was healthy, except adhesion at the upper 
 part, where the anterior wall was firmly united to the stomach and liver. 
 These structures could be separated with care, except at the left hypochon- 
 driac region, where the adhesions were exceedingly firm. The whole of the 
 liver, stomach and spleen, were removed together ; the stomach was found to 
 be contracted at its centre by a large oval ulcer placed transversely ; two 
 pouches were formed, the pyloric being the smaller of the two, and the 
 cardiac one formed a large cavity, capable of holding at least a quart of fluid ; 
 each part contained a large quantity of coagulated blood, partly digested. At 
 the posterior part of the stomach, near the lesser curvature, was a large chronic 
 ulcer, with raised dense round edges, and with a depressed slightly granular 
 centre ; the ulcer was oval or rather reniform in shape, and appeared to be 
 formed by two ulcers which had coalesced ; it was at least three inches in 
 length, and one and a half to three in breadth. Its floor was formed partly 
 by the left lobe of the liver, to which it was firmly adherent, and by the pan- 
 creas. Two small papilliform eminences were found on careful examination, 
 and a bristle could easily be passed into open vessels ; one opening was found 
 to communicate directly wkh the splenic artery, on the upper margin of the 
 pancreas, and a second with the artery in the centre of the pancreas. Each 
 of the perforations in these vessels had a small quantity of blood at their orifices, 
 but did not contain any clot or blood. The pylorus and the rest of the stom- 
 ach were healthy. The intestines contained a considerable quantity of blood, 
 but were otherwise healthy. The portion of the left lobe of the liver in 
 connection with the stomach was atrophied, and it presented fibroid degenera- 
 tion ; the other part of the liver was fatty. The kidneys were granular. 
 
 This case presents us with an unusual mode of termination of gas- 
 tric ulcer. The ulceration had been slow in its progress, and it had 
 apparently extended over at least six years or more ; there had been 
 some hemorrhage, which had probably come from some of the 
 branches of the gastric arteries; as the ulceration extended, the 
 walls of the stomach were perforated, but adhesions prevented peri- 
 tonitis. In this state the health had become impaired by disease of 
 the kidneys, which were found after death in a state of advanced 
 degeneration ; slow ulceration had reached the vessels at the base of 
 the ulcer, and the perforation of two large vessels led to the fatal 
 hemorrhage. These vessels were healthy, but the ulceration had de- 
 stroyed the surrounding structures more extensively than the arteries, 
 and the contraction of the vessels was also prevented by fibro-elastic 
 tissue, so that minute papillary eminences were formed; the disease 
 of the kidneys and the condition of the blood also tended to increase 
 the hemorrhage. It is remarkable that so little blood was vomited, 
 although the stomach was full, and the intestines contained a con- 
 siderable quantity. The absence of this symptom arose partly, per- 
 haps, from the adhesions of the stomach to the parietes, as well as 
 from the prostrate condition of the patient. 
 
 As to the cause of the complaint, we are led to suppose that the 
 intemperate habits of the patient produced the disease of the stomach, 
 as well as that of the kidneys; the one tended to increase the other, 
 and at last hastened the fatal termination.
 
 168 ORGANIC DISEASES OF THE STOMACH. 
 
 CASE LVII. Ulceration of the Stomach. Fatal hemorrhage Joseph G , 
 
 aet. 53, was admitted into Guy's February 28th, and died March Gtli. 
 
 The patient was admitted after hgematemesis had taken place ; it came on 
 suddenly, and there were no premonitory symptoms ; he died on the sixth 
 day, completely blanched. 
 
 On inspection, forty hours after death, a small ulcer about the size of a 
 fourpenny-piece was found at the lesser curvature of the stomach ; it was 
 round, depressed in the centre, and the edges of the mucous membrane were 
 raised ; in its centre was an opening from which exuded a drop of blood, and 
 a probe could be passed into a large vessel beneath, apparently the gastric. 
 The stomach was of normal size, and free from blood, but the large intestines 
 contained blood, as shown by their dark color. A partial inspection only 
 was allowed. 
 
 Numerous instances of hemorrhage into the stomach recover, even 
 after extreme loss; the hemorrhage is checked by the formation of 
 clots in the divided vessel. This obstruction of vessel was well 
 shown in a case of gastric ulcer, which terminated fatally from bron- 
 chitis. Large hemorrhage from the bowels had taken place several 
 months previously, and on inspection two chronic ulcers were ob- 
 served towards the anterior surface at the lesser curvature, and on 
 one of them the truncated extremity of a small vessel was filled by 
 a clot. 
 
 A most interesting and rare case of recovery after apparent per- 
 foration is recorded by Dr. Hughes and Mr. Hilton, in the Guy's 
 ' Reports.' The young woman left the hospital, and appeared con- 
 valescent; subsequent indiscretion in diet produced a return of the 
 symptoms, and a fatal result. A cicatrix of previous ulcer and 
 adhesions were found, but with new perforation. The opiate plan 
 of treatment of Drs. Stokes and Graves was adopted with unusual 
 success. 
 
 CASE LVIII. Chronic Ulceration, with Villous Growth. Stomach ex- 
 ceedingly contracted, simulating cancer Thomas F , set. 34 years, a mar- 
 ried man, who resided at Dover, and followed the occupation of a fruiterer, 
 was admitted into Guy's June 30, 1854, under my care, in the Clincal Ward, 
 in a pale and exceedingly emaciated condition. With the exception of an 
 attack of rheumatism fifteen years before, his health had been good till eight 
 months prior to admission. He stated that eight months previously he took 
 cold, and experienced pain in the chest, at the lower part of the sternum, 
 accompanied with difficulty of deglutition. He obtained no relief, but the 
 pain gradually increased in severity, and was accompanied with vomiting 
 after food; his food was brought up directly after being swallowed, his own 
 description being that it never seemed to reach the stomach, but was brought 
 up unchanged ; the vomiting sometimes subsided for several days, and he 
 was thus able occasionally to retain fluid food ; when this occurred he experi- 
 enced relief from the sense of painful exhaustion. Emaciation had slowly 
 increased. On admission, his exhaustion appeared extreme, but still he ex- 
 perienced no pain ; the abdomen was collapsed ; no tumor could be felt ; the 
 distress on swallowing was localized at the lower part of the sternum. At 
 the base of the right lung there was dulness on percussion, and some tubular 
 breathing, but no cough nor dyspnoea. He sank on the fourth day. 
 
 Inspection. The lower lobe of the right lung was consolidated, granular, 
 and very readily broke down. The heart was healthy. The peritoneum
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 169 
 
 also was healthy. The stomach was so small and concealed that it was not 
 at first perceived ; it was exceedingly contracted and lobulated externally, 
 resembling a portion of large intestine ; it was about six inches in length and 
 two in breadth. On laying it open, from the oesophageal to the pyloricorifice, 
 it presented a very unusual appearance. At the pylorus, and extending 
 along the greater curvature, was a deep excavation, or ulcer, bounded by a 
 sharp, slightly ulcerated border, the surface of which was smooth, and of a 
 grayish color. This ulcerated surface extended about half an inch beyond 
 
 Stomach exceedingly contracted from chronic ulceration, with villous growth, simulating cancer. 
 1. External view, resembling the colon in appearance. 2. Internal surface, showing ulceration near 
 the pylorus, and villous growth ue ar the centre of the stomach. 
 
 the pylorus ; passing towards the cardiac extremity and along the lesser cur- 
 vature, the mucous membrane appeared smooth, shining, and glazed ; and 
 towards the cardiac extremity presented several raised, circular patches ; the 
 largest of these, very near to the ulcer, was about one-eighth of an inch in 
 elevation, and about one inch in diameter, and was composed of villous folds, 
 which appeared to radiate from the centre ; floated under water, this growth 
 from the mucous membrane had a very beautiful appearance ; nearer to the 
 oesophagus was another circular patch of a similar description ; and on either 
 side there were slight folds, but less elevated, and having a longitudinal ar- 
 rangement. On taking a small portion of this villous growth it was found 
 to consist of very delicate plicated folds ; scarcely any epithelium was found
 
 170 ORGANIC DISEASES OF THE STOMACH. 
 
 on the surface, but numerous crystals, resembling triple phosphates, were 
 observed upon it ; the growth was composed of cells of large size, from ^^^t\i 
 to TjjVff*' 1 f an i ncn in s ' ze > many oval, some angular; they contained gran- 
 ules, and large nuclei from the j V, T th to g^^th of an inch. These cells 
 were very similar to those found on the mucous membrane of a healthy 
 stomach, or in connection with the gastric follicles. A section of the growth 
 rendered this more probable ; immediately beneath the surface of the mucous 
 membrane was a thick layer of these secreting cells, reaching to the distended 
 gastric follicles, which were tabulated and much distended by similar cells ; 
 beyond these enormously enlarged gastric follicles was a stratum of white 
 fibrous tissue, from one-sixteenth to one-eighth of an inch in thickness ; and 
 similar tissue extended between the follicles themselves. All the growths 
 from the membrane had a like structure. On the surface of the apparently 
 smooth portion were several small isolated dendritic or imperfect villi, con- 
 taining cells, as before described. Beneath the mucous membrane was a 
 dense fibrous layer, and then hypertrophied muscular fibre. The hypertrophy 
 of the muscular fibre was more marked towards the pylorus, but even there 
 did not exist in an extreme degree. The examination of the ulcerated sur- 
 face did not show any structure which indicated the disease to be of carci- 
 nomatous character. The liver, pancreas, and the remaining abdominal 
 viscera and glands, were healthy. One kidney was large and healthy ; the 
 other appeared atrophied. 
 
 The pathology of the case just detailed is of great interest; it could 
 not be ascertained, from minute inquiries from the patient, that he 
 had taken any poisonous or corrosive substance. There had appa- 
 rently been inflammation of the mucous and submucous tissues, 
 leading to very slow ulceration in one part ; in another, to the de- 
 velopment of contractile tissue in the substance of the membrane, 
 and producing contraction of the whole organ. The villous growths 
 at first gave the idea of epithelial cancer; but the presence of gland 
 follicles in their normal arrangement, though much hypertrophied, 
 and the absence of every other indication of cancer, led me to the 
 belief that these parts were merely portions of changed or hypertro- 
 phied mucous membrane. There was no glandular enlargement nor 
 disease resembling carcinoma in any part of the body. The disease 
 during life was believed to be earcinomatous, and located at the 
 cardiac extremity of the stomach; the manner in which the food was 
 at once regurgitated or rejected from the stomach, the unrelieved 
 pain, and steady emaciation, seemed to warrant such a supposition. 
 The acute disease at the base of the right lung was interesting, as 
 illustrating the manner in which such disease in an exhausted subject 
 may take place without general symptoms. There was neither 
 cough, dyspnoea, nor febrile symptoms; the pulse was quiet, and the 
 tongue clean ; still, there were dulness and tubular breathing at that 
 part, and the lung was found, on inspection, in the second stage of 
 pneumonia. 
 
 CASE LIX The thickening producer! by hypertrophied tissues in chronic 
 ulcer may be so great as to resemble cancerous growths, as in a case under 
 the care of Sir W. Gull, in Guy's, in I860. Caroline D , set. 39. Four 
 months before her death she had rigors after dinner, and two months later she
 
 ORGANIC DISEASES OP THE STOMACH. 171 
 
 began to vomit ; for six weeks she had a burning sensation in the throat and 
 oesophagus, and for five weeks vomited everything. The urine contained 
 albumen, the conjunctiva was yellowish in color, and a movable tumor could 
 be felt. The peritoneum was studded with small, round, wart-like patches, 
 witli black spots as after minute hemorrhage. The stomach contained about a 
 pint of dark-colored fluid, the cardiac end was distended and its walls rather 
 thinner than usual. At the pyloric third of the stomach was .a tumor about 
 two and a half inches in transverse, two inches in vertical, and one and a 
 half inches in antero-posterior measurement ; on section two-fifths of it were 
 hypertrophied muscle ; the fatty tissues were much thickened and indurated. 
 The thickened tissues constituted the bulk of the tumor. There were no 
 enlarged glands, but an ulcer was situated two inches from the opening of 
 the oesophagus. The rest of the stomach Avas healthy. 
 
 Cancerous disease may, however, exist with ulcer. In a woman, aet. 30, 
 who died from cancerous disease of the peritoneum, which led to complete 
 obstruction, there was an old callus ulcer which had destroyed all the coats 
 of the stomach ; the stomach was small and as hard as gristle ; its walls in 
 the pyloric three-fourths were three-quarters of an inch in thickness, at the 
 cardiac position one-fourth to one-sixth. The lesser curvature was the 
 thickest part, at the ulcer the coats were more than an inch in thickness. 
 There was no milky juice. The gastric follicles were much wasted. 
 
 Causes. There is much obscurity as to the predisposing cause of 
 ulceration of the stomach. Some cases are preceded by a state of 
 chronic inflammation of the whole mucous membrane, produced by 
 intemperance or irregularity in diet. In others it appears probable 
 that the general state of nutrition and of the nervous system act as 
 predisposing causes. Mental depression or anxiety, scanty food, late 
 hours at night, and insufficient exercise, pressure upon the scro- 
 biculus cordis, either by direct girthing of the abdomen, or by con- 
 stant and constrained position, as in milliners and shoemakers, or the 
 striking of the epigastrium by the shuttle of the weaver, are also 
 causes of gastric ulcer. 
 
 Treatment. There are several objects to be sought for in the treat- 
 ment of ulceration of the stomach : 
 
 1. The promotion of reparative action by sustaining and increasing 
 general nutritive power. 
 
 2. The relief of distressing symptoms, pain, vomiting, hemor- 
 rhage, pyrosis, constipation, &c. 
 
 3. The prevention of the extension of the disease. 
 
 4. The removal of its complications. 
 
 1. Almost the first consideration, and certainly one of the most 
 important, is the administration of proper food. If absolute rest 
 could be afforded to the stomach, the ulceration affecting its surface 
 would .probablv in many cases rapidly heal ; but, since this is almost 
 impossible, it must be our object to give such forms of nutriment as 
 will spare the stomach ; and in seeking to accomplish this purpose, 
 it must be borne in mind that the especial office of the stomach, and 
 its peculiar secretion, is the solution of nitrogenous compounds. 
 These elements are found in the flesh of animals, in beef and mutton, 
 &c., hence we generally find that solid animal food produces pain
 
 172 ORGANIC DISEASES OF THE STOMACH. 
 
 and vomiting, and must in most cases be avoided. 1 If, however, 
 these elements of food be given, they must be in an uuirritating 
 form, as the less oleaginous kinds of fish, the sole, whiting, cod, &c., 
 or poultry ; or in a fluid sta^e, as veal and mutton broth, clear soups, 
 &c. ; beef-tea often creates nausea and vomiting. Still more must 
 hard and indigestible meats, preserved meats, and cheese be avoided. 
 Oysters, sweetbread, can often be taken when more irritating diet 
 would be rejected. 
 
 Starchy food is converted into sugar by the saliva and by the 
 secretions in the intestine, and in that state is readily absorbed ; but, 
 at the same, it readily undergoes fermentative change and produces 
 flatulence, so that in pyloric obstruction it is well to abstain from it. 
 So also, oleaginous substances are converted into an emulsion by the 
 alkalies in the secretions of the mouth and intestine, and in the bile ; 
 so that these forms of diet, whilst they are demulcent and soothing 
 to the diseased gastric surface, do not require the stomach in order 
 to place them in a state ready for absorption. Good stale bread, 
 biscuit, milk, starchy substances as arrow-root, tapioca, maize, or 
 Indian corn, flour, rice, &c., may thus'be given to the patient; eggs 
 often disagree, but may be taken in the form of light pudding; milk, 
 also, when refused in its simple character, may be better tolerated 
 by combination with isinglass, as in blanc-mange, or with soda water 
 or lime water ; and even cream and bacon are occasionally well 
 borne. 
 
 Kich soups, highly seasoned dishes, peppers, mustard, &c., are 
 better abstained from ; so also pastries, and food containing much 
 insoluble material, as salads, unripe raw fruit, green vegetables, &c. 
 It is, however, undesirable altogether to abstain from vegetables, for 
 we may thus defeat our object, by inducing cachexia ; oranges, 
 lemons, &c., may be often taken with benefit. 
 
 Again, it is most important that food should be partaken of sloAvly, 
 and thoroughly masticated ; and it is better to take small quantities 
 at a time, and to repeat the allowance more frequently, than to dis- 
 tend the stomach by a large and bulky meal ; about three to four 
 hours should intervene in ordinary cases, but when there is great 
 exhaustion, with irritability of the stomach, food may be required 
 more frequently, and in very small quantities. Exertion, both 
 mental and physical, should be avoided directly after meals ; in fact, 
 everything should be done to facilitate the process of digestion. It 
 is well to abstain from alcoholic liquors if possible ; they tend to 
 aggravate the disease, and should not, I think, be given unless the 
 circulation be failing, and there be tendency to syncope ; but, when 
 required, brandy in small quantity and well diluted, or the forms ot 
 sherry which contain the least quantity of sugar are best. New 
 wines, port, and imperfectly fermented malt liquors, generally dis- 
 turb and distress the patient. 
 
 It is desirable to use every means in our power to improve the 
 
 1 Corvisart has shown that the pancreatic fluid promotes the solution ot nitroge- 
 nous substances.
 
 ORGANIC DISEASES OF THE STOMACH. 173 
 
 health, as exercise in the open air; but over-fatigue, or constrained 
 positions, should be avoided. Moderate horse exercise, and bracing 
 air, will sometimes afford more relief than medicinal agents, even 
 when long continued ; but violent shaking is injurious. When a 
 chlorotic or anaemic state has been produced, the preparations of 
 steel, by restoring a more healthy condition of the blood, greatly 
 facilitate reparative changes. We prefer the milder preparations, as 
 the ammonio-tartrate or citrate ; the compound steel pill, with aloes 
 and myrrh, or quinine with iron, as the sulphate or citrate conjoined, 
 majr also be beneficially prescribed. 
 
 It is obviously most desirable to administer that form of aliment 
 which will nourish the body, so that healing may be favored, but 
 without irritating and disturbing the process which is going on 
 towards recovery. The difficulty is still more increased by the occa- 
 sional irritability of the stomach itself; and this leads us to the con- 
 sideration of the means we possess for the mitigation of distressing 
 symptoms pain, vomiting, hemorrhage, pyrosis, constipation. For 
 the relief of pain, opium or its alkaloid morphia is often the best 
 remedy, in doses of | to 1 grain of the former two or three times a 
 day, or a few minims of the solution of the latter. Chloric ether, 
 in doses of 10, 15, to 20 minims, will be found very efficacious, espe- 
 cially when combined with nitrate of bismuth in 10- to 20-grain 
 doses. Chlorodyne is stated as being a valuable substitute, but I 
 have no experience in its use. Dilute hydrocyanic acid, in doses of 
 3 to 5 HI, is also a useful adjunct in some cases, especially when given 
 with alkalies. Both potash, soda, lime, and magnesia, have been 
 used ; they neutralize acid secretion, and oftentimes increase the ano- 
 dyne power of the remedies previously mentioned opium, morphia, 
 chloric ether, &c. If, however, there be constipation, dryness of the 
 tongue, and opium is not well borne, conium or henbane may be 
 used as substitutes. The nitrate arid oxide of silver, in doses of ^ 
 to 1 grain, in some instances diminish the pain and irritability of the 
 stomach, especially when the gastric symptoms are associated with 
 pyrosis. Creasote or carbolic acid in l^l doses we have found very 
 effectual in relieving pain, when accompanied with irritability of the 
 stomach, or with vomiting and fermentative changes in the food. 
 Charcoal is also a remedy which in some cases acts very speedily 
 and efficaciously in relieving pain and flatulent distension. Again, 
 carbonic acid, as in ordinary soda water, is effective in relieving pain 
 as well as vomiting. So also the use of cold water and ice, which 
 are often very grateful to the patient. 
 
 Vomiting is a very distressing symptom in many cases of ulcer of 
 the stomach. It is best combated by only partaking of fluid diet, 
 and of that in moderate quantities. The remedies we have already 
 mentioned are of service, but especially bismuth, hydrocyanic acid, 
 creasote, ice, and the alkalies. 
 
 Sir Wm. Jenner has pointed out the value of the sulphite of soda 
 in checking the fermentative action, and the development of sarcinae 
 in obstruction from chronic ulcer, as well as in cancerous and pyloric
 
 174 ORGANIC DISEASES OF THE STOMACH. 
 
 disease. It may be given in ^j doses, alone or conjoined with other 
 agents; the hyposulphite is also given in similar cases. 
 
 Counter-irritants are often of service for the relief of pain and 
 vomiting in these cases. A small blister, may be applied to the scro- 
 biculus cordis, or croton oil rubbed in so as to produce a pustular 
 eruption. Some even use a seton ; but I think, that we may attain 
 the same beneficial result by milder remedies with less suffering and 
 distress to the patient. 
 
 If there be excessive secretion or hemorrhage, astringents may be 
 given; thus, mineral acids, as the sulphuric alone, or with Epsom 
 salts; acetate of lead, tannin, and alum, are also available; and 
 when we have hemorrhage without great irritability, small doses of 
 turpentine with mucilage or yolk of egg may be prescribed. Tinc- 
 ture of iron is sometimes very effective in checking the hemorrhage. 
 
 When hemorrhage has recently taken place, it is well to avoid 
 the use of anything likely to distend or mechanically to disturb the 
 stomach, as carbonic acid. Ice, however, should be allowed to the 
 patient, as it tends to produce contraction of bleeding vessels. 
 
 Pyrosis may be checked by the astringents just mentioned ; but 
 we have found the greatest benefit from nitrate or oxide of silver 
 with opium, from creasote or carbolic acid, from the compound kino 
 powder, and when other symptoms would permit it, from the astrin- 
 gent preparations of iron. 
 
 The bowels should be acted upon by agents which are neither 
 retained in the stomach, nor irritating to it, as the aloes or colocynth 
 pill, with henbane; the effervescing citrate, the carbonate or Dinne- 
 ford's fluid magnesia ; in other instances enemata are useful, consisting 
 of simple water or castor oil, or of turpentine; and occasionally a 
 mercurial purgative will be found beneficial in thoroughly emptying 
 the canal without increasing gastric irritability, as a few grains of 
 gray powder, one or two of calomel, or of blue pill, with henbane, 
 &c. ; but to continue this form of medicine is, we think, injurious 
 and prejudicial to the patient. In many cases of constipation with 
 gastric disease, minute doses of strychnia, or of the extract of nux 
 vomica with aloes, act very beneficially. 
 
 In order to carry out the third indication of treatment, namely, 
 in preventing the extension of the disease, sudden and violent exertion 
 should be guarded against; and also the distension of the stomach by 
 large meals, or by food which leads to the formation of gaseous pro- 
 ducts, as the result of fermentative changes. 
 
 4th. In the treatment of the complications of gastric ulcer, arising 
 from its extension to neighboring parts, as when perforation has taken 
 place, and the symptoms of peritonitis have been suddenly produced, 
 there is still a slight chance that life may be prolonged, if the patient 
 is not moved, nor anything introduced into the stomach, except a 
 teaspoonful of water or milk to assuage thirst. Opium must be 
 given freely, as recommended by Dr. Stokes and Dr. Graves, so that 
 the patient may be entirely under its influence a grain every three 
 or four hours by this means peristaltic action is checked, nervous 
 shock diminished, extravasation prevented, adhesions promoted, and
 
 ORGANIC DISEASES OF THE STOMACH. 175 
 
 life may be thus preserved. For many days aperient remedies should 
 be avoided, and food only taken in the most cautious manner. 
 
 If local suppuration have taken place, opium is still the best remedy, 
 in order to diminish irritative fever, to relieve pain, and to place the 
 patient in the most favorable condition for reparative action. If the 
 disease have extended into the chest, the prospects of recovery are 
 still less ; for sudden acute pleurisy and empyema, or asthetic pneu- 
 monia are almost certain to follow. Life may be prolonged by 
 sustaining the patient, and the severity of the symptoms of acute 
 disease of the chest may be partially relieved by ammonia and opium. 
 
 The two following cases illustrate the relief that may be afforded 
 by the treatment just recommended. 
 
 CASE LX. Chronic Ulcer of the Stomach. Relieved Jane H , art. 34, 
 
 was admitted under my care into Guy's Hospital, May 1, 1861. She was a 
 married woman, but had had no family. For eleven years she had had pain 
 at the stomach, with frequent attacks of vomiting of clear fluid. In 1858 
 she vomited a large quantity of blood, and eighteen months later had a 
 second attack of haematemesis. During three months prior to admission, 
 she had continued pain at the scrobiculus cordis, extending to the spine, and 
 increased by food ; there was tenderness at the scrobiculus cordis ; and she 
 became so weak as to be obliged to keep her bed. For two months she had 
 had vomiting, sometimes directly after food, at other times an hour after- 
 wards ; the bowels were constipated. On admission she was emaciated, and 
 rather sallow ; there was tenderness and increased pulsation at the scrobiculus 
 cordis. She was most free from pain when lying partly on the back and 
 towards the left side. The pulse was very compressible, 74 ; the tongue was 
 very red in the centre; the respiration was coarse at the' apices of both 
 lungs ; menstruation was scanty and irregular, and had disappeared for two 
 months. She was ordered colocynth pill, with henbane at night ; and nitrate 
 of bismuth with chloric ether three times a day, and food in a fluid form. 
 
 8th Symptoms relieved ; no vomiting, and less pain. She continued to 
 
 improve greatly, and left the hospital convalescent on May 27th. 
 
 There appeared to be little doubt, in this instance, as to the 
 presence of an ulcer in the stomach ; and we have very rarely ob- 
 served a greater measure of relief than she experienced. 
 
 CASE LXI. Ulceration (cancerous 1 ?) of the Stomach. Relieved. David 
 H , aet. 36, was admitted into Guy's Hospital under my care, April 8, 1861. 
 He was a married man, a printer, who had resided at St. Luke's. Fifteen 
 months previously he had drunk gin immoderately, and violent vomiting was 
 produced ; no blood, however, was ejected. After that time he had suffered 
 from pain across the abdomen and in the back. The pain was greatly 
 increased by food, and vomiting came on directly after it had been taken ; 
 but for six weeks the pain had been less severe. His diet had consisted of 
 beef tea, eggs, milk, etc. He was greatly emaciated, sallow, and had an 
 anxious expression of countenance. A hard tumor, about two inches across, 
 could be felt at the scrobiculus cordis. The action of the heart was feeble, 
 and the pulse was very compressible. Extract of nux vomica, with disul- 
 phate of quinine and aloes, and myrrh, were given three times a day. 
 
 April 18th He complained of intense pain at the scrobiculus cordis, 
 
 unrelieved by position, and increased by food. There were spots of purpura 
 on the legs. He craved for meat, but refused vegetables. Soap and opium
 
 176 ORGANIC DISEASES OF THE STOMACH. 
 
 pill were prescribed night and morning; and lemon juice, with infusion of 
 calumba, three times a day. 
 
 20th Although he had no vomiting, the pain was very severe at the 
 stomach ; he was more prostrate and distressed, the bowels were constipated, 
 and he was unable to take solid food. The opium was continued, and he 
 was directed to take chloric ether with bismuth. 
 
 22d He was very much relieved. 
 
 30th Again suffered severe pain. He was in the habit of taking a small 
 quantity of food, and after a short time, because the pain became very severe, 
 he endeavored to excite vomiting, as affording the only means of relief. He 
 was very much emaciated and prostrate ; but he said that he was rather easier 
 when sitting up. Opium was added to his medicine. 
 
 May 28th. Very prostrate, and emaciated to an extreme degree ; but he 
 said that he was well, because the pain and vomiting had subsided. The 
 tumor at the scrobiculus cordis was less distinct. 
 
 June 8th The gastric symptoms continued in abeyance, and he left the 
 hospital in improved health. 
 
 The pain produced by the reception of food into the stomach, and 
 increasing till vomiting had taken place, was very characteristic of 
 organic gastric disease. The prostration was excessive ; but when 
 almost pulseless, and when the pain and vomiting had subsided, the 
 patient stated that he was well, and he insisted on endeavoring to 
 walk about. It was a good illustration of the benefit of avoiding 
 fresh causes of irritation, and opium with chloric ether afforded 
 great relief; but although he left the hospital free from pain, we 
 fear the disease was advancing, and would lead to a fatal result. 
 
 Sloughing of the Mucous Membrane of the Stomach. The action of 
 caustic poisons is the ordinary cause of sloughing of the mucous 
 membrane of the stomach ; but in the two following cases the ap- 
 pearance was peculiar, and very different from that produced by a 
 clot of blood covering an ulcer. At the lesser curvature of the 
 stomach there were several black patches, the largest being about 
 an inch in length ; and other smaller patches were placed in the 
 same direction along the lesser curvature. The black central por- 
 tion could not be removed from the tissue beneath ; but, on section, 
 it was found that a cup had been formed of fibrous tissue surround- 
 ing the base and on either side of the slough, showing either that an 
 inflammatory condition had preceded the loss of vitality in this iso- 
 lated portion of membrane, or that having sloughed, this new action 
 had been set up around it. The appearance presented was very 
 similar to an ordinary bed-sore on the sacrum. A slight, unusual 
 irritation, with depressed vital power, appeared sufficient to cause 
 total loss of vitality. Effusion of blood into the substance of the 
 mucous membrane probably preceded this change, and it closely 
 corresponded with a condition sometimes found in the lung, namely 
 that observed when hemorrhage into the substance of the lung is 
 followed by loss of vitality in the part ; and one or more lobules of 
 the lung are found detached by an attempt at reparative action. 
 
 The cases here recorded, confirm the opinion expressed by Dr. 
 Copland, and are in accordance with the experiments of others, that 
 the condition of the nervous system has an important influence on
 
 ORGANIC DISEASES OF THE STOMACH. 177 
 
 the mucous membrane of the stomach. In both cases there was 
 acute pneumonia ; in the one, with renal anasarca, in the other, with 
 paraplegia. The effect of division of, or disease implicating the 
 pneumogastrie nerve, on the nutrition of the lung, is shown by great 
 congestion, and often by acute pneumonia, as we have remarked in 
 the consideration of diseases of the oesophagus ; instances also are 
 very frequent of functional disease of the stomach arising from irri- 
 tation of the pulmonary branches, and cerebral centre of the pneu- 
 mogastrie nerve ; bat the production of organic change in the 
 stomach by division or disease of the nerve has not been established. 
 
 CASE LXII. Ulcer ati on of the Stomach. Sloughing. Paraplegia. Soft- 
 ening of the Spinal Cord. Disease of the Vertebra Elizabeth G , aet. 
 
 33, was admitted February 23d, 1855. She had been ill for six weeks with 
 paraplegia. 'Sloughing of the hips, &c., followed, and she gradually sank. 
 
 Inspection thirty-six hours after death. Opposite the eleventh dorsal 
 vertebra the cord was quite diffluent ; and this softening extended, though in 
 rather less degree, to the upper part of the dorsal region. It was more marked 
 in the posterior column. Chest The bronchi were congested, and were 
 full of tenacious mucus ; the lower lobes of the lungs were in a state of red 
 hepatization, being red, fleshy, and very soft. The mitral valve was thick- 
 ened. Abdomen Omentum attached to the bladder ; the stomach was 
 placed vertically, and was distended ; it was pulled down lo the pelvis, and 
 occupied half the abdomen. Stomach Much enlarged, containing grumous 
 fluid ; its greater curvature presented post-mortem solution, and the mucous 
 membrane was partially destroyed. Above the line of solution there were 
 several ulcers about the size of a shilling piece. The mucous membrane at 
 the margin of the ulcers was pale and slightly raised, and the floor of the 
 ulcers was covered by a black slough. The intestines were much congested. 
 The liver was very fatty. The spleen was healthy. The bladder was slough- 
 ing, as also were the vagina and os uteri, so that there was free communica- 
 tion between them. The uterus contained a decomposing foetus of about two 
 months. 
 
 CASE LXIII. Mottled Kidney. Anasarca. Pneumonia,. Sloughing 
 Mucous Membrane of the Stomach. Stephen F , aet. 51, was admitted 
 April 10th, and died April 20th, 1855, from chest disease. Nine years before 
 he had had scarlet fever, and for the last eighteen months he had not been 
 well. On admission the urine was very albuminous. 
 
 Inspection fourteen hours after death The body was generally anasarcous. 
 The lower lobe of the left lung was red, consolidated, and almost breaking 
 down. The rest of the lung was very cedematous. The bronchi were full of 
 frothy mucus. The left ventricle was much hypertrophied. The weight of 
 the heart was 17 oz. At the lesser curvature of the stomach were several 
 sloughs ; the largest two inches in length, and about one in breadth, black, 
 and slightly raised; a section showed that the slough was situated in a cup 
 of slightly thickened tissue. Two smaller sloughs were situated near to it. 
 On microscopical examination of the adjoining portions of mucous membrane, 
 the gland follicles were not distinct ; and on the surface were columnar epi- 
 thelium and crystals, &c. The small intestines were healthy. The spleen 
 was small, firm, and lardaceous. The kidneys were mottled, and the Mal- 
 pighian bodies were degenerated and lardaceous. 
 
 An instance recently occurred in Guy's of acute tuberculosis in a 
 young man, in whom the lungs were filled with miliary tubercle; in 
 12
 
 178 ORGANIC DISEASES OF THE STOMACH. 
 
 the stomach, at the lesser curvature, on both the anterior and posterior 
 walls, were several ulcers about a quarter of an inch in diameter, 
 with red well defined margins, and containing at their bases a dark 
 slough. Excepting at the edges of the ulcers the mucous membrane 
 appeared healthy, and there was no evidence of chronic disease. 
 There was no obstruction about the coronary arteries or veins. The 
 liver contained three small hydatid cysts, and there was the remains 
 of one, a calcareous cyst, at the apex of the left ventricle. There 
 was strumous disease of the left kidney and prostate gland. 
 
 Fibroid Degeneration of the Pylorus. The condition of the pyloric 
 valve in which degeneration of a fibroid character is found to exist, 
 has been and still is by many pathologists considered as a form of 
 cancerous disease, by others as hypertrophy of the normal constitu- 
 ents of the affected part. If, however, the diseased structure be 
 carefully examined, no evidence of cancer will be found in it, or in 
 the adjoining parts. The diseaise apparently commences in the sub- 
 mucous cellular tissue, which undergoes fibrous thickening, whilst 
 the mucous coat is in many cases unacted upon. This fibroid deposit 
 leads to obstruction at the valve ; the muscular coat then becomes 
 hypertrophied, and the amount of the hypertrophy is an indication 
 of the degree of obstruction ; the disease may be essentially hyper- 
 trophic in character and due to excessive action of the valve. 
 
 The growth beneath the mucous membrane is whitish in color, 
 firm, and without any juice, as in cancer, sometimes cartilaginous in 
 hardness; it consists of elongated or wavy fibres, resembling a fibroid 
 tumor, which with acetic acid present numerous elongated nuclei ; 
 bands of similar tissue pass between portions of involuntary muscular 
 fibre; and externally the omen turn may be contracted, and adhesions 
 may have been formed with adjoining structures. 
 
 The symptoms closely resemble those of cancerous obstruction; 
 and they consist in chronic dyspepsia, followed by emaciation, vomit- 
 ing occurring several hours after food, pain, distension of the stom- 
 ach, with eructations, fermentation, and the development of sarcina 
 ventriculi, constipation and gradual exhaustion, till at last the patient 
 sinks from inanition. The abdominal walls are wasted and collapsed, 
 and a tumor is often felt at the epigastric region, consisting of the 
 thickened tissues at the pylorus. If, however, the stomach be free 
 from adhesions, the thickened pylorus is often pushed downwards, 
 so as to be felt near the umbilicus, or even near to the pubes. It 
 must not, however, be supposed that the pylorus can always be felt 
 by tactile examination ; sometimes the most careful manipulation 
 fails to detect it, although it may be in a thickened condition. Pain 
 is not generally a marked symptom of this form of pyloric disease ; 
 but tenderness on pressure is sometimes present, and this, perhaps, 
 arises from peritoneal adhesions. 
 
 The distension of the stomach often becomes extreme, and the 
 movements of the hypertrophied muscular fibre may be seen through 
 the wasted parietes. This peristaltic movement may be induced by 
 swallowing a little water or food ; but both the distension and peris-
 
 ORGANIC DISEASES OF THE STOMACH. 179 
 
 talsis are less distinct when pyloric disease is acute, and may be 
 altogether absent. 
 
 After death, in some cases, we find evidence of chronic change, 
 and a gray and .thickened appearance of the mucous membrane of 
 the stomach, and a chronic ulcer or cicatrix are occasionally present. 
 At the pylorus the mucous membrane may be quite healthy, having 
 distinct, or even hypertrophied gastric follicles ; but the irritation at 
 the part may have excited secondary disease and ulceration. The 
 glands near the pancreas are not usually affected. 
 
 The diagnosis is sometimes obscure, and the presence of other 
 more acute disease may entirely mask the complaint. The duration 
 of life after fibroid degeneration has taken place is greater than in 
 .the ordinary forms of cancer, especially medullary and epithelial 
 cancer; and in simple fibroid disease the cachexia has not the 
 expression peculiar to cancerous affections ; but it will be found 
 extremely difficult to distinguish these diseases during life, especially 
 when only observed at their earlier stages. 
 
 We are not acquainted with the predisposing, nor with the exciting 
 causes of this fibroid disease ; but it is probable that long-continued 
 irritation, as indicated by dyspepsia, generally precedes it. The 
 intemperate do not appear to be more liable, and one sex is equally 
 the subject of it as the other ; it occurs, also, in early and middle, 
 as well as in advanced life. 
 
 As to treatment, we can afford relief, but cannot remove the ob- 
 struction. The change from solid and irritating food to fluid and 
 unirritating nutriment is often followed by much benefit; and we 
 may use with advantage those agents and means which have been 
 recommended in chronic ulceration of the stomach. It is very im- 
 portant to administer fluid diet of a kind that does not easily under- 
 go fermentative change, as milk, meat, soup, &c., but if vegetable 
 food cannot be taken, lemon juice should be substituted for it. 
 
 CASE LXIV. Thickened Pylorus. Cicatrix of the Mucous Membrane, 
 with Hypertrophy. Ulceration of the Caecum and Colon. Fatty degenera- 
 tion of the Heart G G , a silk weaver, get. 62, was admitted in a pros- 
 trate and anaemic condition. He had had haemorrhoids for twenty years ; 
 and he had occasionally lost a considerable quantity of blood. Four months 
 before admission, he had violent rain from the hip to the foot, and his legs 
 swelled. Violent pain also came on in the region of the stomach. Diarrhoea 
 followed, and continued till death. 
 
 On inspection, the heart was found to be fatty, the colon and caecum ulce- 
 rated. The stomach was somewhat enlarged, and its mucous membrane pale ; 
 at the greater curvature, for a space of about two inches in circumference, 
 the mucous membrane was thickened, and was a little puckered ; and at the 
 upper border of this patch was a small growth, consisting of thickened and 
 prominent mucous membrane, about one-eighth of an inch above the remain- 
 ing part. On examining the raised portion, it was found to consist on the 
 surface of columnar epithelium, and beneath of cell structure. The nuclei 
 of the cells were very distinct ; and gave the idea of cancer, but they were 
 identical with the secreting cells ordinarily observed in a healthy organ. The 
 pylorus was much thickened, and consisted of dense fibrous tis ue, passing 
 between bundles of involuntary muscular fibre. There were no true cancer-
 
 180 ORGANIC DISEASES OF THE STOMACH. 
 
 ous structures, and the diseased condition of the pylorus arose from fibroid 
 degeneration of the submucous and submuscular tissues, which had been 
 followed by hypertrophy of the muscular coat. See Drawing, in Museum, 
 No. 298 50 , Prep. 180G 73 . 
 
 This fibroid degeneration, with hypertrophy, contrasted remark- 
 ably with true scirrhous disease, ft had not led to the ordinary 
 symptoms of obstructed pylorus, and was not diagnosed during life; 
 the cause of death was exhaustion from diarrhosa in an anaemic 
 subject. 
 
 CASE LXV. Diseased Pylorus. Phthisis Mary W , jet. 22, admitted 
 into Guy's Hospital December, 1856. She stated that she had worked at the 
 fur trade, and was nearly always in a stooping posture ; three years previously 
 vomiting had come on, preceded by pain across the chest ; the symptoms, 
 however, were much relieved, and she married ; in a short time she became 
 pregnant,, and the symptoms returned ; they were, however, regarded as 
 sympathetic from the uterine condition. After her confinement she nursed 
 for seven months ; and for four months prior to admission she had constant 
 vomiting, which came on, several hours after taking food ; she suffered from 
 constipation, and gradually emaciated. 
 
 On admission into Guy's she was exceedingly wasted, and had a strumous 
 appearance ; her complexion was dark, and she was anaemic ; she suffered 
 from flatulent distension, which was easily dispersed, and complained of 
 burning pain at the stomach ; the vomiting often came on about six o'clock 
 in the evening ; on examination of the abdomen, a prominent tumor could be 
 felt at the region of the pylorus. The vomiting after food and emaciation 
 continued, and medicine afforded very temporary relief; a few weeks before 
 death cough came on and expectoration ; she died March 10th ; her death 
 had been expected week after week, but still she lingered on, and at last the 
 emaciation became extreme. A short time before admission she had slight 
 haemoptysis, but there was no evidence of disease of the chest at that time. 
 
 Inspection was made on March 12th. On opening the abdomen scarcely 
 anything but the enormously distended stomach could be seen ; the pylorus 
 was somewhat depressed, and the greater curvature reached nearly to the 
 pubes. The tumor consisted of the diseased pylorus. The interior of the 
 stomach presented a growth at the pylorus which completely surrounded the 
 valve, so that the little finger could not pass ; the growth extended nearly 
 two inches into the stomach ; the disease was of the character which has been 
 described as hypertrophy, and was manifested in a very marked degree. The 
 semi-transparent muscular layer was more than a quarter of an inch in thick- 
 ness, and was traversed by delicate lines ; upon it was placed a very dense, 
 whitish substance, nearly half an inch in thickness, firm and tough in texture, 
 which could be cut with difficulty ; on pressure no juice exuded ; upon this, 
 again, was thickened mucous membrane ; the surface was not ulcerated, but 
 was whitish in color, and irregularly tuberculated. The disease did not ter- 
 minate so abruptly in the duodenum as we often find, but gradually subsided 
 to the natural thickness of the intestine. The duodenum was otherwise 
 healthy ; so also the mucous membrane of the rest of the stomach. The in- 
 testines, liver, kidney, and glands were healthy. 
 
 On microscopical examination, the non-maglignant character of the growth 
 was well shown. The mucous membrane at the pylorus covering it was 
 thickened, but presented normal structure ; the gastric follicles were beauti- 
 fully distinct, elongated, and filled with nuclei, apparently quite healthy. The 
 white submucous substance was composed of dense fibre, and with acetic acid
 
 ORGANIC DISEASES OF THE STOMACH. 181 
 
 presented elongated nuclei, arranged as in fibrous tissue ; there was no evi- 
 dence of cancerous deposit. The muscular tissue had the usual involuntary 
 fibre, but firmer bands intersected it. There was no cancerous disease in any 
 part of the body. 
 
 At both apices of the lungs there was disorganization ; there were several 
 small vomicte filled with pus, and surrounded by iron-gray pneumonia, and 
 with some white, granular deposit, resembling tubercles; but no cancerous 
 disease could be found on microscopical examination. 
 
 The disease apparently commenced in the submucous cellular tissue, 
 and consisted of abnormal development of the ordinary fibrous tissue, 
 and closely resembled the fibrous growths of other parts. This 
 hypertrophy of the muscular and mucous coats was probably secon- 
 darjr, and the result of the obstruction. The history of the case, the 
 disappearance of the symptoms, and their recurrence after an interval 
 of more than two years, are more allied to fibrous degeneration than 
 to cancer. 
 
 The occurrence of phthisis with the diseased pylorus is rare; the 
 patient was a strumous subject, and during the exhaustion consequent 
 on the disease of the stomach pneumonia was set up, and a low or- 
 ganized product effused. The age of the patient was less than that 
 in which we generally find this disease, only twenty-two; and it is 
 doubtful how far her employment induced the complaint. 
 
 In another instance fibroid disease of the pylorus was found in a 
 young man set. 29, the vomiting had come on about six months 
 before death; and the peristaltic movements of the stomach were 
 visible. The stomach contained a large quantity of fluid, but its 
 surface was healthy. The pylorus would only admit a probe a 
 quarter of an inch in diameter. The section showed fibrous material 
 in the submucous tissue, but no milky juice was present, and there 
 was no ulceration. 
 
 The pylorus is sometimes found to be remarkably thickened, 
 although no symptoms of disease have been detected during life. 
 On the post-mortem table fibrous nodules are also occasionally ob- 
 served in the submucous coat; in an instance of this kind the growth 
 was supposed to be of syphilitic origin, but this opinion was not 
 borne out by other appearances ; the patient aged 61, had an athero- 
 matous state of the aorta, and embolism of the cerebral arteries ; he 
 had pneumonia also, and granular kidneys. In another case a 
 woman, aged 64, who had pneumonia on the right side, presented a 
 growth beneath the peritoneum of the stomach on its anterior surface 
 and near the pylorus. The growth was about the size of a hazel- 
 nut ; it was easily enucleated, and did not involve any of the mus- 
 cular fibres. It was fibrous under the microscope: several more 
 were in the neighborhood over the stomach, and one or two appeared 
 to be in the course of the minute subperitoneal vessels. 
 
 Polypoid Growths in the Stomach. The mucous membrane of the 
 stomach not unfrequently presents polypi attached to its surface; 
 several of those which I have examined have presented the appear- 
 ance of healthy mucous membrane, and they had not produced any 
 symptoms ; sometimes smaller growths of this character appear
 
 182 ORGANIC DISEASES OF THE STOMACH. 
 
 incorporated together, and closely resemble the appearance of com- 
 mencing carcinoma; it would seem that a cicatrix or some irritating 
 cause has in some cases induced them. They are especially found 
 towards the cardiac extremity of the stomach. We have already 
 referred to the views of Rindfleisch, who considers them to be ex- 
 treme conditions of mammillation, and traces them from a rugose 
 state to pedunculated masses of hypertrophied mucous membrane. 
 Mammillation is, however, almost invariably found, not at the 
 cardiac, but at the pyloric end of the stomach. It is rare to find 
 mammillation at the cardia, and therefore most unlikely that it 
 should advance to such an extreme stage as that indicated by a 
 polypoid growth ; and, on the other hand, the instances which have 
 come under our own notice have given no evidence of such an origin, 
 and we regard them as independent growths which occasionally 
 occur in the stomach, similar to those which are found more com- 
 monly in other parts of the intestinal tract, more particularly in the 
 rectum and sigmoid flexure. 
 
 Cancer of the Stomach. The stomach is one of the organs most 
 frequently affected with cancer, and in this frequency a remarkable 
 contrast is presented when compared with the rarity of strumous 
 disease of the same organ. Every form of cancer is found to occur 
 in the stomach, but instances of medullary and scirrhous cancer are 
 the most numerous, whilst epithelial, villous, colloid, and melanoid 
 are more rarely found. It is seen, however, that these varieties fre- 
 quently pass the one into the other, and thus, while one part has 
 almost the firmness and structure of scirrhus, another has the char- 
 acteristics of medullary growth ; and again, the surface also of a 
 medullary cancer may have the appearance of a villous structure. 
 The disease originates in the mucous membrane of the stomach, or 
 its submucous tissue, or it is propagated to the stomach by the affec- 
 tion of the glands in the neighborhood of the pancreas; and the 
 pylorus, lesser curvature, and cardiac extremity are the parts gene- 
 rally affected. It is not necessary for me to describe the ordinary 
 characters of the several forms of cancer ; the cases I have briefly 
 given show the general appearance of the structures found in them. 
 Bamberger, following Bokitansky, describes the three chief forms of 
 cancer of the stomach, as fibrous, medullary, and areolar or colloid. 
 The melanotic and villous are to be looked upon as varieties of the 
 medullary. Bidder has noticed epithelial cancer. 
 
 AH these forms of disease have a tendency, unlike ulcers, to attack 
 the orifices of the viscus, and the medullary and more particularly 
 the colloid varieties are prone to spread in the submucous tissue. 
 Blended, as they often are, the one with the other, it becomes scarcely 
 necessary to distinguish between them clinically, but it might per- 
 haps be said in relation to diagnosis, that the symptoms vary ac- 
 cording to the form of disease. Thus in scirrhus there is local 
 obstruction and dilatation, and some vomiting; there may also be 
 contraction, so that the calibre of the stomach is narrowed, like a 
 portion of intestine. Alveolar cancer, on the other hand, leads to 
 enormous thickening, sometimes of the whole stomach, and the
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 vomiting may be the chief and the only sympton. Medullary cancer 
 forms large fungoid masses, which may slough away and thus no 
 obstruction is produced ; in these cases emaciation is the only symp- 
 tom present. Other forms of tumors, spindle-cell sarcoma, and 
 fibroid tumors have been noticed. 
 
 "We are not acquainted with the determining cause of the forms 
 of cancer, or whether the opinion which is maintained by some 
 pathologists can be established, that scirrhus is connected in its 
 origin with the fibrous tissues of the part ; medullary with the 
 mucous surface or gland-structure, and colloid especially with the 
 latter ; or whether they are rather indications of the intensity of the 
 morbid action. The part affected has a modifying influence on the 
 character of the disease, the epithelial cancer of a surface covered 
 by squamous epithelium is different from the same disease, where 
 the epithelium is columnar; an instance of differentiation as applied 
 to morbid changes. It would seem that scirrhous disease is less re- 
 moved from normal nutritive change than medullary cancer ; in the 
 one there is a greater disposition to form fibroid tissue, in the other 
 the growth is cellular or even nucleolar. The vascularity of these 
 growths is very different, sometimes the whole structure is reddened 
 and it is full of blood, and the size of the vessel may be so great as 
 to cause active pulsation, and in this way may simulate aneurisrnal 
 disease. The stomach may be affected secondarily from the liver or 
 peritoneum, or cancerous disease of the stomach may be associated 
 with chronic abscess extending to the diaphragm or between the liver 
 and the pylorus ; in one instance this secondarj'- suppuration extended 
 up the oesophagus as high as the division of the trachea; in another 
 case under my care in which cancerous disease of the stomach was 
 well marked, adhesion of the lesser curvature to the abdominal walls 
 had taken place, and at this part a small abscess had perforated the 
 stomach. 
 
 The symptoms of cancerous disease of the stomach, when a tumor 
 cannot be detected on manipulative examination of the abdomen, 
 are often exceedingly obscure, especially in the earlier stages of the 
 disease. It may be convenient to divide the symptoms into three 
 classes, as they are manifested in different stages of the complaint. 
 First, before the formation of any perceptible tumor ; secondly, during 
 the development of a growth; and thirdly, the last stage, that of dis- 
 integration, by ulceration or sloughing. The first symptoms are 
 those of dyspepsia; and with these there is often a peculiarly sallow 
 and anxious expression of the countenance ; pain at the stomach may 
 be entirely absent, or there may be severe gastrodynia; pyrosis is 
 frequently present. 
 
 In the second stage of the disease vomiting is generally the most 
 prominent symptom, especially when the disease is situated at the 
 pylorus or cardia, and the rejection of food takes place according to 
 the seat of obstruction or irritation of the gastric surface, either a 
 short time or several hours after a meal. In some instances the 
 vomiting so quickly follows deglutition as to lead to the supposition 
 of oesophageal disease. The pain also becomes more severe, and is
 
 184 ORGANIC DISEASES OF THE STOMACH. 
 
 generally of a more lancinating character than that experienced in 
 chronic ulcer of the stomach. The vomited matters are often frothy 
 and fermenting, and present us with abundant sarcina ventriculi. 
 Hematemesis is occasionally present. Flatulence distresses the pa- 
 tient, and eructations are frequent ; the bowels become constipated ; 
 emaciation steadily advances, and the countenance becomes haggard 
 and cachectic. On careful examination, a tumor may generally be 
 felt at the region of the stomach, or of the pylorus; it often increases 
 rapidly, and on account of the wasted condition of the parietes, be- 
 comes very apparent. 
 
 In the third stage of the disease the symptoms are more severe and 
 the emaciation extreme, and the vomiting of coffee-ground substance 
 often precedes a fatal termination. The earlier stages are sometimes 
 so slight that the sudden onset of the last stage appears to be the 
 commencement of the disease: thus a patient may fall down after 
 some exertion and attribute the malady to an accident ; this obscu- 
 rity of the earlier symptoms has been observed in several cases of 
 villous cancer, especially when the orifices are free. The vomiting 
 sometimes ceases on account of the sloughing of the growth ; the ob- 
 struction thereby being removed, or the branches of the pneumogastric 
 nerve being destroyed, there may be cessation of consequent irritation ; 
 the pain, also, sometimes diminishes from similar causes, and as the 
 exhaustion becomes typhoid in its character, the pain may entirely 
 cease, or it may be almost absent throughout the course of the disease. 
 Again, as has been shown by Dr. Kennedy, 1 the size of the tumor 
 may actually lessen from the sloughing process. 
 
 The immediate cause of death in cancer of the stomach differs 
 exceedingly; the fatal termination may result from exhaustion con- 
 sequent on the interference with the absorption of nutriment and the 
 completion of the digestive function ; the exhaustion may cause 
 comatose symptoms, and what has been designated serous apoplexy ; 
 or after sloughing has taken place, the patient may rapidly become 
 prostrate ; the breath is then very offensive, he is seized with hic- 
 cough, and in many instances, the absorption of septic matter takes 
 place, typhoid prostration ensues, and lobular pneumonia is the 
 result; or the ulcerative process may produce, in rare cases, fatal 
 hemorrhage, as in an instance in which the splenic artery was 
 divided. Again, the extension of disease to adjoining parts may 
 materially modify the later symptoms of disease, by extension to 
 the liver, by pressure of enlarged glands on the bile-ducts, thus pro- 
 ducing jaundice, or ascites may follow the implication of the perito- 
 neum. The cancerous ulceration sometimes extends to the actual 
 destruction of adjoining tissues, and may pass into the liver ; in an 
 instance of this kind a secondary opening made its way into the 
 duodenum, and death resulted from hemorrhage. Communication 
 sometimes takes place with the transverse colon by a valvular or 
 sloughy opening ; and if the opening is large, feces also pass into 
 the stomach. In some cases there is no evidence of the passage of 
 
 > ' Dublin Quarterly,' 1851.
 
 ORGAXIC DISEASES OF THE STOMACH. 185 
 
 feces into the stomach, but merely gas, which greatly distresses the 
 patient by the fecal odor of the eructation. Dr. Gairdner 1 states 
 that fecal vomiting is more likely to take place when the pylorus is 
 free ; but Dr. Murchison, on the" contrary, and we think correctly, 
 remarks, that fecal vomiting is regulated by the size of the commu- 
 nication between the stomach and colon. The adhesions and slouo-h- 
 ing occasionally reach the external parietes ; and if a commuuicatTon 
 also exist with the colon, an artificial anus is the result. We have, 
 however, more frequently found this perforation of the skin in 
 instances of cancerous disease affecting primarily the transverse 
 colon, and sometimes coming on after blows, &c. (See Disease of 
 Colon.) 
 
 The coffee-ground substance to which we have referred consists 
 of blood which has oozed from the diseased surface, and has become 
 darkened by the action of the gastric juice ; in some instances the 
 hemorrhage is great, and leads to a fatal termination. 
 
 Cancerous disease is generally found to have involved the glands 
 in the small omentutn at the lesser curvature. Next in frequency 
 we find the liver also attacked, sometimes to a very great extent; 
 the bile ducts may be so implicated as to form a mass, as it were, 
 imbedding the duct ; and, in an instance of this kind under my care 
 in which jaundice existed for ten days or a week before death, it 
 was difficult to state in which structure the disease commenced; 
 next the glands in the anterior or posterior mediastinum are infil- 
 trated, and tubercles may be found on the pleura or in the lungs. 
 And lastly, other abdominal viscera, the peritoneum, kidneys, or 
 spleen, may contain cancerous growths. In cancerous disease, also, 
 we observe that the coats of the stomach themselves become infil- 
 trated, and in this respect contrast with the condition which we find 
 in fibroid degeneration of the pylorus. In any form of obstructive 
 disease at the pylorus the muscular walls become hypertrophied ; 
 but if there have been ulceration at the pylorus, and the obstruction 
 has subsequently been removed, the hypertrophy may be exceedingly 
 slight ; so also when the central portions of the stomach or the cardia 
 are affected. 
 
 Diagnosis. It will be found that the symptoms of cancer closely 
 resemble those of chronic ulcer of the stomach ; both are preceded 
 by a period of dyspeptic suffering, during which the diagnosis is 
 exceedingly obscure. The expression of the countenance in both is 
 indicative of distress, but in chronic ulcer there is pallor, in cancer 
 cachectic sallowness. Vomiting of blood is more frequently ob- 
 served in ulceration than in cancer; but in the closing stages of 
 cancerous disease the rejection of coffee ground substance is of very 
 frequent occurrence. The pain of chronic ulceration is often very 
 intense, even more so sometimes than in cancer; but it is of a gnaw- 
 ing character in the former, more acute and lancinating in the latter; 
 again, the vomiting is often more severe in ulceration than in cancer. 
 The tumor of cancer is generally much larger and more perceptible 
 
 1 ' Edinburgh Medical Journal,' July, 1855.
 
 186 ORGANIC DISEASES OF THE STOMACH. 
 
 than the thickening around an ulcer. The emaciation in both may 
 be gradual, progressive, and extreme ; but the termination in ulcer 
 is more frequently by hemorrhage or perforation, whilst in cancer it 
 generally arises from the typhoid exhaustion consequent on the de- 
 generation or sloughing of the growth, the absorption of decompos- 
 ing material into the blood, or the extension of disease to adjoining 
 structures. Both diseases may occur at the same age, but it is more 
 common to find chronic ulceration at an earlier period than cancer. 
 This is shown by contrasting the ages of the cases we record of 
 chronic ulcer of the stomach with those of cancerous disease of the 
 same organ ; the average of the former being male and female 45 
 and 40, and of the latter 52 in men, and in women 49. From 40 to 
 60 years is the age at which we are most likely to have cancerous 
 disease of other organs, and this law holds good with the stomach. 
 The age will in some measure assist us in the diagnosis even at the 
 later stages, but still more in the earlier ; for the varied forms of 
 dyspepsia, gastrodynia, pyrosis, &c., are very frequent at a period 
 long antecedent to the age at which cancer generally manifests 
 itself; dyspepsia being exceedingly common among young females, 
 whilst cancer is almost unknown. Cancerous disease sometimes 
 supervenes upon a chronic ulcer, so that in these cases the symp- 
 toms may occur at an earlier period and be of longer duration than 
 in simple cancerous disease. 
 
 Taking our actual numbers, the comparative ages at each decade 
 are as follows : 
 
 Age 10 20 30 40 50 60 70 80 
 
 Cancer 1 2 10 17 24 18 2 =74 
 
 Ulcer 14 18 6 15 8 2 =63 
 
 This comparison indicates that cancerous disease occurs especially 
 in the later period of life, whilst ulcer occurs more frequently at an 
 earlier period. If, however, we remove instances of acute perfo- 
 rating ulcer, the proportion of ulcers at the earlier periods would be 
 greatly diminished, and would approximate more closely to the age 
 in which cancerous disease prevails. 
 
 The investigations of Dr. Brinton 1 on this subject are very inte- 
 resting and important ; he has collected from varied sources a con- 
 siderable number of cases of cancerous disease of the stomach ; and 
 he shows that males are more subject to the disease than females in 
 the proportion of 2 to 1 ; out of 223 cases, 151 were males, and 72 
 were females; in our cases, out of 74, 52 were males, and 22 females ; 
 as to the age of those affected, the period given by Dr. Brinton does 
 not coincide with the age of those which have come under my own 
 observation as compared with ulceration of the stomach. The follow- 
 ing table, taken from the work of the author just mentioned, shows 
 the liability to cancer and ulceration of the stomach at various ages : 
 
 Age 10 20 30 40 50 60 70 80 90 
 
 Cancer 11 318 63 88 100 52 60 
 Ulcer 20 51' 49 47 56 80 75 100 ' 
 
 1 'Med. Chir. Review.'
 
 ORGANIC DISEASES OF THE STOMACH. 187 
 
 The average age of those affected with cancer he mentions to be 
 51 in the male, and 40J in the female; and in reference to the posi- 
 tion, he confirms the well-known fact, that whilst the pyloric portion 
 is the most frequent seat of cancer, the lesser curvature and poste- 
 rior surface are the positions of ulcer, by the following tabular 
 statement : 
 
 Position. In 360 cases. 
 
 Cancer. 219 Pylorus. 38 Lesser Curv. 36 Cardia. 13 Stomoch generally. 11 
 Greater Curv. 11 Posterior Surface. 11 Anterior Surface. 4 Middle. 
 
 Ulcer. 52 Pylorus, 98 Lesser Curv. 5 Cardia. Stomach generally. 8 Greater 
 Curv. 177 Posterior Surface. 18 Anterior Surface. Middle. 
 
 As to the duration of chronic ulcer compared with cancer, the 
 former disease extends over a longer period of time ; in cancer the 
 disease may be very rapid ; in a case under my care the patient was 
 only ill seven weeks, and had no pain, although there was vomiting 
 for three weeks ; the duration may be from three to six or twelve 
 months, or even two years ; in ulceration, the disease will be found 
 continuing three, four, or even seven years, with varied accessions 
 of severe symptoms ; and instances have occurred in which twenty 
 or more years have intervened between the commencement of the 
 symptoms and their removal by restoration to health or their fatal 
 termination. Moreover, ulceration is more amenable to treatment. 
 
 Beside ulceration of the stomach, there are other maladies to be 
 borne in mind in the diagnosis of gastric cancer. In aneurism al 
 disease of the aorta, or of the coeliac axis, the pain is of a different 
 kind ; it is less, if at all affected by food ; it is most severe at night, 
 and the constitutional symptoms are less decided. A systolic or 
 diastolic bruit may be absent in aneurism, and pulsation is a very 
 deceptive symptom ; for it is often very marked in functional dis- 
 ease of the stomach, and the aneurism may be so near to the dia- 
 phragm that pulsation cannot be felt. In aneurism the sac dilates 
 uniformly, and is not affected by position, as we may find to be the 
 case in diseased glands at the lesser curvature, or in an enlarged left 
 lobe of the liver reaching the aorta and so receiving pulsation. In 
 some forms of medullary cancer the growth is so vascular that it 
 pulsates uniformly, and resembles aneurismal disease ; in these cases, 
 however, ihe gastric symptoms are very decided. In disease of the 
 glands at the lesser curvature, there is less functional disturbance of 
 the stomach than in primary disease of that organ. So also in dis- 
 ease of the liver there is an absence of gastric symptoms, but the 
 pulsation of the left lobe of the liver is often deceptive, as just men- 
 tioned. In disease of the pancreas, the mischief is more deeply 
 seated, the stomach symptoms are less decided, and we not unfre- 
 quently find that jaundice is produced by obstruction of the bile 
 duct where it approximates to the pancreatic duct. Disease of the 
 omentum. The omentura is sometimes thickened by chronic inflam- 
 matory deposit, and forms a hard mass immediately below the 
 stomach, and may simulate disease of the stomach; when, however, 
 there is deposit in the omentum, the mass is movable, and the diag- 
 nosis is more easy. Where there is cancerous disease in the trans-
 
 188 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 verse colon there is exhaustion and cachexia, but the pain after food 
 comes on at a later period ; vomiting is absent, unless there be 
 fistulous communication with the stomach, and there is frequently 
 discharge of blood from the bowel. Local peritonitis and suppuration 
 are productive of great tenderness in the region of the stomach, but 
 true gastric symptoms are absent. In simple fibroid disease at the 
 pylorus, the duration is longer, the tumor is less distinct, and the 
 symptoms are more amenable to treatment. 
 
 The evidence of cancer is most marked when the pylorus is affected, 
 and obstructive disease set up. Where this is not the case, cancer 
 is sometimes, however, found after death, without having led to any 
 special symptom, the patient having died from another disease ; the 
 regurgitation of glairy, gelatinous fluid, and gradual emaciation, may 
 constitute the most prominent symptoms. It sometimes happens 
 that cancerous disease of the liver is followed by infiltration of the 
 glands at the head of the pancreas, which become united to the 
 pylorus ; and, without having infiltrated the mucous membrane, 
 these glands lead to obstruction at this part, causing hypertrophy of 
 the muscular coat, and, by this obstruction, they simulate primary 
 cancer of the stomach itself. The stomach is sometimes secondarily 
 involved in cancerous disease of the oesophagus, as in an instance in 
 which two malignant ulcers were found in the stomach, and a third 
 in the duodenum. The disease in the oesophagus had led to the 
 prominent symptom of dysphagia, and produced sloughing in the 
 adjoining lung. When the cardiac extremity is diseased, the vomit- 
 ing frequently occurs so immediately after taking food that the 
 symptoms resemble cancerous disease, or some other form of obstruc- 
 tion of the oesophagus. In some instances the pneumogastric nerves 
 may be traced through the medullary tumors of the stomach ; and 
 either the nerve-fibres may be found to present their ordinary 
 microscopical appearance or be entirely destroyed. It is this de- 
 struction of the nerve-fibres which sometimes lead to a cessation of 
 the pain and extreme irritability of the stomach. 
 
 The following table of cases, which have occurred for the most 
 part in Guy's Hospital during the last twenty years, shows the sex 
 of the patient, the form of the disease, the cause of death, the con- 
 dition of the stomach as to dilatation or contraction, and the 
 complications or secondary affections. Out of 79 cases the cancer 
 occurred at the 
 
 Pylorus in 
 Lesser curvature in 
 Cardia in 
 Anterior wall in 
 General in 
 
 41 
 
 11 
 
 10 
 
 5 
 
 4 
 
 Centre in 
 Multiple in 
 Greater curvature in 
 Cardia and pylorus in 
 Not stated in .
 
 ORGANIC DISEASES OF THE STOMACH 
 
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 190 
 
 ORGANIC DISEASES OF THE STOMACH. 
 
 
 
 
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 192 ORGANIC DISEASES OF THE STOMACH. 
 
 In the treatment of cancer of the stomach the same remedies which 
 have been mentioned in chronic ulceration may afford great com- 
 fort to the patient, although they are ineffectual as a means of cure. 
 
 It is of the greatest importance carefully to regulate the diet of 
 the patient ; but it is of no use, and indeed the exhaustion is in- 
 creased, by the continued administration of food that cannot be 
 digested or pass the pylorus. If there be pain, and especially if 
 there be obstruction at the orifices, fluid diet only should be taken, 
 and of a kind that does not easily undergo fermentative change ; 
 milk and simple soup, as mutton broth, chicken broth, eggs, &c., 
 are the best, and some fresh lemon juice with water to supply the 
 place of vegetables ; farinaceous food, although unirritating, is often 
 followed by flatulent distension ; sugar should be avoided, and 
 these patients are, as a rule, better without ardent spirits. A small 
 quantity of wine, such as good Marsala, may sometimes be taken 
 with advantage, and although ardent spirits, as brandy or whiskey, 
 do not ferment, they are more irritating to the mucous membrane 
 and to the liver. 
 
 Medicines which soothe the mucous membrane and which check 
 fermentative action are often of great service. Carbonate or nitrate 
 of bismuth, with carbonate of soda and chloric ether, may be given 
 with almond emulsion or with tragacanth powder and water; if 
 there be pain very small doses of morphia may be added. The dis- 
 advantage of the use of bismuth is the constipating effect that it has 
 upon the bowels, for although the quantity of food taken may be 
 small, there are abundant alvine excretions, and if the transverse 
 colon be loaded and distended the gastric symptoms are increased. 
 Magnesia medicines may be given to obviate this effect, or simple 
 injections used. Castor oil is often easily taken when mixed with 
 tragacanth powder and an aromatic water. Pills are better avoided 
 in pyloric disease and in malignant ulceration ; they do not dissolve 
 in the stomach, and sometimes irritate the diseased part. In one 
 instance, after several pills had been administered and retained 
 for four or five days, they were vomited up almost unchanged. 
 Morphia in small doses alone or with alkalies is often a great relief 
 to the patient, or it may be combined with belladonna. If there be 
 much fermentative action and distension, the sulphite or hypo- 
 sulphite of soda is very useful in 9j doses, along or with the nar- 
 cotics just mentioned. Mineral acids often distress the patient and 
 increase irritability of the stomach, and the mildest tonics, as ca- 
 lumba, cascarilla, increase vomiting and do no good, so also the 
 stronger tonics, as quinine ; sometimes very minute doses of steel, 
 as the amonia-citrate, are tolerated, and if there be hemorrhage, 
 astringents, as the tincture of iron, alum, or tannic acid, may be 
 given. If the stomach refuse these remedies, in cases of great irrita- 
 bility, opiates may be used as suppositories. External remedies 
 afford some relief, and the chloroform liniment alone, or with bella- 
 donna liniment, well shaken together, may be used on linen or 
 spongio-piline. Nutrient injections often prolong life and relieve 
 the patient from much gastric distress ; flatulence, distension, and
 
 ORGANIC DISEASES OF THE STOMACH. 193 
 
 the vomiting of food, are thus avoided, and the sufferer is nourished 
 by this imperfect means more than by ineffectual attempts to induce 
 normal digestion. 
 
 CASE LXVI. Scirrhorts Pylorus. Carcinomatons Tubercles in the Liver, 
 
 Spleen, and Kidney, and on the Diaphragm Edgar C , set. 40, was a 
 
 cooper, and till the attack, for which he applied to the hospital, he had enjoyed 
 good health. Four months previously sickness had come on, and it took 
 place generally a few hours after taking food, but sometimes he was able to 
 retain three or four meals in succession. A tumor could be felt at the region 
 of the pylorus ; there was great emaciation, and he slowly sank. 
 
 Inspection twenty-six hours after death The thoracic viscera were quite 
 free from disease. There were several white, firm tubercles in the abdo- 
 men, on the under surface of the diaphragm, opposed to the liver; similar 
 tubercles were found in the sheath of the right kidney, and a rather larger 
 one on the surface of the spleen. In the liver, on its under surface, were 
 several tubera, about half an inch in diameter, with raised and well-defined 
 edges ; the remaining portion of the viscus was healthy. The stomach was 
 very much distended with air and dark, redish-colored fluid ; at its lesser 
 curvature a small tubercle was observed on the peritoneal surface ; several of 
 the nerves at the lesser curvature were involved in this growth. On opening 
 the stomach it was found to contain fluid, as before mentioned, smelling very 
 strongly of lactic acid. At the pylorus was found a hard mass, composed 
 principally of glands, and on the inferior surface the pylorus itself was infil- 
 trated with dense cancerous deposit. The valve was contracted so as only to 
 admit a large-sized catheter, and its mucous membrane was destroyed by 
 ulceration ; the ulcer extended into the stomach ; its edges were raised, and 
 in some parts were vascular. The muscular coat could be traced nearly to 
 the pylorus, somewhat thickened, but in a healthy condition ; it then became 
 involved in the cancerous infiltration, and was of a whitish color ; at the 
 pylorus both muscular and mucous coats were destroyed, and semi-cartilagi- 
 nous tissue only remained for about three-quarters of an inch. The mucous 
 membrane and the infiltrated tissue presented well-marked cancer-cells, with 
 large nuclei, and aggregated cells, as in epithelial cancer; the dense tissue 
 beneath was gland-tissue, infiltrated with scirrhous product. The duodenum 
 contained bilious matter and a considerable number of white grains, which 
 were at first supposed to be Brunner's glands, but they were found to consist 
 of solitary glands. The pancreas and the remaining portion of the intestine 
 were healthy ; there was some infiltrated glands at the commencement of the 
 rectum, but the mucous membrane was sound. 
 
 The symptoms in this case were well marked, and it was evident 
 that there was obstructive disease at the pylorus. The examination 
 of the growth at that part showed great resemblance to epithelial 
 cancer ; the glands, however, in the neighborhood of the pancreas, 
 which were infiltrated, and the cancerous tubera found in the liver 
 and on the peritoneum, presented the character of ordinary scirrhus. 
 
 It was an interesting fact to find at the rectum, a frequent seat of 
 cancer, the glands infiltrated ; but the lumbar and mesenteric glands 
 were free from disease. 
 
 CASE LXVII. Medullary Cancer of the Stomach, having a villous char. 
 
 acter Thomas G , ait. 62, had been a shepherd at Shoreham, and eight 
 
 months before admission experienced flatulence, loss of appetite, and dys- 
 pepsia. For six weeks he had been very ill, and he ha:l suffered occasionally 
 13
 
 104 ORGANIC DISEASES OF THE STOMACH. 
 
 from vomiting. He had no pain or uneasiness at the stomach ; but he was 
 emaciated, and there was a turner, about the size of an orange, situated just 
 above the umbilicus, but separable from the liver, and slightly movable on 
 respiration. Slight oedema of the ankles came on before death, which took 
 place six weeks after admission. 
 
 On inspection the thoracic viscera were healthy. On opening the abdomen 
 a tumor, about the size of an orange, was found to be situated at the pyloric 
 end of the stomach ; the gall-bladder above was adherent to it, accounting 
 for the movements of the tumor with the liver; and below, the transverse 
 colon and omentum were inseparably united with it. The pylorus appeared 
 ( mbraced by the growth extending from above and below, and on opening the 
 stomach the whole of its circumference was found affected. The intestines were 
 collapsed ; the liver was healthy, but its peritoneal coat was thickened at its 
 lower margin. The gall-bladder was empty ; the pancreas was not at all 
 affected, though in close contact with the tumor ; the kidneys were small, 
 atrophied, and contained cysts. There were several gastric glands in the neigh- 
 borhood of the lesser omentum, which were infiltrated with cancer, but the lum- 
 bar and bronchial glands were not affected. On opening the stomach it pre- 
 sented a large medullary growth, extending about two inches from the pylorus 
 into the stomach, involving the whole of the valve, and forming a projecting, 
 soft, tubercular ring, vascular and extending into the duodenum. The 
 pylorus itself would admit the tip of the little finger. This growth was soft, 
 of a yellowish-white color, and about one inch in thickness. At the margin 
 the muscular coat could be traced into it, forming a semi-transparent layer, 
 about a quarter of an inch in thickness, but evidently infiltrated with cancer ; 
 at the edge of the cancer the muscular coat suddenly became of its usual 
 thickness, showing that there had not been great obstruction, so as to lead 
 to much hypertrophy of that layer. Near to the lesser curvature was another 
 growth, projecting from the mucous membrane, soft, irregular, on its surface, 
 and covering about a square inch in extent ; it was about half an inch in 
 thickness, and at its edges presented small, soft, tubercular growths, projecting 
 from the membrane. The mucous coat, involved in carcinomatous disease, 
 could be dissected away from the muscular, till near the centre of the growth, 
 where all the tissues were firmly united together, and large vessels could be 
 seen passing into the cancerous mass. Near this part, vessels full of blood 
 extended to its circumference, giving it, in some parts, a red and vascular 
 appearance. 
 
 Microscopic examination showed that the mass consisted of cells 
 and nuclei, varying in size ; some cells were about the size of healthy 
 epithelium. The nuclei were large, very distinct, and some had 
 double nucleoli. On taking a portion of the surface of the tumor, 
 and floating it in water, numerous rod-like processes were observed, 
 extending for a considerable distance from it, having the character 
 of villi ; and they gave to the margin of the growth a flocculent 
 appearance. These villi were found to contain numerous nuclei. 
 
 At the margin of the growth the gastric follicles were much de- 
 generated, and they were in some parts distended, but without cells ; 
 in other parts, only the termination of the follicles could be seen ; 
 again, some of the follicles had an irregular outline, and presented 
 crystals on the surface of the membrane. Around the former por- 
 tion of atrophied follicles there was fibrous tissue, arranged in 
 meshes, and with acetic acid the fibres appeared minutely granular.
 
 ORGANIC DISEASES OF THE STOMACH. 195 
 
 The whole appearance of this structure was that of medullary 
 cancer ; it was composed principally of nuclei, and had affected the 
 pyloric extremity, leading to symptoms of obstruction. There was 
 some infiltration of the adjoining glands; but the remaining viscera 
 were healthy. The growth appeared to have commenced in the 
 mucous membrane. It was on the examination of the surface, how- 
 ever, that the resemblance to villous cancer was manifested ; the 
 surface had a flocculent appearance, and microscopical examination 
 showed that this arose from villous processes extending from the 
 surface. 
 
 This case appeared to stand in an intermediate position between 
 medullary and villous cancer ; and it confirms the opinion expressed 
 by Sir James Paget, that the latter may be merely a variety of the 
 more common form. 
 
 As to the symptoms, several months of dyspepsia were passed ; 
 the health then rapidly failed, and prostration of strength, emacia- 
 tion, and occasional vomiting were the principal indications of dis- 
 ease. It was remarkable to observe the absence of pain or even 
 uneasiness of the stomach. 
 
 CASE LXVIII. Cancerous Disease of the Stomach. Exhaustion. Epi- 
 leptic Fit. Coma. Serous Sub-arachnoid Effusion. Some thickening of 
 the Arachnoid William G , aged 64, was admitted into Guy's Hospital, 
 under my care, November 23d, 1870. He was a married man, a mason, his 
 liabits of life had been temperate, and he had never contracted syphilis. 
 Five years previously he had been in the hospital for rheumatism, but had 
 otherwise enjoyed good health. About the commencement of October he 
 began to suffer from aching pain in the chest and pains in the limbs. He 
 then lost his appetite, and the sight of food produced nausea ; although he 
 had been troubled with retelling, he had never vomited. The symptoms be- 
 came more severe, till the period of admission. He was pale and emaciated, 
 his mind not very active ; his complaint was of constant burning pain at the 
 pit of the stomach, and he suffered from great thirst and from nausea. No 
 tumor could be felt at the region of the stomach ; there was some tenderness, 
 and the recti muscles were rigid. The thoracic viscera were normal, but the 
 heart was feeble; pulse 72 ; temperature 99. The bowels were regular; 
 the urine normal. There was no enlargement of the liver, but he complained 
 of pain when percussion WHS made. The spleen was normal. He \v;is 
 ordered the sedative mixture of bismuth (Guy's), and for diet, arrowroot, 
 beef tea, &c., with brandy gij. The pain in the stomach was soon relieved, 
 and he had inclinations for food. December 7th The recti muscles of the 
 abdomen still remained stiff and hard, but there was increased pulsation at 
 the scrobiculus cordis. He was allowed mutton chops, at first pounded, and 
 afterwards, at his request, solid. 21st The countenance had a wasted, 
 haggard expression ; he was able to retain the solid meat diet ; the abdomen 
 was less contracted and a small round growth coull be felt just beneath the 
 cartilage of the seventh rib, Tiear the cardiac end of the stomach. It could 
 be moved, and on pressure communicated pulsation. Castor oil was given, 
 and Dr. Moxon afterwards gave croton oil to unload the bowels, but the 
 swelling remained the same. The moral and intellectual perceptions of the 
 patient were found to be blunted ; he walked out of the ward at night, and 
 supposed that he had been walking for an hour or two ; afterwards tried to 
 get into the next patient's bed ; placed his mutton chops under the bed, as he
 
 196 ORGANIC DISEASES OF THE STOMACH. 
 
 said, to feed the mice. The liquor bismuthi, with citrate of ammonia and 
 iodide of potassium, were ordered. On 21st .January his mind became more 
 clear; he complained of pain in the abdomen, and said that he was \rrv 
 hungry. The abdomen became fuller, more tense, and fluctuation could be 
 felt. The growth in the neighborhood of the stomach became obscured by the 
 effusion. 
 
 In February I again took charge of the ward ; the patient was then in a 
 conscious state, and complained of pain in the abdomen, especially in the 
 gastric region ; there was diarrhoea, which was checked by logwood mixture. 
 His sense of hearing became blunted, and he had a humming noise in both 
 ears. 2oth The abdomen was more full and tense ; there was a slight fit 
 in the morning, the patient lost consciousness for a short time, and on recov- 
 ering retched a good deal. There was pain over the whole abdomen. The 
 left side of the face was slightly paralyzed ; grasp of the hand feeble ; the 
 patient seemed very drowsy. On March 3d he got out of bed in the night 
 and fell down in the ward. He complained afterwards of severe pain 
 over the lower ribs on the right side. No broken rib could be detected, but 
 a flannel bandage was placed around the chest. On March Gth he had 
 rigors; he scarcely understood anything that was said to him. On the loth 
 the urine was found to be albuminous ; the pulse was 90, and very feeble ; 
 he remained in a state of stupor, from which he could sometimes be partially 
 roused, but he almost at once relapsed into a semi-comatose state. lie fre- 
 quently muttered incoherently. Milk with egg and brandy were given. He 
 swallowed food well, and there was no vomiting. He died at halt-past seven 
 in the morning of the 20th. 
 
 An inspection was made in the afternoon of the same day. The brain 
 was small and soft, there was serous effusion between the convolutions, and 
 the fluid in the lateral ventricles was in excess. There was some thicken- 
 ing of the membranes on the surface. The left pleura was adherent: The 
 lung was cedematous, and a patch of recent pneumonia was found. Numer- 
 ous hard, fibrinous nodules were observed on the surface of the pleura, espe- 
 cially at the upper part. The oesophagus was ulcerated. At the cardiac end 
 of the stomach there was a large mass of encephaloid cancer, two inches 
 in depth, very soft, and partially ulcerated. The peritoneum contained six 
 pints of greenish serum, and there were small lymph granulations. The 
 spleen was soft ; the kidneys were healthy ; there was no deposit in the liver. 
 
 The termination of this case was peculiar ; as the exhaustion in- 
 creased an epileptiform attack came on, probably from the atrophy 
 of the brain, with some arachnoid irritation, the faculties became 
 blunted, and the patient slowly sank ; at this time the gastric symp- 
 toms were necessarily obscured, and if the patient had been seen 
 for the first time after the occurrence of the cerebral symptoms, the 
 nature of the malady might have been quite overlooked. The pre- 
 sence of albumen in considerable quantity led us to suppose that the 
 kidneys were diseased, and had some connection with the epilepti- 
 form attack and subsequent persistent drowsiness ; the post-mortem 
 examination showed that the albuminous urine was an effect of the 
 fit rather than its cause, for the kidneys were pronounced to be 
 healthy. It is unusual to find such extensive disease at the cardia with- 
 out vomiting or, at least, regurgitation of food ; but the patient only 
 experienced dry retching. The food having passed into the stomach 
 no further impediment was met with, as the pylorus was free. On
 
 ORGANIC DISEASES OF THE STOMACH. 197 
 
 admission the growth could not be felt, partly from the rigidity of 
 the parietes, and in part from its small size, but as the muscles" be- 
 came relaxed and the growth increased in size, a hard pulsating 
 nodule could be felt ; the pulsation was communicated by contact 
 with the aorta, beneath ; after a few weeks the tumor was again lost 
 to the touch by the serous effusion into the peritoneum. The treat- 
 ment throughout was purely palliative. The movable character of 
 the tumor when first discovered whilst Dr. Moxon had charge of the 
 ward, led to the free use of purgative medicine to remove any pos- 
 sible source of fallacy in the local retention of a fecal mass in the 
 larger bowel ; the true character of the disease, however, being fully 
 recognized. 
 
 CASE LXIX. Villous Cancer of the Stomach. Perforation. Extension 
 into the Left Lobe of the Liver. Secondary opening into the Duodenum. 
 Death from sudden Hemorrhage into the Stomach. Elizabeth C , jet. 56, 
 admitted into Clinical Ward, October 12th, 1870. She had resided near Plum- 
 stead, had worked hard, and had suffered privation. She dated her illness 
 thirteen months back, when on lifting a large tub of water she "felt something 
 snap in her left side, which gave her great pain, and made her feel very faint." 
 For a week she was unable to do any work on account of the seventy of the 
 pain ; hot fomentations afforded partial relief. About a week after the acci- 
 dent she vomited about " half a wash-hand basinful" of dark fluid like coffee 
 grounds mixed with clots of blood, and she continued to vomit similar dark 
 fluid every fortnight till the time of admission. She experienced pain in the 
 side even when lying quiet, but it was rendered much more severe when she 
 moved about or coughed. The appetite was bad, and directly after she took 
 any food great pain in the region of the stomach came on, and in about half 
 an hour it was rejected with black fluid. She lost flesh, and became much 
 paler. The bowels had been regular, the motions sometimes quite black, at 
 other times of a clay color. She was a thin and cachectic woman, with an 
 anxious expression of countenance. She complained of great pain in the 
 left hypochondriac region, extending to the epigastric and right hypochondriac 
 spaces ; the pain was increased by pressure, and was greatest three inches 
 below the left nipple and four inches from the median line. There was dul- 
 ness at the ensiform cartilage. Pain was described as of a stabbing charac- 
 ter, and as commencing on the left side and extending to the right. She had 
 a slight cough, but respiration was normal. There was no bruit with the 
 heart. The urine was free from both albumen and sugar. 
 
 On inquiry it was found that for several months before the hemorrhage 
 from the stomach took place she had suffered from pain, which was relieved 
 by brandy or gin, but that she had been a temperate woman. 
 
 Leeches were applied to the stomach, and conium and blue pill and the 
 sedative solution of bismuth were ordered. She had spare diet. On the 24th 
 meat diet was allowed, the pain having subsided, but it produced at once a 
 return of suffering. The cough was rather troublesome. On November 1st 
 she again had vomiting, and opium was given at night. Oil the 7th diarrhoea 
 came on, but was checked by logwood and opium, etc., and she continued to 
 lose flesh. On the 1st December I took charge of the ward. She was then 
 emaciated and cachectic ; there was defined hardness and tenderness at the 
 scrobiculus cordis, as if the left lobe of the liver was implicated. Opium three 
 times a day gave considerable relief for a time, but she had repeated attacks 
 of diarrhoea and pain across the abdomen, and she steadily lost strength. 
 Bismuth, krameria, &c., afforded partial relief, but she became very despond-
 
 198 ORGANIC DISEASES OF THE STOMACH. 
 
 ing. For some days the pain would cease altogether. On the 20th January 
 she was free from pain, the pulse compressible, the abdomen contracted, but 
 during the night vomiting and diarrhoea supervened, and she gradually sank. 
 
 Inspection was made on the following day. The chest was healthy ; the 
 heart wasted. Abdomen. The peritoneum was healthy, but there were firm 
 old adhesions between the stomach and the left lobe of the liver (the part felt 
 during life), but the parietes were free; the stomach was half filled with 
 blood clot and serum ; the intestines were also filled with blood. On opening 
 the stomach a large villous cancerous growth, five to six inches in length, 
 was found at the lesser curvature on the posterior aspect of the stomach. It 
 had a villous flocculent appearance, its edges were raised, and an inch in 
 thickness. Some of the villi floated loose in the clot ; it was of a pale yellow 
 color, softened, and in the centre was a slough ; at the central sloughing por- 
 tion the walls of the stomach had become perforated and the sac of the lesser 
 omentum opened ; a secondary and also sloughy opening had been formed 
 into the duodenum immediately beyond the pylorus. The valve itself was 
 unaffected. The opposed surface of the liver from the cavity behind the 
 stomach had become affected by direct continuity, and the disease had de- 
 stroyed a considerable portion of the left lobe of the liver ; about half an inch 
 in thickness of liver-structure only remained. The centre of this liver disease 
 was sloughing; it was bounded by sprouting, soft, cancerous growth, which 
 extended into the gland, and was itself surrounded by a more dense whitish 
 zone of firmer tissue. The rest of the liver was fatty and congested ; the 
 ducts were free. There was no secondary affection of the glands. The 
 spleen was normal. u When floated in water the villosities were very long 
 and beautiful, and were full of large vessels injected with blood ; the ramifi- 
 cations of these could easily be seen by the naked eye ; they were soft and 
 easily detached." 
 
 Under the microscope the growth was found to consist of an immense 
 aggregate of cancer cells and nuclei, with very little fibroid or elongated cell- 
 development. 
 
 This case was one possessing many points of great interest. The 
 onset was peculiar ; a short period of dyspepsia was followed by sud- 
 den hemorrhage from the stomach. It is probable that a growth had 
 already formed in the stomach, and that the sudden strain upon the 
 vessels during the muscular effort led to rupture of their coats and 
 effusion of blood ; hemorrhage may also have occurred into the sub- 
 mucous cellular tissue. 
 
 After a short time perforation took place, but it was at the poste- 
 rior part of the stomach, and extravasation was localized by adhe- 
 sions. It is, however, possible that the perforation occurred at the 
 period when, great muscular exertion was made, and this rupture 
 was the cause of the severe pain. The local mischief extended to the 
 liver ; the cancerous disease had involved the gland, and the slough- 
 ing arose from the loss of vitality in the new deposit rather than from 
 destruction of the liver structure itself. This was shown by the 
 margin of cancer growth in the liver. As disease advanced the 
 opening into the stomach not being perfectly free, burrowing took 
 place behind the pylorus, in the direction of the duodenum, and an 
 opening had formed, as before described, into the first part of that 
 portion of small intestine. The perforation of some fresh vessels 
 and the consequent hemorrhage were the immediate causes of death.
 
 ORGANIC DISEASES OF THE STOMACH. 199 
 
 This instance furnishes another example of the insidious com- 
 mencement of cancerous disease of the stomach, but the whole 
 course was obscure, and the more so, as vomiting was greatly less- 
 ened by the removal of all obstruction at the pyloric valve by the 
 secondary opening just described. Distension of the stomach from 
 gaseous evolution tends greatly to increase the severity of the vomit- 
 ing in organic disease of the pylorus. In this instance a free dis- 
 charge of gas could take place into the duodenum by means of the 
 secondary opening beyond the pylorus. The comparative freedom 
 from pain was also remarkable ; in fact, the patient was so destitute 
 of pain that one of my clinical clerks suggested whether there was 
 not a great deal of hysterical exaggeration in her state. 
 
 CASE LXX. Villous Growth of the Stomach. Cirrhosis. Ascites Isa- 
 bella D , aet. 65, was a married woman, who had been accustomed to take 
 spirits, but she stated that she had been in good health till six months pre- 
 viously, when she caught cold, which was succeeded by cough, by shortness 
 of breath, and by burning pain at the scrobiculus cordis. Seven weeks before 
 admission, her legs, and afterwards the abdomen, began to swell ; diarrhoea, 
 great prostration, and syncope came on, and before death she became partially 
 comatose. 
 
 On inspection there were adhesions between the liver, colon, and stomach, 
 and the peritoneum contained about a gallon of serum. The liver was in a 
 state of advanced cirrhosis. The stomach was moderate in size, flaccid, and 
 on the inner aspect of its anterior wall presented a large villous growth, about 
 three inches in diameter, the edges of which were raised, and the centre 
 ulcerated. On floating in water, it presented beautiful villous processes ; 
 these, under the microscope, were found to consist of long, delicate growths, 
 some terminating in points, and filled with granules. The base of the growth 
 presented nuclei. There was no hypertrophy of the pylorus, nor of any por- 
 tion of the muscular coat. The other portions of the mucous membrane 
 presented gastric follicles, containing fat and nuclei. The kidneys were 
 atrophied. 
 
 In this case, with the exception of burning at the stomach two 
 months before death, which is not an unfrequent symptom of dys- 
 pepsia, there was no sign observed of disease of the stomach. This 
 is partly explained by the disease affecting the anterior surface of 
 the organ, leaving the pylorus perfectly free. This absence of ob- 
 struction was further shown by the atrophic rather than hypertro- 
 phic condition of the muscular coat. The advanced disease of the 
 liver, producing dropsy, appeared sufficient to explain all the symp- 
 toms, and the distension of the stomach entirely prevented any 
 tumor being felt at that region. The appearance of the growth, 
 under the microscope, gave less positive proof of a cancerous origin 
 than in the preceding case ; some granules at the base of the villi, 
 but none of the ordinary cancer-cells or nuclei, were present. 
 
 CASE LXXI. Colloid Cancer of the Stomach and of the Colon Eliza- 
 beth T , jet. 37, had been a servant, and had been out of health for four 
 months, but twelve months previous to admission she had had jaundice. She 
 was somewhat emaciated, and had a sallow, aged, and very haggard expres- 
 sion of countenance. She complained much of flatulent distension of the
 
 200 ORGANIC DISEASES OF THE STOMACH. 
 
 abdomen, with a sensation of sinking at the scrobiculus cordis ; after eating 
 she suffered much pain at the stomach, but the pain was most severe after 
 taking fluids. There was occasional vomiting, or rather regurgitation of thin, 
 glairy, and gelatinous fluid; this fluid came up into the throat, especially at 
 night. The bowels were constipated, and she was troubled with hemorrhoids. 
 The abdomen was moderately distended, but no tumor could be felt on manipu- 
 lation. The pulse was feeble. She was in a semi-jaundiced and drowsy 
 condition, complained of a sense of fulness in the head, and of muscoe voli- 
 tantes ; she became more and more exhausted, and gradually sank in about 
 a month. 
 
 Inspection The body was not extremely emaciated. The intestines were 
 much distended with flatus, and the peritoneal sac contained several pints of 
 fluid. The stomach was very much contracted, and its walls were three- 
 fourths of an inch in thickness. The outer or muscular layer was a quarter 
 of an inch in thickness, semi-transparent, and it was divided by white bands 
 which were continuous with the submucous tissue. The mucous membrane 
 had a pulpy, honeycomb appearance, and it was replaced by minute colloid 
 cysts, containing clear, gelatinous fluid ; these cysts were most distinctly ob- 
 se.-ved on the internal surface of the stomach ; there were also some ulcera- 
 tion and congestion of the vessels. The pylorus was not thicker than the 
 rest of the stomach ; but the hypertrophy of the muscular coat extended the 
 whole length of the oesophagus. Some of the glands of the curvature of the 
 stomach were hard and thickened. The fluid from the colloid cysts contained 
 large cells filled with several nuclei, and were surrounded by very delicate 
 stroma. The vessels of the stomach were rendered quite patulous by the 
 tissues placed around them. The small intestines were free, but the large 
 intestine was much thickened ; immediately above the ca3cum there was a 
 portion of colon affected with colloid growth, and from the hypertrophy of 
 the muscular coat it had the appearance of a pyloric valve ; the submucous 
 coat also was much thickened. Some of the solitary glands in the colon 
 were enlarged. The liver, kidneys, and spleen were healthy ; so also the 
 thoracic viscera. The heart was contracted. 
 
 In this case the symptoms at first were not all more severe than 
 those often observed in pyrosis, with flatulent distension of the nl>- 
 domen; nor was the serious nature of the disease for some time 
 anticipated. 
 
 The stomach is preserved in the Museum, No. 1813 29 , and shows 
 in a very beautiful manner the structure of colloid cancer. The 
 hypertrophy of the muscular coat was remarkably extensive, reach- 
 ing into and passing along the whole length of the oesophagus. The 
 small intestine was free ; but the mucous membrane of the colon was 
 affected with similar disease to that of the stomach. Of this there 
 was no evidence during life, although the constipation of the bowels 
 was, perhaps, rather more obstinate than in cases of ordinary cancer 
 of the stomach, but not more than is observed in many cases of dys- 
 pepsia. The most marked symptom was the regurgitation, and the 
 filling of the mouth during sleep with watery, gelatinous fluid ; this 
 unfortunately, was not examined microscopically during life ; it might 
 have afforded clear evidence of the nature of the disease. The seiui- 
 jaundiced condition arose from slight pressure by diseased glands on 
 the common bile-duct, and the colloid growth gradually extended
 
 ORGANIC DISEASES OF THE STOMACH. 201 
 
 through the whole of the mucous membrane of the stomach by con- 
 tinuity of structure. 
 
 CASE LXXII. Colloid Cancer of the Stomach, the Omentum, the Peri- 
 toneum, and of the Rectum John C , set. 47, was a pensioner, and one 
 month before his admission began to experience pain at the scrobiculus cor- 
 dis. Vomiting came on, with costiveness and gradual emaciation. A tumor 
 could be felt extending across the abdomen, and it was doubtful whether this 
 was the margin of the liver, or a tumor involving the pylorus, or merely 
 thickened omentum. 
 
 The parietes of the abdomen were very thin. The peritoneal cavity con- 
 tained several gallons of fluid, of very deep color, almost sanguineous; the 
 serum presented shreds of lymph, and other delicate bands of lymph passed 
 between the coils of the intestine. The omentum was found to be contracted 
 into a thick, yellowish mass, about half an inch in breadth, which projected 
 towards the abdominal parietes. The margin was irregularly notched, and 
 situated immediately above the transverse colon. The surface of the liver 
 was roughened by small gelatinous tubercles, and a thick layer covered the 
 whole opposed surface of the diaphragm, which at this part was much thick- 
 ened, and the pleural surface was also encroached upon. The lesser omen- 
 tum was also much thickened, and a white, hard mass, about the size of a 
 hen's egg, was situated at the lesser curvature of the stomach, near the py- 
 lorus. The small intestines were contracted, the large were distended ; the 
 peritoneal surface was everywhere studded with small tubercles, from the size 
 of a millet-seed to that of a bean ; these were soft, gelatinous, and of a red 
 color. The sac of the lesser omentum contained tubercles similar to those in 
 the general cavity of the peritoneum, and it was distended with fluid. The 
 cavity of the stomach was small, its parietes were thickened, and at the lesser 
 curvature from the oesophagus to the pylorus the mucous membrane was 
 irregularly raised, and presented an appearance of cells distended with clear, 
 gelatinous fluid. The larger curvature was healthy ; the liver was small, and 
 of a deep bilious color; the hepatic cells contained very little fat. The pan- 
 creas and the small and large intestines were healthy, but at the commence- 
 ment of the rectum was a small nodule of cancerous growth ; this had led to 
 the thickening of the mucous and muscular coat, and the intestine at that 
 part would scarcely admit the index finger. Preparation No. 181 3 30 . 
 
 The microscopical examination showed the well-marked characters 
 of colloid cancer. The growths on the peritoneum consisted of large, 
 poly-nucleated cells, with delicate intervening stroma. In the omen- 
 turn there was a greater quantity of fibrous tissue between the ceils; 
 and some of the cells contained four or five large nuclei, which Avere 
 rendered very distinct by acetic acid. The mucous membrane of the 
 stomach presented similar structural elements. The affection of the 
 rectum in this case was an interesting association of disease. 
 
 CASE LXXIII. Chronic Ulceration of the Stomach. Cancer James 
 T , ret. 4G, a weaver, who had been living at Spitalfields, was a regular and 
 sober man, but he had been a great smoker. His father and mother both 
 died of phthisis ; for thirty-four years he had been employed at the loom, and 
 he had suffered much from the shuttle striking the scrobiculus cordis ; these 
 blows at first produced nausea and faintness, which continued for several 
 hours. Five years before admission the same unpleasant symptoms returned, 
 obliging him to discontinue his work ; they were accompanied with vomiting,
 
 202 ORGANIC DISEASES OF THE STOMACH. 
 
 although at first only his breakfast was rejected ; these symptoms continued 
 for four years, and then left him for three months, during which time he 
 rapidly gained flesh, and continued his employment. 
 
 Six months prior to his appearance at Guy's he was again attacked with 
 pain and vomiting, and he began to lose flesh ; he suffered great pain if -he 
 fasted, but on taking food the pain very soon returned, and it was only re- 
 lieved by vomiting ; the vomiting sometimes came on immediately a r ter a 
 meal, or it was delayed for about six hours ; he had never vomited blood ; 
 the bowels were constipated, and the urine scanty. 
 
 He was a small man, of light complexion, and had a diabetic appearance. 
 The chest was healthy ; the tongue was moist and clean ; the abdomen soft, 
 flattened, and contracted ; the integuments dry. Fluid magnesia 5>s, and 
 dilute hydrocyanic acid n^iij, were ordered three times a day ; and a soap 
 enema. 
 
 The vomiting continued very severe, and he became increasingly prostrate ; 
 hiccough came on, coffee-ground vomiting, and he gradually sank. 
 
 On inspection, the body was extremely emaciated ; the lungs were col- 
 lapsed : much black pigment was found upon them, but they were otherwise 
 healthy. The heart was healthy. Abdomen The intestines were collapsed. 
 At the duodenum there was much contraction from puckering of the omentum 
 and stomach. Stomach The walls were exceedingly thin and atrophied ; 
 about two inches from the pylorus was a contraction, which at first was mis- 
 taken for the pylorus ; there was considerable contraction also of the omentum 
 at that part, and firm semi-cartilaginous hardness of the structure. On open- 
 ing the stomach, an oval ulcer, about two and a half inches in length, and 
 one in breadth, was observed surrounding the constriction ; its edges were 
 rounded and elevated ; its base quite smooth. On section, the mucous mem- 
 brane appeared to be continuous with the upper layer of the ulcer ; its deeper 
 layers were very firm, white, and fibrous. Beyond the ulcer and its contrac- 
 tion was a portion of healthy mucous membrane, then the pylorus, which was 
 also perfectly healthy. The first part of the duodenum was congested, and 
 there was pigment in the mucous membrane. In the omentum were several 
 hard tumors, and the omentum itself formed a firm contracted mass, about 
 the size of the middle finger. On section these structures were firm, and 
 contained whitish juice, and under the microscope showed large cells contain- 
 ing large, very distinct nuclei, evidently cancerous. In the stomach no 
 follicles could be detected on the smooth surface of the ulcer ; and in the 
 structures beneath, none of the cancerous cells found in the omentum and 
 glands were present, but abundant fibrous tissue ; there was also much fibrous 
 tissue in the omentum, &c. The rest of the intestine was healthy ; the colon 
 was contracted, and contained some scybala. The liver was healthy ; the 
 spleen was enlarged and firm ; the kidneys also were healthy. 
 
 The history and appearances after death in this case warranted 
 the belief that ulceration of the stomach had existed for a considerable 
 time ; and although we found evidence of cancerous tubercles in the 
 omentum, I think it probable that the development of cancerous 
 growth only took place during the latter stage of the disease ; the 
 growth closely resembled chronic ulcer in its general and microsco- 
 pical appearance, except that it nearly surrounded the pyloric ex- 
 tremity. In some instances, cancerous deposit takes place at the 
 edges of a chronic ulcer : such, however, was not the case here. This 
 case corresponds with those previously referred to, in which a can-
 
 ORGANIC DISEASES OF THE STOMACH. 203 
 
 cerous action took place in the glands and structures adjoining the 
 chronic irritation. 
 
 CASE LXXIV. Cancer of the Stomach. Communication with the Colon. 
 
 Ulceration of the Caecum and lleum. Chronic Phthisis John T , set. 67, 
 
 was admitted August 15, 1855 ; he was a married man, who had resided at 
 Greenwich. He had been out of health for twelve months, complaining of 
 dyspepsia, and pain at the scrobiculus cordis ; the food appeared to remain at 
 the end of the oesophagus, and not to reach the stomach. There had been 
 no vomiting either before or after admission, but a hard defined growth could 
 be felt at the scrobiculus cordis, which left no doubt as to the nature of the 
 complaint; the abdomen was collapsed. On September 15th he was greatly 
 emaciated and able to take but very little food ; his mind wandered *much ; 
 the feet and hands were cedematous ; and numerous spots of purpura were 
 found on the hands and forearms. He gradually sank. 
 
 Inspection The body was much emaciated. Chest Very strong pleu- 
 ritic adhesions were found, especially at the right apex ; the right lung was 
 puckered, exceedingly dense, and on section presented iron-gray consolida- 
 tion, occupying nearly the whole upper lobe ; in the centre it was firm and 
 calcareous ; the lower portion of the upper lobe contained numerous miliary 
 tubercles, some surrounded by dense, others with crepitant lung; in the 
 lower lobe were scattered isolated miliary tubercles, semi-transparent in 
 color. On the surface of the lobe were several lobules, which were broken 
 down in the centre into thin pus, and surrounded by a tolerably defined 
 margin , the extreme edge of the lung was emphysematous ; the left lung was 
 in a similar condition, but the bronchial glands were healthy. The tubercles 
 in the lungs consisted of molecular matter, of small irregular cells and nuclei ; 
 some of the cells were the size of the ordinary ones in the pulmonary struc- 
 ture, but none were like those in the stomach. 
 
 The abdomen was collapsed; the stomach was firmly adherent to the trans- 
 verse colon. On opening the former, along the lesser curvature, a large 
 growth, nearly four inches in circumference, was found at the pyloric ex- 
 tremity, involving the whole of the pylorus, and surrounding the stomach at 
 that part ; the edge was thick, rounded, and raised an inch above the sur- 
 rounding mucous membrane, so that the growth formed a sort of cup ; the 
 margin was of a deep purplish hue ; the centre presented an irregular ragged 
 slough of a brown color; it was deeply excavated, and had a feculent odor. 
 At the pylorus the muscular coat was about four inches in thickness, of a 
 whitish color, with small intersecting semi-transparent bands. Nearer to the 
 cardiac extremity were two small raised growths, one about half an inch in 
 diameter, red and prominent ; the other about a quarter of an inch in dia- 
 meter. The rest of the mucous membrane was pale. The stomach near the 
 pylorus was firmly adherent to the transverse colon, and from the centre of 
 the slough a probe could be passed into the colon ; the opening in the colon 
 was valvular, gray, and about a line in diameter. The pancreas and omentum 
 were healthy ; several mesenteric glands in the neighborhood were infiltrated 
 witli soft cancerous product. The duodenum was gray, but its mucous mem- 
 brane healthy ; at the ilio-caecal valves were the remains of an ulcer occupy- 
 ing nearly the whole of the last Fever's gland, and extending to the caicum ; 
 its margin was raised, and presented several congested nodules. Externally 
 the cellular coat was firm, hard, and contracted. The remaining part of the 
 intestines was healthy. 
 
 On examining the surface with the microscope, the growth presented on 
 the surface columnar epithelium, and consisted of nucleated cells, with very
 
 204 ORGANIC DISEASES OF THE STOMACH. 
 
 large and distinct single or double nuclei, and of delicate intervening fibrous 
 tissue; there was no doubt of their cancerous character. The adjoining 
 mucous membrane presented numerous fat particles in the follicles; the glands 
 contained similar cancerous nuclei. The ulcer in the ileum and ca-cuni ap- 
 peared partly cicatrized ; it did not present any cancerous product, but only 
 fibrous tissue. At the pylorus, bands of involuntary muscular fibre were 
 found to extend between the cancerous elements. 
 
 As far as could be decided by microscopical examination, the 
 disease in the lung was of a non-cancerous character; it appeared to 
 consist in a chronic and almost quiescent state of phthisis ; but besides 
 this chronic disease, there was evidence of acute lobular pneumonia, 
 which had probably come on a short time before death. The condi- 
 tion of the ileum was that of a healing ulcer. It was difficult to 
 obtain a full history from the patient, and the evident cancer of the 
 stomach obscured the signs of pulmonary disease. The existence of 
 a communication with the colon was not known during life. 
 
 CASE LXXV. Struma. Cancer of the Stomach Hannah W , jet. 33, 
 was admitted October, 1857. She was a thin, emaciated young woman, pale, 
 with a dejected and somewhat melancholic expression; she had always bei-n 
 delicate, and had been subject for a long time to vomiting. For twelve 
 months she had suffered constantly from this symptom, which generally came 
 on in the evening; menstruation had also ceased during that period; but 
 there was no evidence of disease of the ovary. January, 1858 The abdo- 
 men was moderately rounded, and there was considerable tenderness at the 
 scrobiculus cordis ; and at the region of the greater curvature towards the 
 pylorus, a large tumor or induration could be felt. At the angle of the jaw, 
 on the left side, there was enlargement of the glands of the neck; no disease 
 could be detected in the chest, but the respiration was very coarse at the 
 apices. The heart was normal. Various remedies, had been tried to relieve 
 the irritability of the stomach, and magnesia mixture, creasote, calomel, &c., 
 had been given. Steel pill and some lemon-juice were occasionally taken, 
 but afforded only slight and temporary relief. Bismuth, and afterwards tin- 
 injection of nutrient enemata, were then tried, but without relief; solid food 
 produced excessive pain, and fluids had the same effect, although in less 
 degree. February 1st She was unable to bear the injections, and com- 
 plained much of pain. The tumor was more distinct, oblong, hard, and 
 tender; the pulse compressible, the face flushed. One drachm of fluid pepsine 
 with mucilage was tried, with a small quantity of chop, and milk diet night 
 and morning. 4th She was rather more comfortable. Gth She com- 
 plained of nausea after the medicine. Opium, 1 grain, was given every night. 
 April 8th Continued in the same anaemic condition, but the emaciation 
 became greater; the abdomen was collapsed; the tumor in the lower part of 
 the epigastric region was distinct, but not enlarged; and there was greater 
 prostration. The pain and vomiting remained as before. She gradually 
 sank, and died July 9th, 1858. 
 
 Inspection nine hours after death. There was consolidation of the lower 
 lobe of the left lung. The bronchial glands were enlarged and filled with 
 firm and cheesy deposit. The glands on the left side of the neck were en- 
 larged from strumous deposit. The heart and pericardium were healthy. 
 The peritoneum was healthy. The stomach was reduced in size; the walls 
 were infiltrated with cancer, extending from the pylorus to the oesophagus, 
 along the lesser curvature, and, in some parts, were three-quarters of an inch
 
 ORGANIC DISEASES OF THE STOMACH. 205 
 
 in thickness, whitish, firm, and consisting of cancerous cellular deposit. The 
 muscular coat was much hypertrophied. The lesser curvature was adherent 
 to the pancreas, and the neighboring glands were infiltrated. The mesenteric 
 glands contained white softened deposit. The liver presented vascular nodules 
 of cancerous deposit, their central parts being depressed ; some nodules were 
 firmer, and white in color. The right ovary was enlarged. 
 
 In this case the association of strumous disease of the glands of 
 the neck and of the chest, with cancerous disease of the stomach, 
 was unusual. The patient was younger than those usually affected 
 with cancer, and the duration of the disease, which lasted two years, 
 was greater than in ordinary cases. The pain was severe through- 
 out the disease, and this suffering was, perhaps, due to the infiltration 
 of the glands about the ganglia, or to the implication of branches of 
 the pneumogastric nerve in the diseased walls of the stomach. 
 
 CASE LXXVI. Cancer of the Stomach. Disease of the Supra-renal 
 Capsule John S , set. 43, a sailor, was admitted into Guy's Hospital, 
 under Dr. Barlow's care, December 21st, 1859. Six years before he had 
 had dysentery in the Black Sea. In November, 1859, he was taken ill some- 
 what suddenly at Malta, he fell down on deck, and sutfered from severe pain 
 at the scrobiculus cordis. He remained in hospital at Malta for a month ; 
 vomiting then came on, and afterwards continued ; but he had occasional 
 intervals of cessation of several days' duration. On admission he was emaci- 
 ated, and had a haggard, distressed appearance ; he had severe pain across 
 the abdomen. In January, 1860, severe vomiting returned, generally after 
 every meal, or at night ; the bowels were much constipated ; he was prostate, 
 and on placing the hand on the abdomen a hard growth could be felt in the 
 region of the pylorus and gall-bladder. The forehead was discolored, as in 
 Melasma Addisonii. He slowly sank, and died February, 1860. There was 
 an inspection on the 20th, and a cancerous ulcer, about three inches in diam- 
 eter, was found at the pylorus ; its edges were slightly raised, and its surface 
 sloughy ; near to the liver was some infiltration of medullary matter. The 
 supra-renal capsules were enlarged and infiltrated. No other part was dis- 
 eased. 
 
 The symptoms in this case were marked, but the sadden onset of 
 the disease, causing him to fall whilst walking and carrying a tray 
 on deck, was unusual, and might have led to an incorrect diagnosis. 
 The patient rapidly became very prostrate, and it is probable that the 
 affection of the supra-renal capsules tended to increase the exhaus- 
 tion, and hastened the fatal termination. 
 
 CASE LXXVII. Cancer at the Pylorus, simulating Disease of the (Eso- 
 phagus. Communication with the Colon James E , set. 61, was under 
 my care in Guy's Hospital in 1859. He was a hawker, who had resided at 
 Kensington ; his habits of life had been intemperate. He had been in St. 
 George's Hospital with fractured ribs ; hajmoptysis followed, and from 1852 
 he had suffered from bronchitis. In 1857 he was in the Consumption Hos- 
 pital for bronchitis; but at the same time he had dyspepsia, with occasional 
 nausea. In October, 1858, he first noticed a small hard swelling in the left 
 'hypochondriac region ; it was movable, and did not cause any pain. After 
 that time he gradually emaciated, and had daily increase of pain at the 
 affected part ; and vomiting, previously occasional, became almost constant,
 
 206 ORGANIC DISEASES OF THE STOMACH. 
 
 although it sometimes ceased for several days. On admission, on March 19th, 
 he had a sallow, slightly jaundiced, appearance ; he was of dark complexion ; 
 his skin was of normal temperature ; the tongue was furred, and brown in 
 the centre, but whitish at the edges. The chest presented the signs of old 
 bronchitis ; the heart-sounds were normal, but the pulse was feeble, 75. The 
 abdomen was tense and resisting, and was resonant, excepting at the epigas- 
 tric and left hypochondriac regions, where a defined tumor was present ; the 
 tumor was painful on pressure, and had slight pulsation, and on taking solids 
 they were instantly rejected, as if there were obstruction at the extremity of 
 the oesophagus ; but fluids were retained for three or four hours, and were 
 then rejected as a chyme-like mass. There was interscapular pain. The 
 bowels were much confined ; the urine was high colored, of sp. gr. 1020, and 
 free from albumen and sugar. On April 14th he vomited dark offensive 
 matter, of almost fecal odor. Local erysipelas of the forehead and right 
 eyelid came on, and slight abscess followed. This, however, subsided ; but he 
 gradually sank, and died June 19th. The abdomen only could be examined. 
 There was a tumor at the pylorus, about the size of a closed fist, firmly ad- 
 herent to the anterior abdominal parietes and to the edge of the liver. On 
 removing it from the parietes a small abscess was found to have been pro- 
 duced anteriorly from the extension of the cancer to the surface, and the con- 
 sequent local peritoneal inflammation. On opening the stomach, the pyloric 
 end was found to be occupied by a large cancerous growth, which extended 
 about three inches into the stomach and surrounded the orifice, and it reached 
 nearly to the oesophageal opening at the lesser curvature. The growth was 
 sprouting and fungating ; it had a green, sloughy appearance, and was situ- 
 ated in the mucous and submucous tissues. Posteriorly the muscular coat 
 was hypertrophied, but anteriorly this coat was invaded by the cancerous 
 disease, and there was adhesion to the anterior abdominal parietes. There 
 was adhesion also with the colon, and a communication existed, through 
 which a probe could be passed. The pancreatic glands were involved, but 
 the other abdominal viscera were healthy. The growth was soft, vascular, 
 and of an encephaloid character. 
 
 Tbe vomiting, in this instance, during the early stage of the dis- 
 ease, took place so quickly after deglutition, that the disease was at 
 first referred to the oesophagus, and, till nearly the close of life, the 
 cardiac extremity rather than the pylorus was supposed to be the 
 seat of organic mischief. The communication with the colon gave 
 a fecal odor to the ejected matters, and the extension of disease to 
 the skin would, in a few days, if life had been prolonged, have led 
 to the formation of an artificial anus. 
 
 CASE LXXVIII. Cancer of the Pylorus. Hydatid Disease of the Cellular 
 Tissue of the Bladder. W. A , set. 52, a clerk, who had resided at Wool- 
 wich, was admitted into Guy's Hospital under my care, March 28th, 1HGO. 
 He had enjoyed good health till eight months previously, when loss of appe- 
 tite and vomiting after food came on ; the rejection of food took place either 
 at once or after long intervals. The bowels were constipated. Emaciation 
 had gradually become extreme, and when brought to the hospital it was 
 thought that he would scarcely reach the ward. He, however, rallied, and 
 survived for three weeks. Vomiting did not recur till two days before death. 
 There were no signs of disease of the chest. The abdomen was much con- 
 tracted ; an ill-defined tumor could be felt in the region of the pylorus; and 
 there appeared to be no doubt that he suffered from chronic disease of the
 
 ORGANIC DISEASES OF THE STOMACH. 207 
 
 stomach. He had not suffered from htemetamesis, neither did he complain 
 of any pain at the stomach. The diagnosis of cancerous disease was confirmed 
 at the inspection. In the hypogastric region was a tumor reaching as high 
 as the umbilicus, precisely resembling in form a distended urinary bladder ; 
 it was dull on percussion, rounded in form, and fluctuation was distinct ; it 
 was also readily felt in the rectum. The patient stated that he never experi- 
 enced any difficulty in passing water, nor had he any pain at the part. A 
 catheter was passed without difficulty, and a few ounces of healthy urine 
 were drawn off. On inspection the thoracic viscera were found to be in a 
 healthy state ; the peritoneum also was healthy. The stomach was slightly 
 distended, and on drawing it aside, a marked constriction was observed at 
 the pylorus ; and several of the glands at the lesser omentum and near the 
 pancreas were enlarged and infiltrated with cancerous product. A firm 
 growth was found to exist at the pylorus, extending into the stomach for 
 about one inch and a half, where it terminated by a rounded, raised, and 
 vascular edge ; the valve was quite surrounded by the growth, and the sur- 
 face was partially ulcerated. The growth had a similar vascular and raised 
 edge on the duodenal aspect, but was there less prominent. The little finger 
 could be passed through the pylorus. The growth was of a yellowish-gray 
 color, moderately firm, containing succulent fluid : it was composed of cells 
 with large nuclei, free nuclei, elongated cells, &c., and was evidently cancer- 
 ous. The liver, kidneys, and spleen, were healthy, so also the intestine. 
 The ureters were not distended, the right one was spread out on the cyst, 
 which occupied the usual position of the bladder; whilst the bladder was 
 itself flaccid and situated on the left side of the hypogastric tumor. The 
 peritoneum was smooth and healthy. The mucous membrane of the bladder, 
 the prostate and urethra, the vesiculse seminales, and vasa deferentia, were 
 all normal. To the right of the bladder, in the median line, and apparently 
 developed in the loose cellular tissue of the bladder, was a large hydatid cyst, 
 holding nearly three pints of small cysts, varying in size from a line to an 
 inch in diameter, and full of clear fluid. At the base of the cyst was a firm, 
 yellowish-gray substance, containing plates of cholesterine. The cysts beau- 
 tifully showed their lineated structure, and numerous booklets of the echino- 
 coccus were observed. The cyst had apparently commenced in the neighbor- 
 hood of the prostate. 
 
 The diagnosis of cancerous disease at the pylorus in this case was 
 made out without difficulty ; but there was much obscurity as to the 
 character of the hypogastric cyst. There was no difficulty in mictu- 
 rition, and the patient was scarcely aware of the presence of the 
 tumor. In some instances the ureters are compressed. This is 
 shown in one of the instances recorded by Dr. Bright; the pelves of 
 the kidneys became distended, and suppuration took place in them ; 
 in that case some of the hydatids were discharged with the urine. 
 Occasionally the pressure is upon the urethra, when the cyst may 
 still more easily be confounded with a distended urinary bladder. 
 The vomiting in this case subsided to an unusual extent, ceasing for 
 a fortnight. 
 
 The preceding cases indicate several important facts in relation to 
 the symptoms and course of cancer of the stomach: 1st. That the 
 symptoms may be exceedingly slight, and the disease easily over- 
 looked. 2d. That the indications are more marked when the orifices 
 are affected. 3d. That the cachexia, the pain, the vomiting, &c., vary
 
 208 ORGANIC DISEASES OF THE STOMACH. 
 
 in almost every case, being sometimes slight, or altogether absent; 
 in other cases intensely severe, -ith. That the onset of the severer 
 symptoms may be very sudden, but it is generally preceded l>v a 
 period of dyspeptic symptoms. 5th. That the disease is not limited 
 to persons in advanced life. 6th. That it is sometimes associated 
 with struma. 7th. That the occurrence of cancer with chronic ulcer 
 of the stomach tends to explain some cases in which the disease ex- 
 tends over many years. 8th. That cancerous disease generally ter- 
 minates within a year after a tumor has formed. 9th. That the 
 mode of termination is greatly modified by the extension of disease 
 to adjoining structures. 10th. That in most cases death takes place 
 from exhaustion or asthenia, and that fatal hemorrhage and peritoneal 
 perforation are more rare than in ulceration of the stomach, llth. 
 That the absorption of degenerating cancer-structure sometimes leads 
 to symptoms resembling pyaemia. 12th. That some of the distressing 
 symptoms may be alleviated, but that over-active treatment appears 
 to hasten the fatal termination. 
 
 Although in several instances which we have recorded strumous 
 disease was coincident with cancer, the former appeared to be in a 
 quiescent state, and the two morbid processes were not, therefore, in 
 active operation together. Still there may be some unrevealed con- 
 nection between these morbid states; for the phthisical parents have 
 children who die from cancer, and some who are apparently strumous 
 in early life are affected at a later period with cancerous disease. 
 We must hesitate, however, to consider as causative and connected, 
 conditions which may merely have coincident relationship. 
 
 Reference has been made to the presence of foreign bodies in the 
 stomach, and perhaps one of the most remarkable specimens is that 
 which is preserved in the Museum of Guy's taken from an English 
 sailor, who had repeatedly swallowed clasp knives ; after several 
 years emaciation ensued and death took place. The stomach was 
 found after death to contain several knives and parts of others, which 
 had been partially dissolved. 
 
 Stones are sometimes swallowed and afterwards discharged by the 
 rectum, and it is surprising how foreign bodies may thus harmlessly 
 pass through the stomach and intestine without producing pain or 
 any distressing symptom. Coins, nails, in one instance a drawing- 
 pin, passed without pain. Accumulations of hair and string have 
 been found in the stomach, as in a case recorded in the fourth volume 
 of the 'Clinical Society's Transactions.'
 
 209 
 
 CHAPTEE VI. 
 
 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 THE imperfect performance of the digestive process constitutes 
 dyspepsia ; but, this general term is the expression of an effect which 
 arises from numerous causes, and it associates maladies which differ 
 in their course, and in their termination. Thus, at the commence- 
 ment and throughout the course of organic disease of the stomach 
 the food is imperfectly assimilated ; but in the greater number of in- 
 stances of gastric disease the dyspepsia is a transient symptom, and it 
 entirely ceases after a longer or shorter period ; and where other dis- 
 eases are the immediate cause of death, we are often unable to find 
 any structural change in the stomach, either in its secretions or 
 component parts, although dyspepsia may have existed for some 
 time ; these cases, then, constitute what are ordinarily regarded as 
 'functional diseases of the organ, the conditions being either transient 
 or of such a character as to be beyond our sphere of observation. 
 
 In the consideration of functional diseases of the stomach there 
 are some points which are essential to bear in mind, in order that we 
 may rightly understand the symptoms, and adopt means for their 
 relief. 
 
 Its anatomical relations. The diaphraym is situated immediately 
 above the stomach, and is connected to it at the oesophageal opening; 
 its movements affect the stomach, and are concerned with the abdomi- 
 nal muscles in the act of vomiting. Contraction of the diaphragm 
 favors the opening of the cardiac orifice of the oesophagus, and is 
 also the cause of hiccough. The liver partly overlaps the stomach 
 by its left lobe, and disease of the one part may be referred to the 
 other. The relationship of the transverse colon is equally important, 
 for not only does its distension press upon the stomach and interfere 
 with its functional activity, but the omenturn, which is attached both 
 to the stomach and the colon, may drag the former viscus considera- 
 bly downwards. Again, the aorta is situated behind the stomach 
 upon the spine, and its pulsations are easily transmitted, especially 
 when there is any thickening or tumor in the viscera in front. The 
 situation of the stomach corresponds with the scrobiculus cordis, or 
 the depression marked out by the division of the ribs, and reaches 
 downwards in an ordinary state of distension to midway between 
 ' that part and the umbilicus. In great distension it may occupy the 
 greater part of the abdominal cavity ; it reaches to the spleen in the 
 left hypochondrium beneath the ribs, and on the right side terminates 
 in the duodenum at the pyloric orifice, at a line corresponding to 
 about one inch to two inches nearer to the median line than the end 
 of the ninth rib. Flatulent distension of the stomach greatly alters 
 14
 
 210 
 
 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 the form of the abdomen, especially towards the left side and in the 
 central portion. 
 
 We need not dwell upon the physiology of the stomach, further 
 than to remark that the especial function of the stomach is the solu- 
 tion of nitrogenous food, and that saccharine and farinaceous food, 
 as also oleaginous food, undergo changes and become absorbed in- 
 dependently of the action of the stomach itself. The conversion of 
 cane sugar into grape sugar, and of farinaceous food into similar 
 principles, produces substances which easily undergo fermentation, 
 and we have to bear this circumstance in mind in our endeavors to 
 relieve flatulent distension of the stomach and vomiting. The oleagi- 
 nous food becomes emulsified by the action of the bile and pancreatic 
 secretion, prior to its absorption b} 7 the villous processes in the small 
 intestine. Absorption takes place in a very limited degree from the 
 mucous membrane of the stomach, but we have numerous glands 
 gastric follicles which secrete an acid digestive fluid. This fluid 
 or gastric juice is strongly acid in its reaction from the presence of 
 lactic and hydrochloric acids, and it contains an organic principle 
 pepsin which causes the solution of the nitrogenous food in the 
 diluted acid fluid. Pepsin is closely allied to albumen and to fibrin. 
 It is soluble in water, but insoluble in alcohol. The dissolved pro- 
 ducts pass on in more or less complete solution, through the pylorus, 
 to be still further acted upon by the biliary and pancreatic secretions, 
 and thereby fitted for absorption by the minute villous processes of 
 the small intestine. 
 
 Schmidt gives the analysis of the gastric juice as consisting of 
 
 Water 
 
 Pepsin 
 
 Sugar, albuminates, lactic a id, butyric ac d, ammonia 
 
 Chloride of potassium 
 
 Chloride of sodium . 
 
 Potash 
 
 Phosphate of lime 
 
 Phosphate of magnesia 
 
 Phosphate of iron 
 
 954.13 
 
 .78 
 
 38.43 
 
 .70 
 
 4.26 
 
 .17 
 
 1.03 
 
 .47 
 
 .01 
 
 Dyspepsia or Indigestion is due to several causes, and it may be 
 well to remark upon these before passing to the consideration of the 
 different forms of the disease. Indigestion may be due to an im- 
 proper kind of diet ; the food may be unsuitable, it may be adminis- 
 tered in such a manner, or at such periods, that it does not undergo 
 normal changes, and fermentation instead of solution is the result; 
 or the apparatus for digestion may, in one or other of its parts, be 
 impaired, either : 1st. Its mucous membrane arid its secretion may 
 be disordered. 2d. The vascular supply may be in an abnormal 
 state. 3d. The nervous system may be affected. 4th. The muscular 
 layer may be so changed that the movements of the stomach are 
 impeded. Several of these causes of dyspepsia may be combined ; 
 thus, a deficient secretion of the gastric j uice may be due both to the 
 state of the nervous system, and also to the state of the capillary 
 vessels, whether they are in active or passive congestion ; some of
 
 FUNCTIONAL DISEASES OF THE STOMACH. 211 
 
 these functional diseases are very transient maladies, others pass into 
 or are the commencement of irremediable disease. 
 
 It would lead us beyond our purpose were we to describe the whole 
 system of dietary which is suitable in health and disease, neither is 
 it necessary, in referring to each malady as it comes before us, we 
 allude to the most suitable form of diet in each case ; but, we may 
 remark upon the importance of considering the age of the patient, 
 and the requirements of the system ; at a very early period of life, 
 although digestion is active, a solid meat diet is unsuitable and would 
 produce serious results, for the blandest nourishment, such as milk, 
 can only be borne; so also in advanced years, the full diet which is 
 an advantage and necessary during the vigor of middle life, and 
 when active exercise can be taken, becomes injurious to health when 
 this activity has ceased. The period at which food is taken is 
 scarcely of less importance ; in early life it must be repeated every 
 hour or every second or third hour; in middle life three, four, or 
 five hours may elapse between each meal, whilst, again, in declining 
 years the quantity partaken of is generally less ; a smaller interval 
 of time should intervene between the meals, and it is often necessary 
 to relieve the weakness of the system by a supply of nourishment 
 during the night. 
 
 In describing the forms of dyspepsia we may consider them as 
 follows : 
 
 1. Those depending on an altered condition of the mucous mem- 
 brane and of the gastric juice. 
 
 (a) Deficiency of gastric juice, atonic dyspepsia, as in the 
 dyspepsia from weakness, whether from diseased vessels and 
 impaired nutrition, from an exhausted state of the cerebro- spinal 
 system of nerves, from exhaustion of the vaso-motor nerve. 
 
 (/>) Excess of gastric-juice. 
 
 (c) Irregular secretion. 
 
 (d) Abnormal composition, as in pyrosis, gout, rheumatism, 
 hepatic disease, albuminuria; in all these the nervous and vas- 
 cular systems are also involved. 
 
 2. Dyspepsia from an altered vascular supply, active and passive 
 congestion. 
 
 3. Dyspepsia from disturbance of the nervous system, whether the 
 sympathetic or the cerebro-spinal system of nerves and especially of 
 the pneimiogastric. 
 
 Gastralagia. 
 Excessive irritability. 
 Anorexia. 
 Perverted appetite. 
 
 4. Dyspepsia from impeded muscular movements ; and 
 
 5. From fermentation of the contents of the stomach. 
 
 1. Dyspepsia arising from deficiency of the gastric juice is often 
 connected with general weakness and may be designated "atonic 
 dyspepsia." Some of these forms of disease present marked and 
 distinctive symptoms, and for convenience of description we may
 
 212 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 divide them (1) into those connected with diseased vessels and a 
 general failure of power, as in advanced life ; (2) exhaustion of the 
 cerebro-spinal system of nerves; and (3) exhaustion of the sympathetic 
 or vaso-motor nerve. In advanced life the glands are less active to 
 secrete gastric juice, the vessels are less elastic, and in their degene- 
 rated state the circulation becomes feeble, and the mucous membrane 
 receives a diminished supply of blood, the nerves are less sensitive 
 to excite normal movements. In age the destruction of tissue takes 
 place without proportionate repair of tissue, and emaciation is the 
 result: but this emaciation may be so great and the circulation so 
 enfeebled that the patient suffers from anaesthesia and disturbed 
 sensation in varied parts. It may be merely numbness in the hands 
 and feet, or pain, cramp, sensation as of "pins and needles." The 
 special senses may be also disturbed, and both sight and hearing 
 affected, or the brain may be unable to carry on its functions and 
 syncope and vertigo may follow. Distressing symptoms may ensue 
 upon the introduction of food into the stomach; the food remains 
 undigested, it produces pain and a sense of weight, headache, flatu- 
 lence, and sometimes the symptoms just referred to, vertigo, disturbed 
 vision, and even syncope. These effects of indigestion are more 
 severe if associated with another frequent trouble of advanced life, 
 namely, an inactive state of the colon, for if the transverse colon be 
 distended the gastric affection is rendered more severe. It is sur- 
 prising how gradual is the failure of power of the stomach : and we 
 frequently remark how greatly the functional activity is reduced 
 without the loss of life. For months life may be sustained with only 
 a very small supply of food, when there are no great demands upon 
 the strength ; in extreme age, a cup of milk or of arrowroot may be 
 almost the only sustaining food partaken of week after week. In 
 the treatment of this condition we must bear in mind that we have 
 to cope not so much with actual disease as to retard a degenerative 
 process ; the diet should be carefully regulated, it should be of a 
 nourishing kind, and as large meals cannot be taken, a shorter inter- 
 val between them should be allowed than in ordinary health ; and 
 if there be wakefulness at night or restlessness, some fluid nourish- 
 ment should be taken, especially between two and four in the morning. 
 
 Alcoholic stimulants are often taken at this age with advantage, 
 and other stimulants as ammonia combined with vegetable bitters ; 
 stimulating condiments may be useful, as mustard and the various 
 peppers, &c. As to other tonics, nux vomica or its alkaloid strych- 
 nia, nitro-hydrochloric acid, and the milder preparations of steel, 
 may be given. If the bowels are inactive, an aloetic dinner pill 
 with nux vomica and soap, or with guaiacum is often very useful. 
 Large-meals should be avoided, so also the immoderate use of tobacco 
 and of tea. 
 
 Another form of atonic dyspepsia is that connected with exhaustion 
 of the cerebro-spinal system of nerves ; here also there appears to be a 
 deficiency of gastric juice, probably from an anaemic state of the 
 mucous membrane, and it may be produced by sedentary occupation, 
 want of exercise, mental distress, over-excitement, and anxiety.
 
 FUNCTIONAL DISEASES OF THE STOMACH. 213 
 
 The nervous energy of, and the vascular supply to the digestive 
 organs, appear to be inadequate to their requirements, and digestion 
 becomes oftentimes a painful process, from which the patient shrinks. 
 This state is marked by pallor, and by an anxious expression of the 
 countenance ; the appetite is lost, or it is a fastidious one ; the pulse 
 is sharp, irritable, but compressible ; palpitation of the heart, throb- 
 bing sensations, and often pain in the head, are produced ; the tongue 
 is slightly injected in its papillae, and has a whitish fur upon it, 
 though in many cases the tongue is clean, large, and indented; there 
 is sometimes nausea, or actual vomiting ; the bowels are constipated 
 or irregular ; a sense of oppression or weight comes on after eating, 
 sometimes followed by a throbbing sensation in the abdomen, and 
 almost over the whole body, with languor or drowsiness ; at other 
 times there is faintness ; and when undigested food passes into the 
 pylorus and duodenum, violent cramp or spasmodic pain is produced. 
 
 The ingesta may be retained in the stomach for many hours, and 
 in some cases even days in a crude state ; the secretion is not suffi- 
 cient to dissolve what is placed in the viscus ; the irritation produced 
 by the retained food aggravates the ailment, and fermentation or 
 decomposition is set up, with flatulence, pain, heartburn, or severe 
 gastralgia. These symptoms, however, may arise from excess of 
 food rather than from diminished solvent power, as we have pre- 
 viously noticed. When the nervous power is thus weakened the 
 process of digestion is sometimes watched with the most scrutinizing 
 care ; one kind of food after another is said to produce pain and is 
 left off; digestion is said to be so slow that a long interval must 
 elapse before further supplies are taken, life is rendered miserable, 
 and the patient complains of inability to attend to ordinary duties ; 
 some of these instances of indigestion from exhaustion pass into the 
 condition of great nervous irritability, marked by severe neuralgic 
 pain, or by great irritability of the stomach. 
 
 Eecovery takes place, but it is often greatly protracted. In the 
 treatment it is unwise to underrate the sufferings and distress of the 
 patient. Stimulants afford relief, but must be used with great cau- 
 tion, otherwise they will be taken at irregular times without corre- 
 sponding nourishment; the mucous membrane of the stomach will 
 then become irritated and congested, subacute gastritis and all the 
 symptoms of congestive dyspepsia will be produced, and the second 
 disease will be tenfold worse than the first, for a craving for alcoholic 
 stimulants may be induced. Patients should be encouraged to take 
 suitable nourishment, to masticate it properly, and exercise in the 
 open air should, if possible, be taken daily. Constipation should be 
 relieved by aloes and myrrh, or by colocynth and henbane, with or 
 without extract of nux vomica ; a dose of blue pill or of oxide of 
 mercury is sometimes of advantage ; and to rectify the condition of 
 the stomach, capsicum with small quantities of ipecacuanha may be 
 given to increase the secretion ; dilute hydrochloric acid to add to 
 its solvent power, or carbonate of ammonia with bitter infusions to 
 stimulate the vascular and nervous systems of the abdominal organs.
 
 214 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 Or the dilute phosphoric acid with tincture of nux vomica, or with 
 three to five minims of the solution of strychnia, may be given. 
 
 Some years ago Dr. Ballard 1 introduced into English practice, ac- 
 cording to the suggestion of M. Corvisart, an artificial digestive 
 compound, in the form of pepsin, prepared from the stomach of rumi- 
 nants. This constitutes the basis of the various kinds of "Poudre 
 Nutrimentive" (Boudault). I have not met with the success ex- 
 pected from this remedy ; but when properly prepared as by Mr. 
 Squire, and given in doses of two to five grains combined with dilute 
 hydrochloric acid, pepsin promotes digestion, and has in some cases 
 proved of great service. In all cases, however, it is desirable to 
 remove the causes of the imperfect secretion, if possible, rather than 
 to supply a very imperfect artificial substitute. 
 
 The stimulant effects of coffee, ammonia, &c., are not so effective 
 as those of alcohol in these cases, and brandy or wine is often better 
 than malt liquor. In saying this we are very far from recommend- 
 ing the habitual use of such stimulants. 
 
 The habit of smoking, or snuff-taking, produces a relaxed and 
 enfeebled condition of the mucous membrane, the secretions of which 
 become insufficient to insure solution of the food; stimulants are 
 often resorted to, to counteract this effect, and many suffer severe 
 dyspepsia from this cause. 
 
 In a third form of atonic dyspepsia the defective condition of the 
 gastric secretion and of the power of digestion is connected with the 
 state of the nerve of nutrition, as it has bee"n termed, the vaso-motor 
 or sympathetic nerve. 
 
 During chronic disease, as phthisis, the power to digest food seerns 
 to fail entirely in some cases ; the symptoms of chest disease may be 
 relieved, but the patient cannot take food, and if constrained to 
 swallow it, it does not digest ; this may be quite independent of the 
 state so often found at the close of chronic disease in which the 
 mouth becomes aphthous, the tongue red and clean, almost like raw 
 meat, the gums spongy, the throat sensitive, and the gullet irritable. 
 
 In extreme poverty and want in starvation we do not find the 
 craving for food that some would imagine, but the appetite may be 
 almost destroyed from exhaustion. There is sallowness of counte- 
 nance, the eye is sunken, the tongue clean or irregularly furred, 
 injected at the tip and edges, there is irritable cough, the pulse is 
 irritable but compressible, there is pain at the scrobiculus cordis, the 
 stomach is very sensitive and the bowels easily disturbed. It would 
 be very unwise to place food of a kind difficult of digestion in a 
 stomach so enfeebled ; the gentlest measures must be used ; stimu- 
 lants cautiously used, and by degrees, more sustaining nourishment 
 allowed. 
 
 Another cause of this nervous exhaustion is that observed in 
 young persons during rapid growth, and during climacteric changes, 
 as at the commencement of menstruation ; there is gradually increas- 
 ing weakness and loss of strength, the countenance becoming pale, 
 
 1 Ballard, 'On Artificial Digestion.'
 
 FUNCTIONAL DISEASES OF THE STOMACH. '215 
 
 the lips blanched, there is inactivity of both mind and body, and 
 frequently severe headache, sometimes intense in character, on one 
 temple, or in one eye, or it may be at the vertex ; the pupils are 
 dilated, the tongue pale, the bowels generally confined, the pulse 
 compressible, the blood is generally deficient in red corpuscles, and 
 in young women this state passes into what is designated chlorosis ; 
 the menstruation becomes scanty or it ceases altogether, there is 
 venous murmur in the neck, systolic bruit over the aortic valves, 
 the nervous system is disturbed, and pain is easily induced ; it is 
 generally complained of in the left side below the left breast, in a 
 small circumscribed space. In this state of general weakness diges- 
 tion is impaired, and it is on this account especially that we refet to 
 the state at all ; the appetite is perverted or lost, patients will take 
 scarcely any food of a nourishing kind, a little tea and bread, or 
 sweets, and the like. Sometimes the stomach is irritable, and there 
 is pain at the scrobiculus cordis, food is rejected at once, and although 
 scarcely anything is retained there may be a plumpness of the sys- 
 tem, which shows that some portion of nourishment is absorbed. 
 The vomiting appears to take place as soon as the food reaches the 
 stomach; it has been well designated "hysterical stomach" and 
 " regurgitative disease of the stomach." Sometimes, however, the 
 emaciation is extreme. So, again, when there is complete anorexia, 
 and determination not to take food, the wasting necessarily becomes 
 very great. Intense neuralgic pain is another of the indications of 
 exhausted nervous power. This form of indigestion may be greatly 
 relieved by the judicious use of chalybeate medicines, and it is well 
 to begin with the milder preparations, as the ammonio-citrate of 
 iron, which may be conveniently given in an effervescent form ; the 
 bowels should be relieved by aloetic aperients, but it is most import- 
 ant to insist on a nourishing diet, as milk, cocoa, meat, vegetables ; 
 and malt liquors, as good draught stout, are of great service. If 
 the imperfect nutrition goes on there is fear of tubercular formation 
 and its attendant subsequent changes. 
 
 Another condition of indigestion is that associated with the ex- 
 haustion consequent upon child-bearing^ over-lactation, repeated hemor- 
 rhages, &c., the face becomes sallow, blanched, the forehead often 
 irregularly bronzed, there is headache, neuralgia, pain at the top of 
 the head, ringing noise in the ears, the eyes are intolerant of light, 
 the pulse is compressible, the mind often becomes disturbed, delusions 
 may distress the patient, and the appetite is gone. The stomach in 
 this state often becomes irritable, and there is a sensation of emptiness 
 or faintness. This condition is one requiring careful treatment, for 
 stimulants are 'of great value, but require extreme care, for the relief 
 afforded prompts to the continuance of the remedy when the disease 
 has passed away. In these patients the heart becomes feeble, there 
 is faintness, and strong stimulants are at once resorted to to relieve 
 the distress. 
 
 Carbonate of ammonia, with aromatics and bitter infusions, may 
 be used, and steel at first in small doses and in the milder prepara-
 
 216 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 tions; afterwards mineral acids, as previously mentioned, and qui- 
 nine, strychnia, &c., should be given. 
 
 In very stout persons, or in those in whom the appetite has pre- 
 viously been pampered, we find feebleness of digestion, with a sense 
 of weight or exhaustion; spasmodic pain also, and irregular action 
 of the heart are easily induced. These symptoms arise in part from 
 the feeble condition of the heart and circulation, and are increased by 
 an inactive state of the liver. The appetite is often small in stout 
 persons ; and the hydrocarbons are stored up, instead of being re- 
 moved in the ordinary changes of respiration ; but the mischief is 
 still further increased when the heart is irregular from an excess of 
 fat about it, or when the feeble circulation of the brain manifests 
 itself in vertigo and disordered sensations. Much relief is afforded 
 by occasional alteratives, by aloes, rhubarb, and taraxacum, or by 
 nitro-hydrochloric acid with bitter infusions ; stimulants should be 
 avoided if possible, and out-door exercise gradually increased. 
 
 Dyspepsia is also occasioned by an excessive secretion of gastric 
 juice., which is apparently, in some cases, poured out in unusual 
 quantity from a slight stimulant. A burning sensation at the stomach 
 two or three hours after a meal, heartburn, pain in the back, are the 
 usual symptoms of this state. It may be associated with hepatic or 
 with cerebral disease, and it is then best combated by remedial 
 agents calculated to relieve the exciting cause of the disease; imper- 
 fect secondary assimilation, such as exists in gout and in rheumatism, 
 produces symptoms similar to those just mentioned, and they are 
 probably due to a changed character of the secretion rather than to 
 mere excess. 
 
 In the treatment of this form of dyspepsia the diet should not 
 contain an excess of nitrogenous substances; and food should be 
 slowly and thoroughly masticated; it is also important not to limit 
 the patient to fluid forms of food which are rapidly absorbed, and 
 often leave an undigested sedimentary deposit ; the evil of this form 
 of dietary we have often seen in chronic disease, in which dyspepsia 
 has apparently been produced, or, at least, aggravated by this cause. 
 Stimulants are better avoided, or they should be taken in great 
 moderation ; whilst ardent spirits, and the stronger wines are better 
 abstained from altogether, for a temporary relief does not compensate 
 for the injury they perpetuate. Exercise, and the maintenance of 
 good action from the skin are very important, especially when this 
 gastric disturbance is combined with hepatic derangement. 
 
 As to other remedies, the carbonate or caustic alkalies with bitter 
 infusions often afford almost immediate relief; but they do not 
 remove the cause of the malady, and are ineffective unless the diet 
 b3 regulated, and right exercise maintained. Creasote or carbolic 
 acid, combined with sedatives and aperients, greatly mitigate the 
 distressing symptoms; and in all these cases it is well carefully to 
 watch that the bowels are not confined, and that the liver performs 
 its functions. It is not necessary, however, to resort continually to 
 blue pill or calomel to rectify any deviation from healthy action in 
 the hepatic secretion.
 
 FUNCTIONAL DISEASES OF THE STOMACH. 217 
 
 Dyspepsia from an irregular secretion of the gastric juice is closely 
 allied to the state just described. Such irregularity Dr. Budd has 
 mentioned as one cause of the varied degrees of gastric solution 
 observed after death, where other conditions have previously been 
 the same. He states, very truly, that whilst in health the stimulus 
 of food leads to the effusion of gastric juice, in disease it may be 
 poured out without this stimulus. In organic cerebral disease, and 
 also in gastric disease connected with disturbance of the nervous 
 system of a functional kind, a perverted and craving appetite, and 
 desire for food at unusual periods, may be due to this irregular 
 secretion ; and, it is not uncommon to find those who suffer at irregu- 
 lar periods from burning pain at the stomach, which is at once re- 
 lieved by partaking of a mouthful of biscuit or dry bread. When 
 the complaint arises from gastric causes, the directions we have 
 briefly given for the relief of the excessive secretion of gastric juice, 
 may be found of service ; but where it arises from the former, 
 namely, from cerebral disease, other symptoms will be generally 
 present, such as pain in the head, a slow and laboring pulse, .dis- 
 turbed special or general sensibility. In this case, a spare and 
 unstimulating diet is called for; the free action of the bowels is 
 desirable and the avoidance of all causes of mental excitement is 
 most important. Too frequently in children a ravenous appetite is 
 found to be the precursor of organic disease of the brain ; and in 
 mania the sufferer is oftentimes prompted to swallow the most extra- 
 ordinary substances, as large quantities of gravel, possibly from a 
 sense of gastric distress, and of unsatisfied morbid appetite. 
 
 Dyspepsia produced by morbid changes in the gastric secretion 
 leads us to other symptoms of disease ; and the first that we have 
 to notice is Pyrosis or water-brash. This is a symptom of frequent 
 occurrence, and it receives its appellation from the fact of its con- 
 sisting in the rejection of a thin watery mucus. Haifa pint of thin 
 watery fluid, sometimes resembling the white of an egg, is occasion- 
 ally vomited or regurgitated at once ; itis generally neutral in its 
 chemical reaction, and often tasteless, but sometimes it is found to 
 be slightly alkaline, and the patient complains of its saltness. The 
 period at which the discharge of fluid takes place varies both as to 
 the hour of the day, and the frequency of the occurrence of the 
 attack. The vomiting, however, generally occurs when the stomach 
 is empty; and it is accompanied with a sense of contraction and of 
 pain at the epigastric region and at the spine ; with some patients 
 the attack comes on in the forenoon, with others during the night, 
 as at one or two in the morning, that is to say, several hours after 
 retiring to rest. As to the other symptoms, the tongue may be clean, 
 the pulse normal ; the patient tolerably nourished, or anaemic and 
 enfeebled ; headache is often present, and in some instances the water- 
 brash alternates with more severe gastralgia, and often with mental 
 languor and depression. 
 
 It is the opinion of Dr. Handfield Jones 1 that pyrosis is a chronic 
 
 1 Handfield Jones, 'On the Mucous Membrane of the Stomach.'
 
 218 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 catarrh of the mucous membrane of the stomach, similar to blenor- 
 rhcea from the bronchi ; there is much to warrant this supposition. 
 Dr. Chambers, 1 however, favors the idea that the oesophagus is the 
 source of the discharge, and it may be that pancreatic secretion is 
 regurgitated into the stomach and then rejected. The disease comes 
 on after the continued use of oatmeal, and hence it is more common 
 in the north ; it may follow symptoms of chronic gastritis ; and it is 
 produced by great anxiety of mind, by exhaustive disease, by over- 
 fatigue, or by an overworked frame ; it also occurs during pregnancy, 
 and it is met with amongst the symptoms of commencing cancerous 
 disease of the stomach. With such causes, it is not surprising that 
 numerous instances of this disease are found among the out-patients 
 of dispensaries and large hospitals. 
 
 The remedies which relieve pyrosis are astringents and tonics, as 
 the sulphate of iron with the extract of logwood ; quinine with aloes 
 and myrrh ; nitrate of bismuth alone or with conium and nux 
 vomica ; an alterative of blue pill, with rhubarb, is sometimes 
 beneficial. Solution of potash, with hydrocyanic acid or with hen- 
 bane and bitter infusion, is of great service when there is much pain. 
 Other astringents may be advantageously employed with sedatives, 
 anodynes, and tonics, as the compound Kino powder, catechu with 
 morphia or opium, oxide of silver, sulphate of copper, strychnia, or 
 the infusion, tincture or extract of nux vomica. 
 
 A form of pyrosis is found to arise in connection with colloid 
 cancer, watery fluid being regurgitated into the mouth ; and it is 
 important to bear this fact in mind in the diagnosis of colloid disease ; 
 and in ordinary pyrosis the symptoms are sometimes so severe and 
 persistent as to cause hesitancy in our prognosis, and to suggest the 
 presence of carcinomatous disease. 
 
 Beside the abnormal conditions of the gastric juice already men- 
 tioned, there are two others which must be considered, namely, the 
 dyspepsia occurring in what has been termed the lithic acid diathesis, 
 and the dyspepsia found in albuminuria. The former is especially 
 observed in those who are the subjects of rheumatism and of gout, 
 and the following symptoms mark its presence: A fastidious appe- 
 tite, heartburn, flushes of heat, pain at the scrobiculus cordis and in 
 the left hypochondriac region, a constipated or irregular condition of 
 the bowels, a furred tongue, pain in the head, mental depression or 
 unusual excitement, and sometimes severe vomiting and intense pain 
 at the stomach. 
 
 The disease appears to be produced by imperfect secondary assimi- 
 lation, as explained by Dr. Prout. The functions of other viscera 
 are disordered, particularly of the liver and kidneys; the motions 
 become pale, the urine high-colored, and it deposits lithates, or it 
 contains an excess of uric acid. The heart and sympathetic nerve 
 are affected ; there is often irregularity of the pulse, and there may 
 also be vertigo or transient anaesthesia. The blood contains lithic 
 acid, as shown by Dr. Garrod, or other elements from the decompo- 
 
 1 Chambers, ' On Digestion.'
 
 FUNCTIONAL DISEASES OF THE STOMACH. 219 
 
 sition of tissue ; and in this state the gastric juice has an abnormal 
 character; it becomes preternaturally acid from lactic or hydro- 
 chloric acids, or is excessive in quantity, and may be otherwise 
 changed. 
 
 This form of d}^spepsia is easily produced when hereditary ten- 
 dency exists ; but, even where this is not the case, it may arise from 
 over-stimulating diet, from excess, and from other irregularities. 
 
 In few dyspeptic conditions is the regulation of the diet more im- 
 portant, both as to its quality and its quantity ; and it should consist 
 of well-cooked, plain, animal food, with vegetables, the latter being 
 in excess. Stimulants should be avoided, or the lighter wines taken ; 
 for although the immediate distress is relieved by ardent spirits, the 
 disease is subsequently aggravated. 
 
 As to medical treatment, the first object is to mitigate present dis- 
 tress and pain ; if the suffering be severe, chloric ether, chlorodyne, 
 opium, or morphia may be resorted to ; the salts of potash, soda, and 
 magnesia afford relief to the heartburn and distress, and may be 
 combined with carminative or antispasmodic remedies. Charcoal will 
 often relieve the flatulent distension, and may be taken in the form 
 of capsules, or merely mixed with some fluid, as milk or gruel. It 
 is, however, most desirable to remove, if possible, the cause of the 
 disease, namely, the secondary mal-assimilation ; and to correct an 
 inactive condition of the liver, if such a state exists, small doses of 
 blue pill may be combined with colchicum, rhubarb, aloes, and some- 
 times also, with quinine. Taraxacum with bitter infusions, and with 
 the alkaline bicarbonates, acts sometimes as a useful laxative. If, 
 however, there be exhaustion and general feebleness of power, 
 ammoniacal stimulants must be given in combination, and wine 
 allowed. The saline mineral waters are in some of these instances 
 justly recommended ; those of Bath, Bristol, Buxton, and of Chelten- 
 ham are most likely to be of service amongst British springs ; and 
 on the Continent, the springs at Homburg, Wiesbaden, Ems, Karls- 
 bad, and Vichy may be resorted to. Kissingen also and many other 
 places. 
 
 Nothing will avail effectually, however, unless strict dietetic rules 
 be observed, accompanied by exercise in the open air. If the meals 
 be daily hurried, the mind constantly on the stretch from business 
 occupations, the hours of rest shortened, and the consequent ex- 
 haustion removed by stimulating potions, the physician has no 
 chance of affording relief. 
 
 In albuminuria, the vomiting and nausea, which are amongst its 
 most common symptoms, are generally considered as sympathetic ; 
 and the renal plexus of nerves, in its connection with the semilunar 
 ganglion, with the pneumogastric nerves, and with the gastric plexus, 
 is regarded as the exciting cause of the vomiting and nausea. This 
 is probably in great measure the case; but another cause exists, 
 namely, the altered condition of the blood, and the excess of urea 
 which it contains ; the urea is poured out with the normal gastric 
 juice, and acts as an irritant to the stomach, and tends to neutralize 
 the gastric juice. Urea has been demonstrated in the secretion from
 
 220 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 the bronchi, and it is probable that, in these cases, it exists in all the 
 secretions ; but perhaps, in none, to a greater degree than in that 
 from the stomach. 1 It is in vain to expect much relief from reme- 
 dies directly applied to the stomach ; attention must rather be given 
 to the disease of the kidney, and means employed calculated to 
 restore the blood to its normal state, or to free it from poisonous 
 excreta. 
 
 Diaphoretics, as antimony with acetate of ammonia, and salines ; 
 purgatives, as jalap or elateriurn ; warm baths or vapor baths will 
 afford more relief than hydrocyanic acid or creasote ; and cupping 
 from the loins will sometimes remove, or, at least, greatly mitigate 
 the nausea and vomiting; counter-irritation may be applied to the 
 loins or to the scrobiculus cordis; and in some instances of extreme 
 general anasarca, the gastric symptoms and the distress of the patient 
 are greatly diminished by puncturing the thighs and thus allowing 
 the serum gradually to exude. 
 
 There are other forms of mal assimilation which occasion dys- 
 pepsia, and we find indications of this in some of the varieties of 
 cutaneous disease. No organ sympathizes more closely with the 
 stomach than the skin ; in every period of life this fact is noticed ; 
 in infants we have strophulus, and eczema from gastric irritation ; 
 in adults some of the forms of urticaria and roseola, eczema, and 
 lepra ; in advanced life eczema and prurigo, &c. 
 
 It not unfrequently happens that flatulence is produced by the 
 formation of gas in the stomach, irrespective of the decomposition 
 of food, to which reference will subsequently be made ; and in cases 
 of hysteria, or in prolonged abstinence from food, &c., the stomach 
 sometimes becomes painful ty distended, eructations take place, and 
 the power of digestion is diminished. It has been supposed that gas 
 is effused from the capillaries, but of this we have no proof; and 
 equally hypothetical is the opinion that it arises from mucus becom- 
 ing decomposed by gastric juice, and thus evolving gaseous products; 
 the flatulence is generally preceded by slight pain, or by a gnawing 
 sensation at the scrobiculus cordis ; a full meal in this condition will 
 probably not be digested, but the flatulence will be prolonged, and 
 colic be produced. The better method is to take a small quantity of 
 nourishment, with some stimulant a cup of coffee, or a glass of 
 wine and afterwards a more substantial repast, giving time for 
 thorough mastication. Charcoal may in some cases speedily relieve 
 this symptom, but it is more advisable to try and remove the cause. 
 
 We have next to consider those conditions of functional disease of 
 the stomach in which the vascular supply is disturbed, whether in 
 acute or chronic congestion. 
 
 The experiments and observations of Dr. Beaumont on Alexis St. 
 Martin have pointed out the state of the mucous membrane which 
 sometimes exists after improper food or stimulants have been taken ; 
 the surface of the stomach was found in such cases much injected, or 
 erythematous. The secretion was diminished, and during this period 
 
 1 Bernard, also Goodfellow, 'On Diseases of the Kidney.'
 
 FUNCTIONAL DISEASES OF THE STOMACH. 221 
 
 more or less discomfort was generally produced; this condition 
 entirely ceased in a short time, and the surface presented its usual 
 appearance ; but if death had taken place from some other cause 
 during that condition of dyspepsia, the abnormal state would also 
 have disappeared, and no structural lesion would have been dis- 
 covered on careful or even microscopical inspection. This form of 
 dyspepsia is perhaps one of the simplest degrees of acute catarrh or 
 erythema, of which mention has been made in the last chapter. 
 
 After intemperance, either in eating or drinking, the gastric 
 mucous membrane becomes over-stimulated, the portal system is at 
 the same time engorged, and the liver is congested and disordered ; 
 in this state natural secretion does not take place in the stomach, 
 and dyspepsia is produced. 
 
 In this hyperaemia or erythema of the gastric mucous membrane 
 the complexion becomes slightly sallow, and the patient complains 
 of mental depression, lassitude, or headache ; the tongue is furred, 
 the appetite is impaired, and the condition of the bowels is dis- 
 ordered, as shown by a confined state, or by irregular action, with 
 more or less pain. In some cases pain comes on at the scrobiculus 
 cordis and between the shoulders, with thirst, nausea, and vomiting, 
 and often with the rejection of green bilious fluid. 
 
 When excess is habitual the same symptoms are produced in a 
 modified degree ; the patient is hypochondriacal ; he often believes 
 himself to be the subject of serious disease of the liver ; the bowels are 
 constipated or irregular ; flatulence, spasmodic pain or cramp in the 
 abdomen, pain across the chest, tenderness at the scrobiculus cordis 
 are produced ; the .tongue is furred, or its papillae are distinct and 
 injected, the appetite is lost, especially in the morning, stimulants 
 are longed for, and at the same time a bitter or nauseous taste in 
 the mouth distresses the patient ; the pulse is compressible, and a 
 sense of exhaustion and of physical fatigue are attributed to actual 
 loss of power. Sometimes also there are severe headaches, vomit- 
 ing, disturbed special sensibility, as indicated by double vision, 
 muscse volitantes, noises in the ears, disturbed general sensibility, 
 as manifested by numbness, formication, loss of sleep, or sleep dis- 
 quieted by frightful dreams. In this condition, food taken into the 
 stomach remains undigested, and there is a sense of weight or " load 
 at the chest ;" the thick mucus covering the congested membrane 
 prevents the action of the gastric juice on the alimentary mass, as 
 in the instances of chronic catarrh previously described. 
 
 In the treatment of dyspepsia following excess an emetic may be 
 advisable, but not unfrequently this natural mode of relief takes 
 place spontaneously, and the vomiting is preceded by pallor and 
 faintness. If the irritability of the stomach continue, soda water or 
 effervescent salines, as the carbonate of potash, soda, or magnesia 
 with citric acid, may be administered with or without the addition 
 of hydrocyanic acid. The carbonic acid acts as an anodyne and 
 sedative to the mucous membrane, and the sedative compound which 
 is produced relieves the portal congestion. Bismuth is often of great 
 value, and may be given with carbonate of soda and chloric ether
 
 222 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 with almond emulsion, or with water and in effervescence by means 
 of citric acid. 
 
 In this condition of great irritability of the stomach, in which the 
 nausea and vomiting are sometimes excessive, and the disrelish for 
 food well marked, even the sight or smell of it being distressing to 
 the patient, the administration of alkalies is more beneficial than 
 that of mineral acids ; the former act as sedatives, rendering the 
 abnormal as well a& scanty secretion less irritating, and enable the 
 diseased membrane more quickly to recover itself, and to put forth 
 its proper secretion ; the latter act as astringents and tonics to a re- 
 laxed mucous membrane. Cold drinks and ice are often craved for, 
 and when given in moderation tend to relieve the congested state of 
 the gastric membrane. 
 
 If more chronic effects have been produced, small doses of blue 
 pill with rhubarb, and with magnesian purgatives, may be useful ; 
 for, by these means the portal system becomes freed from engorge- 
 ment, and proper secretion takes place ; should a sense of exhaustion 
 then continue, it is well to give hydrochloric or nitro-hydrochloric 
 acids with infusion of gentian or calumba. 
 
 The diet should be plain and easy of digestion, not rich or highly 
 seasoned, and without stimulants, for medicines are of no avail, if 
 stimulants be continued ; three to four hours should be allowed to 
 intervene between each meal. The character of the diet, and the 
 quantity of the food taken are most important considerations ; for 
 meals taken too frequently or in excess, may, equally with the ad- 
 ministration of improper and indigestible substances, be the cause of 
 the malady. Before the stomach can empty itself it is often again 
 irritated by a fresh supply ; numerous dishes may prompt to intem- 
 perance, and excess is especially injurious when associated with late 
 hours and deficient exercise. The function of the stomach is con- 
 nected with the solution and preparation for absorption of the nitro- 
 geneous articles of diet, as they are present in our ordinary animal 
 food ; and in the conditions of active congestion and great irritability, 
 bland demulcent and starchy substances, as milk, arrowroot, &c., are 
 to be preferred. 
 
 Again, imperfect mastication increases the difficulty of digestion ; 
 for the secretions of the stomach are then unaided by the division of 
 the food, and the action of the saliva in changing the starchy por- 
 tions into saccharine matter is not duly performed. This defective 
 division of food may arise not only from the hurry of business and 
 the force of habit ; but also, because the agents of mastication are 
 destroyed ; and the dentist, by restoring the teeth, may afford the 
 most effectual means of removing this form of dyspepsia. 
 
 The more severe forms of subacute gastritis produced by excess, 
 and the chronic congestion in the gastric catarrh connected with pul- 
 monary and cardiac diseases, have been already noticed. 
 
 III. The state of the nervous system is an important consideration 
 in the study of disease of the stomach, as the diseases of other organs 
 lead to disturbance of this viscus by their nervous and sympathetic 
 relations with it. The stomach receives its nervous supply from the
 
 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 Dissection showing the distribution of the pneumogastric nerve on the anterior surface of the 
 stomach, its extension to the pancreas and pylorus, and its connection with the semilunar gauglia, 
 &c. (a) oosophageal extremity of the stomach ; (6) pylorus ; (c c) pnenmogastric nerves ; (e e) branch 
 of the pneumogastvic to the pancreas, connected also with the sympathetic, and then passing onwards 
 to the pylorus ; (//) other branches to the pylorus ; (g g g y) branches of the pneumogastric nerve 
 distributed on the anterior surface of the stomach, presenting a peculiar dichotomous division, and 
 repeated union of its branches ; (h h h h h h) splanchnic nerves ; (i) aorta ; (j) diaphragmatic artery, 
 with a filament of nerve upon it ; (k k) coronary artery ; (I) splenic artery ; (m) hepatic artery turned 
 aside from its position in front of the aorta, and from its origin at the cosliacaxis ; and thus it appears 
 to be behind the aorta ; the large branches of the sympathetic nerve upon it are continuous with the 
 portion of ganglion (r*) close to the coronary artery; (n) vena portse ; (o o) supr.a-renal capsules 
 receiving numerous nerve filaments ; (rr) semilunar ganglia, and descending branches to the mesen- 
 teric artery and renal plexus, &c. ; (s) mesenteric artery drawn aside. 
 
 In this distribution of nerves, the close sympathy of the stomach with the parts supplied by the 
 semiluuar ganglion is explained; thus, it is brought into connection with the liver by its hepatic 
 branches with the pancreas, with the diaphragm and phrenic nerve, with the supra-renal capsules, 
 and by its desceuding branches with other abdominal viscera.
 
 224 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 pneuinogastric nerve, as well as from the vaso motor nerve of the 
 abdomen. The pneumogastric has its origin in the brain, at the 
 floor of the fourth ventricle, and is brought into intimate relation 
 with other nerves arising at the same part ; it then passes to the 
 base of the skull, and is united with other nerves, with the spinal 
 accessory, the facial and the fifth in the neck ; it is distributed to 
 the larynx and to the oesophagus; in the chest to the lungs and to 
 the heart, and in the abdomen it is brought into intimate rela- 
 tionship with the nerves of the liver and pancreas and of the 
 kidney, and it unites with the large sympathetic ganglia at the 
 upper part of the abdominal aorta. Hence the intimate relation 
 of the parts supplied by this nerve. In structural diseases of the 
 stomach the nervous supply is concerned in many of the symptoms 
 produced, as the irritability and the severe pain, in ulceration of the 
 stomach, and in malignant disease, but it is with functional diseases 
 that we have especially to do in the present chapter. Pain, or gas- 
 tralgia, as it has been technically called, irritability of the stomach 
 leading to nausea and vomiting, loss of appetite or anorexia, and 
 perverted appetite, are the symptoms that are produced in these 
 affections ; and it is to the pneumogastric nerve, in its extensive 
 connections, that these symptoms are due. The symptoms just re- 
 ferred to may be caused by irritation, either at the origin or at the 
 peripheral extremity of any of the branches of this important nerve. 
 On examination it is found that the stomach 'itself is not at fault, 
 but that the source of its disturbance is elsewhere. We will take 
 these symptoms seriatim, and first in reference to pain. Gastralgia 
 is sometimes very intense ; although partly neuralgic, it is the nerve 
 at its origin and the state of the whole nervous system that are at 
 fault. The pain is irregular iu its onset; it is not necessarily con- 
 nected with food ; in fact, it is sometimes relieved by food ; there is 
 not the same association with vomiting that we find in gastric ulcer; 
 the expressions of pain by the patient are made in the strongest 
 language; it is "an agony," the pain is "intense," but the other 
 conditions do not correspond, and it is found that when the attention 
 of the patient is diverted the pain ceases. This form of disease is 
 observed where the nervous system has been overwrought, in 
 patients with hypochondriasis, in young persons with disturbed 
 menstruation, with leucorrhcea and dysmenorrhoea. The appetite 
 is impaired, the bowels irregular, vomiting is not usually present, 
 the tenderness at the stomach is not such as we find in organic dis- 
 ease, neither do we find that the remedies which relieve organic dis- 
 ease are of service. Those remedies which strengthen the nervous 
 system, as fresh air, strengthening diet, cheerful occupation, horse 
 exercise, are of value, although sometimes opium, morphia or bella- 
 donna are required to quiet the pain and procure sleep. It is often 
 found that this state is associated with disturbance of the uterine 
 functions ; and sometimes it suddenly ceases, but gives place to irri- 
 tation in some other branches of the pneumogastric nerve. 
 
 Vomiting and irritability of the stomach are also common symp- 
 toms of disturbance of the nerves of the stomach, both of a primary
 
 FUNCTIONAL DISEASES OF THE STOMACH. 225 
 
 and reflex character ; in disease of the brain these are most impor- 
 tant symptoms; in tumors of the brain the vomiting comes on 
 nearly every day, at irregular times, but with a clean tongue and 
 without connection with food, so also in tubercular meningitis and 
 in hydrocephalus ; at the commencement of ingravescent apoplexy 
 we find that vomiting takes place, so also after severe concussion of 
 the brain ; again, in some cases of anaemia of the brain vomiting is 
 induced. 1 In diseases of the larynx and of the pharynx we find that 
 the irritation of the peripheral nerves in these parts*causes vomiting, 
 but still more important are those gastric symptoms produced by 
 disturbance of the pulmonary branches of the pneumogastric nerve. 
 In early phthisis the irritation from tubercular deposit at the apices 
 of the lungs causes violent vomiting, sometimes so severe that the 
 thoracic mischief may be entirely overlooked. Another circum- 
 stance often observed in connection with these forms of reflex irri- 
 tation is, that when the thoracic disease has advanced or has be- 
 come suddenly increased by the onset of acute inflammation, then 
 the gastric symptoms cease. In cardiac disease and pericardia! effu- 
 sion we also find that the stomach becomes sympathetically irritated. 
 The sympathy of the stomach with disturbance of the abdominal 
 viscera is still more manifest; we find vomiting a very common 
 symptom of pregnancy and of ovarian disease ; the vomiting may 
 be especially marked at the earlier period of pregnancy ; but in 
 other cases it continues throughout the whole course; so also in 
 ovarian disease, the irritability of the stomach is often so decided 
 that the fear is entertained of organic disease of the stomach, when 
 the sudden enlargement of the ovary by the distension of an ovarian 
 cyst takes place, and all the gastric symptoms cease. During the 
 passage of gall-stone vomiting is an almost constant symptom, as 
 well as in diseases of the liver; it is seen in renal calculus, as well 
 as in many forms of renal disease ; in intestinal obstruction, in dis- 
 ease of the supra-renal capsules it is usually present, and lastly as 
 an expression of sympathy of the stomach with a morbid state of 
 the whole system at the onset of acute disease, as exanthems, &c. 
 Each of these conditions produces peculiar and characteristic symp- 
 toms, but all of them may be accompanied by violent and most dis- 
 tressing vomiting, and unless care be taken in the investigation it 
 may obscure the primary malady. 
 
 But not only does the stomach itself become functionally affected 
 by peripheraHrritation, but we find that true disease of the stomach 
 leads to sympathetic disturbance of other viscera, as of the head, 
 causing pain, disturbed vision, muscas volitantes, throbbing in the 
 head and ears, tinnitus aurium ; the hepatic and renal secretions may 
 be similarly affected ; and as it has been justly observed by Dr. Philip, 
 these secondary conditions may become so severe as to be more per- 
 sistent and trying than the disease of the stomach itself; thus intense 
 
 i 
 
 'Gastric Crisis in Locomotor Ataxia," by Dr. Grainger Stewart, 'Medical Times 
 and Gazette,' Oct. 7, 1876 ; Charcot, 'Lesons sur les Maladies du Systeme Nerveux.' 
 Tome ii, 2e edition, p. 32. 
 15
 
 226 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 neuralgic pain in the face and head may liave its source primarily 
 in the stomach, and in functional disease connected with an irritable 
 state of the pneumogastric nerve we find that first one then another 
 set of branches may be involved. Acute asthma gives place to irri- 
 tation of the stomach, and vice versa; excessive irritation of the heart 
 may also follow, or laryngeal spasrn. 
 
 An equally marked association of disease, arising from the state 
 of the nervous system, is the irritation of the lungs from disturbance 
 of the stomach equally with that of the stomach in consequence of 
 mischief in the lung; thus dyspepsia gives rise to dyspnoea, and to 
 cough, from the irritation of the gastric branches of the pneumogastric, 
 producing reflex irritation; so also with the heart, by means of the 
 cardiac branches of the same nerve; for palpitation or irregular 
 pulsation may be due to gastric disturbance, and may simulate severe 
 organic disease of the heart. 
 
 In phthisis, it has been long noticed, that indigestion may precede 
 the physical signs of disease in the lungs ; nausea, loss of appetite, 
 impaired digestion, furred tongue, pain at the scrobiculus cordis, as 
 well as severe vomiting to which we have referred, and, after a time, 
 haemoptysis and the general signs of tubercular disease become de- 
 veloped. 
 
 The observations of Dr. Theophilus Thompson, in reference to the 
 state of the gums in phthisis a red injected line being produced 
 along the margin of the teeth is a further confirmation of the irri- 
 tated conditio'n of the mucous membrane. This early state of phthi- 
 sis is that in which the greatest benefit is derived from prophylactic 
 treatment ; by change to salubrious or sea air, by attention to warmth 
 and clothing, the avoidance of night exposure, by taking cod-liver 
 oil, and sometimes vegetable tonics, the further progress of the disease 
 may in many cases be warded off'. 
 
 The irritability of the stomach induced by functional disturbance 
 of the uterus is sometimes excessive, so that any substance is instantly 
 rejected ; leucorrhcea and dysmenorrhcea may be the cause of this 
 excitable condition; and these symptoms may exist without pro- 
 ducing any emaciation in the patient. It is to this condition that 
 Sir Plenry Marsh has given the name of " regurgitative disease," in 
 which the food or the greater part of it is regurgitated rather than 
 vomited; and this takes place without previous nausea, or progres- 
 sive emaciation; and pain may be entirely absent. 
 
 In the treatment of these forms of irritation much relief is afforded 
 . by hydrocyanic acid, by creasote, by calcined magnesia with opium, 
 by chloroform or chloric ether, or by nitrate of bismuth with coniurn. 
 Morphia may be used hypodermically, and in uterine irritation opiate 
 enemata or suppositories are often of great value. The oxalate of 
 cerium is another remedy which is sometimes of great service in 
 this reflex irritability of the stomach. Small blisters applied to the 
 scrobiculus cordis or to the spine, sometimes alleviate the symp- 
 toms. 
 
 When the symptoms result from pregnancy, the mineral acids 
 will often aft'ord relief, or the oxalate of cerium just mentioned. In
 
 FUNCTIONAL DISEASES OF THE STOMACH. 227 
 
 this condition of excessive irritability it is often advisable to omit 
 all medicine, and allow the stomach to rest, employing nutrient ene- 
 mata, and giving only a teaspoonful of water occasionally to relieve 
 thirst. Another plan may be followed, of giving a small quantity 
 of milk and water every ten minutes or half hour. 
 
 In some instances a determined effort of the will will overcome the 
 gastric irritation ; the viscus has become so irritable that the least 
 distension, or it may be voluntary pressure at the scrobiculus cordis, 
 suffices to cause instant rejection of the contents of the stomach; but 
 the presence of a stranger or the absence of any vessel into which 
 the patient may vomit may check the action ; as in a young patient 
 in Guy's Hospital, who was cured because the nurse did not give her 
 any vessel into which she might vomit. 
 
 Calomel is used by some as a sedative to the mucous membrane 
 of the stomach ; but since this condition of irritability is so fre- 
 quently found associated with an anaemic and chlorotic or hysterical 
 state, the administration of mercurials, except as occasional aperients, 
 is better avoided. 
 
 A form of dyspepsia, which primarily arises from the condition of 
 the nervous system, has been already noticed in reference to deficient 
 secretion of gastric juice ; namely, the dyspepsia in hypochondriasis, 
 and in an overworked or imperfectly developed brain ; this condition 
 is exceedingly distressing to the patient, and equally trying to the 
 physician ; it is sometimes the precursor of epilepsy or of mania. 
 In these instances of dyspepsia the whole attention is occupied by 
 the diet, the mind is depressed, and its energies enfeebled; one 
 change after another is tried, but pain and discomfort equally follow: 
 the stomach is sometimes exceedingly irritable ; the bowels are 
 watched with undue anxiety, the sleep is unrefreshing, and life 
 rendered miserable. To tell the patient nothing is the matter, would 
 be to drive him to some one who would give an opinion more in 
 unison with his feelings. By carefully regulating the diet and the 
 bowels, by cold sponging, by taking frequent exercise, either walk- 
 ing or on horseback, or a pedestrian tour when it is possible, by 
 keeping the mind free from anxiety, and by cheerful society and 
 occupation, all the symptoms may be greatly relieved. 
 
 In some men we 'observe a state closely resembling hysteria ; as 
 shown by flatulence, loss of appetite, sensibility of the surface of the 
 abdomen, sensations almost amounting to globus hystericus, dis- 
 turbed cerebral function, depression, anesthesia, incapacity for exer- 
 tion, &c. ; in this condition, which is often combined with distension 
 of the colon, I have found marked benefit result from the use of aloes 
 combined with steel and with assafcetida; fresh air and vigorous 
 exercise are important remedial agents when they can be attained. 
 
 In other cases much resembling those just mentioned, the head is 
 badly formed, and the forehead is narrow ; the body is well nour- 
 ished, but the patient complains of pain at the scrobiculus cordis 
 and in the back, or in various parts of the body : the mind is de- 
 pressed, and the appetite irregular. Although muscular, a man 
 may be quite incapacitated for exertion; the tongue may be clean,
 
 228 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 the bowels regular, the evacuations normal or pale, the pulse tolera- 
 bly full, or depressed and irregular. It would seem that dyspepsia 
 has arisen from ordinary causes, but the sympathetic nerve reacts 
 upon the cerebro-spinal centres, and these being easily disturbed 
 from their healthy balance, again react upon the sympathetic nerve, 
 perpetuating and aggravating the original and slighter malady. In 
 this we find the close connection between dyspepsia or disordered 
 chylopoietic viscera, and mental disease, mania, and melancholia. 
 
 By acting freely on the bowels so as thoroughly to unload the 
 colon, and by the steady perseverance in the milder preparations of 
 iron, this state may be greatly relieved; the mind should be occu- 
 pied and some out-door exercise should be enjoined; continental 
 travel or a sea voyage will often prove of great value, for nothing is 
 of greater disadvantage than to allow the mind to prey upon itself, 
 and to be absorbed with its own morbid sensations. 
 
 Disease of the nervous system is also associated with morbid states 
 of the appetite. There may be a state of anorexia, or loss of appe- 
 tite; we do not refer to the loss of appetite seen in acute disease, nor 
 in general exhaustion from chronic or other disease, but to those cases 
 in which food is refused, or gradually lessened till only a little bread 
 and water may be taken; some of these are instances of religious 
 melancholia, others are cases of cerebral disease, in which the will 
 is at fault rather than the stomach, and to this group belong the 
 vaunted instances of young women surviving for months without 
 food hysterical deception. The appearance of these patients is 
 characteristic, sometimes anasmic and blanched, in other cases with 
 haggard expression, wasted features, sunken eye, dressed in a manner 
 as if to assume great sanctity, the chest and abdomen wasted to an 
 extreme degree, the mind agitated with extravagant notions or per- 
 verse delusion, the bowels confined, the uterine functions in women 
 disturbed. Most of these cases, as Sir Wm. Gull has justly said, are 
 diseases of the mind, and require treatment directed to the cerebral 
 functions, in others kindness with firmness will enable the nervous 
 system to overcome the objection to food, the will resumes its control 
 over the emotions, and, as a proper diet is taken, the nervous system 
 works in a healthy and vigorous manner. Aloes, steel, assafoetida, 
 valerian, are remedies which are of service, but these are of no avail 
 unless accompanied with proper diet and healthful exercise. 
 
 Of a somewhat different character are those cases of anorexia 
 where disease of the uterus, amenorrhoea, and dysmenorrhcea have 
 produced functional disturbance of the stomach ; food may cause pain 
 and vomiting ; the appetite is gradually lessened, and one thing after 
 another is left off; the increasing weakness renders the stomach still 
 more enfeebled, digestion becomes a painful process, and great ex- 
 haustion may be produced. In these instances the patients require 
 encouragement, and may be assured that, as they gain strength t the 
 stomach will become less irritable and the pain will also 1< 
 Mild chalybeates in effervescence are often of value, with a nourishing 
 and vegetable diet. 
 
 Another form of anorexia is that which follows irritability of the
 
 FUNCTIONAL DISEASES OF THE STOMACH. 229 
 
 stomach after ulceration ; whether of a chronic or superficial kind. 
 The patient has left off one article of diet after another, and the 
 system has become so weakened that appetite is entirely lost. Ex- 
 treme emaciation is found in these cases; they resemble cancerous 
 disease or still existing ulceration, but by careful management, and 
 encouraging the patient to persist in taking suitable food, although 
 a part may be rejected, the nervous system gains power : chalybeates, 
 with gentle laxatives, are often of value in these instances. 
 
 The last form of nervous affection of the stomach to which I have 
 to refer is perverted appetite, bulimia. It is not necessary to remark 
 on the habits of some insane patients, who will swallow stones and 
 even things of an offensive character, but to other states of functional 
 disease. In diabstes we have craving, connected not only with the 
 state of the nervous system, but with the condition of the whole 
 organism; other instances often occur in which there is a sense of 
 craving at the stomach, sometimes connected with excessive secretion 
 of the gastric juice, to which we have already referred, but in other 
 instances patients will complain that soon after a meal they experi- 
 ence a craving appetite ;[ there is no pain, no evidence of sugar in 
 the urine, no symptoms of cerebral disease, but the body is wasted 
 and badly nourished, although abundant supplies of food are intro- 
 duced into the stomach. These instances are connected with over- 
 strained nervous energy, and the system generally requires rest and 
 change, and mere medicine is only a very partial benefit, Ammonia, 
 opium, and valerian may be of some service. 
 
 IY. The impeded movements of the stomach are not sufficiently 
 considered as causes of dyspepsia. In hernia, when the omentum is 
 fixed and the stomach is dragged from its position, pain in the hy- 
 pochondrium is produced ; and the habit of tight lacing, which few 
 young ladies are willing to admit, is a fertile source of the same suffer- 
 ing; in most cases the mischief is done very early in life, the ribs 
 are scarcelv allowed to expand, and the stomach is gradually tilted 
 into a vertical position whilst development is taking place. Neural- 
 gic pain in the side, flatulent distension of the stomach, pain after 
 food, spasm, borborygmi, hysteria, are the usual sequences of this 
 folly. Digestion requires that the nutriment should slowly revolve 
 within the stomach, and as it is converted into chyme, that it should 
 pass into the duodenum. When the stomach is placed vertically, its 
 semi-digested contents are more likely to be impelled at once into the 
 pylorus. In the modern dress of ladies the suspension of the weight 
 of the clothes from the waist often leads to interference with the 
 functional activity of the abdominal viscera, and is a fertile source 
 both of dyspepsia and dysmenorrhcea. 
 
 The dyspepsia which is so common in those who spend many hours 
 over the desk, in writing, or in reading, or in any constrained posi- 
 tion, is of the same kind; and amongst tailors, shoemakers, dress- 
 makers, &c., this unnatural and long-continued posture is productive 
 of severe indigestion, which is increased, in many cases, by irregular 
 and intemperate habits. 
 
 Constant pain at the scrobiculus cordis and between the shoulders
 
 '230 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 is complained of; eructations sometimes distress the patient; the 
 bowels are often constipated; the tongue is furred, and the mind 
 depressed. We may often do much to remove the disease by enforc- 
 ing an erect posture during the hours of occupation, by strict atten- 
 tion to diet, by well "regulating the bowels, by relieving torpor of 
 ihe liver, and, if needful, by administering mild alteratives, or nitric 
 acid with taraxacum. 
 
 In tumors developed in the lesser omentum, or about the pancreas, 
 &c., the pylorus becomes pressed upon, and a free passage is pre- 
 vented ; in this case, also, we find pain and heartburn, and sometimes 
 the obstruction is sufficient to produce vomiting. 
 
 In other instances, the movements of the stomach are prevented 
 by the presence of fluid in the peritoneal cavity; in ascites and in 
 ovarian dropsy the stomach may be so much pressed upon, that ex- 
 pansion cannot take place, and its contents may be rejected .or severe 
 pain may be produced. 
 
 It is probable that in some cases of over-distension from flatus, 
 the muscular coat of the stomach is unable to contract, or becomes 
 paralyzed. Dr. W. Philip gives such as his opinion ; and cases are 
 not very rare in which, after death, we find the stomach occupying 
 nearly the whole of the abdomen, reaching nearly to the pubes, and 
 apparently causing death, by interfering with the action of the dia- 
 phragm and of the heart. Lesser conditions doubtless arise, and are 
 attended with much discomfort, as a sense of distension, flatus, and 
 sometimes of intense pain. The symptoms are relieved by ether, by 
 antispasmodics, by the gum resins, as galbanum. assafcetida, &c. 
 
 It must be borne in mind, however, that this tympanitic state 
 sometimes arises from inflammation coming on insidiously, and in- 
 volving the muscular as well as the peritoneal coats, as in some cases 
 of strumous peritonitis. I have seen several such instances, in which 
 fatal results followed without any pain from the commencement to 
 the close. A short time ago, a policeman complained of fulness of 
 the abdomen, which gradually became tympanitic, but no pain was 
 produced; this state increased for six weeks, with prostration; about 
 a fortnight before death the tympanitis was less, and fluctuation 
 indistinct. He gradually sank, about ten weeks from the commence- 
 ment of the illness, but he suffered no pain throughout. There was 
 chronic peritonitis, the whole serous membrane being studded over 
 with whitish grains of lymph. There were bands of adhesion, and 
 the peritoneum contained several pints of bloody serum. The serous 
 investment of the spleen was a quarter of an inch in thickness, and 
 contained small opaque cheesy masses. The small intestines were 
 matted together, but not very firmly, and the ileum presented several 
 passive ulcers. In the lungs, at the left apex, was puckering and 
 iron-gray consolidation. We might readily mistake such cases for 
 ordinary dyspepsia with flatulence, since they occur in youth as well 
 as in middle life. These latter cases must be distinguished from the 
 great distension of the stomach which we have described as connected 
 both with pyloric disease and with paralysis of the muscular fibre of 
 the stomach.
 
 FUNCTIONAL DISEASES OF THE STOMACH. 231 
 
 V. The >. fermentation of the contents of the stomach, and the symp. 
 toms consequent upon it, are due partly to an abnormal state ol the 
 secretions, in part to the muscular movements being impeded, or the 
 pylorus obstructed, and sometimes to the character of the food itself. 
 Dr. Budd has distinguished several varieties of fermentation: so also 
 Dr. Turnbull. 1. The formation of carbonic acid, as in ordinary 
 fermentation. 2. The formation of sarcina ventriculi. 3. Lactic or 
 butyric acid fermentation; and, 4. The formation of sulphuretted 
 hydrogen by simple putrefactive decomposition. 
 
 When the pylorus is obstructed by cancerous disease, by spas- 
 modic contraction, and by tumors, the contents of the stomach are 
 prevented from passing onwards; the viscus becomes distended bv 
 flatus; pain is produced; and vomiting, which affords partial relief 
 to the patient, generally follows a few hours after food has been 
 taken ; the ejected matters are found partially dissolved, and under- 
 going fermentation ; they have a sour smell, and a yeastlike surface; 
 this action is allied to simple fermentation ; alcohol is formed, and 
 carbonic acid evolved ; some acetic acid is produced ; and the sarcina 
 ventriculi discovered by Mr. Goodsir are often detected. 1 
 
 Fermentation of this kind, and the presence of the sarcina, may 
 exist without any pyloric obstruction or organic disease; and sarcinae 
 have been detected in the urine, in the feces, in pus, in pulmonary 
 abscess, and on the healthy mucous membrane ; Robin even states, 
 " ce ve'ge'tal semble etre sans action nuisible sur Tanimal qui le porte." 
 Fermentation may be favored by the imperfect mastication of food, 
 and by taking exercise immediately after it ; by drinking fermenting 
 or new malt liquors; by indigestible vegetables, and fruit; by new 
 bread, salads, &c. Distension is felt almost at once, and regurgita- 
 tion of food into the oesophagus, eructation, palpitation of the heart, 
 &c.. take place ; colic is often produced, and sometimes diarrhoea, by 
 the continuance of the fermentation, or by the presence of semi- 
 digested substances in the intestine. 
 
 In the more severe cases arising from obstruction the sulphite or 
 hyposulphite of soda, as recommended by Sir Wm. Jenner, is a 
 valuable remedy; the sulphurous acid is set free, and checks the 
 fermentative action. Charcoal has the same effect, so also carbolic 
 acid and creasote. The spasmodic pain from distension is relieved 
 by sulphuric or chloric either, by chloroform or by opium. In the 
 more easily remediable cases arising from fruits, vegetable, or undi- 
 gested food, an emetic or purgative may be given, and may be 
 advantageously followed by ipecacuanha and capsicum, or by the 
 nitre-hydrochloric acid with calumba, cascariila, or gentian. These 
 medicines apparently increase the secretion of the gastric juice or 
 improve the tone of the mucous surface; but after the immediate 
 relief of the urgent symptoms the most likely plan to afford perma- 
 nent benefit is to change the diet to such substances as the stomach 
 can easily digest. 
 
 Another form of chemical change described is that which takes 
 
 1 The Merismopaedia Ventrieuli of Robin, PI. xii, fig. 1, p. 331.
 
 232 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 place from the fermentation of starchy elements, milk, &c., and which 
 leads to the formation of lactic or butyric acid ; severe heartburn is 
 pro luced with pain at the stomach and between the shoulders, some- 
 times with vomiting, but without distension ; the pain is occasionally 
 very severe and persistent, even after vomiting ; there is often a 
 sour, nauseous taste in the mouth, and there may be spasmodic 
 attacks, or even alarming collapse. The state is much relieved by 
 creasote, carbolic acid, opium, bismuth, or by magnesia and hydro- 
 cyanic acid. 
 
 In infants the most severe collapse ensues from the coagulation of 
 milk in the stomach, and the patient may be utterly prostrate, as if 
 suffering from perforation of the intestine or from cholera ; if re- 
 covery take place, small masses of casein and fatty matter are some- 
 times passed from the intestine. 
 
 An infant about a year old was seized with sudden collapse shortly 
 after being fed, deathly prostration followed, and it was believed by 
 the parents that the child was poisoned ; the flour, milk, water, c., 
 of whi'ch the food had consisted, were carefully analyzed by my 
 friend Dr. Odling, and pronounced normal. The infant became cold, 
 and was apparently in severe pain ; its eyes were sunken, and, after 
 a few hours, several masses of cheesy substance, about half an inch 
 in length, were passed ; these I carefully analyzed, and they were 
 found to consist of oily matter and casein ; and the symptoms arose 
 from milk coagulated in the stomach having passed into the duode- 
 num in a solid form. Such at least was my diagnosis of the case ; 
 and the rapid recovery of the little patient showed the correctness 
 of the opinion. 
 
 In some persons affected with dyspepsia the breath becomes ex- 
 ceedingly offensive, almost of the odor of sulphuretted hydrogen, 
 being similar to that caused by carious teeth, diseased tonsils, or 
 ulcerated nares. This state is due to the putrefactive decomposition 
 of food retained and undigested in the stomach ; it is associated 
 generally with vitiated secretions ; there is headache, mental depres- 
 sion, the tongue is furred, a sense of uneasiness at the stomach comes 
 on, or pain in the bowels ; the evacuations are sometimes dark and 
 unusually offensive, or there is slight diarrhoea. It would appear 
 that, to some extent, effects similar to those observed when sulphur- 
 etted hydrogen is respired are the result of this state, and that the 
 blood itself is contaminated by the absorption of gas from the ali- 
 mentary canal. Putrefactive decomposition may also arise in ob- 
 structive disease at the pylorus. 
 
 In cases where no obstruction exists, it is well to prescribe a warm 
 saline aperient, as sulphate of soda, and the potash tartrate with 
 aromatic spirit of ammonia; again, rhubarb, soda, and calumba, or 
 the compound gentian mixture, may be advantageously given. Crea- 
 sote tends to check the decomposition, but its employment is less 
 suitable in these than in previously mentioned instances.
 
 FUNCTIONAL DISEASES OF THE STOMACH. 233 
 
 H^EMATEMESIS. 
 
 There are several symptoms of disease of the stomach which de- 
 mand separate notice, and the first of these to which we shall allude 
 is haematemesis, or vomiting of blood. 
 
 Great alarm is naturally excited by the rejection of blood from the 
 stomach, whether in small or large quantities; but the import is 
 very different, for whilst in some cases it is a symptom free from 
 danger, in others it is the indication of serious, if not of fatal disease. 
 
 The causes of hasmatemesis are 
 
 1st. Ulceration of the stomach. 
 
 2d. A congested or obstructed state of the portal circulation. 
 
 3d. Vicarious menstruation. 
 
 4th. Cancerous disease. 
 
 5th. A vitiated state of the blood, as in purpura, renal disease, 
 yellow fever, typhus, &c. 
 
 6th. Aneurism. 
 
 The hemorrhage may, however, have its origin in parts connected 
 with the mouth, the throat, and the oesophagus (as from ulceration, 
 cancerous disease, and aneurism, and from varicose conditions of the 
 cesophageal veins 1 ), and the rejection of blood from these sources 
 may be erroneously regarded as hsematemesis ; or it may proceed 
 from the nose, the larynx, and the lungs, and in some cases consid- 
 erable difficulty arises in distinguishing the source of the discharge, 
 for the blood may be swallowed and afterwards vomited. 
 
 As to the quantity of blood exuded, there may be the greatest 
 diversity : sometimes it is only recognized by the most careful, or 
 even microscopical examination ; it may be merely coffee-ground 
 fluid ; at other times several pints or even quarts are rejected at 
 once ; and if a large vessel have been divided, the first hemorrhage 
 may cause fatal syncope. Blood which is thus discharged into the 
 stomach is generally coagulated, and is often deepened in color by 
 the action of the gastric juice ; it is devoid of the bright frothy ap- 
 pearance presented by blood from the lungs, which is consequent on 
 the admixture of air. A portion of the blood in the stomach be- 
 comes still further acted upon by the gastric juice, and passes into 
 the duodenum. As it extends along the small and large intestine, 
 the depth of the color is increased, and at last it is discharged as a 
 pitchy, liquid stool, constituting melsena. Sometimes this black 
 evacuation or melasna is the only symptom of hemorrhage into the 
 stomach, for no blood may be rejected by the mouth ; and when the 
 blood is effused into the small or large intestine, and discharged, the 
 depth of the color is proportionate to the length of the tract through 
 which the blood has passed, but it never assumes the black color to 
 which we have referred. 
 
 The green fluid which is sometimes vomited in states of great 
 irritation of the stomach has been regarded by Dr. Fraser as altered 
 blood ; and the coffee-ground substance so often rejected towards the 
 
 1 'Schmidt's Jahrbuch,' 1859, Le Diberder und Fauvel.
 
 234 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 close of organic disease of the stomach, consists also of blood which 
 has slowly exuded, the haernatine being acted upon by the gastric 
 juice. In some cases of purpura, a similar appearance is presented 
 from a like cause. Much discussion has arisen as to the possibility 
 of the transudation of blood through wnruptured capillaries ; but 
 the examination of a portion of intestine distended with blood, and 
 presenting points of ecchymosis, and found after disease of the 
 mitral valve, will suggest the probable explanation of instances in 
 which blood has been vomited or discharged, and in which no appa- 
 rent perforation of vessels has subsequently been found. In such a 
 portion of intestine as is present with mitral valve disease, some of 
 the capillaries are found to be beautifully injected, whilst others are 
 collapsed, and blood is extravasated around them, but limited by the 
 basement membrane, thus constituting a point of ecchymosis ; if the 
 basement membrane had given way, the blood previously extrava- 
 sated would have escaped, and no ruptured vessel would have been 
 detected. A similar action takes place in the stomach ; ecchymosis 
 is produced, but the action of the gastric juice prevents our observing 
 the changes with the same facility as in the intestine. There is little 
 doubt that the capillaries thus become over-distended, and then 
 ruptured in the ordinary form of hsematemesis, when no ulceratiou 
 has taken place. This statement of the pathological condition does 
 not militate against the now generally received opinion of the extru- 
 sion of the blood-corpuscles through uuruptured vessels. 
 
 The symptoms which precede hasmatemesis are a sense of faint- 
 ness followed by weight at the scrobiculus cordis ; the countenance 
 becomes pallid, the pulse compressible and failing, the extremities, 
 cold, and sometimes actual syncope takes place; vomiting is then 
 produced, and several pints, or even quarts, of half-coagulated blood 
 are rejected; the patient becomes faint, blanched, and the bleeding 
 is checked. After a few days or hours, there may be return of hem- 
 orrhage, till at last, in some cases, the patient appears almost drained 
 of blood. The subsequent symptoms are especially due to this loss, 
 as found in other instances of anaemia; and severe headache, noises 
 in the ears, disturbed vision, dilated pupils, palpitation or irregular 
 action of the heart, with a sharp but compressible pulse, are present. 
 If a large vessel have been divided, the first attack may, as we have 
 before remarked, lead to fatal syncope. This sudden termination is, 
 however, unusual ; the patients slowly rally, and after a few hours, 
 the black, pitchy discharge of altered blood takes place from the 
 bowels. 
 
 The character of the disease which has led to the hemorrhage 
 must necessarily modify the preceding as well as the general symp- 
 toms and their termination; thus, in ulceration of the stomach, and 
 in cancerous disease, the peculiar symptoms of those maladies are 
 present; in aneurism a pulsating tumor may sometimes be felt, and 
 severe local pain, or pain in the course of the spinal nerves, may be 
 experienced. In a congested state of the portal system, the signs 
 are those of engorged liver, as shown by pain in the right side, dys- 
 pepsia, a sallow or semi-jaundiced complexion, furred tongue, occa-
 
 FUNCTIONAL DISEASES OF THE STOMACH/ 235 
 
 sional nausea or vomiting, impaired appetite, spasmodic pain at the 
 stomach or in the region of the colon, constipation of the bowels, 
 disturbed sleep, and pain in the head; enlargement of the liver and 
 haemorrhoids are also frequently present. It is this form of hemor- 
 rhage that sometimes occurs in valvular disease of the heart. 
 
 In vicarious menstruation, local congestion of the mucous mem- 
 brane, or of the edges of a pre-excitiug ulcer as we sometimes find 
 in an ulcer on the leg leads to the effusion of blood into the 
 stomach. In these cases we may have very slight symptoms an 
 absence of the proper menstrual discharge, slight pain in the side, 
 and periodical vomiting of blood, without constitutional disturbance, 
 and without the blanched countenance that we find in hemorrhage 
 from other causes. With this vicarious discharge we not unf're- 
 quently find hysteria, neuralgic pains, and leucorrhcea, &c. 
 
 In purpura hernorrhagica there is a blanched countenance, faint- 
 ness, &c., but we have an indication of the cause in the changed 
 character of the blood, as shown by effusion into the mucous mem- 
 brane and into the skin. The haernatine is probably acted upon, 
 and the corpuscles broken down, so that actual exosmosis of colored 
 serum takes place. 
 
 During the course of fever, hemorrhage from the bowels, appa- 
 rently of a critical character, occasionally takes place ; the patient, 
 who may be in a state of great prostration, with a dry and brown 
 tongue, rapidly improves, and hence the discharge of blood has been 
 regarded by some as indicating a " crisis" in the disease. In the few 
 cases of profuse hemorrhage which have come within the sphere of 
 our own observation, the effusion of blood has probably taken place 
 from ulcerated surfaces; in one, presently to be detailed, minute 
 ulcers were found in the stomach, from which a profuse and fatal 
 hemorrhage occurred ; in another instance, a young woman, whilst 
 prostrate from typhoid fever, suffered from hemorrhage to a great 
 extent from the bowels; the patient became blanched, the pulse for 
 many hours could scarcely be felt, but very slowly she completely 
 recovered. These cases resemble those in which very minute quan- 
 tities of blood are detected on microscopical examination of the 
 evacuations during typhoid fever, but must be distinguishe 1 from 
 the hemorrhages described by Dr. Kennedy as occasionally taking 
 place during typhus without ulceration, and followed by rapid re- 
 covery. We have known hemorrhage from the stomach to occur 
 both in lardaceous disease of the viscera and in chronic renal mis- 
 chief; possibly from degeneration of the vessels, as has been de- 
 scribed by Charcot 1 as occurring in the vessels of the brain, and by 
 Lionville in the retina. 2 
 
 When blood is poured out from the oesophagus or mouth, it is re- 
 gurgitated or rejected without effort, rather than vomited, and we 
 generally find either dysphagia or ulceration of the throat, &c. 
 
 The blood from the lungs is sometimes so retained in a vomica or 
 
 1 Brown-Sequard, 'Archives de Physiologic,' 18G8. 
 
 2 'Gazette des Hopitaux,' 1870, p. 141.
 
 236 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 dilated bronchus, that it loses its frothy appearance and florid color, 
 and the patient is often scarcely able to tell us whether he vomited 
 or coughed it up ; no actual cough may be produced, but the blood 
 may easily be brought up into the throat and then spat out, or it 
 may be swallowed and then vomited, or discharged by the bowels ; 
 in these cases we attach much importance to the general signs of 
 disease, and to the physical examination of the lungs and heart. 
 
 As to the prognosis in hemorrhage from the stomach, we must bear 
 in mind that it is rare for a patient to die from simple hasmatemesis, 
 although such cases occur ; patients appear to be almost bloodless, 
 but steadily convalesce. Still tbe cause of the symptom must be our 
 guide as to its termination; sudden and large bleedings after symp- 
 toms of organic disease should always be regarded with alarm, for 
 ulceration often extends into the larger arteries, and the dense fibrous 
 tissue prevents contraction of the adjoining parts, and thus the hem- 
 orrhage persists unchecked. 
 
 As to the treatment when bleeding takes place from ulceration or 
 cancerous disease, the use of styptics is advisable alum with dilute 
 sulphuric acid, acetate of lead, gallic acid, catechu, tincture of iron, 
 or oil of turpentine, may be used; but in cases where it arises from 
 congestion of the liver, I have generally looked upon the haemate- 
 mesis as to a great extent curative, and have prescribed remedies 
 calculated to relieve the congested liver, as a grain or two of blue 
 pill with conium, and magnesia mixture, in order to remove the 
 effused blood from the intestines. 
 
 Ice and cold drinks are grateful to the patient, and beneficial in 
 producing contraction of bleeding vessels ; but food should be ab- 
 stained from, because coagula may be removed by it from divided 
 vessels, and hemorrhage may be again produced. After a short 
 time, fluid, demulcent nourishment can be given, but it should be 
 in a. nearly cold condition ; and when there is evidence of a cessation 
 of the hemorrhage, solid substances, easy of digestion, may be taken 
 in small quantities. Vegetable tonics with mineral acids, and the 
 milder preparations of steel, will then be found of service ; but we 
 shall be often much disappointed by the various astringents, as gallic 
 acid, alum, &c., which afford only partial relief; oil of turpentine, in 
 doses of "Ixx, has been much recommended, and has been followed 
 by beneficial results ; its stimulant as well as astringent effects have 
 been well marked. 
 
 It is exceedingly important that the patient should avoid those 
 habits or excesses which have led to the disease, but advice on this 
 subject is generally disregarded. 
 
 In vicarious menstruation, our efforts should consist in endeavor- 
 ing to establish the proper and natural discharge, rather than imme- 
 diately to check that which proceeds from the stomach, unless it be 
 excessive. Hip baths, steel, aloes and myrrh, change of air, exercise, 
 the avoidance of tight lacing or unnatural excitement, will probably 
 restore the health, but this form of hasmatemesis will sometimes con- 
 tinue for a considerable period. 
 
 In purpura, the preparations of steel with acids are generally the
 
 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 best remedies that we can use, as the tincture of the sesqui chloride 
 or the sulphate of iron, with sulphuric acid; the oil of turpentine 
 also is sometimes of great value, although its taste may offend the 
 palate. 
 
 CASE LXXIX. Hcematemesis from Cancer of the Liver The most 
 
 marked case of haematemesis and makena from this cause that I have ever 
 witnessed was in a man about 55 years of age ; he was in an emaciated con- 
 dition, cachectic, and semi-jaundiced ; the liver was enlarged, and it was 
 believed that he suffered from cancerous disease of that organ, a diagnosis 
 which was found after death to be correct. He was suddenly seized with 
 violent vomiting of blood, and black stools were passed. In about eight 
 hours he died. On inspection, we found cancerous disease of the liver ; there 
 was no ulceration in the stomach, nor evidence of any ruptured vessel ; the 
 intestine contained a considerable quantity of blood ; but no ulcer. On open- 
 ing the vena portse, it was found that the cancerous disease had extended into 
 the vessel, and completely occluded it, and that softened cancerous matter was 
 injected along the branches of the vena portae, so as completely to check the 
 circulation. The cause of the luematemesis was at once apparent the capil- 
 laries of the stomach had become suddenly engorged with blood, and had 
 ruptured, leading to the fatal hemorrhage ; but no openings nor ruptured 
 vessel could be found, for the distension had disappered, and the minute 
 vessels had collapsed. A similar result is found in many instances of vomit- 
 ing of blood after intemperance. 
 
 CASE LXXX. Hcematemesis from Portal Congestion. James P , aet. 
 45, residing at Milton Street, was admitted into Guy's Hospital, February 
 2d, 1859. He was a man of intemperate habits, and whilst at work some 
 time previously, packing hay and exerting his strength, sickness and flatu- 
 lence came on, and he vomited about a pint and a half of grumous blood, and 
 afterwards smaller quantities of clear blood. He was under treatment for 
 fourteen days, and then returned to his work. From that time he had had 
 pain across his chest, which sometimes moved to the epigastrium with much 
 flatulence. Three weeks beforf admission, immediately after jumping to 
 reach a handle above him, he vomited up half a gallon of brown -colored blood 
 in clots ; and some blood passed per rectum. When brought to Guy's he 
 had a yellowish semi-jaundiced complexion, and suffered from pain at the 
 scrobiculus cordis ; the lungs were healthy ; the pulse was full, soft, 80 ; the 
 tongue coated : the appetite defective ; the bowels open ; the urine not albu- 
 minous. He was ordered infusion of roses with acid, and milk diet. 4th. 
 There was slight pain, no return of vomiting, but he had j assed blood by the 
 bowels ; the tongue was furred. 8th He appeared nearly well, and was 
 soon afterwards presented. 
 
 This case of hsematemesis probably arose from bepatic engorge- 
 ment, due to intemperance ; and the hemorrhage from the over-con- 
 gested mucous membrane of the stomach was in itself curative. 
 
 CASE LXXXI. Hcematemesis after great Intemperance Alfred W , 
 set. 38, admitted into Guy's under my care in May, 1855, was a tall man per- 
 fectly blanched in appearance, and on admission he was almost in a state of 
 syncope. He had been for some time a porter at the Brighton Railway, and 
 had drunk very freely of spirits, although accustomed to eat but little food. 
 During the Epsom races, having harder work than usual, he drank still more 
 intemperately ; he had been troubled with occasional pain at the stomach,
 
 238 .FUNCTIONAL DISEASES OF THE STOMACH. 
 
 and with vomiting. The day before admission he felt a sense of weight at 
 his stomach, which he tried to relieve by taking more spirits ; a feeling of 
 faintness came over him, and he vomited several pints of dark-colored blood. 
 lie was much excited on admission, and there was considerable; tremor of the 
 hands. The skin was moist, the tongue and lips pale, the bowels confined. 
 The liver was much enlarged, and there was slight tenderness at the scro- 
 biculus cordis. 
 
 There was evidence in this case of great engorgement ol the portal 
 system, and although some additional hemorrhage took place I 
 adopted the plan of endeavoring to relieve the distended liver, and 
 constipated bowels, rather than of administering styptics. Blue pill 
 and conium were given, and magnesia mixture. In this way black 
 blood, acted upon by the gastric and intestinal secretions, was dis- 
 charged, and the patient rapidly improved. The hemorrhage re- 
 turned slightly on the third day, probably from spirits surreptitiously 
 obtained. He steadily, however, convalesced; food was given as he 
 could take it, and afterwards steel medicine. 
 
 Most of these cases arise from the rupture of over distended capil- 
 laries, rather than from ulceration, and we may generally give a very 
 favorable prognosis. Where ulceration exists, and arteries are per- 
 forated by the disease, a fatal result sometimes ensues; several cases 
 of this kind are recorded with ulceration of the stomach, in one of 
 which, although fatal hemorrhage took place, nearly all the blood 
 passed into the duodenum, and scarcely any was vomited. Death, 
 however, does occasionally follow without any ulceration being de- 
 tected. 
 
 CASE LXXXII. Hcematempsis, vicarious Menstruation, aggravated 
 Hysteria, simulating Fever Mary H , a?t. 19, was admitted into Guy's 
 under my care in May, 1855. She liad enjoyed good health till she was six- 
 teen years of age, when she said that she had a convulsion followed by ''brain 
 lever ;" and on recovery began to vomit blood three days successively at her 
 regular monthly periods ; if this did not occur she had pain between the 
 shoulders, at the epigastrium, and dyspnoea ; this vomiting of blood continued 
 regularly for three years, but she never menstruated properly. For nine 
 months the discharge had ceased altogether, and three months before admis- 
 sion she had a severe hysterical or epileptic tit. 
 
 On admission she appeared stout, tolerably nourished, but prostrate ; the 
 tongue was dry and brown, and almost black ; she lay motionless in bed, 
 without speaking, and altogether refused food, sometimes groaning, and if 
 taken from her bed appeared to fa ; nt. She. complained of pain at the lower 
 part of the back, and in the inguinal region ; the abdomen was tympanitic 
 and distended i she stated that surgeons had twice removed clots of bloo.l 
 from her; but my friend and colleague, Dr. Oldham, could find no enlarge- 
 ment nor disease of the uterus, and believed that an attempt had been made 
 to divide the os uteri. She refused to swallow food; the pulse was feeble and 
 very quick. There was sliirhtly increased antero-posterior curvature of the 
 spine in the lower part of the dorsal region. 
 
 Milk was poured into the mouth, and she was made to swallow it ; in this 
 way a considerable quantity of food was taken. 
 
 Galhamim and zinc with aloes and myrrh were prescribed, and the bowels 
 were thoroughly cleared by blue pill with colocynth and henbane, and by
 
 FUNCTIONAL DISEASES OF THE STOMACH. 239 
 
 enemata of rue or soap. Local depletion was used from the groins by the 
 application of leeches, and afterwards quinine and steel were given with wine, 
 and sparks of electricity were taken from the spine ; a shower batli was occa- 
 sionally used. 
 
 The stomach retained food, and the patient soon became able to walk, and 
 left the hospital in a few weeks convalescent. 
 
 This was one of the most severe cases of hysteria that we ever 
 witnessed ; and the disturbance of the stomach and alimentary canal 
 were no doubt produced by the functional disease of the uterus, 
 aggravated by treatment which I think few obstetricians would 
 approve of. The vicarious discharge of blood from the stomach was 
 not observed during the period she was in the hospital, but it is 
 received on the testimony of the patient and her friends. 
 
 CASK LXXXIII. Vicarious Menstruation from the Stomach Ellen 
 
 H , set. 23, was admitted under my care into Guy's Hospital, August 28th, 
 1860. She was a needlewoman, who had resided at Kingsland, and she had 
 for several years been in feeble health, complaining of, pain at the chest and 
 palpitation of the heart, &c. Menstruation commenced when she was eighteen 
 years of age, but the function had been irregularly per brmed, sometimes 
 ceasing for four to eight months. For six months prior to admission she had 
 vomited blood at her menstrual periods, but occasionally she had menstruated 
 regularly, and no haematemesis then took place ; before the attacks of hemor- 
 rhage, and for several days before menstruation, she had pain at the stomach 
 and in the right side, loss of appetite, and nausea; the vomiting of blood then 
 came on and continued for several days. She was a spare, and somewhat 
 anremic woman, with an anxious expression of countenance, and rather dark 
 complexion ; her S3 - mptoms were those of amenorrlicea with dyspepsia ; and 
 during the time that she remained in the hospital she complained of pain at 
 the scrobiculus cordis, and sometimes also at the right side, and the pain 
 was increased by food ; there was occasional nausea, but no vomiting ; the 
 bowels were regular. Her general health was improved by preparations of 
 steel and quinine, with a carefully regulated diet ; but during the time she 
 was in the hospital there was neither return of hemorrhage trom the stomach, 
 nor was menstruation established. She continued under my care as an out- 
 patient, and was afterwards re-admitted, sutfering still from dyspepsia; but 
 she had had no return of hemorrhage. The dyspepsia was again relieved. 
 
 In this case there was probably ulceration of the stomach, and we 
 regard a periodical congestion of the mucous surface, and consequent 
 rupture of minute capillary vessels, as the cause of the repeated 
 hemorrhage. Although during the time the patient was under ob- 
 servation there was no hsematemesis, we have no reason to doubt 
 her very positive assertion that for several months she vomited 
 blood at the ordinary period of menstruation, and the discharge was 
 in that respect evidently vicarious. Normal menstruation has since 
 been established, and has continued regularly, but she has suffered 
 occasionally from severe dyspepsia. 
 
 CASE LXXXIV. Typhus Fever. Hcematemesis. Ann M , set. 19, a 
 hawker on the streets, was admitted into Guy's Hospital, February 2 1, 1859, 
 and died February 4th. Fever exited in the house where she lived, and 
 she had been ill for nine davs. When brought to the hospital she had tl.e
 
 240 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 symptoms offerer, with great depression, and with mottling and lividity of 
 the skin ; still she was rational. On the evening of the 4th, the eleventh 
 day of fever, vomiting of blood took place, and was passed per rectum ; in 
 a few hours she died. 
 
 On inspection the lungs were healthy ; the heart was firm but empty ; the 
 stomach was full of blood, and at the lesser curvature there were several 
 minute depressions or erosions affecting only the surface, and not penetrating 
 the entire thickness of the membrane; one, a little deeper than the rest, ap- 
 peared to have a minute vessel at the base ; but this fact could not be satis- 
 factorily established. The duodenum was reddened and congested, and blood 
 was found in both the jejunum and ileum, and the colon was also full of 
 blood. No ulceration nor disease of the intestine was found; the spleen was 
 large and soft, but the mesenteric glands, as well as the liver and kidneys, 
 were healthy. 
 
 This instance of hemorrhage could not be regarded as precisely 
 analogous to those which sometimes occur when the character of the 
 blood is changed, as in yellow fever, purpura, &c., for erosions ex- 
 isted in the stomach from which the blood escaped ; but the pros- 
 tration of fever doubtless rendered the hemorrhage more persistent, 
 and perhaps had an important influence in determining the minute 
 ulcerations. The patient was about the age at which perforating 
 ulcer sometimes occurs. In her case, the loss of blood led to a rapid 
 fatal issue. 
 
 PAIN AS A SIGN OF DISEASE OF THE STOMACH. 
 
 The two symptoms which are regarded as especially indicative of 
 disease of the stomach are, perhaps, more than any other liable to 
 mislead ; we refer to vomiting and to pain in the region of the 
 stomach ; and we shall briefly enumerate the causes from which 
 these symptoms proceed as the best safeguard against error. The 
 explanation of the uncertain diagnostic, value of these symptoms is 
 found first, in the intimate connection of the nerves of the sympa- 
 thetic plexus with all the abdominal viscera and with the spinal 
 nerves ; and, secondly, in the extensive distribution of the pneumo- 
 gastric nerve, which supplies, in the abdomen, not only the stomach, 
 but the duodenum, the liver, the pancreas, the kidney, and the supra- 
 renal capsule ; and, in the chest, the same nerve extends to the lungs 
 and respiratory tubes, and communicates with the cardiac ganglia. 
 And, again, it is frequently found that irritation of one set of 
 branches of nerves manifest itself in the disturbed function of another 
 part supplied by the same nerve, and that disease at the central 
 origin of the nerve is shown at the peripheral branches ; thus, pain 
 in the ear is produced by a decayed tooth, the branches of the fifth 
 pair of nerves supplying both the tooth and the ear ; disease at the 
 origin of the pneumogastric nerve in the brain, or of the pulmonary 
 branches, is often manifested by a disturbed condition of the fila- 
 ments supplied to the stomach, and vomiting is the result. 
 
 As a sign of disease pain is of doubtful value : oftentimes it is a 
 certain guide to the locality, if not to the character of the morbid 
 action ; at other times, on the contrary, its presence misleads, or its
 
 FUNCTIONAL DISEASES OF THE STOMACH. 241 
 
 absence disposes us to underestimate changes which may be going 
 on in the system. Generally speaking, we find that the mucous 
 membranes, except where they approach the outlets of their respec- 
 tive canals, are free from ordinary sensibility, and may undergo 
 very marked changes in their condition without any painful mani- 
 festation. Acute disease may take place in the mucous membrane 
 of the small or large intestine, in the mucous membrane of the 
 kidney or bladder, with complete immunity from suffering. A 
 similar fact is observed in relation to the parenchymatous viscera ; 
 thus the substance of the .liver or the kidney is often changed in a 
 marked degree ; and if disease, such as an abscess, forms in their 
 structure without much distension, the patient may be unconscious 
 of morbid change. On the contrary, in serous membranes an oppo- 
 site condition is found to exist, almost any change is appreciated, 
 and in sudden or acute disease the pain is often extremely severe in 
 its character. We well know the stabbing pain of pleurisy, the 
 agony of acute peritonitis, and the intense suffering of severe syno- 
 vitis. In each of these latter diseases rest is a very essential ele- 
 ment in the alleviation of the malady, and this rest can be attained 
 to a great extent without the cessation of life. In pericarditis, on 
 the contrary, we find, as for many years shown by Dr. Addison, 
 that there is an absence of pain, unless there be pleurisy occurring 
 at the same time ; for in the pericardium, however desirable rest 
 may be, movement must continue as long as life lasts. 
 
 In reference to pain as an indication or non-indication of disease 
 we have to remark 
 
 I. That acute inflammation and disease of the stomach may exist, 
 with entire freedom from pain, if the mucous membrane only be 
 affected. Acute gastritis is generally regarded as an exceedingly 
 rare form of disease, excepting when produced by irritant poisons. 
 This may be the case ; but we are of opinion that in many instances 
 the absence of pain has led to this belief. In the gastro-enteritis of 
 children, and not very unfrequently in that of more advanced life, 
 conditions of great irritability with cessation of the right functions 
 of the stomach, and probably with hyperaemia, must be regarded as 
 closely approaching the character of gastritis. However this may 
 be, we have evidence from the action of irritant poisons that, while 
 the mucous membrane only is affected by them, pain may be entirely 
 absent, excepting that consequent on the violent muscular action 
 exerted in the act of repeated vomiting. Thus in a patient who had 
 taken a large dose of oxalic acid, violent vomiting was produced, 
 with failing pulse, and a sense of exhaustion, but no pain. In a few 
 days after taking demulcent forms of diet, she completely recovered. 
 In"an instance of poisoning by sulphuric acid, in which a large por- 
 tion of the mucous membrane of the stomach was destroyed, and 
 although the patient survived eleven days, she did not appear to 
 suffer from any pain at the stomach. The same fact was still more 
 strikingly shown in an instance in which chloride of zinc had been 
 taken; life was prolonged for three months; the absence of suffering 
 was remarkable till eight days before death ; and the pam then, we 
 16
 
 242 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 do not doubt, was due to the formation of an abscess in the left hy- 
 pochondriac region. I have witnessed the same immunity from 
 suffering in poisoning by arsenic, and by corrosive sublimate ; and 
 we are, I think, warranted in the belief that acute disease may take 
 place in the mucous membrane of the stomach without any pain. 
 
 II. Organic disease of the mucous membrane, as for instance cancer, 
 may be comparatively free from pain. It frequently happens iu 
 cancerous disease of the liver, that after death tubercles or growths 
 of similar character are observed on the mucous membrane, and of 
 which there had been no indication during life. Thus, a patient 
 aged sixty, who died from cirrhosis, and in whom after death a large 
 villous growth was found attached to the anterior surface of the 
 stomach, although the orifices were free, made no complaint of any 
 pain at the stomach, neither was there any vomiting; and it is 
 probable that the burning pain she had before admission was of the 
 character often observed in ordinary dyspepsia, for she was of intem- 
 perate habits. The freedom from any obstruction at the orifices, and 
 the growth involving only the mucous membrane, were, we think, 
 the causes of the absence of pain. No supposition was entertained 
 of the presence of this growth in the stomach during life. 
 
 III. Disease extending to the muscular or peritoneal coats pro- 
 duces generally severe pain, as observed in ordinary ulceration or 
 cancer. This symptom is present as one of the most ordinary signs 
 of the conditions just mentioned, often coming on directly after food 
 has been taken. In several instances, in which the suffering was 
 exceedingly intense, we have found branches of the pneumogastric 
 nerve involved in the thickened, dense, and fibrous edges of the 
 ulcer. In a case of this kind which I watched with much interest, 
 the cause of death was gradually increasing exhaustion, as the con- 
 sequence of the intense pain and constant vomiting. It was a young 
 woman aged twenty -one, who suffered from constant and severe pain, 
 with progressive emaciation, continuing for many months, unrelieved 
 by the administration or application of any anodyne that we possess. 
 A month before death symptoms of acute phthisis came on ; and, at 
 the inspection a large chronic ulcer was found at the lesser curvature, 
 and several branches of the pneumogastric nerve were traced to the 
 edges of the ulcer, and some passing across its base were only covered 
 by fibrous tissue. 
 
 IV. Over-distension of the stomach produces severe pain. The 
 formation of the stomach and its peritoneal attachments are such as 
 to allow of moderate distension in the performance of ordinary diges- 
 tion ; but whenever the distension becomes greatly increased, pain 
 is the result. 
 
 Y. Disease, especially of an acute kind, affecting the peritoneum, 
 is also, with few exceptions, accompanied by severe pain. In refer- 
 ence, however, to the position of the pain in peritonitis, it is not 
 always a certain guide to the precise seat of injury. A young woman, 
 under the care of the late Dr. Golding Bird, was seized with sudden 
 severe pain at the scrobiculus cordis and towards the left side, fol- 
 lowed by rapid collapse ; from the seat of the pain perforation of the
 
 FUNCTIONAL DISEASES OF THE STOMACH. 243 
 
 stomach was diagnosed ; it was, however, found to be perforation of 
 the appendix caeci. 
 
 VI. Dr. Osborne has shown, that in some cases of gastric ulcer 
 the position which gives the greatest ease to the patient may serve 
 as a guide to the exact seat of the disease ; that if the ulcer be on the 
 posterior surface, lying upon the face would be the most comfortable 
 position, and vice versa. Food, on its entrance into the stomach, 
 generally passes directly along the lesser curvature; and if the viscus 
 be contracted, it would come in contact with an ulcer, whether placed 
 on the anterior or posterior aspect of the median line of the curva- 
 ture. If more distended, there might be less direct application to 
 the diseased surface ; in the case of severe suffering from gastric 
 ulcer previously referred to, the patient appeared tobe most easy 
 when leaning somewhat forward and towards the left side, which 
 would have the effect of allowing fluids to gravitate from the ulcer, 
 as mentioned by Dr. Osborne. We have seen several cases which 
 tend to confirm this opinion. 
 
 YII. In disease of the lesser curvature, near the pyloric orifice, 
 pain is sometimes experienced by the patient as soon as the food 
 enters the stomach, and, in some cases, this conveys the idea of dis- 
 ease at the cesophageal orifice. This fact may lead to the supposition 
 that the oesophagus is the part affected, and the opinion may be 
 strengthened by the rejection of food almost before it has reached 
 the stomach. 
 
 VIII. Many conditions of functional disease are entirely free from 
 pain. It is, indeed, well for us that there is such insensibility, other- 
 wise the least deviation from healthy action might be followed by 
 suffering, and the strict rules of a dyspeptic would be essential in 
 ordinary life. 
 
 IX. The pain, in many functional diseases of the stomach, is ex- 
 ceedingly severe ; but it is often produced by a mal-condition of the 
 nerves or nerve-centres, and it arises from the intimate connection 
 of the spinal and sympathetic nerves. In some states of exhaustion 
 the whole of the nervous system appears to be in a state of great 
 irritability, and the sensibility of structures becomes greatly increased. 
 We often find, in these conditions, that the stomach is incapable of 
 bearing the presence of food; it is at once rejected, or produces 
 intense pain, or flatulent distension ensues, or a sense of fainting; 
 and the means best calculated to relieve are those which invigorate 
 and strengthen the whole system. Of this class are the stomach 
 diseases observed in connection with uterine disease, with loss of 
 blood, exhaustion, mental anxiety, &c. The deficient nervous supply 
 also interfering, perhaps, with the right secretion of gastric juice. 
 
 X. The effect of a diseased condition of the pneumogastric nerve 
 at its centre, or at its peripheral branches, in connection with stom- 
 ach disease, is of great interest, and it is probable that pain is some- 
 times the result. We have, however, more frequently observed 
 vomiting rather than pain produced by an irritable condition of the 
 pneumogastric nerve. 
 
 XI. In some forms of functional disease of the stomach, in which
 
 244 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 severe pain comes on three or four hours after food, it is probable, 
 as we have elsewhere stated, that extreme irritability of the pyloric 
 orifice exists. 
 
 XII. In functional, as in organic disease, pain often arises from 
 distension of the stomach, consequent on chemical decomposition of 
 the alimentary mass. 
 
 - XIII. The absence of pain sometimes arises from the destruction 
 of the pneumogastric nerve. This fact was remarkably shown in a 
 patient suffering from sloughing at the extremity of the oesophagus; 
 and in cancerous disease of the stomach the same thing has been 
 observed. 
 
 XIV. Pain at the scrobiculus cordis, simulating disease of the 
 stomach, often arises from spinal disease, the pain being referred to 
 the extremity of the irritated nerve. 
 
 XV. Severe pain at the scrobiculus cordis is frequently present in 
 chronic bronchitis and in obstructive valvular disease of the heart ; 
 in fact, from any state which leads to over-distension of the cavities 
 on the right side of the heart. In these conditions we very gene- 
 rally find that food produces pain and flatulence, and is very imper- 
 fectly digested ; the vessels of the stomach and of the whole of the 
 chylopoietic viscera are much engorged, and the surface of the stom- 
 ach is very generally covered with a thick layer of mucus, a state 
 of chronic catarrh of the gastric mucous membrane being produced. 
 Many observers, however, attribute the almost constant pain at the 
 scrobiculus cordis in these instances to the over-filled cavities of the 
 right side of the heart, and we are disposed to refer part of the dis- 
 tress to this cause. 
 
 XVI. In aneurism of the abdominal aorta we have sometimes 
 observed pain of a most intense kind, and the disease might very 
 readily have been mistaken for cancerous disease of the stomach 
 with glandular infiltration, producing pressure upon the aorta. In 
 one instance, which I watched with much interest, the aneurism 
 existed at the position of the cceliac axis ; it was rightly diagnosed, 
 and the patient became exhausted f nd died from the intensity of the 
 pain, the false sac not having given way. I dissected large branches 
 of the sympathetic nerve spread out upon the surface of the tumor ; 
 and the intense suffering and fatal exhaustion appeared to arise from 
 the implication of the nerve structures ; no qther cause of death 
 could be found on very careful inspection. 
 
 Enough has been said to show that the most careful investigation 
 of this symptom is necessary in order to form a correct diagnosis of 
 disease of the stomach. 
 
 VOMITING AS A SIGX OF DISEASE. 
 
 The causes of vomiting are still more varied than those of pain 
 at the stomach ; and the importance of carefully estimating these 
 causes is in proportion to their complexity ; and although some of 
 them are not connected with gastric disease, we still make brief 
 reference to them. They may be divided into those which originate
 
 FUNCTIONAL DISEASES OF THE STOMACH. 245 
 
 in the stomach and intestines, and secondly, into those which arise 
 from alteration in the nervous supply elsewhere, either central or 
 peripheral. 
 
 In the first division we must place 
 
 1. Inflammation of the stomach ; gastritis and gastro-enteritis. 
 
 2. Undigested food, or foreign bodies in the stomach. 
 
 3. Irritants and medicines. 
 
 4. Great irritability of the mucous membrane. 
 
 5. Ulceration of the stomach. 
 
 6. Obstructive disease of the pylorus. 
 
 7. Cancerous disease. 
 
 8. Acute peritonitis. 
 
 9. Pressure on the stomach, as in acites and ovarian dropsy, in 
 abdominal tumors, &c. 
 
 10. Diseases of the duodedum. 
 
 11. Hernia, intestinal obstruction, intussusception. 
 
 12. Pharyngeal and oesophageal regurgitatiou. 
 
 In the second division are 
 
 1. Diseases of the liver and gall-bladder. 
 
 2. Diseases of the kidney. 
 
 8. Diseases of the suprarenal capsules. 
 
 4. Diseases of the uterus and ovaries. 
 
 5. Diseased conditions of the blood and general nervous system, 
 as at the onset of exanthems, fevers, pyaemia, erysipelas, &c. ; ague, 
 yellow fever, and cholera may, perhaps, be classed among these as 
 arising from blood change. 
 
 6. Diseases of the spine. 
 
 7. Diseases of the brain. 
 
 8. Diseases of the lungs. 
 
 I. There is something remarkable in the presence of vomiting in 
 circumstances where pain is absent ; thus, in acute disease of the 
 stomach, where only the mucous membrane is affected, the patient 
 may be free from all suffering at the region of the stomach, except- 
 ing that produced by the violent straining of the muscles during 
 vomiting. We need not do more than to refer to the instances of 
 poisoning by oxalic acid, by sulphuric acid, by arsenious acid, and 
 by corrosive sublimate, which have been already given as illustra- 
 tions of this fact ; and in the symptoms of gastro-enteritis the same 
 immunity from gastric pain occurs, whilst vomiting greatly distresses 
 the patient. 
 
 II. Undigested substances often remain in the stomach for some 
 time without producing pain, unless they pass within the pyloric 
 valve ; and we sometimes find that they are retained for many hours 
 or even days before they are rejected by vomiting. 
 
 III. In reference to vomiting caused by msdicine and by irritants, 
 it is only necessary to mention that in some instances the action 
 appears to be one of primary irritation of the stomach, in others it 
 is secondary, through the medium of the blood; but whether this
 
 246 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 secondary action and its consequent vomiting arises from the excre- 
 tion of the medicinal substance from the mucous membrane of the 
 stomach is doubtful ; thus tartar emetic produces vomiting when 
 injected into the blood equally as when taken directly into the 
 stomach. 
 
 IV. We have referred, in our remarks on functional disease of the 
 stomach, to states of extreme irritability of the mucous membra n > 
 in which food of every kind is at once rejected.. This form of func- 
 tional irritability we have found to be generally associated with 
 uterine and ovarian disease ; or it has been produced, apparently, 
 by irritation of the pulmonary branches of the pneumogastric, to 
 which we shall presently have to refer ; but in some instances we 
 have not been able positively to trace the complaint to one or other 
 of these causes, and at present we must acknowledge, though unwil- 
 lingly, as a cause of vomiting, functional irritability of the stomach 
 itself. It is to this form of disease that Sir H. Marsh has given the 
 name of regurgitative disease, in which food is rejected ivithout any 
 effort, and often without corresponding emaciation. In his valuable 
 paper on this subject, he refers to its connection with pulmonary and 
 with uterine disturbance. 
 
 V. In ulceration of the stomach, vomiting often comes on as soon 
 as food enters the stomach, or a period of variable length intervenes, 
 the pain increasing till the rejection takes place. 
 
 VI. In obstructive disease at the pylorus, the vomiting is gene- 
 rally deferred till nearly the close of the digestive process; much, 
 however, may be done to diminish this symptom by the administra- 
 tion of fluid diet, and one that does not easily undergo fermentation, 
 so that sometimes several days elapse between the attacks. 
 
 VII. Cancerous disease affecting the orifices of the stomach consti- 
 tutes a common cause of persistent vomiting. It must, however, be 
 borne in mind that vomiting is not a constant sign of cancerous dis- 
 ease of the stomach ; if the orifices be free, it may be entirely absent, 
 although the disease is very extensive; and again, if sloughing take 
 place, even when the orifices also are diseased, vomiting often sub- 
 sides, sometimes in consequence of the obstruction being removed 
 by the sloughing; at other times, apparently, from the destruction 
 of the branches of the pneumogastric nerve. Further, the period at 
 which vomiting occurs does not always indicate the seat of the can- 
 cerous obstruction ; in some instances of obstruction at the pylorus, 
 with disease at the lesser curvature, vomiting takes place imme- 
 diately after food has entered the stomach, so as to convey the idea 
 of obstruction at the cardiac orifice or in the oesophagus itself, and 
 the symptom has been regarded as dysphagia rather than vomiting. 
 
 VIII. Acute peritonitis, especially when the gastric peritoneum is 
 involved, is often accompanied with severe vomiting. The state- 
 ment has been made, that vomiting does not take place in acute 
 peritonitis unless the peritoneum in the neighborhood of the stomach 
 is implicated ; but although this is generally, it is not constantly the 
 case. Chronic peritonitis is also a cause of vomiting ; so also local 
 peritonitis and effusion near the stomach. In some of these in-
 
 FUNCTIONAL DISEASES OF THE STOMACH. 247 
 
 stances the stomach is affected by its direct implication in the dis- 
 ease; in others vomiting arises from the pressure of effused pus or 
 the constriction of adhesions. 
 
 IX. Pressure on the stomach is a direct cause of vomiting. In 
 ciscites and ovarian dropsy, the stomach is sometimes so compressed 
 that vomiting comes on soon after, food has been taken, apparently 
 from this cause alone ; and when paracentesis has been performed, 
 the pressure being removed, the sickness ceases. When glandular 
 tumors in the neighborhood of the pancreas or disease of the pancreas 
 itself exert pressure on the stomach, the symptoms closely resamble 
 primary disease of the stomach, and the diagnosis is exceedingly 
 difficult ; but, since the pancreas receives .a branch from the pneii- 
 mogastric nerve, it is not easy to ascertain how far vomiting in some 
 of these cases is due to nervous irritation, and how far itis due to 
 direct pressure. In those cases in which the pancreas has baen dis- 
 eased, without great enlargement and without pressure on the 
 stomach or duodenum, I have not observed vomiting as a promi- 
 nent symptom. 
 
 In aneurismal disease of the abdomen, the remark which we made 
 in reference to disease of the pancreas and its glands holds good ; 
 and the same difficulty arises in determining how far the vomiting 
 is due to pressure or to sympathetic irritation. 
 
 In some cases we have found direct pressure made by the patient 
 at the scrobiculus cordis the cause of vomiting ; many persons can 
 thus at once empty the stomach; and in an instance of a boy, some 
 years ago, in Guy's Hospital, it was only after very careful watching 
 that the true character of the complaint and the deceit of the patient 
 was ascertained. 
 
 X. As to vomiting not dependent upon the condition of the stom- 
 ach itself, we have to refer to morbid states of other abdominal 
 viscera, and first to disease of the duodenum, as inflammation of its 
 mucous membrane, ulceration, and especially obstruction. There is 
 great similarity between the diseased condition of the first portion 
 of the duodenum and of the stomach. In the first portion, for in- 
 stance, ulceration produces many of the symptoms of like disease in 
 the stomach. A form of dyspepsia in which vomiting, with pain at 
 the seat of the duodenum, comes on at the close of digestion has been 
 attributed to the duodenum ; but whether this class of cases is con- 
 nected with the abnormal irritability of the pylorus itself, we cannot 
 affirm. Again, in some cases of acute jaundice, febrile symptoms 
 arise with violent irritability of the stomach, but without pain ; and 
 the disease has been attributed to mischief commencing in the duo- 
 denum, and 'extending to the biliary ducts. In some fatal cases of 
 this kind, great congestion in the duodenum has tended to confirm 
 the idea ; so also the fact, that these symptoms have come on after 
 intemperance. 
 
 XI. In hernia, obstructive disease of the intestines, intussusception^ 
 &c., vomiting is generallv present. If the obstruction be in the small 
 intestine, the vomiting comes on very quickly; but if the colon, 
 sigmoid flexure, or rectum, be the seat of disease, vomiting is often
 
 248 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 postponed for a considerable time, unless irritant medicines and vio- 
 lent purgatives have been administered. As the vomiting continues, 
 the ejected matters present the character of the fluids at the seat of 
 obstruction, and if that obstruction be intestinal, their odor and 
 appearance have more or less of a fecal character. 
 
 XII. The regurgitation of food, rather than vomiting, which is 
 consequent on disease of the pharynx, larynx, or oesophagus, must 
 be distinguished from actual vomiting. By carefully observing the 
 process of deglutition, the seat of mischief may be accurately ascer- 
 tained. In paralysis of the muscles of the soft palate and of the 
 pharynx, deglutition cannot be properly completed, and food is re- 
 jected through the nares ; so also when the epiglottis is ulcerated 
 from strumous, syphilitic, or cancerous disease, the act of deglutition 
 is scarcely performed before the substance swallowed is violently 
 ejected, and severe pain in the throat, and cough, are set up. It is 
 remarkable, too, in these cases, how a solid bolus of food may be 
 formed and swallowed, slipping beyond the diseased surface, whilst 
 the smallest quantity of fluid produces most violent pain and distress. 
 In obstruction of the oesophagus, the act of deglutition being already 
 completed, regurgitation takes place. Very extensive disease may, 
 however, affect the oesophagus without this rejection of food ; for 
 ulceration or sloughing may have removed obstruction, or the 
 branches of the pneumogastric nerve and the whole wall of the canal 
 may be destroyed. Vomiting in other cases is the manifestation of 
 the general and intimate connection of the stomach with other 
 viscera; it is produced by reflex irritation, and is properly desig- 
 nated sympathetic in its origin ; its study as a symptom, is of essen- 
 tial importance in the diagnosis of disease of the stomach. As to 
 vomiting due to other extraneous sources we shall do little more than 
 enumerate them ; and the first of this class to which we allude is 
 
 XIII. Disease of the liver and of the gall-bladder ; large branches 
 of the pneumogastric nerve extend to the liver, as well as numerous 
 nerves from the large sympathetic ganglia. In gall-stone, violent 
 vomiting is generally associated with intense pain ; and in many, 
 conditions of hepatic disease the same symptom is constantly present. 
 
 XIV. In disease of the supra-renal capsule, vomiting is rarely 
 absent ; but sometimes it is a sign of such prominence as to simulate 
 primary disease of the stomach. On post-mortem examination we 
 have found arborescent injection of the mucous membrane of the 
 stomach, and sometimes slight superficial ulceration ; but it must 
 also be remembered, that the pneumogastric nerve affords a branch 
 to the supra-renal capsule, and that the connection of the capsule 
 with the semilunar ganglia is a very intimate one. 
 
 XV. Diseases of the kidneys and renal calculus constitute other 
 causes of vomiting. During the passage of a calculus down the 
 ureter, vomiting is a very distressing symptom. In acute albumi- 
 nuria vomiting is also associated with nausea ; and in chronic albu- 
 minuria it is sometimes the precursor of a fatal termination. So 
 severe, indeed, may be this symptom in ischuria renalis, as even 
 to suggest the possibility of intestinal obstruction, as shown by Dr.
 
 FUNCTIONAL DISEASES OF THE STOMACH. 249 
 
 Barlow. The vomiting in albuminuria is not only due to the direct 
 connection of the nerves constituting the renal plexus with those of 
 the stomach, but to the urea excreted from the mucous membrane 
 of the stomach and intestines. It is found to be present in large 
 quantity in the blood, and is separated in all the excretions and 
 secretions ; and in the stomach, this abnormal excremeniitious sub- 
 stance appears to act as a direct irritant. 
 
 XVI. Both functional and organic diseases of the uterus and ova- 
 ries are causes of vomiting. In dysmenorrhoea, most distressing 
 irritability of the stomach is occasionally set up ; and in pregnancy, 
 vomiting may be so severe as to exhaust and completely to prostrate 
 the patient, and in ovarian disease, the gastric symptoms are often 
 mistaken for primary disease of the stomach. 
 
 XVII. The remaining causes of vomiting arise from the condition 
 of the nervous system, and are most interesting and important in 
 the correct diagnosis of disease ; the first of these is a diseased con- 
 dition of the spine. The splanchnic nerves pass from the spinal cord 
 to the large sympathetic ganglion of the abdomen, and constitute an 
 intimate connection between these centres of nerve-force ; in those 
 diseases, however, of the spine in which we have observed irrita- 
 bility of the stomach, other sources of disturbance have been present. 
 
 XVIII. At the onset of acute diseases, especially the exanthems, 
 the continued fevers, pyaemia, erysipelas, &c., vomiting is often pre- 
 sent. It is not known how this is produced, whether directly by the 
 altered condition of the nervous system, or secondarily from the 
 state of the blood. Sudden nervous shock, fright, &c., will produce 
 vomiting ; and in some more chronic diseases, when the blood is 
 altered in character, as in renal disease and even gout, the same 
 symptom is occasionally very intractable. 
 
 Dr. Graves, in his 'Clinical Medicine,' makes the following valuable 
 remarks in reference to this subject : " Every fever which commences 
 with vomiting and diarrhoea, whether it be scarlatina, or measles, or 
 typhus, is a fever of a threatening aspect ; and in all such fevers the 
 practitioner should be constantly on the watch, and pay the most 
 unremitting attention to the state of the brain. There is much differ- 
 ence between the vomiting and diarrhosa of gastro-enteritis, and this 
 cerebral diarrhoea and vomiting. The latter sets in generally at a 
 very early period of the disease, perhaps on the first or second day, 
 and is seldom accompanied by the red and furred tongue, the bitter 
 taste of the mouth, the burning thirst, and the epigastric tenderness 
 which belong to gastro-enteric inflammation.' 1 He also states very 
 truly, that in cerebral disease there is often a large quantity of bile 
 rejected by vomiting, and passed also by stool ; and that leeching 
 the abdomen is less efficacious in cerebral inflammation than in 
 gastro-enteritis. 
 
 Very little is known as to the proximate cause of vomiting in 
 cholera and in yellow fever; but we sometimes find in the intermit- 
 tents of our own country that vomiting is a prominent symptom ; 
 and we have several tiines witnessed instances in which vomiting,
 
 250 FUNCTIONAL DISEASES OF THE STOMACH. 
 
 excited possibly by uterine or hepatic mischief, assumed regular 
 periodicity in those who had been exposed to miasmatic poison. 
 
 A young person, who had resided in a low, marshy locality in 
 Cambridgeshire, presented this periodicity of symptoms in a re- 
 markable degree. She was a phthisical subject, and the mucous 
 membrane was very irritable. A tertian irritability of the stomach 
 and intestines existed ; on every other day there were vomiting and 
 diarrhoea with coldness and chilliness. Long residence in a mias- 
 matic district had probably given this periodicity to the symptoms, 
 and aggravated her anaemic condition. 
 
 XIX. Irritation of the peripheral branches of the pneumogastric 
 nerve in the abdomen has already been referred to as one causa of 
 vomiting in disease affecting the organs to which they are supplied: 
 but the same nerve may be changed at the peripheral branches in 
 the chest, and at its origin in the brain. Disease of the brain, then, 
 is another cause of vomiting, and one which it is important to bear 
 in mind in the diaganosis of disease ; too often the so-called bilious 
 attacks of children are the first indications of acute hydrocephalus. 
 The irritability of the stomach is sometimes so great, that vomiting 
 is at once produced when the patient is raised from the recumbent 
 position. The diagnosis of these cases is sometimes exceedingly 
 difficult when commencing with symptoms of true gastro-enteric dis- 
 ease ; but it would be well if the remark of the great authority in 
 clinical medicine just quoted were borne in mind, that, " in all fever- 
 ish complaints, where during the course of the disease the stomach be- 
 comes irritable without any obvious cause, and where vomiting occurs 
 without any epigastric tenderness, you may expect congestion or in- 
 cipient inflammation of the brain or its membranes." In simple 
 cerebral disease the abdomen is generally collapsed; in primary ab- 
 dominal disease there is, on the contrary, distension. This difficulty 
 in diagnosis is not, however, limited to very young subjects. In 
 strumous disease of the brain, the vomiting is sometimes excessive, 
 and I have seen it associated with chlorosis and ausemia. 
 
 After concussion of the brain, vomiting comes on ; and in some 
 cases, when inflammatory disease has followed and suppuration has 
 taken place, the vomiting is excessive. One of the most severe 
 cases of secondary vomiting which I have ever witnessed was of this 
 kind. A man in middle life had received a blow at the back of the 
 head ; cerebral symptoms came on, and suppuration took place at 
 the origin of the pneumogastric nerve ; the membranes were adhe- 
 rent at that part for the space of half an inch, and about half a 
 drachm of pus was effused. The vomiting was excessive; anything 
 swallowed was rejected with violence beyond the extremity of his 
 bed. 
 
 XX. Disease of the lungs, or irritation of the pulmonary brandies 
 of the pneumogastric nerve, is the last cause of vomiting to which 
 we refer. The vomiting in whooping-cough appears to be of this 
 kind, and equally so the vomiting which is often present at the early 
 stage of phthisis; the same symptom may occur in acute as well as 
 in chronic disease of the lung. Sir Henry Marsh has mentioned
 
 FUNCTIONAL DISEASES OF THE STOMACH. 251 
 
 early phthisis as one of the causes of the irritability 7 oTthe stomach, 
 to which he has given the naree-of regAiFgitativexliseastK-and -tpo 
 frequently it leads to the unfortunate ^expression, that the symptoms 
 of early consumption are "all stortiach'." It seems that as the 1 pul- 
 monary disease advances, and disorganization takes place, this con- 
 dition of irritability is lessened, although we often find that the par- 
 oxysms of cough are productive of violent vomiting. 
 
 Many interesting physiological questions in reference to vomiting 
 might have been dwelt upon ; but sufficient has been stated to show 
 that it is impossible satisfactorily to diagnose and to treat disease of 
 the stomach without duly recognizing the value of each symptom in 
 its general bearing; and further, that the most effective manner of 
 alleviating any symptom, however distressing, is not by the treat- 
 ment of that symptom, but by the removal of its cause. 
 
 The importance cannot be over- estimated of distinguishing be- 
 tween vomiting of cerebral, spinal, or nervine origin, and that which 
 arises from gastric or other abdominal disease.
 
 252 
 
 oiHW.e^i ro 30 HpHJqo 
 
 HeYHS 
 CHAPTER VII. 
 
 DUODENUM. 
 
 THE symptoms which have been regarded by some writers as 
 proceeding from disease of the duodenum have by others been re- 
 ferred to states of the liver, of the stomach, or of the pancreas. 
 
 My own observations, and the facts which I adduce in the following 
 remarks, show that there are symptoms of disease justly attributable 
 to this portion of the alimentary canal; and that in some cases we 
 may, with care, satisfactorily diagnose that the duodenum is diseased. 
 The peculiarities of its position and structure deserve our careful 
 attention. Extending from the pyloric extremity of the stomach to 
 the jejunum, it is about twelve inches in length, and may be divided 
 into three nearly equal portions; the first is the most movable, is 
 almost surrounded by peritoneum, and is horizontal in its direction ; 
 it may be called the pyloric or stomachic portion of the duodenum, 
 for it is associated with the stomach in its diseases. The second is 
 vertical in direction, closely fixed near to the crura of the diaphragm, 
 and to the venacava; it receives the common bile and pancreatic 
 ducts generally by a single opening, and is hepatic in its morbid 
 relations. The pancreas is situated on the left side of the second 
 portion ; and the vena portae, the hepatic artery, and the branches 
 of the pancreatico-duodenal artery are also in relation with it. The 
 third is horizontal in direction, and is simply intestinal in its function ; 
 the pancreas is situated above it; in front the superior mesenteric 
 vessels enter the mesentery, and behind it are placed the aorta and 
 the vena cava. The three portions of the duodenum are situated on 
 different planes, the first portion being near to the anterior abdominal 
 parietes, whilst the third part is immediately upon the spine ; and 
 this arrangement allows the contents of the canal mechanically to 
 gravitate quickly into the jejunum, and assists also the discharge of 
 bile from the ducts. 
 
 The muscular layers of the duodenum are double; a circular and 
 a longitudinal coat, as in other portions of the small intestine. The 
 mucous coat is covered with villi, which commence at the duodenum, 
 and soon become exceedingly numerous ; so also the valvulie conni- 
 ventes are gradually developed, till we find them as large as in the 
 jejunum. The whole of the surface is studded over with Lieber- 
 kiihn's follicles! ; not unfrequently, especially in young subjects, there 
 are solitary glands, as in the jejunum and ileum. There are also the 
 glands of Brunner, minute compound glands peculiar to the duode- 
 num, and which are situated beneath the substance of the mucous 
 membrane; these commence a few lines from the pylorus, and extend 
 about as far as the common bile duct ; their function is not definitely
 
 DUODENUM. 253 
 
 known, but they are believed to resemble minute salivary or pancre- 
 atic glands. It sometimes happens that the solitary glands are so 
 distinct, that they may very easily be mistaken for Brunner's glands; 
 the latter are, however, situated beneath the mucous membrane, and 
 microscopical examination at once manifests their difference. 
 
 There is still another point in connection with the duodenum that 
 deserves consideration, and which indicates its close connection with 
 the stomach and with the liver. The pneumogastric nerves, branches 
 of which supply the stomach, and also the liver, send filaments along 
 the first portion of the duodenum, continued onwards from the lesser 
 curvature of the stomach ; this associates that part of the duodenum 
 very intimately with the stomach. Besides this nervous supplv we 
 have, according to the observations of Meissner and Auerbach, 
 minute plexuses of nerves, both in connection with the mucous and 
 muscular coats. 
 
 The pancreatico-duodenal artery, which supplies the greater part 
 of the duodenum, is from the hepatic, and the pyloric branch of the 
 coronary extends into the first part of the duodenum, so that in the 
 arterial supply we find the same association. 
 
 State, of secretion. The secretion is stated to be alkaline, and such 
 is probably the case ; the acid reaction after death arising from the 
 gastric juice, which has gravitated through the pylorus. Whether 
 a patulous, feeble contractile power in the pylorus, allowing the 
 secretions of the stomach to pass at irregular periods into the duo- 
 denum, is the cause of the discomforts associated with these forms 
 of dyspepsia, we have no data on which to form an opinion. Cor- 
 visart states that the pancreatic fluid discharged into the duodenum 
 has the power of dissolving albuminous substances ; this opinion is, 
 however, controverted by Dr. Brinton ; the former describes duo- 
 denal dyspepsia as arising from an abnormal condition of this 
 secretion. 
 
 Congenital malformation. The duodenum sometimes has a double 
 sigmoid curvature a peculiar arrangement which I observed in a 
 patient who died from intestinal obstruction. The ascending colon 
 was adherent to the sigmoid flexure, and the caecum, twisted upon 
 itself, was situated in the left hypochondriac region. The person 
 had been born at the seventh month, and the cascum was preter- 
 naturally free. 
 
 In a cyclopean monster, I found the viscera of a double foetus in 
 a single peritoneal cavity; a double oesophagus was united in a 
 single stomach, with a large convexity extending across the abdo- 
 men ; and a single duodenum, placed vertically, received the biliary 
 pancreatic ducts on either side. 
 
 Diverticula are exceedingly rare as compared with those which 
 arise from the lower part of the ileum ; but small pouches are more 
 frequently present, and they consist generally of mucous membrane, 
 thus constituting a sort of hernial protrusion. In the museum of 
 Guy's is one of these situated near the opening of the duct into the 
 duodenum. 
 
 Some believe that the duodenum becomes distended with flatus, or
 
 254. DUODENUM. 
 
 with retained chyme, as the result of indigestion; and where there 
 is mechanical obstruction, which we shall afterwards describe, this 
 may be the case. It is possible also that an enormously distended 
 transverse colon may impede the free passage of the contents of the 
 third portion, but such is problematical. The distension which has 
 been supposed to arise from the duodenum, will generally be found 
 to be distension of the stomach or the transverse colon ; for the duo- 
 denum passes quickly to a lower level, and I believe its contents at 
 once gravitate into the jejunum. 
 
 As to the strictly pathological states, we find congestion sometimes 
 active, more frequently passive ; ulceration, cancer, and lastly me- 
 chanical obstruction are also noticed. 
 
 To some it may appear altogether futile to speak of congestion or 
 hyperaemia of the duodenum, but observation of the appearances 
 after death convinces me that marked changes occur, and that in 
 some instances a careful investigation might have pointed out their 
 existence during life. 
 
 Great congestion of the duodenum is found in various diseases in 
 which a similar condition extends to the whole tract of the alimentary 
 canal, as in disease of the mitral valve, and in portal obstruction in 
 hepatic disease ; but there are other cases in which we find active 
 congestion, especially in acute pneumonia. The latter state of acute 
 hypersemia is illustrated in the following case : 
 
 CASE LXXXV. Inflammation of the Bronchi, of the Bile-Ducts, or 
 Biliary Hepatitis, fyc. Acute Congestion of the Duodenum. Thomas H , 
 aet. 42, was admitted into Guy's Hospital, March, 1852 ; he had been ill for 
 three weeks. He was a large, stout man, who for fourteen years had been 
 in the police service ; his habits of life had been very intemperate. Four 
 years previously he had received a severe blow in his right side from a prize- 
 fighter, and for some time he had been subject to vomiting in the morning, 
 and the bowels had at times been much relaxed ; before admission jaundice 
 came on ; he had had more anxiety of mind than usual, and gradually be- 
 came languid and icteric. For four days his legs had swollen, afterwards his 
 abdomen, and his strength became prostrated. The skin was of a dusky 
 yellow color; the tongue was dry, brown, and furred; respiration 44; the 
 pulse 100, soft and compressible ; the abdomen was much distended with 
 flatus, and fluctuation could also be felt ; the liver extended several inches 
 below the ribs, and there was tenderness on pressure in that part. In the 
 chest there were general bronchial rales ; he was delirious at night, and slept 
 but little ; the motions were light in color, the bowels relaxed, the urine con- 
 tained lithates and the coloring matter of bile. Three days after admission 
 he was more prostrate, and was delirious ; the pulse was very compressible ; 
 lie had pain in the right hypogastric region, and on the following day he 
 died. 
 
 On inspection severe capillary bronchitis was found ; the larger bronchi 
 were also diseased ; they were somewhat congested, and contained yellow- 
 colored tenacious mucus. The heart was large, and had around it a consider- 
 able quantity of fat ; the right ventricle was thin ; the left ventricle had 
 undergone partial fatty degeneration. The valves were healthy, with the 
 exception of slight thickening of the mitral. Abdomen There were several 
 pints of yellow serum in the peritoneum ; the intestines w r ere considerably
 
 DUODENUM. 255 
 
 distended with flatus, and the liver extended several inches below the ribs. 
 The duodenum contained bloody mucus, the lining membrane was very much 
 congested, and in some parts ecchymosed. The lower part of the small intes- 
 tine contained clayey feces. There was a considerable quantity of fat in the 
 omentum, and in the abdominal parietes. 
 
 The liver weighed 7 Ibs. ; its surface was smooth, and of a deep greenish- 
 yellow color, and some veins were seen upon it ; the acini were whitish in 
 color. The section of the liver appeared coarse along the smaller branches 
 of the vena portse ; the capillary vessels in Glisson's capsule were much dis- 
 tended, and some of them were quite turgid with blood. The smaller biliary 
 vessels contained tenacious mucus, and their lining membrane was congested ; 
 this state of the bile-ducts contrasted remarkably with the pale color of the 
 veins. The cells of the liver were gorged with fat, some of them were dis- 
 tended with oil-globules ; other hepatic cells appeared ruptured, and granules 
 witli oil-globules were dispersed upon the field of the microscope. The deep 
 green spots did not present any cells, but only granular matter. 
 
 The larger bile-ducts were free, but the opening into the duodenum was 
 very much congested ; the gall-bladder was empty ; the kidneys were large 
 and congested ; the spleen was firm, and contained several n'brinous masses. 
 
 The health of this man was much impaired by his intemperate 
 habits, and his liver had probably been diseased for a considerable 
 period. The affection of the chest came on subsequent to his admis- 
 sion into the hospital, and consequently after the jaundice. There 
 Avas evidently acute disease of the smaller biliary tubes, as indicated 
 by the congestion of Glisson's capsule, by the congestion of the lining 
 membrane of the biliary tubes, and the tenacious mucus they con- 
 tained ; the hepatic structure was stained with bile. The bronchitis 
 which subsequently took place was, perhaps, the cause of the fatal 
 termination, and tended, doubtless, to increase the congestion of the 
 mucous membrane. The very congested state of the duodenum near 
 the entrance of the bile-ducts indicated an extension of disease from 
 the duodenum to the bile-ducts, or vice versa; it was much more local- 
 ized than is observed in the secondary congestion of the mucous 
 membrane in pulmonary obstruction. This did not appear to be an 
 affection in which much benefit could be obtained from the admin- 
 istration of mercury, but rather from salines with sedatives. 
 After burns the mucous membrane of the duodenum has been 
 found greatly congested, and in several cases recorded by Mr. Curling 
 in the ' Medico- Chirurgical Transactions' this part of the intestine 
 was ulcerated. This statement has not been confirmed by the obser- 
 vations of Dr. Wilks, recorded in the 'Guy's Eeports' for 1856. I 
 witnessed many of the cases to which he refers; and although in 
 some the first'part of the duodenum was hyperaemic, in none did 
 I observe Liberation. A case of ulceration of the duodenum after a 
 burn has however, been placed in the Museum at Guy's, by Sir Wm. 
 Gull. The child survived twenty-five days, but died comatose; a 
 small cicatrizing ulcer was found in the first part of the duodenum. 
 
 Since the former edition of this work was written three cases of 
 ulcer of the duodenum after burns have occurred at Guy's. 
 
 In one the patient was admitted for an extensive scald, and died 
 thirteen days after admission. The duodenum contained two small
 
 256 DUODENUM. 
 
 ulcers, one the size of a pea, the other of a hemp-seed, and Brunner's 
 glands were swollen. The ulcers appear to have had nothing to do 
 with the man's death. 
 
 The second, a male child, aet. 4, died nineteen days after a severe 
 burn of the lower extremities. He was doing well, and the burn 
 was healing, when three days before death he began to pass blood 
 into the bed. A large ulcer was found in the duodenum, and the 
 pancreatico-duodenal artery was opened. The child had also two 
 small ulcers on its tongue, extending through the mucous membrane. 
 
 The last case occurred in a girl, set. 13, who died from tetanus 
 about thirteen days after an extensive burn. The stomach was ec- 
 chymosed, and immediately beyond the pylorus was a small ulcer 
 with thick raised edges. The thickening was considerable, so as to 
 cause a suspicion that the ulcer antedated the burn. There was 
 irregular injection around it. 
 
 The pathology of such cases is still involved in much obscurity. 
 Embolism and necrosis of tissue from blood extravasation after con- 
 gestion have been suggested, as we have already mentioned, in 
 stating the hypothetical explanations of acute perforating ulcer of 
 the stomach. 
 
 Mr. Curling describes diarrhoea, and the discharge of blood, as 
 having arisen from this condition of the duodenum, and sometimes 
 severe haematemesis and prostration. In some instances death took 
 place from peritonitis consequent on perforation. After such severe 
 injury to the skin, it is not surprising to find great disturbance of 
 the circulation or of the internal organs, and especially of the mucous 
 membranes, which are known to sympathize so closely with the 
 skin ; in some of these cases stimulants appear to have been admin- 
 istered freely, and these have probably conduced to this diseased 
 appearance of the duodenum. 
 
 Chronic congestion produces gray discoloration of the mucous mem- 
 brane ; and in the examination of the discolored part we find that 
 the deep color is produced by the deposit of irregular grains of pig- 
 ment, very thickly placed in the substance of the mucous membrane, 
 near to its upper surface, and probably in the coats of the capillaries ; 
 the apparent explanation of this state being, that gastro-enteritis, or 
 long-continued hyperaemia, has been followed by the deposition of 
 haematine or pigment in the substance of the membrane. 
 
 In several cases of this gray discoloration the appearance, both in 
 children and in adults, has been uniform. A child, set. 9, a thin, 
 poorly nourished, pale boy, who had been subject for some time to 
 looseness of bowels, whilst running, hurt his thigh ; he shortly after- 
 wards complained of pain at that part ; he was admitted into Guy's 
 in a typhoid state, and died two days afterwards. There was sup- 
 puration in the brain, and gray discoloration of the mucous mem- 
 brane of nearly the whole of the small and large intestines. 
 
 Chronic congestion is observed, as before stated, in connection 
 with pulmonary and hepatic congestion, in fact, in any disease which 
 leads to distension of the vena portae ; and we also find a less general 
 condition of congestion of the first part of the duodenum in disease
 
 DUODENUM. 257 
 
 of the pylorus, whether it be simple fibroid degeneration and hyper- 
 trophy, or true cancerous disease. The mucous membrane becomes 
 thickened, its vessels congested, and its glands enlarged ; sometimes, 
 indeed, so much so that the glands might easily be mistaken for 
 minute cancerous tubercles. The continued irritation thus leads to 
 hypertrophy of the glands of the mucous membrane, as we find in 
 other similar structures. 
 
 The duodenum is sometimes found, after death, to be filled with 
 blood, and a coagulum is occasionally moulded into its exact form. 
 This is due to extravasation of blood from ulceration and perforation 
 of an artery, in the duodenum or in the stomach. 
 
 As to the symptoms arising from the conditions just described, 
 they appear to be so continually bound together with those indica- 
 tive of simple disease of the contiguous viscera, that definiteness and 
 certainty cannot be attained. The vomiting and pain connected 
 with hepatic disease and gall-stone are possibly due partlv to the 
 condition of the duodenum. In the latter there is probably spas- 
 modic contraction of the canal; but of this we do not speak with 
 certainty. In the cases described by Mr. Curling, vomiting was a 
 frequent symptom ; and the bilious evacuation in violent vomiting 
 indicates that the first and second portions of the duodenum have 
 been involved. 
 
 Instances are not unfrequently met with in which, several hours 
 after food, there is pain at the region of the duodenum, perhaps with 
 violent vomiting, faintness, pallor of the countenance ; and these 
 symptoms have by some persons been referred to the duodenum, as 
 a form of duodenal dyspepsia or inflammation; by others to the 
 pyloric valve ; but occasionally jaundice follows, which appears to 
 strengthen the former supposition. After intemperance, also, vio- 
 lent bilious vomiting, a furred state of the tongue, loss of appetite 
 and loathing of food, diarrhoea, tenderness of the right hypochon 
 driac region, are followed by jaundice; and we are prone to regard 
 the duodenum as being in, at least, a state of great hyperoamia. 
 Exposure to cold, with great mental anxiety, tends also to promote 
 this state of duodenal disease ; and the mischief appears to be pro- 
 pagated to the bile-ducts. Sir H. Marsh has drawn attention to the 
 occurrence of jaundice with disease of the duodenum, in the 'Dublin 
 Medical and Surgical Journal ;' so also Dr. Stokes, in the ' Encyclo- 
 paedia of Practical Medicine.' 
 
 Congestion of the duodenum is best relieved by diminishing portal 
 and hepatic engorgement, and by stimulating the abdominal excre- 
 tory organs to increased action. These objects may be attained by 
 giving saline and mercurial purgatives, by aperient enemata. and by 
 the application of leeches to the anus or to the scrobiculus cordis. 
 A free dose of calomel, blue pill, or gray powder, followed by a 
 saline aperient draught, often acts very effectively as a purgative ; 
 but in many instances, especially where the morbid condition 
 arises from "chronic pulmonary disease or obstructive disease of 
 the heart, small doses of mercurials may be very advantageously 
 combined with squills and foxglove, so as thoroughly to act on the 
 17
 
 258 DUODENUM. 
 
 abdominal excretory glands ; but to give mercury so as to produce 
 salivation, or to prescribe it in every instance where bilious fluid is 
 rejected, appears to be an unwise course. The most bland nourish- 
 ment should be given, and abstinence from stimulants should be en- 
 joined; ice and cold drinks often afford great relief when vomiting 
 distresses the patient. In acute hypersemic states, salines, as the 
 solution of potash, the bicarbonates of potash or soda, the carbonates 
 or the citrate of magnesia, may be given with diuretics in efferves- 
 cence or otherwise, as the individual case may require. But in 
 chronic hypenemia, where there is profuse secretion of mucus, more 
 advantage will be found from the dilute nitric or nitro-hydrochloric 
 acids, with laxatives, as taraxacum, or with cinchona, and from the 
 old compound gentian mixture of the London Pharmacopoeia. 
 
 The most acute form of inflammation is sometimes observed after 
 the administration of poisons. In a case of poisoning by sulphuric 
 acid, where several square inches of the mucous membrane of the 
 stomach had been destroyed, the duodenum was found intensely con- 
 gested, and covered throughout by a thin, adherent, diphtheritic 
 membrane. In this case the vomiting and dysphagia disappeared on 
 the third day, and the patient, though extremely prostrate, did not 
 appear to suffer much from pain. Arrowroot, lirne- water, and milk, 
 &c., were administered, and for a week it was thought that the 
 patient might rally. (See " Diseases of Stomach.") In ordinary 
 practice, however, we do not meet with this form of disease. 
 
 Ulceration of the duodenum varies both in degree and extent ; 
 sometimes it is merely superficial, and is associated with other dis- 
 eases, as in a patient who died from albuminuria with pericarditis, 
 in whom the duodenum presented superficial ulceration, the result 
 of erythematous or acute inflammation; or there may be chronic 
 ulcer, resembling that found in the stomach, and presenting many 
 symptoms in common with that disease. 
 
 Some duodenal ulcers have raised and thickened edges, with de- 
 pressed centres, being evidently of slow formation. They are mostly 
 found in the first portion of the duodenum; and since this part of 
 the intestine is almost surrounded by the peritoneum, we sometimes 
 have fatal peritonitis, produced by perforation, as in the stomach, 
 the muscular and peritoneal coats being also destroyed by the ulcer; 
 or adhesion takes place with the adjoining structures, as the liver and 
 pancreas, &c. ; and these oftentimes constitute the floor of the ulcer. 
 
 Several cases have come under my own notice the early symptoms 
 of which were exceedingly slight, till sudden and fatal peritonitis 
 had been set up by perforation. In some instances these ulcers have 
 been associated with violent vomiting, the persistence and aggrava- 
 tion of which were attributed to this diseased condition ; this occurred 
 in a young woman, aged twenty-four, who was admitted into Guy's 
 Hospital with very urgent vomiting ; the pulse was small and fre- 
 quent; she was pregnant, and died in a short time from peritonitis; 
 a small ulcer was found in the duodenum. 1 The vomiting was proba- 
 
 1 Dr. Hodgkin on 'The Pathology of Serous and Mucous Membranes.'
 
 DUODEXUM. 259 
 
 bly referred to sympathetic irritation from the uterine state ; and a 
 favorable prognosis would in many such cases have been given till 
 the symptoms of peritonitis came on. 
 
 The second portion of the duodenum is, however, also liable to 
 ulceration, as in a case preserved in the museum of Guy!s, where 
 the coats of the whole of the vertical portion on the pancreatic side 
 were destroyed, and the pancreas formed the base of a large chronic 
 ulcer, in the centre of which was seen the opening of the biliary and 
 pancreatic duct. There was a small ulcer in the third portion of the 
 duodenum, and peritonitis had been set up ; the pancreas was en- 
 larged. The patient was forty-four years of age, and had empyema; 
 he became exceedingly emaciated before death, and suffered from 
 vomiting as well as from meltena. 
 
 Ulceration is sometimes followed by constriction ; and adhesions 
 also frequently form between the first part of the duodenum and the 
 gall-bladder ; in some, ulceration extends from the gall-bladder into 
 the duodenum, thus allowing the passage of calculi; and the gall- 
 bladder is, in other cases, entirely obliterated. 
 
 Pain several hours after food, a sallow complexion, furred tongue, 
 feebleness of circulation, mental depression, nausea, and irritable 
 bowels, have been ascribed to ulceration of the duodenum, but the 
 facts do not fully warrant this conclusion. In the several instances 
 we have observed there were no such indications ; in some, the ulce- 
 ration was associated with disease of the gall-bladder; in others, 
 Avith chronic disease of the liver ; and the predisposing and exciting 
 cause of the hepatic disturbance had probably induced the duodenal 
 mischief. 
 
 Ulceration of the duodenum must be remembered both as a source 
 of fatal perforation and of intestinal hemorrhage, as well as of haema- 
 temesis. 
 
 The treatment of these cases is similar in all respects to that re- 
 commended for corresponding gastric disease. 
 
 CASE LXXXYI. Ulceration of the Duodenum. Perforation George 
 E , set. 30, a man of light complexion, and of steady and temperate habits, 
 was admitted into Guy's Hospital, October, 1851. He was by trade a surgi- 
 cal instrument maker, and accustomed, when at work, to exercise pressure 
 against the umbilicus. Four months before admission he had slight expecto- 
 ration of blood, but it was doubtful whether it proceeded from the lungs or 
 stomach. On October 20th, whilst apparently in good health, he suddenly 
 experienced severe pain in the abdomen ; to use his expression, he was 
 " doubled up ;" he fell down in a fainting state, and was taken into a drug- 
 gist's shop, where ammonia and some, castor oil were administered. The 
 pain was situated on the right side. On admission, he was in a state of col- 
 lapse ; the pain of which he complained passed in the course of the ureter. 
 On the following morning he was exceedingly depressed, the skin hot, the 
 abdomen tender, and there were the. symptoms of general pertitonitis ; vomit- 
 ing of coffee-ground fluid came on, and pulsation was felt at the scrobiculus 
 cordis, which suggested the idea of aneurism. He survived fifty-six hours. 
 On examination, the peritoneum was found to be intensely inflamed ; lymph 
 was effused, and castor oil was found floating in the peritoneal cavity. At 
 the first part of the duodenum, about one inch from the pylorus, an ulcer was
 
 200 DUODENUM. 
 
 found of the size of a shilling ; and at its base there was a circular opening, 
 the third of an inch in diameter. In the stomach several small aphthoiis 
 ulcers were observed, and two small ones were covered with coagula. The 
 remaining parts of the small intestine were healthy ; so also the cu-cum, colon, 
 kidneys, spleen, and liver. 
 
 In the chest there were old pleuritic adhesions on both sides, especially on 
 the left, where there was also a small vomica, with indurated lung, and thick- 
 ened tubes. 
 
 The patient was only thirty years of age; and, as he believed, in 
 good health, though evidently of feeble constitutional power, as 
 indicated by the condition of the lungs and the previous haemop- 
 tysis ; he was doubtless phthisical, but the disease of the duodenum 
 resembled, in its insidious character, corresponding disease of the 
 stomach, and gave no previous indication of its existence. 
 
 The treatment of the patient, before his admission, precluded all 
 chance of recovery ; but such, unfortunately, is too frequently the 
 case. Brandy and castor oil, probably both, found their way into 
 the peritoneal sac: and the necessary removal of the man, at first 
 into a druggist's shop, then to his own home, and afterwards a con- 
 siderable distance to the hospital, tended to induce increased extra- 
 vasation and peritonitis ; the judicious administration of opium 
 prolonged life many hours. 
 
 As to the cause, the stooping posture at his work probably assisted 
 to produce the disease ; but this is involved in much obscurity. 
 
 The position of the pain did not point out the seat of the perfora- 
 tion ; but this is only what has frequently been observed in cases of 
 gastric ulcer ; the pain was principally in the right iliac fossa, and 
 it was believed that the ileurn, or appendix caeci, had given way. 
 
 Mr. Travers, in the 'Medico-Chirurgical Transactions,' mentions 
 a case of perforation of the duodenum, about a finger's breadth from 
 the pylorus, in a gentleman, aged thirty-five, who was strumous, but 
 considered to be in good general health. There was a large irregular 
 ulcer in the first part of the duodenum, with a small perforation, 
 which had led to fatal peritonitis and death in thirteen hours ; the 
 perforation tooK place a short time after a meal, the period at which 
 such accidents are generally found to occur. 
 
 CASE LXXXVII Chronic Ulcer in the Duodenum. Carcinoma of the 
 
 Liver. Jaundice. Granular Kidneys. Obliteration of the Bile Di-t 
 George C , oet. 46, was admitted into Guy's Hospital December 14, !*.").'>, 
 and died January 4. For a fortnight lie had had jaundice, vomiting, and 
 typhoid symptoms, and for three months, after exposure to cold, oedema of the 
 lower extremities had been present. In the liver there were from six to ten 
 carcinomatous tubercles ; the bile duct was obliterated near its opening into 
 the duodenum, and throughout the liver, the ducts were very much distended; 
 the cells of the liver were normal. In the first portion of the duodenum there 
 was a chronic ulcer, about an inch in diameter, with raised thickened edges, 
 but not cancerous in its character; the rest of the intestine was healthy ; the 
 kidneys were large, and their sin-face irregular and granular. 
 
 The disease in the duodenum was not discovered till after death ; 
 the cancerous condition of the liver, inducing pressure on, and ob-
 
 DUODENUM. 261 
 
 literation of the ducts, and the albuminuria appeared sufficient to 
 explain all the symptoms. The ulcer in the duodenum, however, 
 was in a chronic and passive condition, but nothing was ascertained 
 as to its cause ; we suppose that intemperance increased it. We 
 rarely find such a complication of disease as cancer of the liver, acute 
 disease of the kidney, and the condition of the duodenum just men- 
 tioned. 
 
 CASE LXXXVIII. Strum on s Disease of the Abdomen. Perforating 
 Ulcer of the Duodenum and Caecum Jane B , jet. 18, was admitted into 
 Guy's Hospital February 19, 1860, and died October 4. At first the most 
 prominent symptom was vomiting, which was supposed to be hysterical ; but 
 after a time the abdomen began to swell, diarrhoea came on, and emaciation, 
 &c., increased, and these signs indicated the presence of organic disease. 
 On inspection, the body was much emaciated ; the legs were cedematous. 
 The pleura was opaque, from the recent effusion of lymph, and the lungs were 
 studded with tubercle. The peritoneum was acutely inflamed ; the intestines 
 were reddened, and there was lymph upon them ; there were tubercular 
 masses upon the peritoneum, covering the liver. On withdrawing the caecum, 
 a small collection of offensive pus was found at its posterior part, and the 
 abscess communicated with the caecum by means of an opening about an inch 
 above the ileo-colic valve. At the seat of perforation was a transverse ulcer, 
 the edges of which were injected ; the ulcer was one inch in length, and the 
 opening one- third of an inch. A few other ulcers were observed in the colon, 
 but none were found at the termination of the ileum. The mesenteric glands 
 were enormously infiltrated with cheesy deposit ; so also were the lumbar 
 glands. Behind the first portion of the duodenum, and close to the pancreas, 
 was a collection of offensive pus in front of the spine. This abscess com- 
 municated with the first portion of the duodenum by an opening about a 
 quarter of an incli in diameter; the ulceration of the mucous membrane was 
 more extensive than the external opening ; and near to the perforation was a 
 second smaller ulcer involving the mucous membrane. The first portion of 
 the duodenum appeared to be contracted. The stomach was healthy ; so also 
 the kidneys. The spleen contained a softening strumous mass. The liver 
 also was fatty. 
 
 Although the history of this case is imperfect, I have introduced 
 it as an illustration not only of the obscurity of strurnous disease in 
 its earlier stage, but as an instance of irritation of the duodenum and 
 colon, followed by ulceration and perforation, and producing perito- 
 nitis, at first of a local, but afterwards of a general character. The 
 perforations in both situations were not directly into the serous cavity; 
 the abscess connected with the duodenum was close to the pancreas 
 upon the spine, and the one in the colon was placed behind the 
 cascum. 
 
 In an interesting case of haematemesis under my care in Ouy's 
 Hospital in 1875, the hemorrhage which proved fatal was supposed 
 to have come from the stomach, but on examination after death, it 
 was found that a large ulcer in the duodenum had perforated the 
 intestine, and led into a sloughing abscess in the portal fissure, with 
 which the vena portse communicated by an ulcerated opening par-
 
 262 DUODENUM. 
 
 tially filled by clot; the common bile-duct and hepatic dnct were also 
 divided ; the hepatic artery was obliterated. 1 
 
 It is probable that this perforation of the duodenum was from 
 without, as was also the case in a patient under my care in lsi;ii. 
 A woman, aged 46, died a few weeks after admission, and a large 
 abscess was found on the right side of the abdomen in the neighbor- 
 hood of the ascending colon, along which it extended to the duode- 
 num, where it opened by a rounded aperture an inch beyond the 
 pylorus. The stomach contained a little altered blood. The patient 
 had also cancerous disease of the gall-bladder, which, however, had 
 no apparent connection with the peritoneal abscess. 
 
 CASK LXXXIX. Gall-stone. Ulceration of Gall-bladder and Duode- 
 num. Large Gall-stone impacted in the Jejunum. Death from Hemorrhage. 
 A. B , jet. 56, had suffered from loss of appetite and mental depression 
 for some time, due to family anxiety and trouble. lie was a strong, muscular 
 man, rather stout, and he had generally enjoyed good health. On November 
 29th, after a late dinner, severe pain came on in the region of the stomach, 
 and for several hours was very intense ; there was vomiting, and the pain 
 extended to the back. On the following day the intense pain had subsided, 
 but left soreness at the stomach, at the scrobiculus cordis, and in the region 
 of the gall-bladder. He had no appetite, and the tongue was furred ; a pur- 
 gative was given and saline medicine. On December 2d he had become 
 jaundiced ; the pulse was good, but the tongue was furred ; there was no 
 appetite for food, but much mental depression. The symptoms of jaundice 
 gradually lessened. On December loth the urine was still deep in color, 
 but the motions were less pale. He lost the pain at the stomach, regained 
 his appetite, the urine became normal in color, and he was able about Christ- 
 mas to visit his friends ; the skin, however, did not completely regain its 
 color. On January 12th he returned to town, feeling tolerably well, but 
 during the night nausea came on. On Saturday, 13th, sickness supervened, 
 and he took blue pill with colocynth ; the bowels acted a little. On 14th the 
 vomiting- persisted, and saline effervescing medicines were prescribed ; in the 
 evening vomiting of blood occurred mixed with acid fluid. On Monday, 
 January 15th, I saw him in consultation. The stomach was very irritable; 
 everything was at once rejected ; the pulse was quiet, 80 ; temperature nor- 
 mal ; the abdomen was full, but there was no tenderness; he complained of 
 soreness across the abdomen, just above the umbilical region, and hardness 
 could be felt at the scrobiculus cordis, which was thought to be the left lobe 
 of the liver; there was no fixed pain, and no evidence of hernia. Bismuth 
 medicine in effervescence was given, and a dose of calomel with colocynth. 
 On the 16th he was rather easier, but there was no action from the bowels ; 
 the pain increased in the afternoon ; the calomel and colocynth were repeated, 
 and an injection used. On January 17th there was still no action of the 
 bowels ; a dose of castor oil was followed by violent vomiting of brown acid 
 fluid ; no flatus was passed ; the pulse was 80, temp. 98, the respiration 
 easy j the abdomen was lull and stipple, and tympanitic ; there was soreness 
 in the epigastric region; no peristalsis could be seen. It seemed evident 
 that there was obstruction in the bowels ; purgatives were not repeated, but 
 a grain of opium was given, and a turpentine enema was used. On January 
 
 18th The opium given night and morning had relieved the sickness ; a full 
 
 injection of oil and afterwards soap-and-water produced a discharge of hard 
 
 'See 'Path. Trans.,' vol. xxvii, 1876.
 
 DUODENUM. 263 
 
 scybala. Still there was no free action from the bowels ; the pulse was 80, 
 temperature still normal, the abdomen as before ; the urine was normal in 
 color, tolerably free in quantity, sp. gr. 1017, and it contained a trace of 
 albumen. On the 19th he felt better in the morning, but as he could not 
 pass urine freely a hip-bath was allowed. About 4 P. M. faintness came on, 
 and he again vomited blood. The patient became restless. Still there was 
 no action from the bowels ; no flatus was passed, but the urinary bladder 
 being distended a catheter was introduced, and about a pint of urine drawn 
 off. Ice was applied externally, and some was swallowed, and astringents 
 given. Nutrient injections were used repeatedly. At 10 P.M. he had 
 rallied ; about a pint of blood mixed with acid fluid had been rejected. On 
 January 20th, about 5 A. M., more blood with clots were vomited, but he 
 again rallied. On the 21st he had return of vomiting several times; in the 
 evening he got out of bed, again vomited blood, faintness followed, and he 
 died about 8 P. M. 
 
 Post-mortem examination by Dr. Goodhart twenty hours after death 
 
 Abdominal wall thickly coated with fat. On opening the abdomen, the 
 omentum and liver were found adherent to the abdominal wall in front at the 
 upper part. The jejunum was much distended and dark in color ; on tracing 
 the small bowel from the caecum upwards, the ileum was small and paler till 
 its upper part was reached. Here it was blocked by a gall-stone of black 
 color, somewhat irregular in shape, with a facet at either end of its long 
 diameter, and measuring about l^Xl^ inches. It moved about in the bowel 
 under external manipulation with considerable freedom, though it would not 
 pass far, and it quite filled the canal. Below, the bowel was empty or nearly 
 so, and above, it was considerable dilated, and contained clayey and brownish 
 pultaceous fecal matter. The mucous membrane where the stone lodged was 
 superficially ulcerated in some parts. About three inches higher up was a 
 smaller gall-stone more like a fragment than a distinct calculus. It lay loose 
 in the intestine with some fluid, brownish fecal matter, and was easily crushed 
 between the fingers. Nothing else abnormal was found till the duodenum 
 was reached. On reaching the right lobe of the liver the first part of the 
 duodenum was seen to be pulled upwards and adherent to the fissure for the 
 gall-bladder, and to hide the gall-bladder from view. The latter was further 
 concealed by the omentum, also adherent to the liver. To the right of these 
 structures was a little treacly blood, about a drachm, lying close to the duo- 
 denum underneath the liver, but free in the peritoneum. Its position there, 
 must have been of recent occurrence, as it was not shut in by adhesions, and 
 yet no peritonitis, was present. Dissecting out the gall-bladder and the ves- 
 sels of the portal fissure, it was found that the fundus of the gall-bladder, the 
 cavity of which was much contracted, opened by a large hole into a shreddy 
 cavity which contained blood of treacly consistency; this cavity also opened 
 by a large and irregular aperture into the duodenum, immediately beyond the 
 pylorus at its anterior part. The vessels of the portal fissure ran to the left 
 and in front of the cavity external to the gall bladder, and they were not im- 
 plicated, with the exception of the main branch of the hepatic duct to the 
 right lobe of the liver. This was quite destroyed, and the truncated ex- 
 tremity opened into the abscess immediately behind its junction with the duct 
 from the other side to form the main hepatic duct ; the cystic duct was also 
 destroyed. All the other vessels were normal. The cystic artery of the 
 pancreatico-duodenal, splenic and gastric arteries, were all quite sound, and 
 so also were all the branches of the portal vein in the neighborhood. The 
 source of the hemorrhage could, therefore, only be attributed to venous oozing 
 from the surface of the ulcer in the gall-bladder and the duodenum, and the
 
 264 DUODENUM. 
 
 sloughing cavity outside. The liver substance was unaffected by the ulcera- 
 tive action, which was quite external to the capsule of the organ. The liver 
 was small, but quite healthy, except a slight excess of fat. The kidneys 
 were rather large and coarse ; the right contained a cyst ; the spleen was 
 pale but healthy. The lungs were emphysematous. The muscular fibre of 
 the heart was tatty. 
 
 From the observations I bad made in November I felt convinced 
 that the patient had gall-stone, and I supposed it had passed, although 
 one was not detected. In the last attack the hemorrhage was differ- 
 ent from that which we generally observe in gastric ulcer ; the blood 
 was poured out more gradually. The clinical history was not that 
 of gastric ulcer, neither was the hemorrhage such as we have in 
 engorgements of the portal circulation. From its gradual character, I 
 thought it probable that it arose from the duodenum and was venous 
 in character. It was evident, also, that there was mechanical ob- 
 struction of the intestine, for purgatives were instantly rejected, no 
 true action from the bowels took place, and no flatus was passed. It 
 occurred to me that possibly a gall-stone, impacted high up in the 
 small intestine, was the cause of the obstruction, and this opinion 
 was confirmed by the post-mortem examination, and also that the 
 hemorrhage arose from an ulcer in the duodenum. 
 
 No peristaltic movement, although several times looked for, could 
 be detected, and yet the gall-stone was pushed down to the end of 
 the jejunum. It is true that the abdomen was covered by a thick 
 stratum of fat, which would render the observation of movement 
 more difficult ; again, the intestine was filled with blood, and it is 
 possible that the peristaltic movements were very feeble on account 
 of the hemorrhage. Another circumstance of great interest was the 
 comparative absence of pain, although an enormous gall-stone, more 
 than an inch in diameter, had ulcerated its way through the gull- 
 bladder, then outside the bile duct, into the duodenum ; there was 
 soreness, but no severe pain and no rigor. This comparative absence 
 of pain I have previously noticed in a case where a large gall-stone 
 had led to fatal obstruction by impaction immediately beyond the 
 duodenum. ^ 
 
 The following is a table of the cases in which we have found ulce- 
 ration of the duodenum.
 
 DUODENUM. 
 
 265 
 
 Sex. 
 
 Age. 
 
 Disease or injury. 
 
 Cause of death. 
 
 Remarks. 
 
 F. 
 
 13 
 
 Burn 
 
 Tetanus 
 
 Thirteen days after ; 
 
 
 
 
 
 stomach. 
 
 M. 
 
 4 
 
 Burn 
 
 Hemorrhage 
 
 Ecchymosed ulcer on 
 
 
 
 
 
 the tongue. 
 
 M. 
 F. 
 
 30 
 
 Scald 
 Primary disease 
 
 Exhaustion 
 Portal pyaemia 
 
 Braune glands swollen. 
 
 M. 
 
 39 
 
 Amyloid viscera 
 
 Scrofulous pyelitis 
 
 
 M. 
 
 ... 
 
 Diseased knee 
 
 Hemorrhage 
 
 
 M. 
 
 55 
 
 Hydrocephalus 
 
 Convulsions 
 
 Hypertrophy and dila- 
 
 
 
 
 
 tation ; stomach. 
 
 F. 
 
 55 
 
 Renal disease 
 
 Large white kidney 
 
 
 F. 
 
 12 
 
 Disease of hip 
 
 Hemorrhage from ulcer 
 
 
 M. 
 
 30 
 
 Primary disease 
 
 Perforation, peritonitis 
 
 
 M. 
 
 46 
 
 Cancer of liver, &c. 
 
 Exhaustion from cancer, &c. 
 
 
 F. 
 
 18 
 
 Tapes mesenterica 
 
 ... 
 
 Abscess behind caecum, 
 
 
 
 
 
 &c. 
 
 M. 
 
 56 
 
 Gall-stone 
 
 Hemorrhage ; gall-stone im- 
 
 Ulcer due to the pas- 
 
 
 
 
 pacted. 
 
 sage of a gall-stone. 
 
 Cancerous disease of the duodenum. It is far more frequent to find 
 the duodenum secondarily involved, than to be itself the primary 
 seat of this fatal form of disease. In many cases the disease appears 
 to have commenced in the pancreas or in the adjoining lymphatic 
 glands, or in the liver; and although cancer of the stomach and of 
 the pylorus is generally very defined and ceases abruptly at the com- 
 mencement of the duodenum, such is not constantly the case ; for 
 the disease sometimes extends onward into the pyloric portion of 
 the duodenum. Again, it is oftentimes very difficult to state pre- 
 cisely in which part the disease has commenced. 
 
 As to the symptoms, the earlier ones are often very insidious ; and 
 are more likely to be mistaken for hepatic disease than the early 
 symptoms of cancer of the stomach : still the first indications are 
 those of dyspepsia and malaise, sallowness of complexion, mental 
 depression, followed by nausea, vomiting, and sometimes pain, seve- 
 ral hours after food has been taken. The patient emaciates, and a 
 hardness or tumor is felt about the cartilage of the tenth rib ; a very 
 difficult question then arises, as to whether it is the pylorus that is 
 affected, or the pancreas, or the lymphatic glands. Pulsation com- 
 municated to the growth may suggest the idea of aneurism. In 
 aneurismal disease the vomiting is a less marked symptom, and the 
 pulsation more uniform; the pain also is often very intense. In 
 primary pancreatic disease the tumor is generally more central ; the 
 evacuations have been found sometimes to contain fat, 1 and until 
 pressure take place on the duodenum, or the disease extend to the 
 stomach, and to the lymphatic glands, the symptoms are less pro- 
 nounced. Pyloric disease is indicated by more persistent vomiting 
 than we find' in simple duodenal disease. Occasionally local ulcera- 
 tion, with chronic thickening, takes place at the union of the trans- 
 
 1 The observations of Bernard tend to show that this symptom would be a constant 
 one, if the duct were always obstructed.
 
 266 DUODENUM. 
 
 verse and ascending colon, or cancerous disease may be developed 
 at this site, arid subsequently perforate the duodenum. (See "Cancer 
 of the Colon.") The formation of adhesions with the duodenum in 
 these latter instances sometimes causes partial mechanical obstruc- 
 tion ; vomiting is produced, and thus the diagnosis is rendered unu- 
 sually difficult ; such was the case in an instance which we shall 
 presently give. In all these maladies there is emaciation, pallor, 
 cachexia. Lastly, we must refer to numerous diseases of the ornen- 
 tum and of the liver as complicating the diagnosis. Here, however, 
 the difficulty is less ; for in the former the tumor is more central, 
 there is greater mobility, and the gastric symptoms are less marked ; 
 in the latter, hepatic cancer, the tumor is more strictly in the hypo- 
 chondrium, and the enlarged gland may be often felt with tubera 
 projecting from its surface. 
 
 The termination of cancer in the duodenum is generally one of 
 progressive emaciation and cachexia. If enlarged glands press upon 
 the bile-ducts, jaundice will be added to the symptoms ; if perforation 
 or sloughing takes place, local abscess occasionally forms, which, by 
 giving resonance on percussion, adds increased difficulty in forming 
 a correct diagnosis. 
 
 The treatment of these cases generally consists in trying to relieve 
 the distress and pain of the patient, and in sustaining his exhausted 
 powers. Anodynes are required opium, morphia, chloroform, or 
 its preparations ; and bland, but very nutrient diet, and especially 
 of a fluid kind, should be given. Stimulants assist in keeping alive 
 the flickering flame of life. When great sallowness of the com- 
 plexion comes on, or jaundice, it is very unwise to give mercurials ; 
 they hasten degenerative changes, exhaust the patient, without any 
 mitigation of his sufferings, and tend to hasten the fatal termination. 
 
 CASE XC. Cancer of the Duodenum (Reported by Mr. C. Longmore.) 
 
 James R , set. 40, was admitted under my care into Guy's Hospital June 
 23d, 1858, and died July oth. He was by trade a coach-builder, and he had 
 resided at Newington; his habits of life had been temperate, and with the 
 exception of a slight winter cough, he had enjoyed good health till Christmas 
 of the preceding year. The first symptom of which he complained was a 
 shooting pain in the back and stomach ; the pain at last became very violent, 
 especially at night after he had finished his work ; there were also moving 
 pains in both sides, especially on the right, and in the testicles ; he had neither 
 cough nor vomiting ; about four weeks prior to his admission swelling of the 
 feet came on, and after a few days his abdomen began to swell. He was a 
 man of sallow complexion, with dark hair and eyes ; he was much emaciated, 
 but the feet and legs were anasarcous ; there was dulness on percussion at the 
 sides of the abdomen, and fluctuation was indistinctly felt. In the scrotum 
 on the right side was a large hernial protrusion ; and in the abdominal cavity 
 a hard tumor could be felt, situated on the level of the umbilicus, and two 
 inches to its left side ; the tumor was an inch -and a half to two inches in 
 diameter, dull on percussion, but there was resonance around it ; on pressure 
 very slight pain was produced. Over the cartilage of the tenth rib then; was 
 also a minute pea-like tumor. The thoracic viscera were apparently healthy ; 
 the pulse feeble, compressible, 70. The surface of the body was cool. The 
 tongue was coated with a brown fur in the centre, but was red at the tip.
 
 DUODENUM. 267 
 
 The bowels were freely acted upon, 'and the evacuations were paler than 
 natural. The urine was scanty, sp. gr. 1032, free from albumen, but loaded 
 with lithates. Small doses of acetate of morphia were given, and dilute 
 nitric acid with infusion of cusparia. On June 25th, the abdomen had greatly 
 increased in size, it was very tense and resonant on percussion except in the 
 lumbar regions. On the 26th, the report states that, during the previous 
 evening and on this day, he vomited about two quarts of bitter bilious fluid, 
 but became more comfortable after its rejection ; although a sensation of in- 
 tense thirst came on. On the 28th he had become jaundiced, and complained 
 of jrreat pain across the loins, of an aching, dragging character. 
 
 On the evening of the 3d July vomiting of coffee-ground substance came 
 on, and continued till his death on the 5th, at 11 P. M. The tumor several 
 days previously seemed larger and more distinct. Inspection was made six- 
 teen hours after death. There was rigor mortis ; the whole body was jaun- 
 diced ; the tissue of the heart was pale and softened. The liver was much 
 enlarged. A tumor about the size of the fist surrounded the vessels at the 
 fissure of the liver; the duodenum was situated in front of this growth, and 
 was adherent to it. The commencement of the duodenum was quite de- 
 stroyed by cancerous ulceration, and a large slough occupied the position of 
 the first portion. The interior of the intestine communicated with the can- 
 cerous mass beneath it ; the cancer tumor was altered in structure, and con- 
 tained blood. The gall-bladder was distended to about twice its natural size, 
 and contained a few gall-stones. The hepatic duct was slightly obstructed. 
 The vena cava was in several places penetrated by the cancerous growth. 
 The whole liver was filled with cancerous tubera, which were rounded, 
 vascular, and softened. The disease appeared to run more especially in the 
 course of the portal vessels, as if its entry into the liver had been by Glis- 
 son's capsule. The cancer growth consisted of large nucleated cells. The 
 pancreas, supra-renal capsules, and kidneys, were healthy. 
 
 Instances of this kind are often very difficult of diagnosis, as to 
 the precise seat of the disease; the glands close to the duodenum 
 were probably first affected; but, although really behind the duode- 
 num, the intestine did not cause resonance, probably on account of 
 its becoming early implicated in the disease. -The subsequent symp- 
 toms arose from pressure on the bile-ducts and the vena portre, and 
 from the degeneration of the cancerous growth. Mr. John Dix, of 
 Hull, has recorded a very interesting case somewhat allied to this; 
 and in which there was a tumor apparently connected with the liver, 
 but resonant on percussion. "The tumor was hepatic and malignant. 
 It was softening down sloughing, in fact ; and in this process it 
 had involved and laid open the duodenum, to which it was attached ; 
 and whence air had escaped into a circumscribed cavity formed by 
 the tumor behind, and the abdominal wall in front, to both of which 
 the transverse colon was adherent below, forming the lower boundary" 
 of the resonant space. The patient, " Mrs. M , aged fifty-five, was 
 pallid, feeble, and emaciated; she complained chiefly of pain in the 
 right side of the abdomen,, with vomiting and other symptoms refer- 
 able to derangement of the hepatic and digestive functions. She had 
 suffered/before that time, from jaundice and gall-stones." She died 
 in about three months after the first medical examination^; but the 
 resonance in front of the tumor remained till death. 
 
 Primary cancer of the duodenum is of rare occurrence ; a patient,
 
 268 DUODENUM. 
 
 under my care in Guy's in 1872, aged forty-five, suffered eighteen 
 months before admission from violent vomiting and purging ; for a 
 week he was jaundiced, and he gradually sank; the stomach and 
 pylorus were healthy, but the first portion of the duodenum was 
 occupied by a large cancerous growth as large as a cricket ball, soft, 
 milky, vascular, and invading the liver by direct extension. 
 
 Instances also occur of primary disease of the pancreas extending 
 to the duodenum, and we have witnessed such cases in which the 
 mucous membrane of the duodenum had become infiltrated with 
 medullary cancer. Cancerous cachexia is then generally well marked, 
 but till the pylorus or duodenum become involved, vomiting is not 
 generally a prominent symptom. We have also seen the duodenum 
 perforated in cancerous disease of the caecum, which had extended 
 upwards; and in another case, one of villous cancer of the bile-ducts, 
 a large cyst had formed in the right side of the abdomen below the 
 liver and opened into the upper third of the duodenum by four 
 separate ulcers. 
 
 Mechanical obstruction. Other parts of the intestine are much 
 more liable to obstruction of a mechanical character than the duode- 
 num. In the course of several years we have observed, or have 
 found recorded, isolated cases of this kind of obstruction, arising 
 from the following causes : 
 
 1. Peritoneal adhesions. 
 
 2. Gall-stones of large size, which having ulcerated through the 
 coats of the gall-bladder, have become impacted in the duodenum, 
 and have led to fatal obstruction. 
 
 3. Enlarged glands, infiltrated by cancer, compressing the second 
 or third part of the duodenum. 
 
 4. Diseased pancreas. 
 
 5. Hydatid disease of the liver, opening into the duodenum. 
 
 6. Foreign bodies. 
 
 It is exceedingly common to find, after death, that adhesions have 
 taken place between the first portion of the duodenum and adjoining 
 viscera, either the inferior surface of the liver and gall-bladder, or 
 the transverse colon ; and, in many instances, the impediment to the 
 free passage of the chyme is so slight that no symptoms point to any 
 disturbed function. In the following case adhesions with the colon 
 were followed, however, by great distension of the first part of the 
 duodenum ; but there was also some ulceration of the same part of 
 the intestine ; there was chronic ulcer of the colon, and chronic as 
 well as acute peritonitis, with strumous and glandular disease, so 
 that there was considerable difficulty in unravelling the symptoms, 
 which resembled those of organic disease of the stomach. Still we 
 believe that the pain and the vomiting several hours after food had 
 been taken, were the result of this duodenal obstruction. 
 
 CASE XCI -Chronic Peritonitis. Acute Peritonitis. Tubercular De- 
 posit on the Serous Membranes and in the Glands. Constriction of the 
 Duodenum, and great Dilatation of its first portion. Small Ulcer in the 
 Duodenum. Large Chronic Ulcer in the Colon William C , a^t. 38, was 
 admitted into Guy's Hospital under my care, April 15, 1861. He was a
 
 DUODENUM. 269 
 
 married man, by trade a cooper, and he had resided at Dockhead. About 
 seven years previously he suffered from severe pain at the epigastric region ; 
 and tor several years since that time he had had pain at the same part, 
 but less acute in its character. He had never had any hemorrhage from 
 the stomach, but he had complained of slight pain in the dorsal region, be- 
 tween the sixth and eighth vertebrae. Some years before he had had violent 
 vomiting ; but since that time vomiting had been slight, the attacks coming 
 on some time after food had been taken. He had had slight pyrosis, and 
 acid taste after vomiting. The pain at the epigastric region was not constant, 
 but it was worse after lood, and was especially aggravated by constipation. 
 
 On admission he was very much emaciated, witli a sallow complexion, and 
 on the forehead there was a bronzed condition of his skin ; the skin at the 
 elbows was also slightly discolored. There was moderate tenderness at the 
 scrobiculus cordis ; the abdomen was rounded and supple ; no tumor could 
 be felt ; the bowels were rather confined ; the pulse was very compressible ; 
 the tongue was red in patches. No disease could be detected in the lungs or 
 heart. The patient stated that the bronzed color of the forehead had existed 
 for three years, and had been produced by exposure to the sun ; the lower 
 part of the abdomen was also found to be slightly discolored. 
 
 On April 20, the bowels were freely moved, and he had severe pain at the 
 scrobiculus cordis ; the pain was neither relieved nor modified by any change 
 of position. 
 
 He continued in the same prostrate condition without pain or vomiting 
 till June 11, when violent pain and symptoms of acute peritonitis came on, 
 and he sank on the 13th. 
 
 1 4th. Inspection. The body was very much emaciated. Chest. On the 
 left side the pleura was firmly adherent, and on tearing it away, rounded, 
 yellowish tubercles, two to three lines in diameter, were found thickly cover- 
 ing the costal surface. The left lung itself was very small ; but there were 
 no tubercles in it. The right pleura was free from adhesions or tubercles, 
 and the lung was also quite healthy. The heart and pericardium were 
 normal. There were several yellowish-white tubercular masses in the glands 
 in the anterior mediastinum. On opening the abdomen, the intestines were 
 seen to be distended ; and the enlarged transverse colon, extending from one 
 hypochondriac region to the other, prevented the stomach from being seen. 
 There were numerous peritoneal adhesions, especially at the upper part of the 
 abdomen, the transverse colon, stomach, and duodenum, being united firmly 
 to the under sur'ace of the liver. The coils of the small intestines presented 
 considerable injection at their lines of contact ; but neither was lymph effused, 
 nor had the serous membrane lost its shining color. Numerous tubercles 
 were present on the serous membrane ; some were exceedingly small, others 
 three or four lines in diameter, and they were situated on the intestines or on 
 the peritoneal surface of the liver. The mesenteric glands were extensively 
 diseased ; and all the glands situated in the neighborhood of the pancreas, 
 and near the origin of the thoracic duct, were enlarged, although it could not 
 be demonstrated that the duct was compressed. The glands contained much 
 cheesy and cretaceous matter, and some more recent semi-transparent deposit. 
 On removing the transverse colon, the stomach was found to be distended, 
 and an elongated sac was produced, partially contracted, about three inches 
 from the right extremity; this sac was at first supposed to be from hour- 
 glass contraction of the stomach, but, on opening it, the first contraction was 
 seen to be pylorus, and the second enlargement was an enormously distended 
 first part of the duodenum. The stomach and duodenum contained grayish- 
 green tiuid and mucus. The mucous membrane of the stomach did not pre
 
 270 DUODENUM. 
 
 sent any abrasion, thickening, nor ulceration, nor was the pylorus hypertro- 
 phied ; there was a little arborescent injection. The sac formed by the first 
 part of the duodenum was capable of holding eight to ten ounces of fluid, and 
 was also injected. Immediately beyond the pylorus was a small ulcer about 
 five lines by three in size, its edges rounded and without any injection ; it 
 did not extend into the muscular coat. Three inches from the pylorus the 
 intestine was narrowed, and there was a constriction resembling a second 
 pylorus; there was no thickening nor cicatrix, and it appeared probable that 
 the peritoneal adhesions had looped up the intestine. On the gastric side of 
 this constriction there was a small pouch, capable of admitting the tip of the 
 finger. The rest of the duodenum, the jejunum, and the ileum. were healthy, 
 with the exception of one or two small ulcers with tubercular deposit on their 
 peritoneal surface. Peyer's glands were healthy. The caeeum and appendix 
 also were normal. In the ascending colon the solitary glands were verv dis- 
 tinct, and at the commencement of the transverse colon were the remains of 
 an old ulcer ; for two to three inches the mucous membrane was irregularly 
 destroyed and puckered, and of a gray color. Tiie rest of the intestine was 
 normal. The supra- renal capsules, the kidneys, and the liver, were healthy; 
 two or three strumous tubercles were, however, situated on the peritoneal 
 surface of the liver. 
 
 In mechanical duodenal obstruction from the second cause, impac- 
 tiou of a gall-stone, the symptoms resemble those produced by inter- 
 nal strangulation of the intestine, or by hernia, but vomiting is set 
 up at a very early period, and is of a severe character. The vomited 
 matters, however, cannot have a stercoraceous odor nor appearance. 
 The diagnosis is generally obscure and difficult ; but where the symp- 
 toms of the passage of a gall-stone, namely, intense pain in the hypo- 
 ehondrium, vomiting, and subsequent jaundice, are followed also by 
 the symptoms of insuperable obstruction, the nature of the malady 
 is sufficiently clear; but in the ulceration of a large gall-stone through 
 the coats of the gall-bladder into the duodenum, the indications of 
 disease may be so slight as to be almost overlooked, and the subse- 
 quent obstruction cannot then be distinguished from strangulation 
 taking place high up in the intestine. The impaction of the gall- 
 stone is generally found to happen near the termination of the duo- 
 denum, or in the upper part of the jejunum. 
 
 In obstruction from diseased lymphatic glands in the neighbor- 
 hood of the duodenum, the occlusion sometimes becomes suddenly 
 complete, and the symptoms are those of internal strangulation; but 
 more frequently the pressure is less, and the symptoms are those 
 which we shall presently have to refer to in connection with disease 
 of the pancreas; thus, in an instance of femoral hernia after the in- 
 testine had been returned, the symptoms continued, and the patient 
 quickly died. The third portion of the duodenum was then found to 
 have become firmly impacted between two enlarged glands. 
 
 CASE XCII. Obstruction from Biliary Calculus in the upper part of t'ie 
 Jejunum, thirty inches from the Pylorus The calculus is in the museum of 
 Guy's. The case was under the care of Ebenezer Pye Smith, Esq., and is 
 recorded in the ' Pathological Transactions' of 18f>4. The patient was a 
 stout woman, net. 62. She had good health till three months before death, 
 when she suffered slight pain in the right hypochondrium, which continued
 
 DUODENUM. 271 
 
 a fortnight, unaccompanied by sickness or prostration. She recovered, but 
 continued her usual sedentary habits ; five days before death she began to 
 feel sick, and vomited bile in large quantities; the urine was moderately 
 secreted. The vomiting increased in violence, but with only very slight pain 
 in the abdomen ; on the fifth day she became comatose. A calculus com- 
 posed of inspissated bile, and measuring four and a half inches in the circum- 
 ference of its long by two and a half in the circumference of its short axis, 
 was found impacted about thirty inches from the pylorus. There was much 
 fibrous tissue on the under surface of the liver ; and an ulcerated opening ex- 
 tended from the gall-bladder into the duodenum, below the bile-duct. 
 
 The case just recorded of gall-stone with hemorrhage and obstruc- 
 tion is of a somewhat similar kind. An interesting case is recorded 
 by Dr. T. S. Gray in the ' Transactions of the Clinical Society for 
 1873,' in which a large gall-stone led to obstruction and stercoraceous 
 vomiting, but was subsequently discharged, and the patient, a man 
 aged 40, recovered. 
 
 There are in these cases three symptoms which especially deserve 
 attention, as guiding us to a right diagnosis, when viewed in connec- 
 tion with the previous history. The absence of abdominal distension, 
 the early period at which vomiting takes place, with the character 
 of the ejected matters, and the diminution in the quantity of urine 
 which is voided. 
 
 The absence of distension of the abdomen is an important sign of 
 occluded intestine in the early part of its course. In obstruction of 
 the large intestine, or even at the lower part of the small, the abdo- 
 men becomes enormously distended, and the peristaltic movements 
 can often be observed in spare persons through the parieties; this is 
 especially the case in disease of the sigmoid flexure of the colon. 
 The stoutness of the patient sometimes renders this sign less observa- 
 ble ; again, where this duodenal obstruction exists with hernia, the 
 diagnosis must necessarily be most obscure. As to vomiting, it 
 comes on very early, and the matters rejected are bilious. In stran- 
 gulation of the ileum, and obstruction of the colon, unless irritating 
 purgatives are given, this distressing symptom may be considerably 
 postponed ; and when it does take place and is continued, the mat- 
 ters are of a stercoraceous character. Still, in acute peritonitis, as 
 from perforation, the sudden bilious vomiting may greatly mislead 
 us. Again, very violent bilious vomiting sometimes takes place in 
 disease of the stomach, and in cerebral disease ; but the signs of ob- 
 struction are then wanting. 
 
 Gall-stone produces intense pain in the region of the gall-bladder, 
 accompanied with vomiting and constipation; this severe character 
 of pain we do not find in intestinal obstruction, but it must be ac- 
 knowledged, that when slow ulcerative absorption has taken place 
 between the walls of the gall-bladder and the duodenum, a calculus 
 so extruded is followed by less severe suffering than in ordinary cases 
 of biliary calculus. 
 
 A very interesting case, under the care of Dr. Lever, is mentioned 
 by Dr. Barlow in the 'Guy's Exports,' for 1844 : The patient aged 
 fifty-one a year before her death had the symptoms of gall-stone,
 
 272 DUODENUM. 
 
 and the bowels afterwards became constipated ; a short time before 
 her death, excessive pain, vomiting, and constipation came on, v> -ith 
 scanty urine and collapsed abdomen. The gall-bladder and duodenum 
 were firmly adherent ; the two upper thirds of the duodenum were 
 contracted, thickened, and would only admit a common quill ; about 
 the centre of the ileum was a biliary calculus of the size of a walnut, 
 partially sacculated. 
 
 "With regard to the quantity of urine excreted being a sign of the 
 seat of obstruction, as mentioned in the paper by Dr. Barlow, just 
 referred to, he argues that the quantity of urine must necessarily be 
 small, from the diminished fluid brought Avithin the range of the ab- 
 sorbing surface of the portal veins ; and thus there must be diminished 
 supply to the heart and kidneys; but there is often a large quantity 
 of fluid ejected by vomiting, which would proportionately lessen the 
 renal secretion. If the obstruction be incomplete, or low down in 
 the intestine, the kidneys pour out a larger quantity, and the vomit- 
 ing is also less severe. 
 
 Dr. Barlow has, in the paper previously cited, dwelt upon the 
 importance of bearing in mind, that in ischuria renalis, violent vomit- 
 ing, constipation, and scanty urine are sometimes present. 
 
 In diseased pancreas the obstruction is less complete, but it acts 
 by inducing firm adhesions about the first and second portions of the 
 duodenum ; and pressure is also exerted by the increased size and 
 hardness of the pancreas, and by infiltrated glands. The symptoms 
 resemble those of obstructed pylorus, namely, vomiting several hours 
 after food, gradually increasing emaciation, with constipation; and 
 these symptoms are slowly developed during several mouths. A 
 tumor can generally be felt near the region of the pylorus. 
 
 The following very interesting case was regarded as one of cancer- 
 ous disease of the glands in the neighborhood of the pancreas, and 
 secondary implication of the stomach ; for the vomiting took place 
 three or four hours after a meal, as in obstructive disease of the 
 pylorus ; and the general symptoms resembled those of organic gas- 
 tric change. 
 
 CASE XCIII. Disease of the Pancreas. Suppuration and Gangrene. 
 Pressure on the Duodenum. James P , aet. 60, by occupation a publican, 
 and resident at Cambervvell, was admitted under my care on July 4th, 1HG1. 
 He stated that he had always enjoyed good health till four months prior to 
 admission, when he was suddenly seized with severe pain in the region of the 
 stomach, and with vomiting. The vomiting returned at intervals of three or 
 four days, and came on several hours after food. Four years previously he 
 had begun to feel slight pain at the region of the stomach, winch came on 
 every three or four months, but was relieved by taking a little cayenne 
 pepper with brandy. He had not received any blow, nor had he sutf'civd 
 from any haematemesis. The pain was situated at the epigastric and umbili- 
 cal regions, and extended to the spine ; it was of an acute kind, and had not 
 the gnawing character of pain often described by patients affected with ulcer 
 of the stomach. 
 
 On admission he was very much emaciated, with an anxious countenance, 
 sallow complexion, and sunken eyes ; his skin was hot and dry, and he com- 
 plained greatly of thirst; the tongue was furred, the pulse frequent and sharp,
 
 DUODENUM. 273 
 
 the respiration normal; he had slight cough, but it did not distress him; and 
 there was no evidence of thoracic disease by percussion nor by auscultation. 
 The abdomen was contracted moderately, except at the lower part of the 
 epigastric and at the umbilical region, where there was a rounded tumor, 
 evident on visual examination. The tumor was dull and tender on percus- 
 sion; no fluctuation could be felt, and it had slight pulsation anteriorly from 
 contact with the aorta, but no general aneurismal thrill. There was reso- 
 nance between the tumor and the liver, as well as between the tumor and 
 the spleen ; in fact, both the hypochondriac regions were more than usually 
 resonant. Pressure on the tumor produced a feeling of nausea ; the bowels 
 were constipated; and the appetite was very poor. His weakness compelled 
 him to remain quietly in bed. The urine was high colored and scanty, and 
 was free from albumen. Fluid food was ordered, and soda-water with brandy, 
 and chloric ether n^x, with nitrate of bismuth gr. x in mucilage mixture. 
 
 July 5th He was slightly relieved by the medicine, but the vomiting con- 
 tinued ; the ejected matters consisted of deep-green fluid, containing a large 
 quantity of mucus, of squamous epithelium, and some nucleated cells (from 
 gastric glands). These attacks of vomiting distressed him greatly ; every 
 kind of food was rejected at once, but the medicine and ice partially relieved 
 his distress ; his prostration, however, increased ; hiccough distressed him ; 
 and he had an offensive taste in the mouth. 
 
 July 8th He was extremely restless and prostrate, and the vomited mat- 
 ters were of very deep-green color. At P. M. he was suddenly taken 
 worse, and continued in great pain during the night. At 7 A.M. next 
 morning he expired. 
 
 Inspection seven hours after death The body was very much emaciated. 
 The thoracic viscera were healthy, excepting old pleuritic adhesions. The 
 peritoneum contained some dirty gray fluid, and had in some parts lost its 
 shining smoothness; the intestines were slightly distended. The sac of the 
 lesser omentum was distended by a large abscess, which had constituted the 
 tumor felt during life. On tracing the duodenum upwards, at its centre was 
 found an oedematous portion bulging out; and containing fluid resembling 
 that in the peritoneum ; but there was no perforation. By dividing the peri- 
 toneum between the stomach and the colon, an abscess was opened ; it had 
 dense fibrous walls, about two lines in thickness, in some parts irregularly 
 sinuous, and having several bands on its walls, the remains of occluded vessels. 
 Above and partly in front of the abscess was the stomach ; below was the 
 colon, and at its superior, right, and inferior parts was the duodenum greatly 
 distended, and its coil enlarged. The abscess contained dirty offensive pus, 
 and at its posterior part was a black slough about two and a half inches in 
 length ; some concrete yellow matter was also found on its walls. The ab- 
 scess rested on the spine, the crura of the diaphragm, and on the superior 
 mesenteric and splenic veins as they formed the vena port*. It extended 
 on the left to the spleen. The pancreas for two to three inches toward the 
 splenic extremity was healthy, but the rest of the gland was in a sloughy 
 state, and constituted the black mass found at the floor of the abscess. The 
 pancreatic duct existed in the centre, and degenerating gland tissue was ob- 
 served under the microscope. The gland and duct were separated from their 
 duodenal attachment. The common bile-duct was healthy, and its opening 
 into the duodenum was free; but the gall-bladder contained numerous gall- 
 stones about the size of peas. The liver and spleen were healthy. The 
 stomach was very much enlarged and distended ; it contained tenacious green 
 mucus, such as was vomited during life ; its mucous membrane presented 
 numerous points of arborescent injection, so al:o that of the duodenum ; but 
 18
 
 274 DUODENUM. 
 
 no direct communication with the abscess could be found, nor any ulceration 
 of the surface. 
 
 The origin of the disease in this remarkable case could not be 
 ascertained, viz., whether a pancreatic calculus had set up the abscess, 
 or whether inflammation had been produced in the cellular tissue 
 about the gland. No direct blow had been received, and the disease 
 slowly advanced. Acute peritonitis, from the transudation of offen- 
 sive purulent serum into the general cavity of the peritoneum, was 
 the cause of the fatal termination. 
 
 Dr. Bright believed that the fatty motions which he found in some 
 of these cases were indicative of disease of the pancreas, but this 
 symptom has not been constantly observed in pancreatic disease, 
 possibly from the duct being only partially occluded. 
 
 The course taken by hydatid disease of the liver is uncertain; 
 sometimes it is towards the surface, and a rounded tumor is then felt 
 on the anterior abdominal parietes; or it extends through the dia- 
 phragm into the lungs. In a case under the care of Dr. Rees, in Guy's, 
 the cyst opened into the duodenum. Hydatids were both vomited 
 and passed by stool, and the former symptom was very severe. The 
 patient was exceedingly ill, and a friction sound was audible over 
 the seat of the tumor, evidently from local peritonitis ; the patient 
 steadily improved after the evacuation of the hydatids by vomiting ; 
 the tumor disappeared, and he left the hospital; but after a few 
 weeks intense peritonitis came on, and he quickly died. The re- 
 mains of hydatids were found in the liver; and the duodenum, 
 colon, liver and kidney, were firmly united by adhesions. A large 
 abscess existed between these structures, and had led to the fatal 
 peritonitis. No communication existed between the liver and the 
 colon ; and although the duodenum at its second part was firmly 
 adherent, no direct opening could be found. 
 
 The patient was twenty-nine years of age, and had resided at 
 Twickenham ; he was temperate in his habits ; for nine years he 
 had suffered from so-called "bilious attacks," and from vomiting, 
 with slight sallowness of the skin ; five years previously he had had 
 severe jaundice, which continued for three weeks. Eight months 
 before admission his appetite became ravenous, but he lost strength 
 and became emaciated ; for seven weeks he had been confined to his 
 bed from severe pain about the umbilical region; jaundice came on, 
 but disappeared, and was followed by very severe pain in the right 
 hypochondriac region, extending to the loins, and a rounded growth 
 presented itself below the ribs on the right side. 
 
 A remarkable instance of mechanical obstruction in the duodenum 
 from a foreign body, is recorded by Dr. Blakeley Brown, in the 
 'Pathological Transactions' of 1851 and 1852 : A delicate young 
 woman, aged eighteen, became gradually emaciated, and at last died 
 from peritonitis. The stomach, duodenum, and upper part of the 
 jejunum, contained casts composed -of agglutinated and interwoven 
 masses of string and hair. 
 
 Gastric Solution of Duodenum. The mucus of the duodenum is 
 frequently found in an acid condition after death, which is probably
 
 DUODENUM. 275 
 
 due to some of the gastric juice slowly gravitating through the py- 
 lorus; but in some instances the pylorus is so patulous, that gastric 
 juice readily passes, and exerts its solvent power after death in the 
 same manner as in the stomach. Such a state was found in a child 
 who died under my care in Guy's. 
 
 CASE XCIV. Perforation of Duodenum after Death from Solution by 
 Gastric Juice William B , get. 4, was admitted July 16th, 185G, and 
 died on the 23d. He was an anaemic child, with large head ; on admission 
 he was in a semi-comatose state, and the pupils were widely dilated ; he had 
 occasional vomiting, but no convulsions ; six weeks previously he had had 
 measles, and one week afterwards hydrocephalus gradually became developed; 
 he was in an almost hopeless condition on admission. 
 
 Inspection was made fourteen hours after death. The arachnoid was cov- 
 ered with a slight layer of lymph, so as to give it a greasy appearance, and 
 at the base of the brain there was considerable sub-arachnoid effusion. The 
 ventricles contained two ounces of fluid, of sp. gr. 1001. There were miliary 
 tubercles in the lungs and in the bronchial glands. 
 
 In the stomach there was considerable gastric solution, the mucous mem- 
 brane being destroyed ; but in the duodenum the intestine was quite divided, 
 all the coats destroyed, and the end of the first portion terminated in an ir- 
 regular ragged margin. The contents of the stomach were found in the 
 peritoneal cavity. There were tubercles in the mesenteric glands, and an 
 isolated one in the kidney.
 
 27(3 
 
 CHAPTER VIII. 
 
 MUCO-ENTERITIS AND ENTERITIS. 
 
 THERE has been considerable confusion in the application of the 
 term enteritis; Broussais considered it to be inflammation of the 
 colon, Abercrombie regarded it as inflammation of the peritoneal and 
 muscular coats of the intestine; others, again, more particularly apply 
 the term to an inflammatory disease of the small intestine, which 
 commences in the mucous membrane, and extends in severe cases, 
 so as to involve all the coats of the intestine, even its peritoneal in- 
 vestment. These latter and more severe instances correspond to the 
 enteritis phlegmonodea of Cullen; the former, when the mucous 
 membrane only is affected, to his enteritis erythematica. 
 
 Watson, Barlow, and others, apply the term only to the more 
 severe cases of inflammation of all the coats, but we shall in this 
 chapter also consider those in which little more than the mucous 
 membrane is affected, called, muco-enteritis, and closely allied to 
 gastro-enterite and gastric remittent fever. Dr. Copland describes 
 glandular enteritis, and ileo-colitis ; the former we consider in the 
 remarks on strumous disease of the intestine and enteric fever, the 
 latter with dysentery. 
 
 Enteritis manifests itself under two forms: 1. That involving only 
 the mucous membrane, and which has a disposition to extend in the 
 course of the mucous membrane muco-enteritis (this state may be 
 acute or chronic and catarrhal in character); 1 and, 2. That in which 
 the disease extends in depth, rather than on the surface, and impli- 
 cates the muscular, and peritoneal coats, and the connecting tissues, 
 whether diphtheritic, ulcerative, or phlegmonous in its nature; both 
 forms commence in the mucous membrane. 
 
 In hernia, whether external or internal, acute enteritis is set up; 
 and there may be symptoms in common with enteritis, as constipation, 
 vomiting, &c., but the pathology and treatment of the two diseases 
 are so diverse that a separate consideration of them is required. 
 
 It would be difficult to draw a defined separation between cases of 
 inflammatory diarrhoea, as described by Dr. West, and the simplest 
 forms of enteritis; they pass the one into the other. Diarrhoea, 
 however, is not a constant symptom of enteritis; for the bowels in 
 the latter disease are frequently constipated. 
 
 Pathological changes. In muco-enteritis we may find very much 
 less change than had been anticipated. Neither ulceration nor con- 
 gestion may be observed throughout the whole canal. It is probable 
 
 1 See further reference to catarrhal inflammation in our remarks on catarrhal diar- 
 rhoea and catarrh of the colon.
 
 MUCO-ENTERITIS AND ENTERITIS. 277 
 
 that the injected condition has in these instances, like erythema of 
 the skin, entirely passed away; thus also some of the most severe 
 forms of bronchitis present scarcely any morbid appearance of the 
 bronchial tubes themselves, the congestion having disappeared, al- 
 though the altered mucus remains. This state of congestion may, 
 however, have caused marked symptoms of disease. 
 
 In catarrhal inflammation, a change in the character of the secre- 
 tion from the mucous membrane is a sure indication of its deviation 
 from the normal condition; but, unfortunately, we do not possess 
 the same facility for the examination of the secretions, from the 
 digestive as from the respiratory mucous membrane. Adhesion of 
 a thin stratum of fecal matter is an indication of an imperfect secre- 
 tion of mucus; or a lyrnph-like exudation takes place; this exuda- 
 tion resembles the diphtheritic membrane found in the throat, and 
 it consists of an immense number of granules with nuclei; it may 
 sometimes be easily scraped off, exposing an injected surface beneath ; 
 in other instances a section of the whole membrane shows that it is 
 firmly united. 
 
 The mucus which is found in the intestine presents indications of 
 rapid change having taken place, nuclei and elongated cells of in- 
 complete epithelium being found in great abundance; and mucus as 
 well as pus are found in the evacuations during life. 
 
 Crystals of triple phosphate are frequently detected on the surface 
 of the mucous membrane. It is probable that in many instances 
 this is a post-mortem change; but in other cases we find such crys- 
 tals when the inspection has been made a few hours after death; 
 and they probably result from decomposition of the mucus, as in 
 the urinary bladder after chronic inflammatory action. 
 
 The solitary glands may be very large and prominent, a state 
 which is due to the age of the patient, and the functional activity of 
 these structures, or to the excitement of morbid action. Sometimes 
 these glands give to the mucous membrane the appearance as if 
 sprinkled over with fine sand. Small aphthous ulcers sometimes 
 exist, the ulceration commencing in the follicles; these ulcers may 
 lead to perforation of the intestine, as in a case recorded among the 
 inspections at Guy's, in which there were minute ulcers extending 
 throughout the whole of the small and large intestine; and perfora- 
 tions of the caecum and transverse colon had led to fatal peritonitis. 
 
 Gray discoloration is often observed around the solitary follicles, 
 or it is more general in character, either in the large intestine, in the 
 lower parts of the ileum, or even in the duodenum. This state con- 
 sists in the deposit of pigment in the membrane in contact with the 
 vessels, and is the result of continued congestion ; it apparently fol- 
 lows also as an effect of muco-enteritis. 
 
 The most intense form of local enteritis exists when a portion of 
 the intestine has become strangulated; the mucous membrane is 
 then swollen, and it is also intensely injected ; portions of feces and 
 mucus adhere to the valvulse conniventes, or the whole surface of 
 the mucous membrane is covered by a thin adherent layer of granu- 
 lar lymph ; all the coats of the intestine become thickened, and the
 
 278 MUCO-ENTERITIS AXD ENTERITIS. 
 
 areolar tissue is oedematous; the peritoneum is covered by lymph; 
 it is intensely congested and of a purple or slate color, or even gan- 
 grenous. The thickening of the mucous membrane in all these 
 cases arises from the presence in the submucous tissue of a large 
 number of cellular elements (pyoid), and, in the more severe cases, 
 they extend between the muscular fasciculi and reach to the perito- 
 neal coat. 
 
 A condition closely resembling that just described is sometimes 
 found without any strangulation, either affecting only the ileum, or 
 of a dysenteric character, and involving also the caecum and colon ; 
 thus, a distended and congested state of the ileum may terminate 
 suddenly, as if there had been a constriction, and the portion of small 
 or large intestine below may be pale and contracted; on removing 
 the intestine, the apparent constriction ceases, the canal becomes 
 perfectly free, and the congestion is the only thing that marks the 
 obstruction. There has been much discussion whether in these cases 
 there is really obstruction by a twist of the intestine, by a spasmodic 
 condition of the contracted part, or by a paralyzed state of the dis- 
 tended one; the last supposition is now generally regarded as the 
 correct explanation, namely, that the inflamed intestine becomes 
 distended, and its peristaltic contraction enfeebled, so that at last it 
 is unable to contract upon and propel its contents. The abrupt 
 termination may be determined by a cicatrix, by slight peritoneal 
 adhesion, or by old disease of the mesentric glands. These instances 
 closely resemble true ileus from strangulation or from other mechani- 
 cal cause. 
 
 Ulceration and sloughing, or gangrene, generally follow this form 
 of enteritis; but, although in hernia and internal strangulation the 
 gangrenous part is at the seat of constriction, this is not always the 
 case in obstruction from other causes; in obstructive disease of the 
 sigmoid flexure, ulceration takes place above the seat of the obstruc- 
 tion ; but the most acute inflammation and ulceration will often be 
 found in the ileum, caecum, and ascending colon. The inflamed 
 mucous membrane in these parts gives way from the enormous 
 distension; numerous ulcers, arranged in transverse lines, are closely 
 set together in the ileum and caecum, and some of these occasionally 
 extend through the peritoneum. 
 
 Obstruction of the mesenteric vessels usually takes place in cases 
 of internal hernia ; but it is probable that obstruction of these vessels 
 is sometimes the cause of the change rather than the effect. Intense 
 engorgement of a few inches of intestine may be found, and the 
 mucous membrane may be almost in a sloughing state, without any 
 symptom having been manifested during life, and without any ob- 
 struction being present after death. In such cases a thrombus has 
 probably formed, or an embolus has obstructed the mesenteric vessels 
 connected with the part, and has led to changes in the nutrition of 
 the intestinal coats. 
 
 In inflammation of the mucous membranes there is a great ten- 
 dency to the extension of the disease by continuity of structure. 
 Sometimes the alimentary canal, in its whole tract, appears to be
 
 MUCO-ENTERITIS AND ENTERITIS. 279 
 
 inflamed; at other times the disease commences in one part, and 
 extends from that as from a centre. Inflammation of the colon will 
 pass into the ileum ; that of the ileum into the large intestine, as 
 well as into the jejunum, duodenum, and stomach. In enteritis the 
 small intestine only may be affected, or the cgecum and colon may 
 be also implicated. Broussais 1 speaks of this extension of disease ; 
 but, though we are not disposed to agree with his opinions, we must', 
 I think, acknowledge the truth of the frequent extension of disease 
 to contiguous and continuous structures; and this is probably as 
 true of the mucous membrane as it is of the skin, as exemplified in 
 erysipelas. 
 
 These changes in the mucous membrane of the small intestine, 
 even though only of a catarrhal character, may be followed by 
 wasting of the mucous membrane, and in some cases the atrophy of 
 all the coats of the intestine is so extreme that together they are 
 scarcely thicker than tissue paper. In others the impairment of 
 nutrition is followed, especially in young subjects, by the deposition 
 of tubercular disease in the mucous membrane, involving first the 
 follicles and lymphatic vessels of the bowel ; to these cases we shall 
 again have to refer in speaking of strumous disease. Lardaceous 
 disease of the intestine may also be associated with symptoms of 
 muco-enteritis; in these instances the mucous membrane is thickened 
 and has a sodden appearance, sometimes it is ulcerated ; the villi and 
 the minute capillary arteries are found to be thickened, so also those 
 surrounding the sacculi of Peyer's glands, and the membrane under 
 examination is at once changed by the action of iodine. These forms 
 of disease are generally found with lardaceous disease of other organs, 
 as of the liver, the spleen, or the kidneys. 
 
 We shall first consider enteritis in the form of muco-enteritis, \ 
 enteritis erythematica or catarrhal inflammation? This is very fre- \ 
 quent among children during dentition or weaning, and after the 
 exanthemata ; but in many cases of infantile diarrhoea and colic a 
 more transient condition of congestion is set up, the indications of 
 which are twisting pain in the bowels, and the evacuation of watery 
 or green motions, with general fretfulness, &c. ; these symptoms pass 
 away in a very short time, and they arise from hyperaemia rather 
 than from true inflammation of the mucous membrane. 
 
 In muco-enteritis a child is found to be fretful, without its usual 
 playfulness and mirth. The lips are dry, and the little patient has 
 a circumscribed flush on one or other cheek ; the skin is dry or 
 roughened ; the abdomen is somewhat enlarged, or considerably dis- 
 tended and tympanitic, and varies in the amount of tenderness, but 
 the restlessness of the child causes it to cry when no pain is pro- 
 duced ; it is unwilling to be disturbed ; the appetite is irregular and 
 capricious, either craving for cooling drinks, as cold water, or for 
 
 1 Broussais, ' Phlegmasies Chroniques.' 
 
 * This term is used in a less extended sense than that of German pathologist?, who 
 include under the word catarrh every form of inflammatory affection of the mucous 
 surface.
 
 280 MUCO-ENTERITIS AND ENTERITIS. 
 
 unsuitable food, which is oftentimes the cause of the malady. The 
 bowels are irregular, ether constipated for several days, or there 
 may be diarrhoea ; the motions are offensive and pale, or greenish 
 in color, or the evacuations consist of slimy mucus, or of food scarcely 
 changed, and these conditions may alternate the one with the other; 
 the tongue has a whitish fur, and its substance or papillae are often 
 much injected ; vomiting may easily be induced, and probably arises 
 from the extension of the mischief to the stomach, when the disease 
 is called gastro-enteritis. In the evening the child becomes still 
 more restless, the skin is hot, and even pungent ; the temperature 
 101 to 103 3 ; the sleep is disturbed, and accompanied with grinding 
 of the teeth or starting, and the child often awakes alarmed; in the 
 morning the febrile disturbance is less, and it may be cheerful and 
 playful. 
 
 This aggregation of symptoms constitutes the so-called gastric 
 remittent or infantile remittent fever, and many look upon it in the 
 same light as enteric fever, considering that the inflammatory con- 
 dition of the intestine is a concomitant, not the essential part, of the 
 disease. This is, I think, incorrect; the intestinal disturbance is 
 the source and the cause of the continuance and extension of the 
 disease, and not, as in enteric fever, the manifestation of a previously 
 existing and general condition. 
 
 It is maintained by some authorities, such as West, Eilliet, and 
 Barthez, that all these forms of disease are essentially enteric fever, 
 but although there is febrile excitement, elevation of temperature, 
 delirium, red and glazed tongue, &c., we do not find any rose spots; 
 the duration of the disease is different, sometimes indefinitely pro- 
 longed, at other times passing off in a few days. Whilst, in the one 
 we have symptoms due to the reception of a specific drain poison, in 
 the other we have no more than can be accounted for by simple in- 
 testinal inflammation, the same difference as between acute derma- 
 titis and a specific exanthem. 
 
 It is also true that other blood poisons, as pyaemia, may produce 
 intestinal lesions, but these could not be mistaken for enteric fever. 
 When the symptoms persist severely for several weeks great pros- 
 tration ensues ; the child wastes sometimes to an extreme degree, it 
 appears haggard and aged, the lips have dry sordes upon them, 
 the tongue is more injected, and often aphthous. There is less re- 
 mission in the morning ; the child will scarcely sleep at all, or, in 
 very young children, allow itself to be taken from the arms of its 
 nurse ; the diarrhoea increases, watery evacuations are discharged or 
 food unchanged is passed a short time after it has been taken ; the 
 pulse becomes very rapid, the eyes are half closed, and the child dies 
 from exhaustion, almost before the nurse is aware of any change ; 
 or the brain becomes oppressed, and a drowsy, torpid condition, or 
 convulsions sometimes precede death. The convulsions and coma, 
 to which we refer as coming on at the close of this intestinal condi- 
 tion, are closely allied to those produced by exhaustion, as in the 
 hydlrencephaloid disease of Dr. Marshall Hall. 
 
 Muco-enteritis is frequently followed by tympanitis, and by stru-
 
 MUCO-ENTERITIS AND ENTEKITIS. 281 
 
 mous diseases of the peritoneum, or of the mesenteric glands. In 
 such cases, although the more prominent symptoms of vomiting and 
 purging subside, the child remains wasted, the abdomen enlarges, the 
 appetite becomes ravenous, and exhaustion steadily progresses to a 
 fatal termination. (See Strumous Disease.) 
 
 In young persons we sometimes find a state of muco-enteritis 
 similar to that described, but without phthisis or tubercular disease; 
 the eyes are sunken and bright, the lips parched, the tongue exceed- 
 ingly injected, and beef like ; the cheek is occasionally flushed by a 
 circumscribed patch on one or other side ; the pulse is compressible, 
 but frequent ; the skin is at one time dry, at another perspiring ; 
 there is thirst, generally with loss of appetite, and sometimes with 
 great irritability of the stomach ; the bowels are constipated, or 
 diarrhoea alternates with constipation. The urine is scanty and high 
 colored. This condition may persist for many weeks, with gradually 
 increasing exhaustion, and in some cases it terminates fatally; in very 
 many instances it yields to judicious treatment, but there is great 
 danger of relapse. In young women this state is sometimes asso- 
 ciated with painful or deficient menstruation, or with leucorrhoea ; 
 and it may be accompanied with severe neuralgic pain in the abdo- 
 minal parietes, and below the mammae. This neuralgia occasionally 
 leads to a more unfavorable prognosis than the case warrants. 
 
 The second form of enteritis is more severe, and all the coats of the 
 intestine are involved. The symptoms are exceedingly acute, and 
 too frequently advance to a fatal termination with great rapidity ; 
 or they may be extended over many weeks or months. Severe pain 
 is generally present, which has more or less of a paroxysmal char- 
 acter, and is accompanied with great tenderness and distension of 
 the abdomen; there is frequently vomiting of bilious fluid, and the 
 bowels are often constipated; the pulse is small, wiry, and sometimes 
 compressible, the tongue is partially furred, the patient lies on the 
 back with the legs drawn up, as in acute peritonitis, and prostration 
 may rapidly ensue ; or, whilst the more severe symptoms subside, 
 the tongue'becomes dry, red, and glazed, the bowels loose, and the 
 strength is gradually undermined ; or again, the convalescence may 
 be as rapid as the occurrence of the symptoms. In these conditions 
 the mind is generally perfectly clear. 
 
 Several instances' which have come under my own observation 
 will illustrate the disease. 
 
 CASE XCV. Acute Enteritis A child about seven years of age. after 
 
 eating freely of raw apples, was seized with pain in the abdomen around the 
 umbilicus ; the bowels were constipated ; the abdomen was tender and dis- 
 tended ; the countenance was expressive of much distress ; the pulse was 
 rapid ; the tongue had a slight fur upon it. The constipation continued; the 
 abdomen became more tender and distended, and the child was found tying 
 on its back in severe pain, with the legs drawn up, and with occasional 
 vomiting. This state continued for several days ; the bowels were then freely 
 acted upon ; but the child became prostrate, and shortly died, four or five 
 days from the commencement of the disease. On owning the abdomen, the 
 intestines were found much distended with flatus ; the peritoneal surface wad
 
 282 MUCO-ENTERITIS AND ENTERITIS. 
 
 intensely injected where the coils were in contact, and was covered with 
 lymph. The mucous membrane of the small intestine was congested, and 
 portions of undigested apples were found in the intestine. 
 
 The inflammation had been set up by crude undigested food ; it 
 extended rapidly from the mucus to the muscular and connecting 
 tissues, and to the peritoneum. The inflamed intestine was unable 
 to propel its contents, and hence the constipation ; and sometimes 
 the constipation is so marked, that it is the most prominent symp- 
 tom. The severe pain in this form of enteritis contrasts with the 
 absence of it where the mucous membrane only is affected. 
 
 The symptoms in other instances closely resemble those conse- 
 quent upon mechanical obstruction. 
 
 CASE XCVI. Enteritis simulating Mechanical Obstruction TIenry 
 
 V , act. 17, was admitted into Guy's Hospital in 1850. He was a tall, thin 
 lad, who had been employed in a tobaconist's shop ; and a week before ad- 
 mission he had had diarrhoea, which had been checked by an opium pill. 
 The day before admission he felt well, and whilst walking out of doors he 
 ate some apples and cherries ; a few hours afterwards severe pain in the 
 abdomen came on. Some rhubarb, with compound chalk powder and opium, 
 was prescribed; the bowels were opened twice during the night ; but at seven 
 in the morning severe pain in the abdomen returned ; his countenance was 
 then expressive of great distress ; the eyes were sunken, and the bowels were 
 confined ; the tongue was furred and clammy ; he was rolling himself from 
 one side of the bed to the other, from the intensity of the pain ; the recti 
 muscles were rigid, but pressure could be borne ; an emetic was administered, 
 and some undigested apples and cherries were vomited. Calomel gr. v. with 
 opium gr. iss, were given, but were at once returned ; a turpentine injection 
 was then administered. Vomiting then came on, at first of bilious, after- 
 wards of stercoraceous fluid ; the injection brought away some scybalous 
 matter, but without relief to the pain. His pulse became exceedingly rapid, 
 and he died at eleven the next morning, about thirty-six hours from the com- 
 mencement of the attack. 
 
 On inspection, the intestines were found to be very much distended ; the 
 peritoneum was injected, and delicate portions of lymph passed between the 
 coils; on turning aside the small intestines, the ctvcum, colon, and about 
 three feet of ileum were found collapsed, pale, and empty ; at this point there 
 was a sudden cessation of the intense congestion and distension, giving the 
 appearance of constriction; but no constriction nor twist could be detected; 
 the mesentery, however, attached to this part, and connected witli the hist 
 lumbar vertebra, contained several hard and calcareous glands, and appeared 
 slightly contracted; on raising the intestine, and placing it in a straight line, 
 air at once passed, and the constriction disappeared. The intestine was full 
 of pale yellow fluid feces, and contained some undigested matter; no uicera- 
 tion existed, and the other viscera were healthy. 
 
 In this case severe colic came on after taking indigestible food; 
 inflammation of the mucous membrane of the small intestine was 
 produced; this extended to the muscular and peritoneal coats, and 
 was followed by intense pain, by distension, and by vomiting. It 
 appeared that the slight interference with the movement of the 
 ileum opposite to the calcareous mesenteric glands led to the limita- 
 tion of the disease at that part, and that over-distension following
 
 MUCO-ENTERITIS AND ENTERITIS. 283 
 
 inflammation was the principal cause of the obstruction. The abdo- 
 men for several hours was tolerant of pressure, and the symptoms 
 of peritonitis came on later; could the enteritis have been subdued, 
 the obstruction would probably have disappeared. 
 
 The following case is one in which the most acute enteritis pro- 
 duced scarcely any symptom ; the patient was semi-comatose; but 
 it is closely allied to cases in which local enteritis is apparently set 
 up by obstruction of the vessels. 1 
 
 CASE XCVII. Sloughing Ileum. Thrombosis of the Mesenteric Veins. 
 
 Peritonitis. Chronic Tubal Nephritis. Lobular Pneumonia Thomas C , 
 
 set. 43, was admitted into Guy's Hospital, December 7th, 1853, and died 
 December 31st. By trade he was a sailmaker, and during the last two years 
 of his life had been very intemperate. He was admitted with anasarca, and 
 coagulable urine ; diarrhoea and wasting came on, and before death lie passed 
 into a semi-comatose condition. The inspection was made forty-seven hours 
 after death. The body was spare and pallid; the lungs were very redematous, 
 and some lobules were softened and breaking down. Abdomen The intes- 
 tines were distended ; there was general peritonitis, but only slight injection 
 of the peritoneum at the edges which were in contact; eight incites from the 
 ileo-cagcal valve, the peritoneal surface of the intestine for several inches was 
 of a dark gray color, as if on the point of sloughing; but there was no con- 
 striction nor strangulation, nor had there been any symptom of it during life. 
 The mucous membrane at the lower part of the ileum was in a sloughing 
 condition, but this diseased portion was defined, and intensely congested at 
 the margin; the slough was thin, but it affected the whole of the mucous 
 membrane, and was not confined to Peyer's glands; the mesenteric veins were 
 Jilted with clot. The left lobe of the liver was wasted, forming a fibrous 
 mass, and was white in color, probably syphilitic; the remaining part of the 
 gland was fatty. The kidneys were large and white. 
 
 In this patient the disease of the kidney had led to unemic poison- 
 ing, and to the semi-comatose condition; hence the non-complaint of 
 pain in the severe peritonitis which ensued. There is great dispo- 
 sition in uraemia to serous inflammation of the pleura, pericardium, 
 and peritoneum; but it is rare to find such a state of acute inflam- 
 mation as that described in this case, which was probably secondary 
 to thrombosis of the mesenteric vein. 
 
 Diagnosis. Correct diagnosis is very important in enteritis, other- 
 wise valuable time may be lost, and such aid as might have been of 
 essential service may be neglected. 
 
 Hernia, external or internal, intussusception and mechanical ob- 
 struction from any cause, may be confounded with enteritis arising 
 from simple inflammation. 
 
 It is well always to examine the ordinary positions of external 
 hernia; many mistakes would have been avoided by this simple 
 means. In internal strangulation the pain generally comes on after 
 sudden muscular movements or after exertion of the strength ; the 
 patients often affirm that until the time of sudden exertion they 
 enjoyed comfortable health, then something seemed to give way, or 
 
 1 See an interesting case recorded in the ' Path. Trans.,' vol. xxvii, p. 124, of acute 
 thrombosis of the superior mesenteric and portal veins, by Dr. Hilton Fagge.
 
 284 MUCO-ENTERITIS AND ENTERITIS. 
 
 there was a "catch," and fixed pain was felt, from which the subse- 
 quent pain radiated; the seat of pain, however, does not necessarily 
 indicate the seat of obstruction, as found after death; because dis- 
 tension and the movement of viscera produce much alteration in the 
 position of the intestine. After the sudden onset of pain, constipa- 
 tion and vomiting with varied degrees of severity come on, till pros- 
 tration, collapse, and death ensue; and the rapidity of the symptoms 
 may be as great as in external hernia. We do not observe this 
 fixity of pain in enteritis, although it may be at first localized to a 
 comparatively small space. 
 
 In internal obstruction without strangulation, we often find pre- 
 vious constipation, and the commencement of the attack is slower, 
 the pain being sometimes very slight till towards the close of the 
 malady. 
 
 In intussusception the sudden severe pain is very different from 
 that of enteritis, and is more likely to be confounded with simple 
 colic. When the symptoms of obstruction from intussusception be- 
 come developed, an elongated tumor can generally be felt, and the 
 discharge of bloody mucus is often observed ; the value of this diag- 
 nostic indication has been shown by Mr. Gorham. 1 In enteritis it 
 is very important carefully to ascertain the symptoms which marked 
 the onset of the disease. In a case of chronic intussusception, where 
 there was occasional diarrhoea with severe colic in a boy of fourteen 
 years, the discharge simulated enteritis and a suspicion of irritant 
 poison was entertained. (See " Intussusception.") 
 
 It is difficult to distinguish some cases of chronic poisoning, or even 
 of acute poisoning, from enteritis arising from other causes. In these 
 instances, inflammation of the mucous membrane is produced. I 
 may refer to cases of chronic poisoning by arsenic ; the vomiting is 
 often very severe, and the irritability of the stomach a prominent 
 symptom, but the vomited matter is never stercoraceous ; the ab- 
 domen is generally less tender than in the worst cases of enteritis ; 
 in doubtful cases we must be guided by the concomitant symptoms 
 and by the analysis of the vomited matters. In the enteritis from 
 crude indigestible food and irritants, as some forms of mushrooms, 
 the symptoms may be very similar to those consequent on ordinary 
 poisons, so that we may be unable to distinguish the one from the 
 other. 
 
 In simple colic there is less difficulty ; here is absence of tender- 
 ness, and the pain may be actually relieved by pressure. 
 
 In peritonitis, suddenly induced by perforated intestine, the col- 
 lapse is greater ; the abdomen becomes exquisitely tender and tyin- 
 panitic; but vomiting is not generally produced, unless the peritoneal 
 surface and other coats of the stomach become involved. From 
 whatever cause enteritis is induced, peritonitis is a very common 
 result; and the muscular coat being implicated, the peristaltic action 
 is by a wise provision checked, and the bowels become constipated. 
 
 In hysteria, we sometimes find tympanitis with constipation, with 
 
 'Guy's Reports,' 1838, p. 300.
 
 MUCO-ENTERITIS AND ENTERITIS. 285 
 
 irritable stomach, and with pain in the abdomen ; and these symp- 
 toms might, by carelessness, be mistaken for acute inflammation. 
 The expression of countenance is not that of severe abdominal dis- 
 ease ; the vomiting may be induced by anything being put into the 
 stomach, but it disappears at other times. The pain is superficial 
 and the abdomen is tolerant of continued pressure, unless there be 
 inflammatory disease of the ovaries. There is generally leucorrhoea, 
 with painful or disordered menstruation ; but the patient often re- 
 mains in a tolerably nourished condition. 
 
 Ischuria renalis.Dr. Barlow has pointed out the importance of 
 bearing in mind the sympathetic symptoms connected with disease 
 of the kidneys. In suppression of the urine, vomiting and constipa- 
 tion often exist ; but the cerebral oppression is generally very marked, 
 and the examination of the urine (drawn off by catheter, if none can 
 be passed) would at once decide the character of the complaint, if 
 there be any obscurity. A temporary ischuria renalis may exist 
 in other abdominal diseases and even in mere flatulent distension. 1 
 
 Cerebral disease. It is not unfrequent, as we have before noticed, 
 to find vomiting present as a symptom of disease of the brain, and 
 then also associated with constipation ; but there are some peculiari- 
 ties in this state which distinguish it from enteritis and mechanical 
 obstruction. There is no pain or distension about the abdomen ; the 
 tongue, the countenance, and the other symptoms of disease are dif- 
 ferent. In young children it is sometimes difficult to distinguish 
 rnuco-enteritis from true hydrocephalus ; there is irritability of the 
 stomach in both, with perhaps diarrhoea, heat of skin, startings in 
 the sleep, loss of appetite, unwillingness to be disturbed, &c. ; but 
 in the former, the abdomen is more distended, in the latter it is col- 
 lapsed ; the tongue is injected, arid furred in the one case, but clean 
 in the other. In hydrocephalus also there is greater pain in the 
 head, or drowsiness ; there is disturbance of the pupils, which are 
 contracted, or in the later stages widely dilated, with strabismus; 
 and the fontanelles become distended ; the vomiting in hydroce- 
 phalus is often induced by only raising the body from the recumbent 
 posture. In the exhaustion which occasionally follows severe diar- 
 rhoea, or muco-enteritis in infants, a series of symptoms, resembling 
 hydrocephalus, or, as they have been called, hydnvncephaloid disease, 
 supervenes ; these, however, are very different from true hydroce- 
 phalus ; they should be borne in mind, lest the effect of exhausting 
 disease be misinterpreted ; in these cases we have the half-closed 
 eye, the emaciated expression, diarrhoea, collapsed fontanelle ; and 
 the early symptoms are seen to commence in abdominal, not in cere- 
 bral disease. 
 
 Causes. The ordinary causes of enteritis are improper or indi- 
 gestible food ; this is especially the case in infants and children in 
 whom the disease is set up during dentition or weaning, or after ex- 
 anthems, especially measles. Exposure to cold or wet, sleeping in 
 damp beds, or in the open air, may induce it ; violent and sudden 
 
 1 Boyd, 'Edin. Med. Journal,' 1873, "On Infantile Enteralgia."
 
 286 MUCO-ENTERITIS AND ENTERITIS. 
 
 contortions of the body, excessive muscular exercise, as in walking, 
 are other causes. It may be associated with acute disease of the 
 lung, so also, with mechanical obstruction, however produced, 
 whether by hernia, intussusception, internal strangulation, tumors, 
 &c., and, lastly, with poisoned conditions of the blood, as pyajmia. 
 
 Proynosis. The unfavorable symptoms of enteritis are the long 
 persistence of the disease, emaciation, the development of peritonitis, 
 distension of the abdomen, hiccough, prostration of strength, irregu- 
 lar pulse, a haggard and anxious expression, sunken eye ; or, after 
 constipation of an obstinate character, the onset of severe diarrhoaa, 
 consisting of thin offensive or serous mucus; also, partial sweats, 
 inability to take food, persistent beef-like tongue. 
 
 In muco enteritis, the continuance of diarrhoea, thin serous evacua- 
 tions like the washing of beef, great exhaustion of the patient, ex- 
 ceedingly rapid pulse, and convulsions, are the precursors of a fatal 
 termination. 
 
 Enteritis is less amenable to treatment when there is a strurnous 
 diathesis ; the mesenteric glands are prone to become congested, 
 swollen, and infiltrated; and the patient gradually becomes ex- 
 hausted, or strumous disease is developed in other parts ; but there 
 is scarcely any condition of simple enteritis and muco enteritis from 
 which patients, especially infants, may not recover. 
 
 A more favorable prognosis may be given when the pain in the 
 abdomen subsides, when the bowels act naturally, and the evacua- 
 tions are of a healthy character: when the tongue is uninjected, the 
 skin supple and generally perspiring, the pulse quiet, the countenance 
 cheerful, and when there has been refreshing sleep. 
 
 Treatment. We believe, then, in the existence, in these cases, of 
 an inflamed condition of the mucous membrane, which may, or does 
 already extend, to the submucous, muscular, and peritoneal coats ; 
 and, if we consider the pathological conditions of the disease, the 
 indications of treatment becomes evident. 
 
 1. Allow the diseased part to rest. 
 
 2. Give the most bland and unirritating diet. 
 
 3. And avoid the use of purgatives. 
 
 It is exceedingly unadvisable to try and produce action on the 
 bowels by violent purgative medicine, as by jalap, senna, scamrnony, 
 calomel, blue pill, croton oil, crude mercury, and the like. The 
 peristaltic action is checked by the inflamed state of the coats of the 
 intestine, and additional irritation retards it still further. Leeches 
 applied to the abdomen, or depletion from the arm, has, in some in- 
 stances, been followed by free evacuation from the bowels, and by 
 the relief of pain, but we should not recommend the resort in these 
 cases to the latter remedy. Warm fomentations should be applied 
 to the abdomen. 
 
 When irritating ingesta are retained, producing and perpetuating 
 the disease, we may administer, at an early period, a purge of calomel 
 or gray powder, followed by castor oil, or linseed oil with opium, or 
 a free saline purge, as the potassio-tartrate of soda, or sulphate of 
 magnesia.
 
 MUCO-ENTERITIS AND ENTERITIS. 287 
 
 "When, however, there is tenderness, it is more safe to give calo- 
 mel, or gray powder, combined with opium, several times during the 
 day ; but it is well to avoid the continued use of mercurials. 
 
 Alkalies are of service, in acting as sedatives to the mucous mem- 
 brane, in diminishing its engorged state, and in neutralizing irritat- 
 ing secretions, as the bicarbonate of potash, in doses of gr. x, or gr. 
 xv, and the solution of potash in doses of "Lxv to xx, properly di- 
 luted. Chlorate of potash, in gr. v to gr. x, and carbonate of soda, 
 gr. v to gr. xv, combined with narcotic remedies, as hyoscyamus and 
 conium, are in other instances apparently beneficial. The latter 
 remedies appear to act on the involuntary muscular coat, and on the 
 nerve supply of the intestine. A valuable combination in less severe 
 cases is gray powder with Dover's powder. 
 
 Some administer rnagnesian salines, as sulphate of magnesia and 
 calcined magnesia ; but, where there is a tendency to extension of 
 the disease to the peritoneal coat, I think sulphate of magnesia is in- 
 jurious, in increasing the peristaltic action of the intestines, although 
 in its direct effect on the inflamed membrane, it may lead to 'the 
 emptying of the capillaries by watery evacuation. 
 
 Best in bed is important, that the intestines may not be disturbed 
 in their position, since perforation, in many cases, follows ulceration 
 of the intestine ; and, there may be also extension of peritonitis from 
 inattention to this simple rule. There must also be abstinence from 
 irritating food ; in fact, nothing but the most mild and bland ingesta 
 should be taken ; demulcent drinks, milk alone, or united with lime- 
 water or soda-water, as the case may be, will be grateful to the 
 patient. Great care is necessary after the subsidence of the more 
 active symptoms, in the return to nourishing and substantial food, 
 as Avell as in the use of any active exertion. The warmth of the 
 abdomen should be maintained, if there be pain, by the use of warm 
 poultices ; and in all cases the abdomen should be well surrounded 
 with flannel. 
 
 In children with muco-enteritis, chlorate of potash is a valuable 
 remedy, and in some cases, it appears to act with as much benefit as 
 in cases of stomatitis. Citrate or bicarbonate of potash are also of 
 real service. In other cases, when the motions are clayey and white, 
 minute doses of calomel are sometimes administered, with carbonate 
 of soda, or chalk, as the compound soda powder of the Guy's Phar- 
 macopoeia; but much injury is often done by calomel and gray powder 
 in these cases, and in numerous instances we have found their use 
 unnecessary ; astringents may be given, as chalk, with catechu, or 
 krameria, or logwood, with small doses of opium ; but in very young 
 infants it is better altogether to avoid the use of opium, if possible. 
 
 Maunsell and Evanson mention the value of dilute nitric acid 
 with minute doses of opium and simaruba, and I have often used 
 this combination with advantage. Ipecacuanha is a valuable remedy 
 where there is no irritability of the stomach, and it may be com- 
 bined with chalk medicine or with alkalies. It has also been recom- 
 mended as an injection. 1 
 
 1 Boudon and Chouppe, 'Bulletin Genfirale de Tlierapeutique,' 1874.
 
 288 MOOD-ENTERITIS AND ENTERITIS. 
 
 In children, also, it is essential only to administer food that can be 
 easily digested, and although it may appear of a proper kind, if the 
 symptoms continue, a change should be made. The disease often 
 comes on at weaning ; and the greatest care is required in seeking 
 for a suitable diet at that period; "tops and bottoms," with water, 
 and with or without a small quantity of milk ; dried flour, biscuit 
 powder, &c., may be given, or milk and water alone. I have seen 
 cases where the only food that could be borne was water boiled for 
 a considerable time with rice, and after partaking of this fluid the 
 vomiting and purging ceased, and a gradual return to more substantial 
 food was attained. For some infants, it may be necessary to obtain 
 a wet nurse, but this is a measure to be avoided if possible. Asses' 
 milk is the best substitute for the natural supply ; and a small quan- 
 tity of cream, with water, can sometimes be taken when simple milk 
 cannot be borne. Swiss milk and Liebig's malt extract are sometimes 
 very useful, and sometimes raw meat may be used as subsequently 
 described. 
 
 The prostration in children is sometimes so great that stimulants 
 are necessary. The aromatic spirit of ammonia may be given with 
 infusion of cusparia, and with astringents: but in many instances I 
 have seen life apparently saved by the timely use of brandy, or wine, 
 administered very frequently and in small doses ; thus to a child 
 aged three, almost in a dying state, the pulse scarcely perceptible, 
 the extremities cold, the eyes half closed, brandy in doses of fifteen 
 drops, diluted with water or demulcents, was given every quarter of 
 an hour, and in a few days the child was really convalescent. In 
 other cases, white wine whey produces a similar beneficial result ; 
 but the use of alcoholic stimulants in young children requires great 
 care and caution ; they are often the cause of enteric inflammation, 
 and I have in some instances known the exhaustion increased by 
 their use, for the irritant effect due to their administration prevented 
 the digestion of proper food.
 
 289 
 
 CHAPTER IX. 
 
 STRUMOUS AND TUBERCULAR DISEASE OF THE ALIMENTARY CANAL. 
 LARDACEOUS DISEASE. 
 
 INFLAMMATORY disease of the alimentary canal in strumous sub- 
 jects can scarcely be separated from the more slow and insidious 
 strumous disease, which has less active symptoms and seerns to origi- 
 nate spontaneously. Struma should not be looked upon as a disease 
 of isolated organs of the body ; but as one in which the power of 
 assimilation is diminished, the nutritive functions are imperfectly 
 performed, and the cellular elements of the tissues unnaturally prone 
 to degeneration. Disease set up by the ordinary exciting causes in 
 subjects of this kind leads to the various forms of strumous deposit 
 and its subsequent changes. A blow on an epiphysis leads to stru- 
 mous disease of the bone; a slight bronchitis to strumous pneumonia, 
 and the formation of tubercular substance in the lungs; over-excite- 
 ment of the brain to hydrocephalus and strumous meningitis; slight 
 irritation of the mucous membrane of the intestine, or muco-enteritis, 
 to caseous changes in the rnesenteric glands, of the mucous mem- 
 brane, and submucous tissues. The antecedent abnormal conditions 
 are, I believe, common to these changes and to tuberculosis; damp 
 air, a want of light and proper food, imperfect rest, hereditary dis- 
 position, and, perhaps, syphilitic taint, induce the imperfect elabora- 
 tion of those products necessary for healthy growth and nutrition; 
 and in this state the blood, the nervous force, the vital activity of 
 every part of the body, are unable to return to the normal type on 
 the slightest derangement, and strumous inflammation and degene- 
 ration take place. 
 
 The strumous and tubercular diatheses are closely allied, and may 
 clinically be regarded as varieties of the same morbid condition. 
 The tendency towards the preponderance of the changes character- 
 istic of the one or the other will vary in different individuals. In 
 one person, the tubercular form is so strongly marked that without 
 any appreciable exciting cause, general tuberculosis will spread 
 throughout the tissues; in another, a chronic disease of similar form 
 is manifested; some will be affected by acute forms of strumous 
 pneumonia, whilst in others chronic processes of caseation gradually 
 extend over a greater or less extent of the lymphatic system; but 
 all these varieties have intermediate states, and show their mutual 
 affinities by combining in many patients their several pathological 
 appearances. These remarks are especially applicable in treating of 
 tubercular or strumous disease of the abdominal cavity; for on the 
 one hand, we shall have to speak of tubercular peritonitis, a disease 
 which may be so distinctive, that it has been proposed to separate it 
 19
 
 290 STRUMOUS DISEASE OF 
 
 from other tubercular affections, and give it a separate name j 1 on 
 the other hand, we shall find what is apparently the same disease 
 mixed up with caseous changes, particularly in association with in- 
 testinal ulceration and diseases of the Fallopian tubes, and we shall 
 also have to describe a caseous degeneration of the mesentric glands 
 without any miliary tubercle whatever. 
 
 Strumous and tubercular disease of the alimentary canal are ob- 
 served under various forms : 
 
 1. Severe diarrhoea as it occurs in children of strurnous diathesis, 
 without amyloid or other disease of the mesenteric glands or intestine. 
 
 2. Primary disease of the mesenteric glands tabes mesenterica. 
 
 3. Tubercle in the peritoneum, and strumous peritonitis in its 
 several forms. 
 
 4. Tubercle in the mucous membrane with enteritis, leading to 
 softening, ulceration, and perforation, as is frequently observed in 
 phthisis. 
 
 5. Tubercle in the appendix caeci. 
 
 1. Diarrhoea in strumous children. The symptoms are very similar 
 to those which we have described as present in gastro-enterite, but 
 here, being engrafted upon a strumous constitution, they are more 
 easily induced, and are less yielding to medicinal treatment. This 
 disease causes the death of thousands of infants among the poor of 
 London, nor does it spare the rich, when there is hereditary predis- 
 position. The diarrhcea is frequently set up by some change in the 
 diet or by other improper nourishment ; by disordered secretion from 
 the stomach, intestines, or liver; and it often follows the exhaustion 
 of measles or scarlet fever. Many of these cases are cured by the 
 removal of the exciting causes, and by the administration of simple, 
 corrective medicines. When, however, these causes cannot be re- 
 moved ; when the infant cannot be taken from offensive exhalations, 
 and from a damp or cold atmosphere ; when no food can be adminis- 
 tered or when there is a very feeble and strumous constitution, too 
 frequently does the diarrhoea continue ; the little patient becomes 
 wasted, the countenance is expressive of extreme distress, and has 
 an aged, care-worn appearance; the evacuations consist of greenish 
 thin mucus, of food only partially changed, or they resemble the 
 washings of meat, and are exceedingly offensive. The skin is dry, 
 sallow, and wrinkled ; the abdomen is full, sometimes hot and tender, 
 and there is pain of paroxysmal character; the mouth is dry, and 
 sometimes aphthous, the tongue is slightly furred, the breath is offen- 
 sive, the eyes languid and the sleep is often disturbed with starting 
 moans. Sometimes the stomach is irritable, or the appetite is craving, 
 and the child distressed by thirst. Such are the symptoms of severe 
 gastro-enterite rendered intractable by strumous deposit, and passing 
 into the condition described as tabes mesenterica. 
 
 In some cases even of extreme exhaustion, the little patient rallies 
 when proper remedial means can be employed ; in others the diar- 
 
 1 Granulia. See Dr. Bastian, "Discussion on Tubercle," 'Path. Soc. Trans.,' vol. 
 xxv, p. 330.
 
 THE ALIMENTARY CANAL. 291 
 
 rhoea persists day after day, slightly abating and then returning with 
 renewed violence, till at last the infant dies exhausted, or convulsions 
 come on before the close of life. It rarely happens that with very 
 severe diarrhoea there is much cough, although the lungs may be 
 throughout filled with miliary tubercles. 
 
 Post-mortem appearance. After death we may find no apparent 
 change in the whole tract of the mucous membrane ; the liver, 
 spleen, and lungs may be normal ; the mesenteric glands may be 
 enlarged and swollen, and in some instances they contain evidence of 
 degeneration at their central parts. It might be questioned, whether 
 a disordered mucous membrane did riot induce this condition of the 
 glands ; but whether so produced or primary in its origin, there can 
 be little doubt that it leads to the maintenance of an abnormal state 
 of the mucous canal, and indicates strumous cachexia. When .we 
 have a more vigorous constitution, one free from struma or imperfect 
 nutritive power, the patient often rallies, and the fatal symptoms are 
 checked. 
 
 Treatment. In the treatment of these cases, it is most important 
 to remove all exciting causes of disease, and every impediment to 
 the healthy performance of nutrition and growth ; to inculcate per- 
 fect cleanliness, and the inhalation of pure air ; to administer the 
 most mild and unirritating food, and to afford warmth to the body. 
 
 The child should have warm baths ; be clothed in flannel ; and the 
 air of the room must be maintained at an equable temperature. Milk 
 will not agree with some infants, in whatever form it may be given ; 
 others will retain asses' milk, or milk with lime-water or .soda- water, 
 when pure milk is constantly rejected. In some cases the condensed 
 milk properly diluted is kept down ; and in others, again, only 
 artificial foods can be taken; the best of these are, water boiled for 
 a long time Avith rice ; "tops and bottoms," gently simmered with 
 water and without sugar ; dried flour ; biscuit-powder ; and, as a 
 dernier ressort, a wet-nurse must be obtained. 
 
 Another very useful food is raw meat, first recommended by Dr. 
 Weisse, of St. Petersburgh. A piece of lean steak is procured, and, 
 after grating it, it is to be beaten into a pulp ; then mixed with a 
 little sugar, and a teaspoonful may be given three or four times a 
 day. Should the child refuse it in this form, it may be stirred into 
 very thin chicken or mutton broth scarcely warm. 
 
 While advocating the occasional necessity of artificial food, it is to 
 be remembered, that for young children it is only to be used to coax 
 the stomach into a quiet state, and that as soon as possible a gradual 
 return to some form of milk diet is to be attempted. 
 
 In the medicinal treatment, where chalk mixture made with dill 
 or cinnamon water, and with or without a few drops of ipecacuanha, 
 does not avail, I have found great benefit from the administration of 
 the compound logwood mixture of the Guy's Pharmacopoeia : 
 
 Misturse Cretae, fluidunc. vj ; 
 Extract! Haematoxyli, dr. j ; 
 Vini Ipecacuanhas, fluidr. j ; 
 Vim Opii, fluidr. ss.
 
 292 STRUMOUS DISEASE OF 
 
 This in doses of one or two teaspoonfuls, or, the compound infusion 
 of catechu, with a small quantity of opium, and, if need be, a few 
 drops of aromatic spirit of ammonia, is very useful. The krameria 
 is also a valuable astringent, with or without chalk and opium, as 
 in the following Guy's preparation: Decoction of krameria Jxv, 
 (root Six, with water Oj, boiled to 3xv). Ipecacuanha wine and 
 tincture of catechu, of each 3vj, and syrup Biss. A teaspoonful to a 
 tablespoonful as a dose, according to the age of the child. 
 
 When a strumous condition exists, great benefit is derived from 
 the administration of cod-liver oil, with steel wine, or from the latter 
 medicine alone. If vomiting be absent, cod-liver oil is sometimes 
 exceedingly serviceable-; when it cannot be taken, dilute nitric acid, 
 with infusion of cusparia, and a few minims of compound tincture 
 of camphor, are of benefit, especially when other means have some- 
 what moderated the diarrhoaa. 
 
 In some cases small doses of sulphate of copper, as | to of a 
 grain, or of nitrate of silver in similar quantity, or of acetate of lead 
 in J or 1 grain doses may be prescribed with one or two grains of 
 Dover's powder. Mercurials are, I have generally found, detrimen- 
 tal, and continued doses of calomel greatly aggravate the disease. 
 Small enemata of starch may be used with benefit, and where we 
 have a good nurse, other agents may be well applied in this way ; 
 a weak solution of nitrate of silver or of borax tends to diminish the 
 irritation of the lower bowel, and may prevent prolapse. When 
 exhaustion is extreme, nourishment must be administered every few 
 minutes, if the stomach can retain it ; and small quantities of wine 
 or brandy, as previously mentioned. In not a few cases alcohol has 
 been the means of prolonging life and restoring infants to health who 
 were apparently in a dying state. 
 
 This form of diarrhoea is, however, not confined to children. The 
 following case is an instance of that kind, where apparently simple 
 diarrhoea assumed an obstinate type ; no form of medicine or diet 
 checked it for many days, and at last the patient sank. There was 
 evidence of some inflammatory action at the lower part of the ileum ; 
 intense congestion, slight diphtheritic effusion, and ulceration of the 
 Peyer's glands were found ; but these appearances were so local that 
 they were not considered sufficient in themselves to explain the 
 severity of the abdominal symptoms. There were minute tubercles 
 in the peritoneum, and degenerating products in the mesenteric glands 
 which indicated the strumous constitution of the patient. The lungs 
 contained neither vomica nor miliary tubercle, but some iron- gray 
 deposit, and a little cheesy matter were found at the apex, and in the 
 lower lobe there was ordinary hepatization, which had evidently 
 come on a short time before death. 
 
 CASE XCVIII. Slight Strumous Disease of the Mesenteric Glands. 
 Diarrhcea. Pneumonia Charles A , get. 30, a waiter, was admitted into 
 Guy's Hospital, August 15th, 1855. 
 
 Three years previously he had had severe diarrhoea ; and five weeks before 
 admission, he had had pain at the stomach, with vomiting and loss of appetite. 
 He lost flesh considerably ; he was feverish and emaciated. The cause of the
 
 THE ALIMENTARY CANAL." 293 
 
 diarrhoea was not evident. The respiration was coarse at the apices of the 
 lungs, but he had no cough. The abdomen was collapsed, and free from 
 pain ; no tumor nor abnormal condition could be detected on careful manipu- 
 lation ; his tongue was moist and not injected, and there was no hoarseness. 
 His urine was non-albuminous; sp. gr. 1014. Chalk, kino, opium, copper, 
 oxide of silver, were prescribed ; the last appeared most effective ; but although 
 the diarrhoea ceased for a short time, he did not appear to derive nourishment 
 from food ; an attack of diarrhoea came on a few days before his death, on 
 October 21st, 1855. Inspection twenty-six hours after death: The body 
 was extremely emaciated, and the eyes were sunken. In the chest there 
 were slight pleuritic adhesions at the right apex ; at the extreme apices there 
 was old iron-gray deposit. No miliary tubercles existed. The lower lobe of 
 the lung was hepatized. The larynx was healthy. The bronchial glands 
 were normal. In the jejunum the mucous membrane was gray, and in the 
 ileum, it was intensely congested ; one of Peyer's patches, about two feet 
 from the caecum, was ulcerated, and the membrane in several parts had a 
 thin adherent brownish covering, as of epithelium stained by adherent feces. 
 On examination this was found to consist of columnar epithelium. The 
 caecum was intensely congested, and its membrane was ecchymosed. The 
 surface presented epithelium, blood, and some mucus ; and the capillaries 
 were full of blood. The colon was in a similar state, but rather less intensely 
 congested ; no ulcer could be found. The appendix caeci was full of feces. 
 The mesenteric glands varied exceedingly in size, from that of a pea to a 
 pigeon's egg ; some were swollen, red, and oedematous ; others contained 
 caseous product ; and in some parts beneath the peritoneum of the mesentery 
 were minute tubercles. A minute examination of the abdominal viscera, 
 nerves, and vessels, failed to show any other disease. 
 
 This case was believed to be one of phthisis, in which there was 
 extensive ulceration of the colon; but this was not found after death; 
 disease of the mesenteric glands appeared to have been the original 
 malady ; and this was the explanation of the gradual emaciation. 
 The diarrhoea was the result of subacute disease of the mucous mem- 
 brane, and of ulceration of the ileum, but it was increased by the 
 great congestion of the mucous membrane of both small and large 
 intestines. This was the most marked symptom, and tended more 
 than any other to exhaust the patient. The ordinary remedies were 
 unavailing ; but of these, the oxide of silver, with conium, appeared 
 to be the most effective. An attack of acute pneumonia was the 
 immediate precursor of a fatal termination. 
 
 2. In disease of the mesenteric glands tabes mesenterica the cel- 
 lular constituents of the glands themselves undergo multiplication, 
 and subsequently degenerating, the structure of the glands becomes 
 destroyed. Extensive disease of this character necessarily prevents 
 the absorption of chyle into the system. The glands show the dis- 
 ease in various stages and gradations ; in some there is but scanty 
 abnormal product, in others the whole gland is destroyed and very 
 much enlarged, constituting a whitish mass, the size of a pigeon's or 
 hen's egg. The disease consists of glandular and fatty matter, and of 
 imperfectly developed cells ; and the swollen and injected state of 
 less diseased glands appears to indicate that inflammation or hyper- 
 aemia is associated with the morbid change.
 
 294 STRUMOUS DISEASE OF 
 
 The pathological process appears in its outset to be essentially of 
 an inflammatory or irritative character. The glands or lymphatic 
 tissue become hyperaemic and fleshy, their cellular elements multi- 
 ply, and crowding upon each other and upon the stroma in which 
 they lie they cut off' their own blood supply and speedily degenerate. 
 While the' cells in the central parts are degenerating into fatty 
 material, those at the circumference are gradually infiltrating the 
 surrounding unaffected parts and increasing the size of each nodule. 
 These changes closely resemble those which take place in a single 
 tubercle. The disease continues to increase, the cells dying in the 
 centre, but growing at the circumference, till large masses of caseous 
 material are formed : if the process be very chronic the outlying 
 cells may be seen to form fibrous tissue so as to encapsule the dis- 
 ease ; and it would appear that by the formation of this envelope 
 the increase of the growth is arrested, and the disease becomes qui- 
 escent. Then it is that the last stage is reached, namely, that of 
 calcareous change in the caseous cells. The spread of tubercle thus 
 traced applies to all parts, whether it be in glands or in minute spots 
 of tissue in the lymphatic spaces of a serous or mucous membrane, 
 and whether it occur in the brain, the lung, the serous surfaces, or 
 elsewhere. 
 
 Whilst these changes are going on in the glands the lacteals be- 
 tween them become enlarged and distended with similar material, 
 and we can trace the distended ducts to the intestine, where they 
 ramify on its surface. At this part we generally find a cluster of 
 tubercles and ulceration of the mucous membrane ; and were it not 
 that the glands appear to be in a state of more advanced disease than 
 the intestine, we should suppose that the ulceration of the mucosa 
 was followed by absorption and then by glandular disease. The 
 peritoneum is sometimes studded with miliary tubercles, or we 
 merely find minute clusters opposite points of ulcerated intestine. 
 Inflammatory products are also found in the serous membrane in 
 various degrees, either constituting bands of adhesion, or uniting 
 the intestine in one mass. (See Strumous Disease of the Peri- 
 toneum.) 
 
 Symptoms. Diarrhoea, as we have previously mentioned, is one 
 of the symptoms of mesenteric disease. There is gradual wasting, 
 from the obstruction of the chyle vessels, and from the cessation of 
 the supply naturally poured into the thoracic duct. The patient 
 has an anxious expression of countenance ; there is dryness of the 
 skin ; injection of the tongue, which is more or less furred, and a 
 craving appetite ; the desire for food being insatiable. The bowels 
 are irregular, for though often loose, they may be sometimes consti- 
 pated. There are occasional attacks of severe pain, and the evacua- 
 tions have sometimes been found to contain a large quantity of fatty 
 matter. 
 
 The marasmus gradually becomes extreme, and, whilst the limbs 
 are wasted, the abdomen is considerably enlarged, and protuberant. 
 The abdomen is full and rounded, but it rarely happens that the 
 enlarged glands can be felt on tactile examination ; we more easily
 
 THE ALIMENTARY CANAL. 295 
 
 discover them in the neck and in the axillae. Where peritonitis, 
 and ulceration of the intestines have baen produced, pain is a more 
 common symptom. 
 
 A fatal termination may result from diarrhoea, or other organs 
 become implicated, as the brain and lungs, causing death by tuber- 
 cular bronchitis, by convulsion, or hydrocephalus. In other in- 
 stances disease in the epiphyses of the bones takes place, but the 
 patients in these cases present less advanced disease of the glands of 
 the mesentery. 
 
 A fatal result does not necessarily follow this condition of the 
 chylopoietic glands unless the disease be very extensive ; we have 
 evidence of this fact in the calcareous condition in which the glands 
 are found when death has followed from other causes, as from 
 phthisis, or from tubercular meningitis ; but the interference with 
 the elaboration of chyle increases the tendency to the formation of 
 strumous products in other parts. 
 
 At the period when this less severe disease existed, and the sub- 
 sidence of which had left the calcareous state just mentioned, gastro- 
 euterite had probably occurred ; or, without any febrile excitement, 
 the child had been observed to be imperfectly nourished, its growth 
 retarded, and its nutritive power evidently feeble. It is in this early 
 stage of the disease that proper attention to the health of the child 
 may correct commencing degenerative changes, which will, if fully 
 developed, necessarily prove fatal. Too frequently, however, the 
 physician is consulted when the opportunity for checking morbid 
 action has passed by. 
 
 Diagnosis. In its earliest condition strumous disease of the me- 
 senteric glands may easily be mistaken for simple diarrhoea, or gas- 
 tro-enterite ; and what is of greater importance, the sympathetic 
 affection of the brain sometimes renders it exceedingly difficult to 
 distinguish between strumous disease of the abdomen and tubercular 
 meningitis. In the former there may be cerebral oppression, grind- 
 ing of the teeth in sleep, smarting, occasional vomiting, and convul- 
 sion ; but in the latter the mind is generally less active, there is 
 strabismus, or an evident abnormal condition of the pupils ; the ab- 
 domen is collapsed rather than distended; there is greater unwilling- 
 ness for exposure of the skin to cold air, the bed-clothes are drawn 
 firmly down when the patient is sensible; and again, the superficial 
 capillary circulation is more disturbed, and the vessels yield easily 
 to distension. It is in this way that the so-called " tache cerebrale" 
 is produced. On drawing the finger across the skin, a deep line of 
 congestion appears and remains for a short time; this indication, 
 however, is by no means constant or certain. In the cerebral disease 
 vomiting is often a marked symptom, especially at an early stage ; 
 and this with irregularity of the pulse are the two symptoms which 
 are most reliable. 
 
 In the cachexia produced by enlarged spleen, by miasmatic disease, 
 by lardaceous disease of the liver, or of other glands, by disordered 
 viscera associated with worms, symptoms arise which in some re-
 
 296 STRUMOUS DISEASE OF 
 
 spects simulate mesenteric disease. The history of the case, and the 
 presence of enlargem?nt of the liver or spleen, assist our diagnosis. 
 
 In children affected by any of the various kinds of intestinal 
 worms, the symptoms are pallor, irregular bowels, wasting, distended 
 abdomen, and voracious appetite ; but there is often present more 
 irritation about the nose and anus than in mesenteric disease; there 
 is less emaciation, and the disease is more amenable to treatment. 
 
 Tubercular peritonitis is frequently associated with mesenteric 
 disease, and is with great difficulty distinguished from it. The ab- 
 dornen is less supple when the peritoneum is implicated, and when the 
 disease is advancsd the intestines move en masse; there are tenderness 
 and distension, the pain is more severe ; but the emaciation is less 
 manifest. Ulceration of the small or large intestine and diarrhoea 
 may be present in either disease, but very many of the cases usually 
 designated tabes mesenterica are really tubercular peritonitis. 
 
 In strurnous subjects, however, after gastro-enterite, or slight peri- 
 tonitis, the intestines sometimes become much distended with flatus, 
 and these cases at first sight resemble ascites ; a very unfavorable 
 prognosis may be given, whilst with rest, good air, cod-liver oil and 
 steel, and occasional alteratives, the health becomes established, and 
 the distension and pain disappear. The insidious character of stru- 
 mous peritonitis must be well remembered ; pain may be entirely ab- 
 sent, and the emaciation steadily progressive. 
 
 The prognosis in well-marked cases of mesenteric disease must be 
 exceedingly unfavorable ; for when there is any general affection of 
 the glands the obstruction to the introduction of food into the system 
 is scarcely less complete than in direct pressure on the thoracic duct. 
 Numerous inspections after death, however, show us that there may 
 be degeneration of many of these glands. Some become calcareous 
 and pass evidently into a passive state, whilst others of them are re- 
 stored to their normal condition, and life may thus be prolonged for 
 many years, till strumous disease in some other form, or another 
 malady, proves fatal. Such cases also occasionally terminate fatally 
 from intestinal obstruction many years after they have been appa- 
 rently cured. The inflammatory deposit causes contraction or leads 
 to bending of the intestine upon itself at an acute angle. 
 
 The age of infancy is most liable to mesenteric disease, but it is 
 frequent at any period from the first to the completion of the second 
 dentition; in those who attain to early manhood it is much more 
 frequently found associated with strumous peritonitis and with 
 phthisis. 
 
 The causes of this disease have been previously mentioned ; they 
 are hereditary predisposition, improper food, and'the substitution of 
 artificial foods for the mother's milk, insufficient rest, the want of 
 cleanliness and light, the exanthems, as measles, scarlet fever, and 
 smallpox, exposure to cold, and to a damp, humid atmosphere, prob- 
 ably also congenital syphilis. Each of these causes diminishes the 
 nutritive energy of the system, and a slight exciting cause then 
 becomes sufficient to set up the disease; and when it is developed
 
 THE ALIMENTARY CANAL. 297 
 
 to accelerate it, so that it becomes quickly manifest in a marked 
 degree. 
 
 Simple mesenteric disease is, however, rare, even in strumous 
 subjects ; for we generally find that there is also tubercular disease 
 of the peritoneum or of the mucous membrane ; and in many cases 
 of tubercular peritonitis, and of phthisis with ulcerated intestine, the 
 glands are unaffected. 
 
 Treatment. It must always be remembered, that in this disease 
 waste advances and increases, whilst the supply of reparative material 
 to the blood is cut off. 
 
 Our chief aim, therefore, must be to facilitate and assist nutrition; 
 whatever is given must be easy of absorption and assimilation, as we 
 have stated in speaking of the diarrhoea of strumous children. Wine 
 may be often taken with advantage, for alcoholic liquors probably 
 prevent waste going on with such great rapidity ; and it has been 
 shown by the observations of Dr. Anstie, and of others, that during 
 the administration of alcohol the excretion of urea is checked, and 
 the function of other organs, especially that of the lungs, is diminished. 
 
 If there be febrile excitement, salines, as the bicarbonate of potash, 
 or the citrate of ammonia, in doses of a few grains, may be adminis- 
 tered ; and when great restlessness exists, gr. j or ij of Dover's 
 powder, or niiij or v of the solution of hydrochlorate of morphia, are 
 of service. Mercurials are better avoided; but when the motions are 
 clayey and pale, and the bowels constipated, their use, in the form 
 of gray powder, or calomel with bicarbonate of soda, is occasionally 
 beneficial. A change to sea air is very desirable in the early stages 
 of mesenteric disease. With cod-liver oil we may with advantage 
 combine iodide of potassium, iodide of iron, &c. The preparations 
 of iron, however, cannot in many cases be taken: pain in the bowels 
 is produced ; but this is less likely to follow the use of steel wine, 
 and the saccharine carbonate of iron, than the stronger compounds. 
 Iodide of potassium with solution of potash, with very minute doses 
 of opium if necessary, continued for a lengthened period, are some- 
 times of considerable service. 
 
 As to external remedies, the tincture of iodine may be painted 
 over the abdomen, or slips of the ammoniacum plaster with mercury 
 may be applied; but the maintenance of an equable and warm state 
 of the skin is of greater importance than external medicinal applica- 
 tion. 
 
 3. Tubercles in the peritoneum and strumous peritonitis. The state 
 of the peritoneum is so closely associated with that of the alimentary 
 canal, that a consideration of strumous disease affecting that part 
 renders some notice of the diseased peritoneum necessary. 
 
 Tubercular peritonitis is manifested in several conditions. 
 
 1. As miliary tubercles covering the general surface of the perito- 
 neum visceral, parietal, and mesenteric, and in some instances 
 associated with ascites. In some of these cases of ascites there may 
 be very little proof of tubercular growth ; but tubercle may be sub- 
 sequently developed as the result of chronic irritation in patients 
 constitutionally predisposed to it.
 
 298 STRUMOUS DISEASE OF 
 
 2. Caseous thickening of the peritoneum and subperitoneal connec- 
 tive tissue by tubercular growth which rapidly degenerates. This 
 form is associated with deposit in the glands, and with inflammation 
 leading to matting together of the intestines; sometimes to perfora- 
 tion from without, and to the formation of small fecal abscesses and 
 sometimes to tympanitis in a marked degree. 
 
 The presence of miliary tubercles on the peritoneum is found in 
 many cases of phthisis, where there is ulceration of the intestine, the 
 corresponding surface of the peritoneum being covered with minute 
 tubercles, and this condition of local tuberculosis may cause an affec- 
 tion of the whole peritoneum. 
 
 In children who have died from hydrocephalus, with miliary '' 
 tubercles in the pia mater, or from acute pneumonia with miliary 
 tubercles studding the whole of the lung, the peritoneum is frequently 
 found affected in the manner described, but the disease of the serous 
 membrane does not assume a condition of clinical or pathological 
 importance. 
 
 The formation is generally seen as semi-transparent grains, and 
 appears to be situated both on the surface and in the deeper layer of 
 the peritoneum ; it consists of an almost amorphous blastema with 
 minute granules, and of imperfectly developed cells, which rapidly 
 caseate in the centre ; but sometimes around the deposit elongated 
 fibre cells and branching cells are observed, and there is in all cases 
 of general tuberculosis a great amount of inflammatory growth and 
 lyrnph product. 
 
 In some cases of peritonitis, thin layers of lymph are deposited on 
 the peritoneum, and the surface assumes a minutely granular appear- 
 ance, almost as if sprinkled with sand ; the grains thus produced 
 must not be mistaken for true miliary tubercles ; they can occasion- 
 ally be scraped off', and they leave the serous membrane smooth 
 beneath, but this cannot always be effected. The movement of one 
 part of the intestine on another, and the gradual deposition of lymph, 
 appear to produce this condition. Sometimes there is a great amount 
 of serous exudation, and ascites is produced, whilst another more 
 severe form of disease is that in which, with strumous deposit, there 
 is ordinary inflammatory change ; the intestines become matted to- 
 gether by lymph, and by low organized product, which rapidly un- 
 dergoes degeneration, constituting cheesy masses. These masses are 
 formed between the coils of intestine, in the omentum, and in the 
 adhesions themselves ; so that we find the peritoneal tunic of the 
 liver, spleen, &c., considerably thickened three to five lines, or more 
 and in the fibrous tissue constituting the firmer part of the deposit 
 are tubercles or strumous infiltration. The stomach rarely, if ever, 
 presents tubercles or tubercular ulceration on its mucous surface, 
 but it is not uncommon to find tubercles on its peritoneal surface. 
 The mesentery and its glands are also generally found in a similar 
 condition. 
 
 The product thus formed leads to union of the intestine, one part 
 with another, so that the peritoneal cavity becomes entirely obliter- 
 ated ; fresh deposition takes place as the disease advances, and the
 
 THE ALIMENTARY CANAL. 299 
 
 tendency to degenerate increases. The masses soften down, the peri- 
 toneal and muscular coats ulcerate, and this process continues till 
 the mucous surface gives way, and an opening is formed into the 
 intestinal canal. The perforation takes place from without, begin- 
 ning at the peritoneal surface. This perforation does not, however, 
 lead to more extensive peritonitis ; the firm adhesions which have 
 already taken place have obliterated the peritoneal cavity, and thus 
 prevent effusion. Thus, either no extravasation follows, or a very 
 small fecal abscess is the result. The extension of ulceration 
 amongst contiguous coils of intestine sometimes leads to several por- 
 tions becoming completely truncated and opening into a fecal abscess 
 in which six or eight communications may exist. I have examined 
 several cases in which there were from twelve to fifteen communica- 
 tions between portions of the intestine in different parts, but without 
 fecal abscess. In these cases it is quite impossible to unravel the 
 intestine, or even to distinguish the various parts in many instances. 
 The intestine becomes, indeed, a sac of many pouches rather than a 
 continuous tube. Should the adhesions be less extensive, perfora- 
 tion will produce more marked symptoms, if a fatal result does not 
 very quickly follow. It is generally the small intestine which is 
 found perforated ; but it may open into the colon ; and once I ob- 
 served the jejunum communicating with the transverse colon. In 
 a recent case, a child, aged three years, after measles had tympan- 
 itic distension of the abdomen with diarrhoea ; perforation took place 
 into the bladder; feces were passed by the penis, and urine was ap- 
 parently discharged by the rectum. There was no pain, but the 
 child sank in a few days. 
 
 It is more rare in strumous than in cancerous disease of the abdo- 
 men and intestines, to find fecal abscesses followed by perforation of 
 the abdominal parietes. In strurna the disease is often very general, 
 and several fecal abscesses exist ; but the adhesions and secondary 
 perforation allow the contents of the canal to be passed onwards ; in 
 cancer the ulceration is more localized in character, and gradually 
 extends through all the contiguous structures. We have seen, how- 
 ever, in a child aged six, strumous disease of the abdomen followed 
 by perforation of the parietes. The effusion in some instances is of 
 an ascitic character, and dropsy is the result. The peritoneum is 
 thickened, clear serum is effused, and with it more or less strumous 
 product. This is not a rare disease among children, but it is of a 
 slow, insidious character, and very intractable. It sometimes exists 
 with a lardaceous condition of the liver or of the spleen, but this is 
 not always the case, nor is it always preceded by one of the exan- 
 thems. 
 
 In some instances of strumous peritonitis the intestine appears to 
 lose its contractile power, and yields to distension, so that most dis- 
 tressing tympanitis takes place, or there is simple distension without 
 pain, the muscular fibre having simply lost its power of contraction. 
 The coats of the intestine become so much softened that after death, 
 they readily separate the one from the other, and may be torn. in
 
 300 STRTJMOUS DISEASE OF 
 
 long shreds. Dr. Hodgkin placed in the museum at Guy's several 
 ^specimens showing this condition in a remarkable degree. 1 
 
 The symptoms of this form of disease are also sometimes obscure 
 at the commencement ; with a well-marked strumous diathesis we 
 have pain in the abdomen of a severe character, resembling colic ; 
 and it is accompanied with considerable tenderness ; diarrhoea and 
 febrile excitement come on, with injected, slightly furred tongue and 
 with a distressed expression of the countenance. There is a circum- 
 scribed flush on one cheek. Under suitable treatment and precaution 
 the active symptoms subside, and the patient feels relieved ; in a few 
 days or weeks, however, the pain returns, and there is renewed 
 aggravation of the symptoms and of the febrile state ; it may be that 
 a defined mass is felt in the abdomen, in the umbilical, hypogastric 
 or iliac regions ; the tumor is tender on pressure, and imperfectly 
 resonant on percussion. 
 
 These attacks are repeated from time to time, and the diarrhoea 
 becomes severe, and occasionally is accompanied by vomiting. The 
 body wastes, but the abdomen is large, and in most cases it loses its 
 suppleness, and moves en masse. The tongue becomes more in- 
 jected, oftentimes red and morbidly clean. The strength of the 
 patient is broken, severe hectic is set up, attacks of pain are more 
 frequent, and portions of the abdomen become exquisitely tender, at 
 length the exhaustion becomes extreme, or more general tuberculosis 
 is set up ; the brain may be affected with tubercular meningitis, and 
 coma or convulsions come on before death. 
 
 The symptoms somewhat resemble those of mesenteric disease ; 
 the abdomen is hot, often distended, and tympanitic ; the recti are 
 rigid ; the body wastes, the countenance becomes anxious, and the 
 eyes sunken ; the patient is fretful and irritable ; the bowels often 
 act with irregularity ; the pain is sometimes a marked symptom, 
 but it is often absent, or it merely resembles occasional colic. The 
 wasting of the body is, however, less than in severe disease of the 
 mesenteric glands. 
 
 The second form is that in which there is less serous effusion, but 
 the strumous product is accompanied by greater inflammation, lymph 
 is effused, and the intestines are matted together by bands of adhe- 
 sion, or there is cough from strumous disease of the lungs ; but this 
 aggravation of the suffering is generally absent, for the pulmonary 
 disease remains latent. The severe attacks of pain often indicate 
 the formation of fecal abscess or fresh accession of inflammation ; but 
 we shall dwell hereafter on the sudden peritonitis, which is some- 
 times set up in subjects affected with csecal disease and phthisis. 
 
 The symptoms may be exceedingly insidious in those cases in 
 which there is serous effusion into the peritoneal cavity. The 
 patient becomes an;emic and emaciated, pain is occasionally paroxys- 
 mal, or less severe but continued. After a time the abdomen becomes 
 enlarged and the fluctuation is perceived ; but there may be neither 
 febrile symptoms nor pain, nor any evidence of enlargement of the 
 
 ' Hodgkin, 'On Mucous and Serous Membranes.'
 
 THE ALIMENTARY CANAL. 301 
 
 liver or spleen, nor disease of other viscera. Strumous disease of 
 other organs, however, generally follows, and leads to fatal results. 
 There is great difficulty in producing absorption of this peritonitic 
 fluid; for the peritoneum is in a passive condition, and medicines 
 which act on the excretory organs, as diuretics, solution of potash, 
 or iodide of potassium, often fail in the desired effect ; and mercurials 
 tend in many instances to increase the effusion. 
 
 Causes. Children in their first dentition, and at the age of puberty, 
 in whom the rapid developmental changes are perverted by struma, 
 are very prone to. this disease, but early manhood from 15 to 25, or 
 30, is by no means exempt ; and we sometimes observe it at much 
 later periods of life, even in patients of 50 to 60 years of age. 
 
 The predisposing causes are those of strumous disease generally 
 hereditary taint, unwholesome food, the want of cleanliness, a damp 
 humid state of atmosphere, exposure to cold, insufficient light, &c. 
 Light is as essential to healthy growth as cleanliness ; but unfortu- 
 nately the absence of the one often entails the loss of the other. The 
 dark offensive dwellings of poverty present terrible manifestations 
 of some of the sources of struma ; but it is also to be found amongst 
 the rich in whom hereditary tendency, exposure to cold, &c., are 
 sufficient, with very slight exciting causes, to induce these affections. 
 
 The hyperaernic state of the ovaries at commencing menstruation 
 sometimes suffices to determine the deposition of strumous product, 
 and to cause strumous peritonitis extending from the pelvic viscera ; 
 this is especially the case when menstruation in young subjects has 
 been checked by exposure to cold. 
 
 Peritoneal disease of this form is sometimes excited by blows or 
 falls on the abdomen, or it follows diarrhoea from injudicious food 
 or excess ; we observe it also as a sequel to typhoid fever ; the follic- 
 ular ulceration of the intestine and irritation of the mesenteric glands 
 being followed by strumous disease. 
 
 The diagnosis has already been spoken of in mesenteric affections; 
 we may further add, that when strumous disease of the abdomen is 
 associated with like disease of the brain, the symptoms are often 
 more than usually obscure; cerebral symptoms, such as delirium 
 and coma, may be followed by prostration, distension of the abdo- 
 men, and vomiting ; and the general aspect of the disease may closely 
 resemble enteric fever. 
 
 The prognosis in well-marked cases is very unfavorable ; but at 
 an early stage, before the disease has become pronounced, much may 
 be done to render the changes which have occurred passive, and to 
 prevent the accession of fresh disease. 
 
 Treatment. The indications for treatment are very similar to those 
 mentioned in mesenteric disease. As far as possible the exciting 
 cause of the disease should be taken away ; and although this is 
 less practicable, we must attempt the removal of the condition which 
 constitutes the disease. This may in part be effected by sea air, by 
 iodine, cod-liver oil, iodide of potassium, and the milder preparations 
 of steel. Nourishment should be freely given, and of a character
 
 302 STRUMOUS DISEASE OF 
 
 that can be easily assimilated. Improper food may induce most 
 severe colic, and defeat all remedial measures. 
 
 The inflammatory state is best counteracted by the application of 
 leeches and counter-irritants; as cantharides, or iodine, applied ex- 
 ternallv; in children, it is well to place a portion of tissue paper 
 betwee'n the cantharides and the skin, and only to apply the plaster 
 for two or three hours ; or to use for a short time the acetum ean- 
 tharidis ; or still better, the Cantharidine Blistering Tissue. 
 
 When fluid exists, diuretics may be tried, but they are not of 
 much service. Great care is required in allowing exercise, because 
 at the same time that fresh air and change are exceedingly desirable 
 to improve the health, rest is most important for the abdominal 
 organs themselves. Slight movements may break down adhesions, 
 and lead to rapid extension of disease, and to a fatal termination. 
 The importance of rest to the viscera of the abdomen can scarcely 
 be urged with sufficient force. 
 
 Again, it is most desirable, that mercurial medicines and drastic 
 purges should be avoided ; the gentlest laxatives and mild enemata 
 are all that are required. 
 
 Various symptoms arise which demand almost daily attention, as 
 diarrhoea or occasional vomiting, each of which must be checked by 
 appropriate treatment. In a case of strumous peritonitis recorded 
 by Dr. Hughes in the 'Guy's Reports' of 1856, creasote was pre- 
 scribed to check severe vomiting ; it produced urine almost of the 
 color of indigo, but it relieved the patient. Pain must be moderated 
 by opium in small doses, or by morphia ; by warm fomentations or 
 cataplasms ; by chloroform. ; or by belladonna applied to the pari- 
 etes. 
 
 Gentle pressure by a bandage, and the irritation of the ammonia- 
 cum with mercury plaster, are sometimes of service; and in those 
 cases in which fluid is poured out, tapping is sometimes advisable; 
 for in chronic peritonitis the serous membrane often forms a thick- 
 ened, and almost a passive sac. 
 
 CASE XCIX. Strumous Peritonitis. Fecal Abscess. Artificial Anns. 
 A little girl, set. 6, had been suffering from chronic peritonitis for about a 
 year. The abdomen became much distended, and there was severe vomiting, 
 with great emaciation. Six months before death a circumscribed tumor 
 formed near the umbilicus ; this afterwards broke, and discharged feces. 
 
 On inspection, the lungs were found studded with tubercles ; the intestines 
 were adherent, and several portions were perforated ; they had formed a 
 fecal abscess near the umbilicus, which had discharged externally. The 
 Fallopian tubes were filled with soft strumous product. (Prep, in Guy's 
 Museum, 244G 50 .) 
 
 4. Disease of intestine in phthisis pulmonalis. The mucous mem- 
 brane of the intestine is frequently the seat of tubercle ; and although 
 tubercles are rarely, if ever, found in the mucous membrane prima- 
 rily, they are often associated with strumous disease of the lung, of 
 the serous membrane, of the brain, or of the bones. 
 
 A very common position for this deposit is in the substance of the
 
 TUB ALIMENTARY CANAL. 303 
 
 mucous membrane, at the lower part of the ileum, and generally in 
 the aggregate or solitary glands. The deposition takes place, as in 
 the lungs, without any evidence of inflammatory disease, and the 
 tubercles are found as minute grains, one sixteenth to one eighth of 
 an inch in diameter, and of an opaque, cheesy appearance. On ex- 
 amination they will be found to consist, in most instances, of an im- 
 mense number of granules of fat, with imperfect nuclei, though if 
 they are found in their earliest stages they consist of the same kind 
 of growth as we have previously described; in other instances the 
 centre is semi-fluid, softened down ; still more advanced, we find that 
 the slight covering of the mucous membrane has given way, and a 
 small ulcer is formed, with a depression in its centre, and with an 
 irregular and slightly excavated margin. This formation is proba- 
 bly in most cases preceded by hypersemia of the mucous membrane 
 or by inflammatory action; and although it appears nearly established 
 that inflammatory action is not essential to its deposition, this state 
 tends to accelerate degeneration, and the repeated deposition of stra- 
 in ous product at the margin of the ulcer. When inflammatory 
 action has taken place, the edge of the ulcer is found to be injected 
 and irregular, and to have extended rapidly ; in some cases, also, 
 sloughing has taken place. The extent of this diseased state varies 
 exceedingly ; generally only the lower part of the ileum is affected, and 
 next in frequency the rest of the ileum and the caecum. With these 
 parts, the colon is sometimes diseased in its whole length; and lastly, 
 also, the other portions of the small intestines, the jejunum, and even 
 the duodenum. 
 
 We frequently find, that, at the base of the ulcer, immediately 
 beneath the peritoneum, there are numerous minute tubercles, appa- 
 rently caused by a direct process of spreading to adjoining parts of 
 infection. In other instances the mucous membrane is raised, and 
 presents a small swelling, about a quarter of an inch in elevation, 
 and a quarter to half an inch in diameter ; and on making a section 
 of this minute tumor, a collection of pus is found in it; a sort of 
 small abscess in the mucous membrane. (/See Cases on Disease of 
 the Caecum.) 
 
 But strumous ulceration of the intestine, when associated with 
 phthisis, sometimes manifests itself differently. There is scarcely 
 any diarrhoea, but sudden intense pain is followed by collapse, and 
 too often by fatal peritonitis. A minute ulcer has increased in depth 
 so as to extend through the muscular coat, and then through the 
 peritoneum. It may be that this peritonitis is localized, or that a 
 fecal abscess is formed, and of these several accidents we shall have 
 to speak more fully. The affections of the appendix caeci will also 
 require a fuller notice. 
 
 In other instances the diseased intestine is found to be in a healing 
 condition, while the affection of the lungs has steadily progressed, or 
 having become rapidly aggravated, has led to a fatal result. I have 
 several times seen cicatrices in the intestine in phthisis, when there 
 was no evidence to show previous disease of a different kind, as 
 typhoid fever. In one instance, admitted into Guy's Hospital several
 
 304 STRUMOUS DISEASE OF 
 
 years ago, there were symptoms of intestinal, and it was feared in- 
 superable, obstruction; but the patient was spared to linger on for 
 many weeks, and died from phthisis pulmonalis. A cicatrix was 
 found in the ileum, leading to very considerable contraction of the 
 intestine, and no doubt it had been the cause of the previous symp- 
 toms of obstruction. 
 
 In some patients in whom the jejunum and ileum have been ulce- 
 rated throughout, with less affection of the colon, the diarrhoea has 
 been exceedingly severe. When the mesenteric glands are also af- 
 fected, we have several times observed, extending from an ulcer in 
 the jejunum or ileum, distended lacteals, reaching to the infiltrated 
 glands, and filled with yellow cheesy product. Some regard the 
 ulceration of the intestine as the cause of the disease in the lacteals 
 and glands ; others consider that the gland was primarily diseased, 
 and that the obstructed lacteals and local congestion consequent upon 
 it have set up the ulceration at that part of the intestine. Simple 
 distension of the lacteals is more common in cancerous disease, from 
 pressure on the thoracic duct; whilst in struma abnormal product 
 fills and enlarges the lacteals. 
 
 In many cases of phthisis the intestine appears to have taken part 
 in the general atrophy of the whole body, and we find the coats of 
 the intestine much thinned, of a pale color, and even semi-transparent. 
 Again, the mucous membrane sometimes does not present any lesion, 
 although the patient may have had severe diarrhoea, and this with- 
 out any evidence of lardaceous disease. 
 
 The extent and severity of the affection of the intestine are very 
 diverse. In cases where the phthisis is of a pneumonic character, 
 when there is extensive effusion into the lung tissue, rapid disor- 
 ganization, considerable fever, and speedy termination, the intestines 
 are sometimes unaffected. It is in more chronic cases that we gene- 
 rally find this condition most marked. 
 
 In one hundred cases of phthisis in only thirteen were the intestines 
 found to be healthy, and those were cases of the character just men- 
 tioned, namely, pneumonic phthisis. In sixty-nine cases the ileum 
 was diseased, and generally the colon also, in a greater or less degree ; 
 in seventeen cases the colon only was diseased. The ileum is the 
 part most frequently affected. In more severe cases, the colon is 
 also diseased, sometimes in its whole length, or merely at the sigmoid 
 flexure ; or we find the whole alimentary tract diseased, and the 
 jejunum, ileum, and colon are all ulcerated and inflamed. 
 
 Attacks of diarrhoea generally alternate with constipation in 
 phthisical disease of the intestine, and thin bilious evacuations are 
 occasionally mixed with blood. The discharge from the bowels is 
 sometimes composed of mucus passed in long strings or casts, or it 
 presents the character of yeast; in a case of this kind under my care, 
 the evacuation closely resembled the matters discharged from the 
 stomach in obstructed pylorus, but with a fecal instead of a sour 
 odor. Under microscopical examination minute cells and grains in 
 a state of change were observed, but not the ordinary torula, nor the 
 sarcina ventriculi. In other .instances the disease resembles acute
 
 THE ALIMENTARY CANAL. 305 
 
 dysentery, blood and mucus are passed, with considerable tenesmus ; 
 there is slight griping pain, but the discharge from the bowels resists 
 all. treatment ; it may be checked for a few days, but again returns, 
 and it is remarkable in some cases how completely the thoracic symp- 
 toms are in abeyance; neither cough, dyspnoea, pain, nor distress about 
 the chest may trouble the patient, although after death considerable 
 vomicse may be detected in the lung. In some of these instances the 
 appearances of the colon are quite those of a dysenteric character, 
 the extent of the ulceration destroying in some cases the mucous and 
 muscular coats, leaving but small islets of injected mucous membrane; 
 in other instances the surface is covered by diptheritic membrane, 
 and presents isolated patches of superficial ulceration beneath. Many 
 of these appearances have been observed in the numerous cases of 
 phthisis which have died at Guy's Hospital, and it is probable that 
 the more damp air of the Borough of Southwark, the ill ventilated 
 home in Bermondsey and Kotherhithe, from which some of these 
 patients have come, have induced this dysenteric state. 
 
 It would appear that exposure to cold and wet is sometimes the 
 cause of the unusual severity in the affection of the alimentary canal 
 in phthisis. In other cases, the administration of mercurial medi- 
 cines, of drastic purgatives, and of improper food, induces this con- 
 dition. 
 
 The presence of fistula in ano, as a complication of phthisis, is 
 frequent ; and it is a question upon which opinions are varied, whether 
 the division of the sphincter is advisable in such cases. Most sur- 
 geons would dissuade from the operation at the later stages, but in 
 the earlier condition, before there is any disorganization of the lung, 
 the removal of a depressing and exhausting discharge may tend to 
 re-establish health, so also when hemorrhage takes place from the 
 part; sometimes, however, the pulmonary symptoms rapidly increase 
 after the operation. 
 
 With albuminuria in strumous subjects, disease of the colon leads 
 sometimes to severe diarrhoea and great exhaustion. The association 
 of phthisis with renal disease is not of very frequent occurrence ; in 
 these cases the ileum and colon, as in ordinary phthisis, may be 
 ulcerated, or the rectum may be especially diseased. ' The use of 
 purgatives to relieve anasarca has been followed in some of these 
 cases by serous diarrhoea of a very intractable nature ; inflammation 
 and ulceration are set up, and, like ulceration on the extremities in 
 dropsy, may be the immediate cause of death. 
 
 Treatment. The 1st object should be as much as possible to re- 
 move the exciting causes of diarrhoea ; 2d, to check irritating secre- 
 tions by correctives and astringents; 3d, to soothe the inflamed 
 membrane by demulcents and by opiates. 
 
 In most cases the avoidance of indigestible food, of uncooked 
 fruit, and of malt liquors, is sufficient to check the purging in ordi- 
 nary phthisical disease of the intestine ; if not, an injection of starch 
 and" opium may be used with benefit. Suet and milk is an unirrita- 
 ting form of nourishment, and is often of much service ; other de- 
 20
 
 306 STRUMOUS DISEASE OF 
 
 mulcents, too, are used with advantage ; and when the powers of the 
 patient are much depressed, port wine or brandy must be prescribed. 
 
 Opium alone, or in combination, is of great value, as in Dover's 
 powder, the compound kino powder ; and it may be given with 
 acetate of lead, with sulphate of copper, with bismuth, or with oxide 
 of silver. Bismuth alone will oftentimes quiet this irritable condi- 
 tion of the alimentary canal; alkalies also, and astringents, as the 
 compound krameria mixture and the compound logwood mixture of 
 the Guy's Pharmacopoeia, will often be found valuable remedial 
 agents. 
 
 Although in some cases cod-liver oil acts on the bowels, in other 
 instances it moderates diarrhoea, and the bowels act with less violence 
 and pain. 
 
 I have found the injection of borax with barley water, or powdered 
 charcoal with the same agent, of more service in some cases where 
 the colon is much affected, than simple starch with .opium. 1 
 
 If there be severe pain the application of hot cataplasms or of 
 mustard affords partial relief. 
 
 It is the exception to find phthisis free from abdominal complica- 
 tion, but the following instances present some peculiarities in refer- 
 ence to this affection : in one case the mesenteric glands were very 
 extensively diseased, and the lacteals distended with strumous pro- 
 duct ; the diarrhoea was exceedingly obstinate, and hastened the fatal 
 termination. In another, the pulmonary symptoms were entirely 
 masked, but there is no doubt that the dysenteric inflammation was 
 more intractable in character on account of the disorganization of the 
 lungs. If there had been no inspection after death, the latter would 
 probably have been considered by many practitioners, who did not 
 take the trouble carefully to examine the chest, as simple disease of 
 intestine. Each case of phthisis must be considered by itself; the 
 different degrees of pneumonic inflammation, of laryngeal disease, 
 and of glandular or abdominal complication, &c., render the secon- 
 dary symptoms exceedingly modified and varied, whilst the broad 
 general characters bear very close similarity ; much relief may be 
 afforded by suiting the treatment to these sources of discomfort and 
 danger. 
 
 CASE C. Strumous Disease of the Mesenteric Glands. Obstruction of 
 the Lacteals. Ulceration of the Small and Large Intestine. Dysentery. 
 Phthisis Willian S , set. 20, was admitted into Guy's Hospital, August 
 29th, and died November 1st, 1855. With the exception of a slight cough, 
 lie had enjoyed good health till the January previous ; he then had severe 
 cold, and his cough increased in severity ; he had gradually become more 
 feeble and emaciated till his admission. His chest was narrow and con- 
 tracted. There was dulness on percussion below the clavicles ; and in the 
 supra- and infra-scapular regions there was also roughness jn the respiratory 
 murmur, with bronchial respiration. 
 
 The diarrhoea continued with short intermissions, and his affection of the 
 throat increased ; he became extremely emaciated, and died November 1st. 
 
 Inspection twenty-one hours after death. The larynx was extensively 
 
 1 See Dr. Th. Thompson, ' On Consumption.'
 
 THE ALIMENTARY CANAL. 307 
 
 ulcerated. At the apices of the lungs were several vomicse, and throughout 
 both lungs were numerous tubercular deposits and miliary tubercles. The 
 bronchial glands were much enlarged ; and they were infiltrated with strumous 
 product. 
 
 Abdomen The intestines were tolerably distended ; the peritoneum pre- 
 sented granular tubercular deposit, and there was considerable injection of it 
 at the parts of the small intestine opposite to the ulcerated portions of the 
 mucous membrane : the mesenteric glands were very large and prominent, 
 of a yellowish-white color, and infiltrated with low organized product ; some 
 of them were the size of a pigeon's egg, and they occupied the whole of the 
 mesentery. In several parts of the small intestine, lacteals were observed to 
 extend from the enlarged glands to the walls of the intestine ; these vessels 
 were white, irregularly distended, and in some places had a moniliform ap- 
 pearance ; they extended in several places upon the walls of the intestine, and 
 beneath the mucous membrane to ulcers situated there. On opening the 
 small intestine, numerous ulcers were observed ; they commenced in the 
 upper portion of the jejunum, and extended with greater or less intervals to 
 the cajcum ; some were one and a half inches in length ; their margins were 
 congested, and were irregular and undermined ; their surfaces were granular, 
 as if presenting minute strumous deposit. The ulcers were scattered about 
 six inches apart, and were larger at the jejunum than in the ileum ; strumous 
 tubercles were observed in many parts of the ileum in the substance of the 
 mucous membrane, and there were several minute ulcers about the size of peas. 
 The ileo-caecal valve was much congested, and was swollen and cedematous. 
 The whole of the ca?cum and colon had a remarkable appearance ; with the ex- 
 ception of a few islets of raised congested membrane, the whole surface, as far 
 as the sigmoid flexure, was destroyed. The surface was of a whitish granular 
 appearance, presenting some congested points or irregular pits ; the section 
 showed that there was low organized product in the superficial layer; some true 
 tubercles and cellular tissue dipped down into the muscular coat, and on the 
 sufrace itself there was granular and imperfectly formed cellular deposit, like 
 diphtheritic membrane. The descending colon presented transverse irregular 
 ulcers, with larger intervening spaces ; the rectum was still less affected. 
 The appendix was much distended at its superior two-thirds, and was ulcer- 
 ated ; it contained strumous tubercles. The white substance in the lacteals 
 consisted of particles of fat irregularly aggregated into numerous spherical 
 masses ; and in the mesenteric glands there was ordinary strumous and im- 
 perfectly formed cellular growth. Tiie liver was normal and not fatty ; the 
 spleen was healthy. 
 
 CASE CI. Ulcerated Colon. Phthisis. No Cough. Mich. M'C set. 
 53, was admitted with violent purging, which had existed a week ; much 
 mucus was passed per rectum, but he had no cough. He sank in a very 
 short time. The whole of the large intestine was intensely inflamed and 
 ulcerated, and the small intestines congested ; an old vomica at the apex of 
 the lung was surrounded by iron-gray pneumonia. 
 
 The pulmonary symptoms were masked ; he had no cough, but the severity 
 of the abdominal symptoms, dysentery of an acute form, rapidly led to a fatal 
 result. 
 
 CASE CII. Phthisis. Ulceration of the Rectum and Sigmoid Flexure. 
 Hemorrhage from the Bowels. Ulceration of the Appendix Ctzci. A. B 
 was admitted into Guy's Hospital, under my care, March 18th, 1857. He
 
 308 STRUMOUS DISEASE OF 
 
 was a married man, of temperate habits, who had considered himself in health 
 till one month before admission ; his principal symptom had been discharge 
 of blood from the rectum with diarrhoea ; he had cough, had rapidly emaci- 
 ated, and he had become completely blanched. He had evidence of phthisis 
 at the left apex. Emaciation rapidly increased, the cough became more 
 severe, and the evidence of disorganization of the lung more decided. He 
 died in one month ; and for several days he appeared to be in articulo mortis. 
 On inspection there was tubercular affection of both lungs, and also of the 
 larynx. Small vomicae and red hepatization were found. The intestines, 
 especially the small, were empty and contracted ; and in the lower part of 
 the ileum were a few tubercles and commencing ulceration. The transverse 
 colon presented a sigmoid twist near the spleen, and the ascending and trans- 
 verse colon contained some scybala, and presented several ulcers, oval in 
 form, about half an inch in breadth, with injected irregular margins. In the 
 sigmoid flexure and rectum, the whole of the mucous membrane was injected ; 
 it was almost covered with patches of ulceration, and in some parts there 
 were portions of adherent diphtheritic membrane. The appendix cfeci was 
 twisted in a sigmoid form ; and at the right of the caecum, near its terminal 
 third, it became very much dilated ; the mucous membrane at this part was 
 entirely destroyed, and the muscular coat much hypertrophied. The kidneys, 
 liver, and spleen were healthy. 
 
 The ulceration of the rectum and segmoid flexure had led to the 
 hemorrhage which blanched the patient ; and in consequence of this 
 exhaustion the disease of the lung rapidly advanced. It was not 
 the part of the intestine usually affected in phthisis; and he had no 
 pain, distension of the abdomen, nor severe tenesmus ; diarrhoea and 
 discharge of blood, were the most marked symptoms of abdominal 
 disease. The mesenteric glands were more than usually affected. 
 The appendix ca^ci was so diseased that ulceration would probably 
 have extended into the peritoneum or into the cellular tissue, if life 
 had been prolonged. The loss of blood apparently hastened the dis-' 
 eased action in the intestine rather than diminished it ; and although 
 the purging was checked, the patient never appeared to rally to any 
 extent. He was unable to take cod-liver oil, but appeared partially 
 benefited by hydrochloric acid, with small doses of opium and ca- 
 lumba. 
 
 These instances, and many others which might have been adduced, 
 show the general constitutional character of phthisical disease ; and 
 that although it may manifest itself with greater severity in one 
 organ than in another, we should closely observe the state of all the 
 viscera, as having a most important influence on the curability of 
 the disease, for these simultaneous developments of morbid action 
 go on very insidiously, and even when the general state of strumous 
 disorganization may be past the stage of reparative action, much 
 may be done in partially relieving distressing urgent complications. 
 
 LARDACEOUS DISEASE. 
 
 There are numerous conditions of the system which manifest 
 themselves in local changes ; those glandular diseases which we 
 have described as the result of a strumous or scrofulous state are the
 
 THE ALIMENTARY CANAL. 309 
 
 result of a constitutional defect, and in lardaceous or amyloid disease, 
 we have a local affection especially of the coats of the minute capil- 
 lary arteries which though not stricly constitutional, is produced by 
 a general cause. This condition had been recognized as a degenera- 
 tive change many years ago, and was believed to be closely allied to 
 strumous deposit; the bacon-like appearance in the liver when 
 affected with this disease had long been known, hence the name 
 lardaceous and waxy ; but it was about 1854 that Yirchow adopted 
 the term amyloid disease from the supposed identity of the morbid 
 product with the vegetable principle starch ; the laminated appear- 
 ance of the corpora amylacea observed in the brain, and the color 
 produced by sulphuric acid and iodine, led that acute observer to 
 regard the blue matter produced, as identical with iodide of farina ; 
 it has, however, been subsequently shown that the iodine is itself 
 deposited and thus produces the blue discoloration. Still there is a 
 reaction with iodine although of a different kind ; the affected tissue 
 assumes with a dilute solution of free iodine a deep brown color, 
 and it is deeply and persistently stained by the blue of indigo. As to 
 the tissue affected, it is found that the coats of the minute capillary 
 arterioles becomes thickened by abnormal deposit, at first the mus- 
 cular, then the other coats become involved, and when colored by 
 iodine the vessels are very easily observed. These thickened vessels 
 may be seen in the mucous membrane of the intestine, in. the kidney, 
 in the Malpighian tufts, and in the lymphatic glands ; and in the 
 liver they may be traced to the circumference of the lobules; but it 
 is not the capillaries alone that are affected, the cells of the glands, 
 especially of the liver, lose their normal appearance, they become 
 infiltrated with similar dense product ; other structures may be like- 
 wise affected, the lymphatic glands, the tonsil, the supra-renal cap- 
 sule, the thyroid, the muscles, the membranes of the brain, the blad- 
 der, and the serous membranes are all mentioned by my colleague 
 Dr. Moxon as liable to this change. 1 As to the nature of the deposit 
 it is albuminous in character, although, according to Dr. Marcet, it 
 contains a diminished quantity of nitrogen. Dr. Dickinson 2 states, 
 that it is a fibrinous matter with a deficiency of alkalies, potash and 
 soda. " In the healthy specimens the alkaline salts varied between 
 89 and 118 parts in 1000. With the amyloid the variation was be- 
 tween 48 and 107." He refers the disease to a " dealkalized fibrin," 
 and proposes the term " depurative" as indicating the nature of the 
 process. This term is suggested by the ordinary cause of the disease, 
 for in numerous instances it is found to follow long continued suppu- 
 ration ; thus it comes on after disease of the bones, as necrosis, 
 caries, chronic abscess, disease of the spine, and suppuration of other 
 kinds, as that which is associated with chronic phthisis, and with 
 long continued ulceration of the intestine, and possibly the cachexia 
 of tuberculosis and struma may also induce the disease ; but syphilis 
 
 1 "VVilks and Moxon, ' Pathological Anatomy,' p. 641. 
 
 2 "On Waxy, Lardaceous, or Amyloid Deposit," Dr. Dickinson, ' Med.-Chir. 
 Trans.,' vol. 1.
 
 310 
 
 STRUMOUS DISEASE OF 
 
 is the second great cause of lardaceous disease, for nearly every case 
 is found to be connected either with syphilis or chronic suppuration. 
 It would appear that unless the part be extensively affected, its func- 
 tional activity may be continued ; still, in later stages whether the 
 mucous membrane of the intestine, the liver, the spleen or the kid- 
 neys be involved, the healthy action of the part is seriously inter- 
 fered with. It has been shown by iny colleagues, Dr. Fagge and 
 Dr. Goodhart, that a small amount of lardaceous disease of the vessels 
 of the kidney soon induces decided changes in the uriniferous tubules 
 with proportionate disturbance of the function of the gland. 
 
 If the liver is diseased it assumes a dense, waxy appearance ; it is 
 heavy, and on a thin section it appears semi-transparent under the 
 microscope; the cells are found to be dense and smaller than normal, 
 the nuclei less distinct; and if iodine has been used the capillaries 
 are observed to be thickened as previously mentioned: similar 
 changes are found in the kidney, &c. We have, however, especially 
 to do with the mucous membrane of the stomach and intestine ; the 
 stomach is less frequently involved than the small intestine ; the 
 mucous membrane appears pale, thickened, and sodden, and under 
 the microscope the thickened vessels are very easily observed. 
 Peyer's patches are said to be less affected than the surrounding 
 membrane ; after the arteries, the adjoining tissue becomes infiltrated. 
 
 As to the symptoms, it is often difficult to distinguish those which 
 are due to the primary change, the chronic suppuration and its con- 
 sequent cachexia, from the true symptoms of lardaceous disease. 
 As it is an affection in which there is a general cachexia, several 
 organs become affected, and we often find both the liver and the 
 kidneys, the spleen and the mucous membrane of the intestine im- 
 plicated at the same time. The manner in which one or other of 
 these organs is involved, modifies the symptoms. 
 
 The patient becomes pale, cachectic, and if the mucous membrane 
 of the intestine be diseased a troublesome and persistent diarrhoea is 
 set up, and hastens the fatal termination; if the kidney be affected 
 the albuminuria and its consequent change upon the condition of the 
 blood increases the anaemia, the exhaustion is progressive,- the legs 
 become swollen, the abdomen is often distended with fluid, the patient 
 generally remains conscious, but drowsiness or convulsions may pre- 
 cede the fatal termination. 
 
 The prognosis is necessarily very unfavorable, and as to treatment 
 very little, beyond palliative measures, can be attempted. It is well 
 to try and check the diarrhoea by stringent remedies. The ordinary 
 vegetable astringents may be given, as tannin, krarneria, logwood, 
 catechu; so also the mineral astringents, as lead; afterwards the 
 alkaline preparations of iron as the tartarated iron. 
 
 Of 150 consecutive cases of lardaceous disease 
 
 The stomach was affected 
 intestine . 
 liver 
 
 spleen . 
 kidney . . 
 
 supra-renal capsule 
 muscle 
 
 9 times. 
 
 63 
 
 73 
 
 99 
 
 110 
 
 S 
 
 1
 
 THE ALIMENTARY CANAL. 
 
 311 
 
 Or stating it in a percentage scale 
 
 The stomach is affected in 
 intestine 
 liver 
 spleen 
 kidney 
 
 supra-renal capsule 
 muscle 
 
 6 per cent, of all cases. 
 
 42 
 
 48.7 
 
 66 
 
 73.3 
 
 5.3 
 
 0.6 
 
 This table is probably a correct statement of the average occur- 
 rence of lardaceous disease in the various organs, except with regard 
 to the stomach. In this viscus the affection occurs much more 
 frequently than the figures would lead us to believe, but it is not 
 examined specially in many cases, and the lardaceous change is 
 overlooked. Still, it should be stated that the stomach is not so fre- 
 quently affected as the other viscera, and generally only when the 
 change is extreme in them. It has, however, been found to be 
 diseased when the other organs were nearly healthy.
 
 312 
 
 CHAPTER X. 
 
 ON DISEASES OF THE CAECUM AND APPENDIX (LECI. 
 
 THE diseases of the csecum and of its appendix are of so peculiar 
 and important a character, as to call for special consideration. 
 
 To a certain extent, the caecum is apart from the direct current of 
 the contents of the alimentary canal ; for the valvular opening from 
 the ileum enters at two to four inches from its lowest part, and the 
 capacity of the sac is several times greater than that of an equal length 
 of the ileum. Hence also its contents move more slowly; and at 
 the same time they become less fluid in their character. The mucous 
 membrane is here destitute of villi, but it is exceedingly vascular, 
 and is furnished with numerous solitary glands. At this part of the 
 intestine also the longitudinal -muscular fibres assume a different 
 arrangement ; they here form three bands, which arise from the 
 position at which the appendix is attached, and they are continuous 
 with its muscular layer. The appendix eaeci is an elongated glandu- 
 lar sac, which opens into the intestine at the termination of the 
 csecum, and generally towards its iliac side. 
 
 The caecum is situated in the right iliac fossa, and is only covered 
 by peritoneum on its anterior and lateral surfaces ; a considerable 
 quantity of loose tissue separates it from the fascia, and from the 
 .nerves and vessels in relation with the psoas and iliacus muscles. 
 The mobility of the caecum is therefore considerably less than that 
 of the jejunum or ileum ; but in this respect there is much variation, 
 for it is occasionally found with a long mesenteric attachment, and 
 the right iliac fossa is then completely covered by peritoneum. 
 
 This freedom is far from being of rare occurrence ; it is probably 
 of congenital origin, and is of great pathological importance ; for it 
 allows the caecum to pass into hernial sacs, and to change its position 
 when there is intestinal obstruction or great distension from other 
 causes. 
 
 In reference to the rotatory movements of the intestine, Eokitan- 
 sky describes three varieties : first, rotation of the intestine upon its 
 own axis ; secondly, upon the mesentery as an axis ; and, thirdly, 
 upon another coil of intestine. The caecum may be regarded as 
 moving either on its long or short axis. In the former it tends in- 
 wards towards the spine, and the colon will thus assume a direction 
 more or less to the right, or even a horizontal course. This con- 
 dition we have observed without any apparent impediment to the 
 passage of its contents ; but when it is assoicated with habitual con- 
 stipation, there is greater liability to distension of the caecum and 
 disease of the appendix. By rotation on its long axis the caecum 
 may be so twisted, that the ileum opens on the right side, but when
 
 ON DISEASES OF CAECUM AND APPENDIX C^CI. 313 
 
 revolving upon its short axis, the appendix may be placed towards 
 the anterior abdominal parietes, or it maybe situated at the posterior 
 aspect of the intestine. When these movements are combined the 
 caecum assumes various positions ; in one case we noticed that the 
 appendix was directly towards the liver, and the transverse colon 
 was adherent to the caecum, forming a sigmoid curve in the centre of 
 the abdomen. There had not been any evidence of obstruction, but 
 if such had occurred, the diagnosis would have been greatly ob- 
 scured. The ileum was in another found to open on the right, or 
 on the posterior aspect, but the head of the caecum was completely 
 inverted, so as to be directed towards the diaphragm. In this state 
 constriction may readily be produced as in a case where an inverted 
 caecum became distended to the utmost, and led to a fatal result. 
 
 In the second form of rotation of the caecum, namely, upon the 
 mesentery as an axis, there seems to be a still greater probability of 
 obstruction. This rotation can only take place when the caecum is 
 very free, and it may then pass into the pelvis, or be completely 
 rotated. We have seen the caecum in the pelvis, enormously dis- 
 tended and ruptured ; it was twisted upon its mesenteric axis, and 
 the passage into the colon obstructed. In another case one of fatal 
 obstruction the caecum was apparently twisted on the mesentery as 
 well as on its own axis. These twisted conditions of the caecum, and 
 the freedom of its mesenteric attachment, are generally found in 
 strumous subjects ; they predispose to disease of this part of the in- 
 testine, and to lodgments in and ulceration of the appendix. We 
 have not, however, observed that they have any connection with an 
 abnormal state of the rest of the intestine. 
 
 The appendix presents characters still more diverse; but some of 
 these appearances are the result of pathological changes, which we 
 shall presently consider. It is generally three inches in length, but 
 is sometimes only one and a half inch, and at other times it is as 
 much as five inches. It is attached on the inner aspect of the caecum 
 by folds of peritoneum, constituting a mesentery; but whilst it is 
 generally free, it is occasionally hidden behind the caecum, or curved 
 in a sigmoid form to the right side. 
 
 The mesentery of the appendix is generally short, and is some- 
 times fixed to the brim of the pelvis, and the appendix is then pen- 
 dant in the pelvis. Not unfrequently the mesentery of the appendix 
 is attached to the lower part of the true or iliac -mesentery; in such 
 a case the appendix runs parallel with the ileum for an inch or an 
 inch and a half, and is then, beyond its mesentery, free. The direc- 
 tion thus assumed is parallel to that of the brim of the pelvis towards 
 the left, and the appendix nearly reaches the attachment of the sig- 
 moid flexure. When this condition is present, we frequently have 
 a more or less dependent pouch formed between the appendix and 
 the ileum, consisting of the folds of peritoneum. This pouch 
 worthy of notice, because from irregular pressure it becomes atro- 
 phied," then probably perforated, so as to form an opening through 
 which other coils of small intestine may pass. The opening thus
 
 314 ON DISEASES OF THE CAECUM 
 
 formed oftentimes becomes the cause of internal hernia: the traction 
 on the borders of this opening being especially manifested in the 
 direction of the attachment of the mesentery of the appendix, that 
 is, along the brim of the pelvis towards the sigmoid flexure, leads to 
 fibroid thickening in that position, and as the band becomes more 
 and more drawn forward, it assumes the appearance of an inflamma- 
 tory adhesion. The same traction may be the predisposing cause of 
 iilceration of the appendix, and we have seen perforation and inter- 
 nal strangulation thus produced, associated with liberation and per- 
 foration of the appendix. Immediately above the ileum, at its angle 
 of union with the caecum, we not unfrequently have another pouch, 
 which undergoes similar changes, and may also lead to strangulation. 
 
 When the appendix cseci is fixed by abnormal adhesions, the 
 rotatory movements of the caecum to which we have referred must 
 necessarily be modified. Again, as to the position o the csecurn, we 
 may further remark, that another congenital peculiarity is sometimes 
 found, namely, its presence in the left, instead of the right iliac fossa; 
 this we observed in a patient who died from chronic bronchitis and 
 emphysema, and in whom the whole of the abdominal viscera were 
 laterally transposed, the stomach, spleen, and descending colon occu- 
 pying the right side, whilst the caecum, the liver, and ascending 
 colon were found on the left. The thoracic viscera were also trans- 
 posed. 
 
 In a normal state of parts, the ileo-colic valve prevents the regur- 
 gitation of fluid from the large into the small intestines ; the greater 
 the distension of the caecum, the more closely are the component 
 parts of the valve compressed, and after death the colon may be 
 fully distended, without escape of fluid into the ileum. Dr. Brinton 
 and Dr. Roper have shown that, if the ileum be also over-distended, 
 the valve ceases to act; there is equal pressure on both sides, and 
 the contents of the cavities may intermingle, or pass from the caecum 
 into the ileum. 
 
 The secretion of the caecum is alkaline in its character. Tiede- 
 mann and Grmelin considered it acid, but in many cases that I have 
 examined, it has been found alkaline. Chemical action probably 
 takes place on particles of alimentary matter left unacted upon by 
 the gastric juice, and by the secretions poured into the small intes- 
 tine. 
 
 This action is very much less than that which takes place in the 
 small intestine, and there does not appear to be sufficient warrant 
 for the statement that the caecum constitutes a second stomach and 
 that true digestion takes place there. It is more probable that the 
 watery parts of the chyme, if the semi-fecal contents of the ileum 
 may be so called, become absorbed by a very extensive capillary 
 circulation; and that the glands remove from the blood excremen- 
 titious material no longer of any service to the system. 
 
 The appendix is an elongated gland of a very simple character, 
 resembling the pancreatic caeca of the intestine of the fish, and as 
 far as is at present known, its secretion is of the character of ordinary 
 mucus. Since the feces here become more solid, were it not for such
 
 AND APPENDIX C^ECI. 315 
 
 a secretion, assisted by that of the ordinary mucous follicles, adhe- 
 sion of feces would be more likely to take place with the parieties, 
 and thus cause distension. The secretion is poured out at that part 
 which is most likely to effect this separation, namely, at the origin of 
 the triple muscular band. 
 
 Pathology. The unusual mobility of the caecum, which has pre- 
 viously been referred to, is of a congenital character, but it may 
 induce serious pathological conditions, as before mentioned. 
 
 The vilh cease at the ileo-colic valve, but we sometimes find in 
 the caecum and ascending colon elongated processes, resembling enor- 
 mously hypertrophied villi scattered over the mucous membrane. 
 In a case which occurred at Guy's, they were nearly half an inch in 
 length, about one line in breadth, and they covered the caecum and 
 ascending colon, but were not known to have produced any symp- 
 toms, nor to have had any influence on the cause of death. 
 
 Atrophy. Since only a part of the caecum is covered by the longi- 
 tudinal bands, we frequently find that in atrophic states of the intes- 
 tine, the right side bulges out in a globular and almost hernial form. 
 This condition is more common in advanced life, and in strurna and 
 phthisis ; and we have observed that by the contraction of a cicatrix 
 this sacculated portion has become almost shut off, so as to render 
 the passage from the ileum to the ascending colon about the size of 
 the ileum itself. 
 
 Distension. Abnormal distension of the caecum is sometimes the 
 consequence of obstruction in the colon, or its own muscular pari- 
 etes contract with less than their wonted vigor, and then it easily 
 becomes distended by the accumulation of feces or of flatus. It is 
 probable that diminished secretion from the appendix caeci may 
 favor this accumulation of feces, which is often amongst the exciting 
 causes of serious disease, and requires attention. Considerable fecal 
 distension in the caecum, and ascending colon produces pain in the 
 iliac region, and by pressure on the last dorsal and genito-crural 
 nerve, induces pain also over the hip, as far as the great trochanter, 
 the groin, and the testicle, &c. 
 
 The pain thus produced is sometimes of an acute character, re- 
 sembling colic, and it may excite considerable alarm. Dr. Copland 
 mentions oedema of the right leg as a result of distended caecum ; 
 this I have not observed, except with very feeble power, or a vari- 
 cose condition of the veins. Pressure of this kind would, doubtless, 
 perpetuate and aggravate a varicose condition of the veins of the 
 lower extremity. 
 
 Many instances of pain in the region of the caecum arise from dis- 
 tension^ and the symptoms entirely disappear when the colon is gently 
 but freely acted upon, and emptied. 
 
 (Edema of the mucous membrane is often observed with renal 
 anasarca, and with long-continued congestion of the vena portae. 
 
 Congestion. The depending position of the vessels often produces 
 a passive fulness of the capillaries of this part of the alimentary 
 canal ; but we also find an active congestion, as shown by arbores- 
 cent injection of the minute vessels. This is probably sometimes
 
 316 ON DISEASES OP THE CJECUM 
 
 produced by medicine administered a short time before death; as the 
 elaterium powder in ascites, renal, hepatic, or pulmonary disease, or 
 it is the result of the transmission of irritating substances and secre- 
 tions from the small intestine, as an excess of bile or excreta of an 
 acrid character, or from undigested food. 
 
 Inflammation. Typhlitis. The distension of the caecum, to which 
 we have previously referred, induces local enteritis, namely, inflam- 
 mation of the mucous membrane of the caecum, and of the peritoneum 
 which invests the part. A numerous class of cases is thus constituted, 
 which are happily more tractable than those in which peritonitis is 
 set up by a concretion in the appendix caeci. The mucous mem- 
 brane is congested, its secretion altered, the feces become adherent, 
 the muscular coat is unable to propel the contents, which constitute 
 a tumor felt on palpation, and the inflamed peritoneum produces ten- 
 derness. In most cases, this tumor consists of portions of intestine 
 united by inflammatory adhesions, and in still more rare instances 
 it is composed of effusion behind the csecum, in the iliac fossa. 
 
 The direct continuity of mucous membrane from the ileum ap- 
 pears in many cases to allow the extension of disease to the crocum, 
 which in all probability would not otherwise occur ; we find this in 
 enteric fever and in strumous disease, in which the ileo-colic valve 
 is often acutely inflamed, swollen, injected, and ulcerated. 
 
 The caecum is also found acutely inflamed in some cases of dysen- 
 tery ; it becomes injected, the mucus scanty, the feces adherent, or 
 the surface covered with a delicate false membrane ; it is here 
 affected as a part of the colon from continuity of structure. 
 
 Gray Discoloration. This is liable to occur from any chronic dis- 
 ease either congestive or inflammatory. It is sometimes general, at 
 other times it constitutes minute zones around the solitary glands ; 
 or there are small circular ulcers, which have originated in disease 
 of the solitary glands, or mucous follicles, around which this gray 
 deposition has taken place. 
 
 A granular condition of the mucous membrane, as if minutely 
 studded with particles of sand, has been already alluded to and ap- 
 pears to be the result of long-continued slight inflammation, asso- 
 ciated with thickening of the mucous and sub-mucous coats. 
 
 Ukeration of the caecum is rare as a disease simply affecting this 
 part, but when associated with other morbid states it is of frequent 
 occurrence ; thus in phthisis, tubercle is deposited, and as a conse- 
 quence ulceration is often observed in the mucous membrane ; so 
 also in enteric fever, it is not unfrequent to find some scattered ulcers 
 in the caecum. In dysentery also, the caecum is not only acutely 
 inflamed, as before mentioned, but it frequently presents extensive 
 ulceration^ sometimes a transverse ulcer is found to present ragged 
 and injected margins ; at other times the mucous membrane is even 
 in a sloughing state, or suppuration takes place between the layers 
 of the intestines, as was found in a remarkable degree in one of the 
 cases of dysentery subsequently detailed. In the acute inflammation 
 and ulceration of the colon consequent on the taking of poisonous 
 substances, as arsenious acid or corrosive sublimate, the rectum and
 
 AND APPENDIX C^CT. 317 
 
 sigmoid flexure are generally more severely affected than the caecum 
 and ascending colon; this, however, is not invariably the case. 
 Again, ulceration is often present from over-stretching, as we have 
 frequently found in obstruction of the sigmoid flexure ; the mucous 
 membrane yields in transverse lines, as when the skin has been simi- 
 larly over- stretched and ulcerates. 
 
 In several instances of enteritis affecting this part'of the intestine, 
 or typhlo-enteritis as it is sometimes termed, the peritoneum becomes 
 also involved ; this may arise from the propagation of the disease 
 from the mucous to the serous layer, or from rupture of the intesti- 
 nal coats ; but perforation into the peritoneal cavity is more fre- 
 quently found to arise from disease of the appendix than from sim- 
 ple ulceration of the caecum ; extravasation and sudden fatal peri- 
 tonitis, even when perforation has taken place, may, however, be 
 prevented by adhesions; or if these adhesions be less extensive, 
 fecal abscess is formed. We shall again have to refer more fully to 
 perforation of the appendix caeci from ulceration variously produced. 
 The peritonitis which ensues when no adhesions exist, is almost as 
 sudden in its symptoms, and as fatal in its results, as perforation of 
 the stomach ; but in cases much more numerous than is generally 
 supposed, extravasation is prevented \)y antecedent adhesions, as 
 has been shown by M. Leudet, the accuracy of whose observations I 
 can fully confirm. But perforation from ulceration may take place 
 on the attached surface of the intestine behind the peritoneum; the 
 disease then extends into the cellular tissue in the iliac fossa ; pus 
 burrows beneath the fascia, and forms an opening near the anterior 
 superior spinous process of the ileum, in the loin, or below Poupart's 
 ligament on the thigh, or it may pass upwards behind the ascending 
 colon, and may reach the under surface of the liver. These cases 
 are, however, rare ; and ulceration of the appendix much more fre- 
 quently leads to adhesions of the peritoneum, to fecal abscess, or to 
 general peritonitis. 
 
 Cancerous disease not unfrequently attacks the caecum ; sometimes 
 the ileo-caecal valve presents an appearance similar to that found in 
 like disease at the pylorus, and an extensive cancerous ulcer is found 
 to extend upon the anterior or posterior surface of the caecum ; when 
 the former course is followed, peritoneal adhesion or inflammation 
 takes place ; and when the latter, the cellular tissue in the iliac fossa 
 is involved, and suppuration sometimes occurs ; in either case fecal 
 abscess and artificial anus may be produced. 
 
 Cancerous disease manifests itself under different forms; it may 
 be of a scirrhous character and slow in its growth. This variety is 
 more likely to lead to chronic obstruction, and is then associated 
 with dilatation of the intestine and hypertrophy of its muscular coat. 
 Sometimes, indeed, there is so much fibrous tissue deposited that it 
 is difficult to find true cancerous product; and it may be doubted 
 whether these cases are not at first inflammatory obstruction, upon 
 which cancer is engrafted. We have alluded to parallel cases when 
 speaking of the relation of chronic ulcer of the stomach to cancerous 
 disease. On the contrary, the disease is sqmetimes soft and funga-
 
 318 ON DISEASES OF THE C^CUM 
 
 ting, and has the microscopical and general appearance of a medullary 
 growth. Again, epithelioma and colloid cancer are occasionally ob- 
 served. The disease has a greater tendency to extend along the 
 coats of the caecum itself than to pass backwards into the ileum. In 
 lymphadenoma the thickening of the coats of the intestine, and 
 dilatation of the canal, are often well marked. It may be further 
 remarked that the caecum, is less frequently affected with cancer than 
 the sigmoid flexure and the rectum. 
 
 The Tricocephalus dispar is described as being frequently present 
 in the caecum. I have only observed them about three times from 
 many hundreds of inspections, in very many of which the intestines 
 were examined throughout with care. 
 
 APPENDIX. Increase of length. The appendix is sometimes five 
 or six inches in length, and perfectly free in its movements. It may 
 be free among the coils of the small intestine, or in other cases it 
 becomes adherent to the brim of the pelvis, to the parietes of the 
 abdomen, or to the mesentery. In this way loops are formed, which 
 in many cases become the cause of fatal internal strangulation, a 
 portion of small intestine passing beneath the band thus formed. 
 Cases have been recorded of the appendix being found in a hernial 
 sac. 
 
 Atrophy. The orifice of the appendix in occasionally obliterated, 
 and the appendix itself bound down by adhesions ; in this way it 
 becomes wasted, and at last almost destroyed. 
 
 Dilatation takes place from obstruction at or near the orifice, so 
 that the secretion is unable to make its escape ; the canal then di- 
 lates, and becomes one-fourth to one-half of an inch in diameter ; 
 the walls are sometimes thickened, and the muscular coat hyper- 
 trophied, as if the attempt had been made to overcome the obstruc- 
 tion, or, on the contrary, it becomes exceedingly thinned almost to 
 perforation; when so dilated it is filled with thin mucus, and the 
 follicles have the appearance of minute semi-transparent cysts. 
 
 Concretions. Substances of diverse character are found lodged in 
 the appendix caeci, and whilst sometimes harmless, they often pro- 
 duce very serious consequences. Some are extraneous, others are 
 entirely formed within the canal itself; and, lastly, there are those 
 which have a nucleus consisting of some foreign substance, but 
 covered over by layers of concretion, from the irritation produced. 
 
 1. Extraneous bodies are found, consisting of nails, pins, stones of 
 fruit, shot, bristles, 1 entozoa, and most frequently, feces. 
 
 2. Concretions, as of albuminous mucus, are formed in the appen- 
 dix. These are not uncommon, and constitute firm semi-transparent 
 masses, which, when dry, are fragile, and free from earthy matter. 
 
 3. Calculi, which generally present a nucleus of feces, or of some 
 foreign body. 
 
 I have frequently found the appendix filled with feces ; sometimes 
 in its whole length, or only forming one or more hard nodules. 
 
 1 ' Transactions of Pathological Society,' 1855. Mr. N. Ward's case.
 
 AND APPENDIX C.ECI. 319 
 
 These minute fecal masses frequently constitute the nuclei of calculi, 
 and become encrusted with layers, composed of carbonate and phos- 
 phate of lime, according to the analyses of Dr. Odling and of the late 
 Dr. Golding Bird. A concretion, examined by Dr. Prout, was found 
 to consist of phosphate of lime, with a little carbonate, and contained 
 a small quantity of animal and oleaginous matter. 1 Thus consti- 
 tuted, layer after layer becomes applied, till the size of a cherrystone 
 is attained ; and many of the so-called cherry stones in the appendix 
 are thus formed. The calcareous matters appear to be derived from 
 the mucous membrane itself in the same, manner as a calculus in the 
 urinary bladder becomes encrusted with phosphate of lime from the 
 abundant mucus thrown out from the irritated surface. In some 
 cases a larger size is attained, and the mass becomes as large as a date- 
 stone or a hen's egg. In the museum of Guy's (No. 1893 25 ) is a large 
 calculus the size of a hen's egg, the surface of which is rounded and 
 fissured ; it was removed from a sinus leading from the parietes of 
 the abdomen to the caecum ; no appendix was found, but a large 
 abscess extended from the caecum to the liver. The calculus was 
 composed of phosphate of lirne, with alkaline chlorides. 
 
 In some it is very difficult to discover a nucleus, a white laminated 
 substance being present throughout. The nucleus, however, may be 
 exceedingly small, as in a case described by Mr. N. Ward, where 
 the bristle of a tooth-brush formed the centre of a calculus; or it 
 may be a portion of pin, or a hair. 
 
 Diminished contractile power of the muscular coat, with distension 
 of the intestine, are the probable causes of the propulsion of feces 
 into the appendix, usually determined by some sudden muscular 
 effort; or it may be that the peristaltic contraction is rendered 
 irregular by an irritated condition, from acrid and crude materials 
 impelled into the caecum, and that this irregularity of action causes 
 the feces, perhaps more fluid than normal, to pass into the appendix. 
 In whatever way produced, any concretion in this part may lead to 
 very serious results. 
 
 I. It excites irritation and ulceration of the mucous membrane. 
 
 II. This ulceration may extend through the muscular coat, and 
 often through the peritoneum. 
 
 III. Inflammatory action consequent on the perforation may be 
 of a purely local character: effusion of fibrinous material takes 
 place, and adhesions form, which prevent extension to the general 
 surface of the peritoneum. Coils of the small intestine may be thus 
 firmly united to the caecum, and constitute a compact mass, felt on 
 manual examination of the abdomen. 
 
 IV. The inflammatory action, although local^may produce a less 
 organizable product; and suppuration may take' place, constituting 
 an abscess, into which a greater or less quantity of feces may escape. 
 The subsequent course of this abscess may vary much: 1. It may 
 resolve into a dried mass of semi-calcareous product. 2. After 
 sudden exertion the adhesions which localize the pus may break 
 
 ' ' Medical Gazette,' vol. vi.
 
 320 ON DISEASES OF THE C2ECUM 
 
 down, and extravasation take place into the general cavity of the 
 peritoneum, with a speedily fatal result. 3dly. It may pass into 
 the intestine by a second opening, and thus be harmlessly discharged. 
 This opening may be into the ascending colon or the ileum, and in 
 a specimen in the Guy's Hospital Museum, an elongated and ulce- 
 rated appendix had opened into the rectum. 4thly. It may burrow 
 down into the pelvis; or the cellular tissue behind the caecum may 
 become involved, the abscess extending sometimes upward behind 
 the ascending colon, or down towards Poupart's ligament. In the 
 latter case the opening is either below that ligament, or near the 
 anterior and superior spinous process of the ileum. 
 
 In a case under Dr. Barlow's care, in Guy's, this ulcerative exten- 
 sion of caecal disease destroyed a part of the wall of the iliac artery, 
 and led to almost immediate death, from the sudden and uncontrolla- 
 ble hemorrhage. 
 
 Abscesses of this kind sometimes contain feees; but, even if they 
 have an external opening, it is difficult to procure their complete 
 evacuation; and we have but little chance of preventing repeated 
 attacks of inflammatory action. The strength at last gives way or 
 life is cut short by intense and general peritonitis. 
 
 V. The perforation sometimes takes place directly into the peri- 
 toneum, and sets up peritonitis so severe and general, that a fatal 
 result follows in a few hours, or at most in a few days. 
 
 The position of the concretion, whether fecal or otherwise, varies; 
 sometimes it is quite at the termination of the appendix, at other 
 times close to the opening into the caecum. Fecal masses are also 
 found adherent beneath the ileo-colic valve, and in sacculated de- 
 pressions on the surface of the caecum; but I have never witnessed 
 true concretions in these parts as in the appendix. 
 
 In strumous patients, these concretions more readily tend to an 
 unfavorable result, leading to perforation, and to fecal abscess or 
 peritonitis. But it must not be assumed in such cases that because 
 there is perforation therefore there has been a concretion, the appen- 
 dix may be itself the seat of ulceration, without the irritation of 
 concretions ; and especially so in strumous subjects. In phthisis it 
 is very common to find ulceration in the appendix caeci, from the 
 degeneration of tubercle ; sometimes several small ulcers are present, 
 at other times the appendix is almost cut in two. This condition 
 sometimes leads to fatal peritonitis in the earliest stage of phthisis. 
 
 Symptoms. The symptoms of some of these pathological condi- 
 tions have been already alluded to ; others afford no sign indicative 
 of their presence during life, and after death conditions are found 
 which would have acted as disturbing causes, predisposing to serious, 
 if not to fatal disease, if life had been prolonged. 
 
 Distension of the caecum is indicated by fulness and pain in the 
 iliac region, especially when the erect posture is assumed, or after 
 walking; it is generally accompanied by fulness in that part, dulness 
 on percussion, and slight febrile excitement with congested portal 
 circulation, and with loaded colon. Hence, we often find other 
 symptoms present, not arising from the caecum, but from associated
 
 AND APPENDIX C^ECI. 321 
 
 disease ; thus depression of mental energy, sallow complexion, furred 
 tongue, offensive breath, pain in the head, arise not from the condition 
 of the caecum, but from the retention in the blood of waste material, 
 which would be thrown off, if the liver and excretory glands of the 
 whole alimentary canal rightly performed their functions. The 
 mechanical distension, however, sometimes by its pressure leads to 
 pain in the loins, or in the course of the last dorsal or genito-crural 
 nerve, the pain extending over the dorsum of the ileum, or into the 
 groin or testicle ; in women this pressure may interfere with the 
 proper function of the ovaries and uterus. 
 
 Typhlitis. Irritation or inflammation of the mucous membrane of 
 the caecum may be productive of diarrhoea. Such cases are generally 
 associated with but slight pain in the region of the caecum. This 
 form of disease is, however, in most cases, only part of a more gene- 
 ral affection of the mucous membrane ; as in bilious diarrhoea, from 
 acrid excreta, in dysentery, and in struma; disease of the mucous 
 membrane alone is not productive of pain. If all the coats be 
 affected, or ulceration have taken place, a very marked train of 
 symptoms follows. After some irregularity of the bowels, either 
 diarrhoea or constipation, generally the latter, and perhaps after 
 more than wonted exertion, severe pain comes on, in many cases 
 suddenly, in the right iliac fossa. It may be confined to this spot, 
 and be accompanied by excessive tenderness, radiating over the abdo- 
 men, and be very quickly followed by collapse, and the signs of 
 general peritonitis, or the tenderness and pain in the neighborhood 
 of the caecum are accompanied with fulness and slight dulness on 
 percussion. There are febrile symptoms, the skin is hot, temperature 
 102-10, the tongue is slightly furred, the pulse is often compres- 
 sible and somewhat excited, and local peritonitis is set up in connec- 
 tion with ulceration or inflammation of the coats of the caecum. 
 These are the symptoms of what has been called typhlo-enteritis. 
 There is often a gradual subsidence of these symptoms, the pain and 
 distress cease, the fulness disappears, the bowels return to healthy 
 action, and the patient is restored to health. In other cases the 
 fulness, tenderness, and pain continue, and a more defined tumor is 
 perceptible ; repeated attacks of severe pain come on, and gradual 
 loss of strength, or sudden accession of fatal and general peritonitis. 
 The local peritonitis has in these cases given rise to suppuration or 
 to fecal abscess; and perforation of this abscess is the cause of the 
 sudden collapse and speedy death. Or, we may have the same result 
 as before described, but retarded for a time by local adhesions. 
 Again, instead of peritonitis, diarrhoea may be set up, irritability of 
 stomach, injected and brown tongue, failing pulse, and the ordinary 
 symptoms of hectic fever. But even from this condition recovery 
 sometimes takes place, by the discharge of pus from the peritoneal 
 abscess into the intestine itself, or through the abdominal panetes ; 
 or by the absorption of the fluid parts of the pus, when a semi-creta- 
 ceous mass is left; if, however, fecal abscess have formed, recurrent 
 attacks of peritonitis, with increasing prostration, generally lead 
 a fatal result. 
 21
 
 322 ON DISEASES OF THE CAECUM 
 
 In those cases where sudden perforation of the caecum or appendix 
 takes place there are scarcely any premonitory symptoms; the pa- 
 tient is struck down in fatal collapse, resembling the equally fatal 
 case of perforation of the stomach. In these cases the pain is not 
 necessarily situated in the region of the caecum, but above, nearer 
 the stomach ; conversely I have seen a case where the pain preceding 
 fatal collapse was in the region of the caecum, when the perforation 
 arose in the stomach. It is difficult to explain this occasional event. 
 but, generally speaking, the pain is situated in the neighborhood of 
 the diseased viscus. 
 
 In cancerous disease of the caecum, the symptoms are very similar 
 to those already described, namely, pain and fulness in the region of 
 the caecum, tenderness on pressure, and a more or less distinct tumor; 
 there is diarrhoea or constipation, but generally the latter; the ciecal 
 pain is often greatly aggravated by food, especially of a fluid kind ; 
 and the accession of pain is sometimes found to arise directly after 
 the nourishment has been taken; the febrile symptoms are, however, 
 less decided, and the pain is of a less severe character. 
 
 There is a greater tendency to the local form of disease in early 
 manhood than in later life. Many cases occur under 20, but the 
 disease is not rare at later periods of life, 30, 40, or 50 years of age. 
 
 Diagnosis. In the diagnosis of inflammation of the caecum it must 
 be borne in mind (1), that simple excessive distension of the ccecuin 
 is sometimes accompanied with severe pain. 
 
 2. That after blows on the abdominal parietes, or from other causes, 
 suppuration sometimes takes place in the cellular tissue, or even in 
 the muscles of the iliac fossa, and may be accompanied by local pain 
 or peritonitis without caecal disease. 
 
 8. That suppuration connected with the right kidney, or its en- 
 velopes, sometimes extends into the iliac fossa. 
 
 4. That we may have disease of the vertebrae, or iliac bones, lead- 
 ing to suppuration in the iliac fossa. 
 
 5. Pain arises in the course of the last dorsal nerve from diseased 
 spine, or in the course of the genito- crural nerve from renal calculus, 
 and might be confounded with caecal inflammation. 
 
 6. Inflammatory disease in connection with ths ovaries, leading to 
 local peritonitis and severe pain, is frequently mistaken for cuecal 
 disease. 
 
 7. Cancerous disease of the caecum, and 
 
 8. Disease of the ileurn in struma or after typhoid fever, as well 
 as 
 
 9. Strurnous peritonitis must each be remembered in forming a 
 correct diagnosis. 
 
 10. I have known cases where the peritonitis from caecal perfora- 
 tion was regarded at first as gall-stone, the sudden pain on the right 
 side, with violent vomiting, closely simulating the symptoms of that 
 disease. 
 
 Dr. Battersby, in a very interesting paper in the ' Dublin Quar- 
 terly' of 1857, refers to other fallacies, as hernia, disease of the hip, 
 and of the genital organs.
 
 AND APPENDIX C^ECI. 328 
 
 The pain in simple distension of the caecum is less severe than in 
 acute inflammation. Disease in the parietes in a very short time 
 manifests its local character; but at first the diagnosis is obscure, 
 and the mere fecal odor of pus does not necessarily imply communi- 
 cation with the intestine. The pain and swelling connected with 
 suppuration of the spine or kidney differ in position ; with the kidney 
 they are more in the loins, or, if extending anteriorly, they are nearer 
 to the median line. Spinal suppuration extends beneath the iliac 
 fascia, and would be distinguished from caecal abscess burrowing be- 
 neath Poupart's ligament, by the fecal character of the discharge in 
 the latter. 
 
 The neuralgic pains connected with urino-genital disease are not 
 accompanied with the tenderness or the other symptoms of intestinal 
 affection. It is, however, sometimes difficult to distinguish inflamma- 
 tory disease about the right ovary from caecal disease. There may be 
 in both excessive tenderness, febrile excitement, constipation, severe 
 pain in the lower part of the iliac fossa. The symptoms which will 
 serve to guide us are, that the ovarian disease comes on with irregular 
 menstruation or with sudden cessation of that flux, and that the pain 
 is situated lower down in the hypogastric region; in some cases, 
 observers have believed that they have felt the swollen ovary. Dr. 
 Barlow records a case in which peritonitis of so severe a character 
 was set up around an inflamed ovary, that the patient succumbed. 
 In cancerous disease of the caecum, which sometimes occurs in young 
 subjects, it is almost impossible, unless there be indication of cancer- 
 ous disease in other parts, rightly to diagnose its character. These 
 are, however, rare cases. In strumous peritonitis the disease is not 
 confined to one part of the abdomen, but in severe cases the intestines 
 are so completely united by peritoneal adhesions as to move en masse. 
 It is impossible to distinguish perforation of the ileum in struma or 
 phthisis from perforation of the appendix caeci; this is, however, of 
 little moment, since the only remedial agents which are likely to be 
 of service in these almost universally fatal cases are precisely similar 
 in both. 
 
 Prognosis. In cases of caecal distension, when the mucous mem- 
 brane only is affected without ulceration, our prognosis is generally 
 a favorable one, unless we find the patient of a strumous habit, in 
 which case there is greater tendency to ulceration and perforation. 
 When, again, there are the symptoms of local peritonitis, many 
 patients do well ; the reverse, however, is the case when the onset 
 of the disease is marked by severe collapse, or by urgent vomiting 
 and by general abdominal pain. 
 
 Causes. The predisposing causes are a strumous diathesis, seden- 
 tary habits, habitual constipation, typhoid fever, &c. 
 
 The exciting causes are, over exercise, much standing, violent 
 athletic exercises ; in many cases caecal disease has come on after 
 very long pedestrian excursions, after indigestible food has been 
 taken, after blows upon the abdomen, after constipation, or an 
 irregular condition of the bowels.
 
 324 ON DISEASES OF THE C^ICUM 
 
 Treatment. I cannot urge in too strong language the importance 
 of avoiding in csecal disease powerful drastic purgatives. They tend 
 to increase the disease by inducing violent peristaltic action; by 
 increasing the irritation of an already inflamed membrane they 
 hasten ulceration ; and if ulceration have taken, place, or if peri- 
 tonitis have resulted, the only hope of the patient would be taken 
 away by these remedies. 
 
 If there be simple distension, with only very slight pain in the 
 erect posture, we should enjoin rest, and administer gray powder 
 with Dover's powder, followed by a dose of castor-oil, or by a castor- 
 oil enema ; afterwards mild aperient tonics, as the compound gentian 
 mixture, are useful. 
 
 If tenderness exist, or there be the symptoms of local peritonitis, 
 rest is still more positively required ; the patient should not move 
 from the bed on any consideration. Local depletion is exceedingly 
 valuable ; ten or fifteen leeches applied to the region of the caecum, 
 and warm fomentations, are often followed by most marked benefit. 
 At the same time mild mercurials may be administered, with opium, 
 such as equal parts of gray powder and Dover's powder, or small 
 doses of calomel with opium ; but I prefer opium or Dover's powder 
 without the mercury. These remedies may be combined with saline 
 medicines, with the acetate of ammonia and bicarbonate of potash 
 or nitric ether, according to circumstances. But little food should 
 be taken, and only of bland unstimulating kind. When the pain 
 has subsided, and the febrile excitement has disappeared, the patient 
 is often tempted to try and get out of bed and use slight muscular 
 effort ; but this is exceedingly injudicious, and is sometimes followed 
 by a fatal result. 
 
 The remedies just mentioned often induce action on the bowels ; 
 but if not, although the pain may have subsided, it is better to wait, 
 than to administer even a gruel or castor-oil injection, still less than 
 to give more powerful purgatives, as aloes, jalap, senna, colocynth, 
 scammony, &c. 
 
 If there be persistence of slight pain, with fulness and dulness, it 
 is well to continue the opium, and a blister may be applied to the 
 illiac region. 
 
 Iodide of potassium and mild vegetable tonics are afterwards of 
 great service, rest being still maintained. Irritability of stomach 
 sometimes arises, and may be alleviated by saline effervescing medi- 
 cine, by hydrocyanic acid, by soda-water with milk, or with brandy, &c. 
 
 If there be evidence of suppuration or of fecal abscess, whilst we 
 endeavor to limit the action by slight counter-irritants, or by occa- 
 sional local depletion, we must" sustain the power of the patient by a 
 generous diet, by quinine, and by tonic treatment. Opium is often 
 of great value by its anodyne and narcotic effect, in checking peris- 
 taltic action, in relieving pain, in soothing an over-excited nervous 
 system, in diminishing the irritability of exhaustion, and often in 
 procuring refreshing sleep. 
 
 When there is collapse and tympanitis, evincing perforation of the 
 appendix or intestine, nothing should induce us to administer any
 
 AND APPENDIX C.ECI. 
 
 325 
 
 aperient, or to urge an action from the bowels. We desire to limit 
 the mischief produced by checking the movement of the intestines, 
 and to diminish inflammatory action by soothing the nervous sys- 
 tem ; opium must be given very freely, and only a very small quan- 
 tity of food administered. 
 
 Cases. Abnormal position of the caecum ; several were connected 
 with fatal obstruction, and a similar instance is recorded bv Mr. 
 Avery, in the 'Pathological Transactions' for 1850, where the opera- 
 tion for artificial anus was performed. 
 
 CASE CIII. Unusually Free Ccecum A boy, aet. 5, died from loss of 
 blood consequent upon an accidental wound of his internal jugular vein. 
 
 CASE CIV. Unusually Free Ccecum A young woman died after a mis- 
 carriage. 
 
 The viscera were healthy, but the caecum was situated among the small 
 intestines, quite surrounded by peritoneum, and as free as a portion of the 
 ileuni. 
 
 The ccecum was attached by a long mesentery to the right side of the 
 spinal column, so that the whole iliac fossa was perfectly free, and covered by 
 peritoneum. 
 
 Such conditions are congenital. They are of importance in modi- 
 fying symptoms of subsequent disease. 
 
 CASE CV. Ccecum inverted. A man, aet. 42, died from phthisis, local 
 empyema, and chronic tubal nephritis. 
 
 On examining the intestine, the appendix caeci was found to be long, and 
 extending over the brim of the pelvis, where it was fixed. The rounded 
 termination of the caecum was directed towards 
 the diaphragm as if inverted. The ascending 
 colon was contracted, and attached deeply at 
 the side of the right iliac fossa, directly opposite 
 the ileo-colic valve, and at an acute angle with 
 the cascum. Very great distension of the caecum 
 in this twisted state might lead to obstruction, 
 for the ascending colon appeared, even in this 
 case, constricted by the sudden twist and by the 
 acute angle which was formed. 
 
 No symptom had apparently been pro- 
 duced by this condition of the caecum ; but 
 in a state of constipation, when the caecum 
 is distended with feces, considerable impe- 
 diment to the free passage would be the 
 result. It is probable there would be a 
 greater tendency to ulceration, and to the 
 passage of feces into the appendix caeci. 
 
 CASE CVI. Intestinal Obstruction of the 
 Ascending Colon. The Ccecum twisted to the 
 
 f , -r ~ T7 . j TT J. J Caecum inverted, appendix to- 
 
 left side into the Left lhac and Hypochondriac ^^ (he pelvis ' wh P ere it was 
 Regions. Death on the 20th day. (Reported adherent ; ascending colon com- 
 
 by Mr. GaltOll.) Eliza S , aet. 40, a COOk, was mencing opposite the ileuni.
 
 326 ON DISEASES OF THE C.ECUM 
 
 admitted into (iuy's Hospital under the care of Dr. Addison, November Oth, 
 ],s .)(,. SIM- had lived regularly and temperately. There were marks of dis- 
 tension upon tin- abdomen, but she stated that she had never been pregnant, 
 but that when a child her abdomen had been much enlarged. She enjoyed 
 good health until she was fourteen years of age, when she fell against the 
 rm-bstone at the head of a well, whilst she was drawing water, and pain in 
 the loins, with difficulty in micturition and hrematuria, came on. Many 
 \-eai> he'ore admission she had jaundice, with great ] ain in the stomach, and 
 was told she had inflammation of the bowels ; she, however, had good health 
 until lS4f>, when during frosty weather, she fell down in a yard, striking her 
 left side against the corner of a stool ; she suffered from pain and tenderness 
 at the part, with cold chills ; the urine was scanty, but no blood was passed; 
 a lei- remaining in bed for three or four days she felt no further inconvenience. 
 The bowels had been frequently confined for three or four days together, but, 
 without any pain or distress. On admission into Guy's she was anu'inic, but 
 her complexion was rather dark; three days previously, without apparent 
 cause, pains came on in the right side, extending to the umbilicus. No im- 
 proper food had been taken, nor was there any stomach derangement. She 
 felt chilly; the bowels had been open previously, and again very slightly, at 
 the time of admission. There had been no vomiting till just before admis- 
 sion, but when once it had supervened everything was rejected. There was 
 no tenderness of the abdomen, but it was distended with flatus. The skin 
 was cool and moist, the urine abundant, pulse 80, the tongue slightly furred. 
 A soap injection was administered, and ,$ss of castor-oil given. The vomit- 
 ing became stercoraceous and then lessened in severity, but the pain was 
 aggravated. 
 
 Various measures were tried for her relief; all were of no avail, nor did 
 they succeed in even modifying the symptoms or in any w r ay aiding the for- 
 mation of a diagnosis, and with gradually increasing prostration she died on 
 the 27th, about twenty days after the commencement of the symptoms. 
 
 On opening the abdomen the small intestine was found enormously dis- 
 tended, and the cnecum was situated in the left hypochondriac region and iliac 
 fossa, forming a large, greatly distended, almost spherical sac; the appendix 
 was situated on the left side. The whole of the visceral and of the parietal 
 peritoneum was intensely injected, and was covered with lymph. The right 
 iliac fossa \vas filled by coils of small intestine, the peritoneum being perfectly 
 smooth. By attempting to unravel the intestine, and tracing the large intes- 
 tine upward from the sigmoid flexure, which was normally situated and per- 
 fectly collapsed, a stricture was found about the middle of the ascending 
 colon ; the stricture, however, was situated near the brim of the pelvis on the 
 left side, and adhesion of the omentum was found at this part, between the 
 ascending colon, sigmoid flexure, and a coil of ileum. 
 
 The line of obstruction was perfectly defined, all the intestine below being 
 quite empty, collapsed, and non-injected. The obstruction was four feet four 
 inches from the anus, and appeared to have been produced by the caecum 
 revolving on the termination of the ileum, which was fixed by its adhesion 
 to the sigmoid flexure. No transverse colon could be found, because it was 
 hidden behind the caecum near the left iliac fossa. On removing the intestine 
 the stricture .disappeared. 
 
 The mucous membrane of the caecum wa* intensely injected, and a patch 
 on the interior surface was of a leaden color; at the centre of this part was a 
 minute slough, and perforation extended into the peritoneal cavity; but no 
 feral extravasation had taken place. 
 
 The mucous membrane of the ileum was healthy, but congested, and con-
 
 AND APPEXD1X C.EGI. 
 
 327 
 
 tained both solid and fluid feces. The stomach contained fluid fecal matter 
 such us was found in the ctecum. The duodenum was healthy, and the liver' 
 kidneys, spleen, &2., were normal. 
 
 Ctecum inverted and twisied on its own axis into the left hypochondriac region, appendix close to 
 the spleen ; ascending colon constricted ; constriction increased by band of adhesion to the sigmoid 
 flexure, which appeareJ to have been the primary cause of the fatal twist and obstruction. 
 
 The previous attack of inflammation of the bowels had probably 
 led to the adhesion between the termination of the ileum and the 
 sigmoid flexure; and this was one of the causes of the fatal obstruc- 
 tion. The caecum was apparently unnaturally free, and its disten- 
 sion associated with this adhesion had led to the twisted and inverted 
 position which was found after death. The pain had commenced at 
 the seat of the disease, near the right iliac fossa -extending to the 
 umbilicus. The patient had had severe falls and blows upon the 
 abdomen, one in particular, in which she struck the right side, and 
 which, perhaps, tended to produce displacement or inflammatory 
 mischief. The bowels had generally been confined, but she had 
 occasionally suffered from diarrhoea. The first symptom was pain 
 in the right iliac fossa, and then constipation; the severe colic, dis- 
 tension, tenderness, and vomiting were later symptoms. The mode
 
 328 ON DISEASES OF THE CJBCUM 
 
 of commencement appeared to indicate that they did not arise from 
 simple impacted feces. For four days there had been no vomiting, 
 which showed the absence of internal hernia, of sadden strangula- 
 tion, and of intussusception. The symptoms were neither those of 
 enteritis nor of acute peritonitis. 
 
 It was evident that there had been some chronic changes in the 
 intestines or peritoneum, and it was difficult to decide the character 
 of those changes. 
 
 No tumor could be felt; but there were three causes of obstruc- 
 tion left, between which it was exceedingly difficult to decide. 1. 
 A slow growth connected with the intestine itself, as cancer or one 
 producing chronic contraction. 2. Old bands of adhesion; and, 3, 
 Twisted intestine. An approximate opinion was formed as to the 
 seat of obstruction ; either that it was at the colon, or at the termi- 
 nation of the ileum. The vomited matters were so fecal in their 
 character that it was even suggested that the transverse colon might 
 have formed a communication with the stomach. 
 
 A somewhat similar case is recorded by Sir W. Gull in the 'Guy's 
 Hospital Keports,' 1858, p. 179. 
 
 CASE C VII. Twisted Caecum. Obstruction. Peritonitis A man, jet. 
 30, was admitted into Guy's Hospital, October llth, 1859. He was a strong 
 muscular man, and for three weeks his bowels had acted irregularly, but their 
 precise mode of action could not be ascertained. On October 9th he partook 
 freely of pork, ale, &c., and was soon afterwards seized with intense pain in 
 the abdomen, which "doubled him up;" vomiting soon afterwards came on; 
 these symptoms continued, and excessive prostration followed. The bowels 
 had acted on Friday the 7th, but not afterwards till the day of his death. 
 At the time of his admission into Guy's, on the evening of the llth, he was 
 cold, almost pulseless, perfectly sensible, but collapsed; he suffered intense 
 pain in the abdomen; the abdomen was tympanitic, and presented distension 
 in the epigastric region. Opium was given: an enema tube was introduced 
 into the rectum, but only passed about six inches, and returned smeared with 
 blood; a catheter drew off no urine from the bladder. Mr. Stocker thought 
 that the introduction of an acupuncture needle into the distended part might 
 relieve the enormous distension ; several punctures were made, and not afford- 
 ing relief, a minute trocar was introduced, much flatus passed, and a small 
 quantity of thin feces ; but this discharge afforded the patient much relief. 
 
 Tincture of opium n\,xl, chloroform rt^x, were given in camphor mixture. 
 On the following morning he still lived, cold, almost pulseless, legs drawn 
 up; abdomen less distended, but very painful; he had passed water during 
 the night; he stated that he had passed flatus several times from the bowels 
 since the commencement of the severe symptoms. About 11 o'clock there 
 was an evacuation from the bowels, but the state of collapse continued, and 
 he died about 3 P.M. 
 
 Inspection on the 13th, nearly twenty -four hours after death Decompo- 
 sition was commencing in the abdomen, which was still much distended. 
 The thoracic viscera were quite healthy. On opening the peritoneal sac the 
 appendix caeci was observed about the centre of the abdomen, and a very 
 large, distended cascum occupied the greater part of the epigastric, umbilical, 
 and left hypochondriac regions ; a distended coil of ileum and a portion of 
 ascending colon were attached to its inferior part; these portions were all of 
 a green color, and evidently strangulated. The rest of the serous membrane
 
 AND APPENDIX CJECI. 329 
 
 was much injected, reddish, covered with a thin layer of adhesive lymph and 
 smeared with red-colored, opaque serum. The small intestines were dis- 
 tended. On passing the hand beneath the strangulated mass the constriction 
 was found to be situated near the right iliac fossa, and was produced by the 
 caecum having rotated on a free mesentery, and then twisted on its axis. By 
 turning the caecum downwards all constriction disappeared. The line of 
 strangulation was very distinctly marked across the colon, about four inches 
 above the caecum, and rather less distinctly across the ileum, about fifteen 
 inches from the valve. The mucous membrane of the whole of this part was 
 intensely injected, in some parts presenting ecchymosis ; it very readily 
 separated, and was covered with a thin, gray, diphtheritic layer; there was 
 effusion of blood also into the constricted mesentery. The intestine in this 
 part and above it contained fluid feces, but some half-digested masses of food 
 were also found in the caecum. The stomach was healthy, as also the rest of 
 the small intestine ; the stomach contained green fluid almost of the character 
 of that in the small intestine. The descending colon was contracted, and in 
 the rectum was found a small ulcer immediately above the sphincter. The 
 course of the intestine was very peculiar. The sigmoid flexure was situated 
 in the right iliac fossa, the left being perfectly smooth and free from intes- 
 tine ; the descending colon crossed the spine in the centre of the lumbar 
 region, from the inferior part of the spleen ; the transverse colon was in its 
 ordinary position, but had the enlarged and twisted cseum concealing it; the 
 ascending colon had a curved position in the right loin, passing from the 
 cascum, which was situated immediately in front of the spine ; and at the 
 lower part of its curve old adhesions existed between the ascending colon and 
 the sigmoid flexure, situated in the right iliac fossa. The left kidney was 
 situated at the brim of the pelvis, and received its arterial supply from the 
 aorta and the common iliac arteries ; the ureter left the kidney anteriorly. 
 The left supra-renal capsule was in its normal position. The liver, spleen, 
 kidneys, &c., were healthy. 
 
 The caecum in this case was preternaturally free, and the sigmoid 
 flexure in the right instead of the left iliac fossa. It is probable 
 that several weeks before death the caecum had a twisted position, 
 and that after an indigestible meal flatulent distension increased the 
 twist, and rendered the obstruction complete. The caecum had ap- 
 parently turned on its mesentery, as an axis, and then on its own 
 axis. The adhesion between the ascending colon and sigmoid flexure 
 was old, and possibly formed during foetal life. The position of the 
 kidney, partly in the pelvis, and its unusual arterial supply, were 
 evidence of congenital malformation. The introduction of the needle 
 afforded no relief, but the trocar gave immediate cessation of pain, 
 and the patient begged to have the operation repeated. The in- 
 strument had perforated the distended caecum, and had diminished 
 the distension of the strangulated part ; it was left in the wound, so 
 that no extravasation took place, and it is probable that this relief 
 to the distended bowel prolonged the patient's life several hours, 
 though we are not prepared to recommend the repetition of such an 
 operation in any but exceptional cases. 
 
 The following are instances of a form of caecal disease very fre- 
 quently met with ; they arise from distension of the caecum, which 
 induces local enteritis, with partial peritonitis; the latter varies 
 greatly in intensity, being sometimes severe, at other times scarcely
 
 330 ON DISEASES OP TIIE CAECUM 
 
 observable. With proper care and judicious treatment, most of them 
 recover. The symptoms are less severe than those in which the 
 appendix is ulcerated, or contains a concretion ; they come on more 
 gradually, the pain is less intense, the dulness and tenderness are 
 entirely removed as the inflammation subsides, and the bowel is freed 
 from its contents. As in cases of more general enteritis, purgatives 
 do considerable harm ; they fail to empty the distended bowel, they 
 increase the enteritis, lead to ulceration, and in some to perforation 
 and fatal peritonitis. The benefit arising from the action of the 
 opium is very marked the bowels act, the pain subsides, and the 
 dulness lessens ; mild mercurials with the opium are sometimes used, 
 but we prefer opium alone ; abstinence from solid food and absolute 
 rest are very important, and should be continued for several days 
 after the subsidence of the pain. If the pain be severe, local deple- 
 tion by leeches affords considerable relief, and should be followed by 
 hot fomentations. 
 
 CASE CVIII. Ccecal Distension and Inflammation. Typhlitis Crota 
 "W , a strumous-looking boy, an apprentice to a cook at a large tavern, after 
 harder work than usual, was seized with severe pain in the abdomen on the 
 right side : after a few hours this partially subsided, but again returned on 
 his making exertion, so that he was obliged altogether to discontinue his 
 work. The bowels were occasionally constipated. 
 
 He was of fair complexion, with long eyelashes, and his countenance had 
 an anxious expression ; the abdomen was hot, tender and full, especially in 
 the region of the caecum ; the tongue was red, the pulse soft, the thoracic 
 viscera normal ; he had no vomiting. 
 
 Calomel gr. j, opium gr. ss, were given every six hours, and a hot poultice 
 applied to the abdomen. Eight leeches were afterwards applied, and spare 
 diet allowed. He rapidly improved, and in a few days was convalescent. 
 He was kept in bed, however, for a longer period, although all the symptoms 
 had subsided. 
 
 CASE CIX. Ccecitis or typhlitis Benjamin B , get. 15, a pale, thin lad, 
 who had been employed on the river, was admitted into Guy's Hospital. 
 January 14th, 18.02. About three days before admission he had experienced 
 griping pain in the abdomen, which had increased in severity. The bowels 
 were constipated, but there was no vomiting, nor could it be ascertained that 
 he had partaken of improper diet. There was fulness of the right iliac region, 
 with dulness and considerable tenderness. Eight leeches were applied, and 
 lie took calomel and opium gr. j of each every four hours. On the 19th the 
 pain had considerably diminished, but still much fulness and hardness re- 
 mained ; there was no febrile disturbance ; the tongue was clean and the 
 pulse natural. The calomel and opium were omitted. 
 
 February 3. He felt much relieved, but hail a haggard look ; the eyes 
 were sunken, and occasional pain came on across the abdomen. There was 
 no marked indication of progressive disease, and the fulness in the iliac region 
 gradually disappeared. 
 
 23d. There was again very perceptible fulness and some tumefaction in 
 the right iliac region, and gurgling on pressure ; slight pain had returned ? 
 the symptoms were, however, very much less severe than before, and he was 
 allowed to move about the ward. He afterwards lelt the hospital convales- 
 cent.
 
 AND APPENDIX C.ECI. 331 
 
 The symptoms in this case were at first very severe, and warranted 
 a very cautious prognosis. . They were probably associated with a 
 strumous diathesis, and more than usual disturbance of the other 
 abdominal viscera. There is much fear that slow strumous dis- 
 organization would extend in this case, and ultimately lead to a fatal 
 result. 
 
 The permission to sit up led probably to the increase of the symp- 
 toms, but happily the relapse was not of a character to prevent his 
 convalescence. This was an instance in which great care, nourishing 
 diet, and change of air, might be followed by complete restoration to 
 health. 
 
 CASK CX. Typhlitis Sarah A. M , aet. 20, was admitted December 
 27th, 1870, into Guy's Hospital, under my care. Her father and brother 
 had died of phthisis. On Wednesday , "December 20th, whilst doing her work 
 MS a collar dresser, she was suddenly seized with severe pain in the stomach, 
 and in halt' an hour the pain became a griping character, accompanied by 
 severe sickness and purging. She went home to bed. and hot poultices were 
 applied; the purging soon subsided, but the sickness and pain continued till 
 admission. The abdomen was rather tense, and she suffered from severe pain 
 in the caecum, where an enlargement could be felt about the size of a cocoa- 
 nut ; the resonance at this part was imperfect, and the abdominal muscles 
 wen; fixed. The tongue was moist, but had a whitish fur; there was thirst; 
 no appetite; vomiting came on if food was taken; the pulse was 130; tem- 
 perature 103 ; the heart and lungs were healthy. She was directed to re- 
 main perfectly quiet in bed, and gr. j of opium was given every four hours ; 
 poultices were applied to the abdomen. The following day she was free from 
 pain, and there was scarcely any sickness. The pulse was 108, and the 
 temperature 98.8. On January 1st the abdomen was less tense and more 
 resonant ; the patient was free from pain, and looked more cheerful ; there 
 had been no action from the bowels; temp. 97.8; pulse 100. The same 
 treatment of perfect rest, with opium less frequently administered, was con- 
 tinued. On January 6th, ten days after admission, as she complained of 
 forcing pain in the rectum, a simple enema was used, which relieved the 
 bowels. Fish was now allowed, and the opium given night and morning. 
 The fulness in the caecum had considerably lessened. On January 13th the 
 bowels acted twice without any enema; the patient expressed herself as well. 
 The opium was discontinued. A little thickening in the caecal region could 
 be felt on deep pressure, but it disappeared before she left the hospital well 
 on the 23d. 
 
 CASE CXI. Ccecal Inflammation simulating Hip joint Disease James 
 C , jet. 11, living at Gravesend, was admitted into Guy's Hospital, under 
 my care, February 18th, '1857. He was a strumous child, but he was stated 
 to have had good health until three months before admission. He was roughly 
 used and beaten whilst at work ; and he did not feel well afterwards ; pain 
 came on in the abdomen ; but it did not become severe till a short time before 
 admission, when his foot slipped, and his abdominal muscles were brought 
 into powerful action. Severe pain in the region of the crccum then came on, 
 and was much aggravated by pressure ; the rest of the abdomen was soft ; 
 the tongue was clean ; pulse 75. The bowels were confined, and the urine 
 was normal. The right leg was flexed at the thigh, and could not be straight- 
 ened ; rotation of the hip, striking the heel, &c., did not produce pain, nor
 
 332 ON DISEASES OF THE C.ECUM 
 
 was there any pain in the knee or in the spine. Seven leeches were applied 
 to the right illiac fossa ; gray powder gr. iij, Dover's powder gr. iij were 
 ordered three times a day, with rest and low diet. 
 
 The leeches and hot poultice afforded much relief; he was able 
 then partially to straighten the hip, which had evidently been drawn 
 up to relieve the pain, by relaxing the' flexor muscles of the joint. 
 The bowels on the second day acted by soap injection, and on the 
 third day the leg was straight. The pain and fulness gradually 
 ceased ; he was, however, kept in bed ; the medicine was continued 
 once a dav for a short time, and animal food was allowed very spar- 
 ingly. The bowels acted without trouble. On March 2d he was 
 convalescent ; cod-liver oil was given three times a day, and on the 
 13th he left the hospital well. 
 
 CASE CXII. Ceecal Disease. Typhlitis. Recovery. (Reported by Mr. 
 Brietzcke.) James B , aet. 23, a draper's assistant, residing in the Bor- 
 ough, was admitted under my care into Guy's Hospital, Novembr 2d, l.sill. 
 Whilst sitting at breakfast, on the 31st of October, he was suddenly seized 
 with severe pain on the right side below the ribs; the severity of the pain 
 bent him double, and rendered him almost insensible; medical advice was 
 at once sought, and medicine given every two or three hours, which how- 
 ever, produced vomiting whenever it was taken. On the 1st November he 
 was partially relieved, but was worse again in the evening. On the 2d he 
 was brought to the hospital ; the pain, which had subsided, again returned 
 severely, and was accompanied with an urgent but ineffectual desire to pass 
 water. The bowels were acted upon once daily till the 31st October, but no 
 evacuation was again passed till after admission. He had a pale and anxious 
 expression of countenance ; he had lost his appetite, and, since the attack, 
 had been deprived of sleep. In the right iliac region there was defined 
 hardness, imperfect resonance, and great tenderness on pressure ; but the 
 abdomen generally was neither distended nor tender. There was pain on 
 passing water, and only a small quantity was discharged. The tongue was 
 furred, and the mouth and throat were dry. The pulse was 04, and com- 
 pressible. There was no pain produced by respiration ; the urine contained 
 a small quantity of sugar. He was ordered, of soap and opium pill gr v 
 night and morning, and to have an injection of castor oil, and a diet of beef 
 tea and arrowroot. 
 
 This treatment was continued, and the bowels acted, no vomiting was pro- 
 duced, and the tenderness in the caecal region subsided, and on the 7th both 
 pain and swelling had disappeared. The bowels on that day acted regularly, 
 pulse GO, tongue clean, and there was no difficulty in passing water. Infu- 
 sion of cusparia 3j was given twice a day. On the llth he left the hospital 
 quite well. 
 
 In this case the symptoms of cascal disease were well marked ; 
 there was severe pain, with hardness and swelling in the region of 
 the caecum, and obstinate constipation; vomiting had apparently 
 been produced by attempts to obtain action from the bowels ; but by 
 the continued use of opium, with bland, demulcent diet and a castor 
 oil injection, the severe pain subsided, the tenderness ceased, and the 
 bowels acted naturally. No mercurial was given, nor did it seem 
 necessary, for the bowels would not have acted more readily if mer-
 
 AND APPENDIX C&CI. 333 
 
 cury had been conjoined with the opium, and the convalescence 
 would probably have been less rapid. 
 
 CASE CXIIL The following is of great interest as showing a state 
 of strumous inflammation of the caecum, in itself probably not of a 
 fatal character, and allied to,- if not identical with those previously 
 detailed, but rendered fatal by its association with phthisis. 
 
 Ann C , aet. 46, was admitted into Guy's Hospital under my care Feb- 
 ruary 28th, 1855, and died March 30th. She was a married woman, who 
 had resided in Southwark, and in her employment as a milk woman had been 
 much exposed to the weather. Some of her family had died from phthisis. 
 For several years she had been subject to cough, which had become more 
 severe during the last eighteen months. She was thin and haggard, the face 
 was slightly congested, and the physical signs were those of general bron- 
 chitis with phthisis. The pulse was irregular and intermittent, and there 
 was a systolic bruit below the nipple. The bronchitis was slightly relieved, 
 and then the signs of disorganization of the lung became more marked. 
 Three days before death severe pain came on in the right side, accompanied 
 with increased dyspnoea. Some irritation of the bowels supervened, but not 
 to a great extent, and she gradually sank. 
 
 On inspection the abdomen was distended and tympanitic. The larynx 
 was healthy ; the bronchi were much dilated ; this bronchial dilatation was 
 very marked on the right side, and on section the dilated tubes covered a 
 considerable portion of the surface. Their mucous membrane was much con- 
 gested, and covered with tenacious mucus ; they were surrounded by crepi- 
 tant lung. The bronchi on the left side were much less dilated. The left 
 pleura was universally adherent, but the right only so at its apex ; at the 
 right base the pleura was covered with lymph, and the cavity contained 
 about a pint of pus ; a small vomica immediately beneath the pleura had 
 opened into the pleural sac. There was a large, irregular vomica at the left 
 apex, and in the lower lobe were other smaller ones, and numerous miliary 
 
 tubercles. The heart was healthy. Abdomen There were old adhesions 
 
 generally in the peritoneum, and several adherent cretaceous deposits. The 
 ceecum was inflamed, and presented raised patches about the size of peas, 
 soft, situated in the mucous membrane and containing pus ; some of these 
 collections of tuberculo-inflammatory product had given way, and slight ulcer- 
 ation was the result. The ascending colon was in a similar condition. The 
 appendix caeci and the other portions of the intestine were healthy. The 
 liver was fatty, the kidneys healthy, so also were the mesenteric glands. 
 
 This case might be considered as one of chronic bronchitis, and 
 afterwards of phthisical disorganization. In the caecum it is pro- 
 bable that the solitary glands became diseased, and degeneration 
 of tubercle led to the production of minute abscesses and ulceration. 
 
 CASE CXIV. Perforation of the Ccecum. Abscess extending to the Groin. 
 
 Phthisis Michael R , aet. 34, was admitted into Guy's Hospital under 
 
 Mr. Key's care, in September, 1835 ; he was a temperate man, but of stru- 
 mous habit, and by trade a compositor. For a year and a half he had been 
 subject to flatulence, indigestion, and occasional purging. Four days before 
 admission, after four days of diarrhoea, he had experienced sudden pain in 
 the right iliac fossa, where was a firm swelling, with persistent pain ; the 
 bowels were variable ; the constitutional disturbance was slight ; the pulse
 
 334 ON DISEASES OF THE CAECUM 
 
 was soft and quickened, and the tongue was slightly furred. Leeches were 
 applied, and antimony was administered ; suppuration and fluctuation became 
 nion- manifest in the tumor, and hectic supervened. Six weeks after admis- 
 sion an opening was made and jjviij of offensive pus evacuated; .-ymptoms 
 of phthisis gradually developed themselves, and the patient died in the follow- 
 ing June. Two openings existed above the right groin ; they communicated 
 with a contracted space, which was surrounded by dense membrane. The 
 caecum was found bound down by firm cellular adhesions to the neighborhood 
 of Foil part's ligament. The appendix was thick, opaque, and filled with a 
 pasty fluid, and communicated with the caecum. A sinuous canal of one and 
 a half inches in length, narrow and apparently closing, led from the opening 
 on the surface into the caecum at its posterior part, nearly opposite to the 
 opening of the ileum. The coats of the intestine were thickened, but the 
 mucous membrane did not appear to be changed, except that a few contrac- 
 tions from cicatrices were evident. (Prep, in Museum, 187D' .) 
 
 In this case the patient survived the immediate effects of the 
 coecal disease; the perforation, instead of setting up inflammation in 
 the peritoneum, produced suppuration in. the cellular tissue of the 
 iliac fossa, and the pus was discharged near the anterior and supe- 
 rior spinous process. If there had been any cicatrices in the caecum, 
 we should have questioned whether the disease had not commenced 
 in the iliac fossa, and afterwards extended into the 'caecum, as we 
 have found to occur in connection with the sigmoid flexure. The 
 commencement resembled that of ordinary csecal disease ; but in its 
 progress it might easily have been mistaken for abscess in the 
 parietes of the abdomen. 
 
 Disease of the appendix sometimes exists without manifesting any 
 symptom ; this is especially the case in phthisis. The appendix 
 often presents strumous deposit in larger or smaller masses ; it is 
 often filled with feces; and not unfrequently we find it distended 
 with thin pus, with occlusion of the orifice, or with ulceration, with- 
 out any pain or tenderness having been complained of, as in the 
 following instance : 
 
 CASE CXV. Tuberculosis. Ulceration of the Intestine. Ulceration of 
 the Ca>.cum. Perforation. Abscess behind the Ascending Colon. Old Hy- 
 datid in the Liver. (Reported by Mr. H. A. Latimer.) Thomas A. T , 
 aet. 54, was admitted under my care on April 4th, 1871. He had resided at 
 Hackney; and been employed as a tea warehouse man. lie had formerly 
 drank freely of beer, but he became a teetotaler in 1855. Till three years 
 ago his general health had been good, but lie then had an attack of pleurisy 
 on the left side ; he was ill for two or three months, but afterwards went to 
 work, and continued at his employment till twelve weeks before admiss'on. 
 For at least twelve months he had been complaining of pain in the right si.le 
 at the region of the liver, and he had been unable to hold himself upright in 
 consequence of the pain. 
 
 "W hen quite young he had a fall from a horse, and antero-posterior spinal 
 curvature in the dorsal region was produced. He had also suffered from 
 double hernia, for which he had worn a truss. Some weeks before he was 
 seized with more severe pain on the right side, and there was enlargement in 
 the region of the right hypochondrium. The practitioner in attendance re- 
 garded the disease as hematic abscess, and this opinion was confirmed by the
 
 AXD APPENDIX CJECI. 335 
 
 discharge of pus from the bowel, and the subsidence of the swelling. On April 
 2d vomiting and purging came on, and continued till admission on the 4th. 
 He had emaciated rapidly before being brought to the hospital. He was 
 then pale and anaemic ; he was free from pain when perfectly quiet, but pain 
 came on when he was moved ; it was located in the right hypochondrium. 
 He was very sick, and vomited almost every ten minutes, all food being at 
 once rejected. He complained of faintness. The left leg was enormously 
 swollen and distended, the veins were iruich enlarged, and there were some 
 petechial blotches below the knee. The leg began to swell on April 2d, and 
 attained its great si/e in an hour and a half. It was very painful when touched 
 or moved. The right leg was of natural size and free from pain. On pres- 
 sure in the right hypochondrium a distinct nodular hardness could be felt, and 
 there was fulness and tenderness extending to the iliac region ; the rectus 
 was rigid. The tongue had a yellowish fur upon it ; the pulse was 126, very 
 small and feeble. The heart and lungs did not present any signs of disease. 
 The urine had a sp. gr. of 1016, and was very albuminous. 
 
 The left leg was wrapped in cotton-wool and a cradle was placed over it. 
 Brandy was allowed. When admitted the patient seemed almost in a dying 
 state. The vomiting, however, ceased, and he rallied. On the 8th the tem- 
 perature was 97.4, the pulse 103 ; he felt stronger and more comfortable, 
 and there was freedom from sickness. There was still much uneasiness on 
 the right side. The sedative mixture of bismuth (Guy's) was ordered. 
 
 On the 15th opium and belladonna were given to relieve pain and sickness, 
 which again distressed him, and relief was thus afforded to those symptoms. 
 
 On the 25th he complained of great weakness. A rounded swelling of 
 great density could be felt in the liver; the mouth was aphthous and ulcer- 
 ated. Borax and honey were ordered. 
 
 On the 26th the left leg had nearly regained its natural size. The right 
 leg, however, became suddenly swollen as the left had been, and the patient 
 soon sank, but was sensible till nearly the close. 
 
 Inspection was made on the 27th. There were extensive old pleuritic 
 adhesions ; the lungs contained an excess of fibrous tissue ; there were nu- 
 merous scattered tubercles, and a few small cavities filled with pus. The 
 heart was healthy, so was also the stomach. There were numerous tubercular 
 ulcers scattered through the ileum. These were most frequent and largest 
 near to the caecum ; and there was tubercular deposit on the peritoneal sur- 
 face of the intestine beneath the ulcers. The appendix caeci was healthy, but 
 the caecum was perforated by ulceration close to its base. The perforation 
 opened into a fecal abscess, which extended behind the colon upwards to the 
 under side of the liver. There had been chronic peritonitis, and the colon 
 had become glued to the peritoneal walls. In the liver, which was rather 
 fatty, there were two old hydatid cysts filled with calcareous substance. One 
 of these, about the size of a small hen's egg, was superficial, and had been 
 felt during life. The mesenteric glands were much enlarged, but did not 
 contain any cancerous product. Booklets of the echinococcus were detected 
 in the fluid from the cysts. The spleen was healthy ; the kidneys were fatty, 
 rather large, and their cortex was wasted. The femoral veins were obstructed 
 by old fibrinous clots. 
 
 The diagnosis of this case was obscure; the history was that of in- 
 flammatory disease in the neighborhood of the ascending colon, but 
 the emaciated and cachectic appearance of the patient and the pres- 
 ence of a hard nodule in the liver, favored the idea of malignant dis- 
 ease ; the enlargement of the legs evidently arose from venous ob-
 
 336 ON DISEASES OF THE CAECUM 
 
 struction. When brought to the hospital it was believed that he 
 could not survive many hours, and he was too ill to be raised from 
 a recumbent position or for the chest to be examined posteriorly. 
 He was, however, free from cough or symptoms of thoracic disease. 
 The post-mortem examination fully explained the nature of the case; 
 tubercular ulceration of the small intestine and of the cascum had 
 been followed by perforation of the latter; a post- peritoneal abscess 
 was formed, which extended to the under surface of the liver; the 
 distension of this abscess with pus and fecesled to the swelling below 
 the liver; and the discharge of pus from the bowel appeared to 
 confirm the supposition of abscess in the liver. Local peritonitis 
 and adhesion had taken place, fixing the colon to the liver and pre- 
 venting the extension of the disease. The exhaustion consequent 
 on this fecal abscess was the cause of death. Tubercles were present 
 in the lungs, and small vomicae were found filled with pus, but the latter 
 would not have afforded any physical sign whilst filled with fluid 
 secretion. The enlargement of the mesenteric glands was tubercular. 
 The malady was one of phthisical disease affecting especially the 
 intestine, leading to perforation, and causing death before the pulmo- 
 nary disease had made extensive progress. The hydatid cysts were 
 very old, and the calcareous envelope prevented the detection of fluc- 
 tuation ; they were mere coincidental conditions, but they tended to 
 render the diagnosis obscure. 
 
 CASE CXVI. Inflammation of the Colon from Plum-stones. Ulcera- 
 tion. Perforation. Peritoneal Abscess. Thickening and Contraction of the 
 
 Bowel (Reported by Mr. F. C. Coley.) Charles G , set. 49, was a married 
 
 man, who had resided at Kensington, of temperate habits and healthy, with 
 the exception of attacks of indigestion. Some years before he had resided in 
 the country, and had much anxiety in his business ; he then came to London 
 and became a warehouseman. His long hours of work led to exhaustion ; lie 
 lost his appetite, was unable to digest his food, and he occasionally suffered 
 from rigors at night. Two years before admission his work was lessened by 
 his removal into the counting-house, and his symptoms were relieved. About 
 three weeks before admission into Guy's Hospital, on September 23d, 1874, 
 the indigestion increased, and the patient suffered from pain in the right 
 lumbar and inguinal regions. He was a well-built man, rather thin and sal- 
 low, with a care-worn expression of countenance. He complained of pain in 
 the right side of the abdomen below the liver, and a lobulated swelling could 
 be detected at this part, which was with difficulty separated from the liver. 
 It extended partly into the loin, and was moderately tender on palpation ; 
 the dulness in the swelling was not complete. The lungs and heart were 
 normal. The tongue was white and marked with the teeth. Urine healthy. 
 He was ordered the bismuth mixture, and allowed fish and giv of wine. The 
 bowels acted by medicine ; the motion was pale and fluid, and free from 
 blood. It was found after admission that taking food increased the pain in 
 the right side. The mucous membrane of the lower lip was raised on its 
 inner side by extravasated blood, but there was no breach of surface. The 
 swelling gave pain during mastication. On the 29th the motion was olive- 
 green in color and free from blood ; the pain in the abdomen was less. The 
 temperature was taken many times, and varied from 98 to 99.4. The
 
 AND APPENDIX C^CI. 337 
 
 bowels became constipated, and a small quantity of blood was passed. Full 
 injections of water 2 to 4 pints brought away hardened feces ; they were 
 repeated on successive days, and carbonate of ammonia mixture given instead 
 of the bismuth. On October 22d the swelling was smaller, but still tender 
 and painful; it could be separated from the liver, and appeared to be adherent 
 to the abdominal walls. The castor-oil mixture was given, and acted gently 
 but freely on the bowels. Iodine was applied externally. The swelling re- 
 mained tender, but the patient gained strength, and wished to return home, 
 which he did on November 30th. On December 28th I saw him at his own 
 home in consultation with Dr. Cortis. The patient appeared thin and ema- 
 ciated ; he had lost strength, and the bowels acted sluggishly ; the hardness 
 on the right side was as distinct as when he left the hospital ; the pulse was 
 very compressible, and the appetite poor. He sank more quickly than we 
 expected, and he died on January 3d. 
 
 Dr. Cortis made a post-mortem examination, and was kind enough to send 
 me the following report : " On opening the abdomen a large portion of the 
 liver was found very firmly adherent to the walls. Between the two at one 
 part was found a circumscribed cavity containing four plum-stones and the 
 kernel of a fifth. Tins cavity communicated by a small opening with the 
 colon, which, beyond the cavity, was very much thickened and contracted, 
 forming a stricture, through which an ordinary holder of a steel pen could 
 just pass. The stones had evidently, years ago, lodged in the colon, produced 
 inflammation and perforation (after adhesion), and afterwards kept up the 
 irritation and consequently the inflammation round the gut, producing the 
 deposit and causing the stricture. The caecum was firmly adherent at the 
 under surface of the liver, and the perforation was at the anterior and external 
 portion." 
 
 In this case the diagnosis was obscure ; there was evidently disease 
 of the ascending colon and caecum, but the hardness was at first 
 separated with difficulty from the liver ; this separation could, how- 
 ever, be well made out afterwards when the bowel was emptied by 
 enemata, &c. It was more difficult to diagnose the nature of the 
 malady than to recognize its position. There was hindrance to the 
 free action of the bowel, and blood with mucus was passed. These 
 signs indicated some ulceration with narrowing of the bowel. The 
 onset of pain about four hours after food also indicated disease of 
 the larger bowel. The mischief had come on gradually, and without 
 any history of febrile disturbance such as we generally find in acute 
 disease of the caecum ; it was irregular and nodular in character, 
 hard and tender, and resembling in these respects malignant disease. 
 We certainly did not suspect that there was such a source of irrita- 
 tion as a peritoneal abscess containing plum-stones. It would seem 
 that inflammation of the mucous membrane had been followed by 
 ulceration and perforation; peritoneal adhesion had localized the 
 effusion ; the presence of the foreign bodies in the peritoneum led 
 to gradual thickening of the coats of the bowel and to obstruction. 
 The obstruction increased, but the exhaustion of strength kept pace 
 with the narrowing of the bowel, and the patient sank from exhaus- 
 tion rather than from intestinal obstruction. The perforation in the 
 first case was in the posterior part of the caecum, and the abscess 
 burrowed upwards behind the intestine ; in this, it was at the ante- 
 22
 
 338 ON DISEASES OF THE C.ECUM 
 
 rior part of the ascending colon, not far from the angle of the trans- 
 verse colon and near to the liver. 
 
 CASE CXVII. Phthisis. Ulceration of the Larynx and of the Jleum. 
 Concretion in the Appendix Thomas E , aet. 18, a delicate, strumous lad, 
 was admitted with phthisis on February 27th, and died May 4th. On inspec- 
 tion, eighteen hours after death, the lungs were found to contain caseous and 
 pneumonic deposit, old gray induration, and a large vomica at the left apex. 
 The larynx was deeply ulcerated at the inferior vocal cords. The ileum con- 
 tained in its mucous membrane strumous deposit, and a large ulcer existed 
 at the valve ; the appendix contained a waxy concretion, white lamellated, 
 about an inch long, and placed at its extremity ; the remainder of its canal 
 was filled with mucus. This concretion appeared to be composed of inspis- 
 sated mucus. 
 
 In another case of phthisis we found that an ulcerated appendix 
 caeci opened into the ileum. 
 
 CASE CX VIII Pyaemia. Necrosed Humerus. Ccecal Disease Wm. 
 S , aet. 72, was admitted into the hospital January 30th, and died February 
 16th, 1856. He had received six months before death a compound fracture 
 of the left humerus, and Mr. Birkett had removed a portion of the resulting 
 necrosed bone ; the wound did not heal, and 'the patient became increasingly 
 prostrate ; nine days before death he suffered from pain in the abdomen. 
 
 Inspection was made forty hours after death. The body was much de- 
 composed : the lungs, liver, and kidneys were too much changed to decide ns 
 to the existence of acute disease. There was considerable development of 
 fat ; the peritoneum was greasy, and in the right caecal region several coats 
 of intestine were adherent ; on removing them about a cupful of pus was 
 poured out; this was found to arise from the neighborhood of the appendix 
 caeci. The appendix contained several small, circular ulcers, and one of these 
 had a pinhole opening into the peritoneal cavity. The whole of its parietes 
 were much thickened, especially at the extremity, which was white and 
 fibrous ; the appendix contained pus. The caecum itself, the ileum, and the 
 rest of the intestines were healthy. There were no tubercles, nor evidence 
 of phthisical disease in the lungs. The right shoulder-joint, the sterno- 
 clavicular articulation, &c., were filled with pus. On the left side was an 
 oblique, ununited fracture of the humerus. 
 
 It is very unusual to find a patient at seventy-two years of age the 
 subject of coecal disease ; neither did it appear to be the direct cause 
 of death ; the man died from pyaemia, consequent on necrosed bone. 
 Cases, however, may arise of pyaemia produced by caecal disease alone; 
 the probability is, that in a poisoned condition of the blood, slight 
 irritation at the caecum had been followed by ulceration, perforation, 
 and subsequent suppuration. 
 
 CASE CXIX Disease of the Caecum following a Blow. Perforation of 
 the Appendix. Suppuration. General Peritonitis. Almost complete 
 secondary Perforation of the Gcecum Christopher B , set. 21, was ad- 
 mitted into Guy's Hospital, in a dying state, June 1st, 1859, and expired a 
 few hours afterwards. Two years previously he had received a severe blow 
 in the region of the caecum, but it was a week before admission that sudden 
 pain came on in the abdomen. On inspection the abdominal serous mem- 
 brane was found to be intensely injected and acutely inflamed. On separat-
 
 AND APPENDIX CJ3CI. 339 
 
 ing the last coil of the small intestine from the caecum, a small abscess was 
 observed, which communicated with the appendix caeci ; nearly the whole 
 side of the appendix was destroyed by ulceration, and the pus had separated 
 the coats of the intestine as far as the caecum, with which it was on the point 
 of forming a second opening. The mucous membrane of the rest of the in- 
 testine, and the other viscera, were healthy. 
 
 The blow had probably in this instance set up caecal disease, which 
 manifested but slight symptoms till perforation took place a week 
 before his death. Suppuration followed, and was localized by adhe- 
 sions; but, most unwisely, he was taken from his bed, and shaken in 
 his transit to the hospital, which he reached in a dying state; the 
 adhesions, on which the prolongation of life depended, were broken 
 down, and general peritonitis was established. The almost complete 
 secondary perforation of the caecum is an illustration of the course 
 which suppuration sometimes takes. 
 
 CASE CXX Local Peritonitis. Perforation of Appendix Cceci. 
 Strangulation of the Ileum bg the Appendix. A young lady about twenty- 
 three years of age jumped from a gate about a year before her death and ex- 
 perienced pain at the lower part of the abdomen, with slight vomiting and 
 some uneasiness for several days ; she remained, however, in apparently good 
 health till August 13th, 1858, when, after partaking of veal and a glass of 
 port wine at dinner, severe pain at the lower part of the abdomen came on, 
 the pain extending from the hypogastric to the epigastric region. The next 
 day the bowels were moved, but the pain towards the right iliac region still 
 remained, and she felt ill. On the 16th her medical attendant saw her, and 
 found her suffering from pain in the abdomen, with an anxiety of expression 
 which appeared to indicate more than ordinary colic. Aperient medicine 
 was administered, and the bowels were moved on the 17th ; she stated that 
 the pain was partially relieved, and that she felt better. On August 18th, 
 in the evening, severe vomiting of offensive matter came on ; the pain con- 
 tinued at the lower part of the abdomen, and there was very little tympani- 
 tis. The vomiting ceased, and the pain partially subsided ; the abdomen was 
 still tense at the lower part, and the tympanitis increased ; the pulse con- 
 tinued below 100 ; the urine was abundant ; but the patient became more 
 prostrate. A large injection of cold water was administered. The bowels 
 acted at 2 A. M. on August 27th, and I was requested to see her in consul- 
 tation the same day. At 10 A. M. I found her with a flushed face and with 
 a distressed and anxious expression ; the skin was clammy ; the abdomen 
 was flattened at its upper part; but below the umbilicus, and especially 
 towards the right iliac region, it was very tense, tympanitic, and tender on 
 pressure. A rounded and dense mass could be felt in the region of the 
 caecum and at the termination of the ileum. No evidence could be found of 
 distension of the transverse or descending colon, nor could enlarged coils of 
 intestine be observed through the parietes, and there was evidently greater 
 distension of the right than of the left loin. The vomiting had ceased, the 
 tongue was slightly furred, the gums were sore from the action of mercury ; 
 about a pint of urine had passed, and menstruation had come on. The pulse 
 was 120, and irritable; the respiration 40. She had not passed any flatus 
 nor blood from the bowels, but an evacuation had been produced by the in- 
 jection a few hours previously ; she had had sleep during the night, 
 mercurial which had been ordered was now omitted, and opium gr. ss given 
 every four hours. Till September 3d she continued in a hopeful state, but
 
 340 ON DISEASES OF THE CJECUM 
 
 was very prostrate, and the bowels acted. In the afternoon of that day she 
 suddenly awoke from sleep with great distress of breathing, and died in a 
 few hours. 
 
 Post-mortem examination -On opening the abdomen the peritoneal serous 
 membrane was found to be dry, but no lymph was effused. At the left side 
 of the caecum there was considerable peritoneal inflammation, bounded by 
 coils of ileum, and by the caecum. At this part, deeply situated, the appen- 
 dix cajci passed over the termination of the ileum, and extended to the 
 mesentery of a portion of adjoining ileum, where it was strongly united, and 
 formed, with its own mesentery, a firm loop. The mesentery of the appendix 
 was adherent to a small gland, which completed the band of adhesion with 
 the ileum ; at the same site another coil of ileum was also adherent by a 
 broad band of organized adhesion. The termination of the appendix was 
 softened, sloughy, ragged, and perforated; but the appendix itself was pale. 
 Above these partially constricting bands the ileum was somewhat distended, 
 but the caecum was also distended with flatus and feces, showing that the 
 strangulation had not been complete. The coats of the ileum towards its 
 termination were exceedingly softened, and broke down in several parts on 
 removal ; but there was no evidence of fecal extravasation before death. 
 The caecum was also softened. The opening into the appendix was free. 
 The uterus and ovaries, &c., were healthy. 
 
 In this case there was evidence during life of local peritonitis in 
 the neighborhood of the caecum and at the termination of the ileum ; 
 and although there was obstruction of the bowels, this was peculiar 
 in its character ; it was more severe than in ordinary coecal disease 
 for, during a short time, there was stercoraceous vomiting and, 
 on the contrary, it was less severe than in complete strangulation of 
 the intestine, for the bowels were many times acted upon. In refer- 
 ence to the position of the obstruction of the bowels, the ileum and 
 caecum were manifestly concerned ; there was dulness and tympanitic 
 distension at that part, with tenderness, and there was no distension 
 of the transverse nor of the descending colon; but the pain was 
 situated near to the pubes, and nearer to the median line of the 
 abdomen than in simple disease of the caecum; and, although it was 
 evident that the symptoms were principally due to inflammation 
 connected with the caecum or the appendix, it appeared more than 
 probable that the pain which had been experienced a year before, 
 and which came on after sudden muscular exertion, might have been 
 induced by some abnormal movements of the intestine. These 
 opinions were confirmed by post-mortem examination ; the appendix 
 caeci had been adherent for some time across the lower part of the 
 ileum. A slight attack of enteritis produced pain, distension, and 
 almost complete occlusion of the intestine ; more severe inflammatory 
 changes then became manifested, closely resembling those of ordinary 
 disease of the appendix ; softening and perforation of the appendix 
 took place, but the peritonitis was localized by adhesions. The 
 strangulation of the intestine then lessened, and the bowels were 
 acted upon several times. Although prostrate and exhausted, there 
 was hope of recovery ; but sudden collapse supervened, and death 
 followed in a few hours. This, we believe, arose from the extension 
 of the disease to the general peritoneum, which was found to be dry,
 
 AND APPENDIX C^ICI. 341 
 
 although sufficient time had not elapsed for lymph to be effused. 
 The value of an opiate plan of treatment was well shown in this 
 case, when associated with complete rest; the pain subsided, the 
 bowels acted, and the vomiting ceased. The mercurials had rendered 
 the contents of the canal more fluid, but had probably induced less 
 elasticity and firmness of those adhesions, on the stability of which 
 the prolongation of life depended, for by them only was the perito- 
 nitis localized. 
 
 CASE CXXI Perforation of Appendix Caci. Abscess behind the 
 Ascending Colon reopening into the Colon. Clot in Vena Portce and 
 Mesenteric Vein. Pycemia G D , set, 23, was admitted into Guy's on 
 December 29th, 1875. She was a married woman ; but had not had any 
 children. Four months previous to admission she had had a miscarriage. Her 
 general health was good, and her illness began three weeks before admission 
 with severe pain in the back, and with diarrhoea and vomiting. When brought 
 to the hospital, she had an anxious expression of countenance, was wasted, and 
 appeared to suffer pain. She lay on her back with the legs drawn up. The 
 tongue was dry, the teeth and gums covered with sordes, bowels loose, and 
 the motions fluid and of a yellow color. The hepatic dulness was increased, 
 and there was much tenderness on pressure. The pulse was small and com- 
 pressible, 140. Temperature 102.6. Respiration 30. There was no 
 maculae observed. A little crepitation was audible at the bases of the lungs, 
 but otherwise they were healthy. The heart was healthy. About forty 
 ounces of urine were drawn off, sp. gr. 1010 ; it contained a slight trace of 
 albumen and diminished chlorides. The patient moaned from pain, but ap- 
 peared in a drowsy state. The pupils were normal ; she had not suffered 
 from any rigor. On the following day she was in the same state, but on the 
 31st she had rigors and vomiting. The previous evening there was constant 
 diarrhoea, with vomiting and retching. Temperature 100. Pulse 130. 
 Respiration 44. On January 1st she was still in great pain, and the diarrhoea 
 returned, motions ochry and loose. Pulse 140, weak and fluttering. There 
 were flatulent eructations, and again vomiting. She complained of severe 
 pain about the heart, and great restlessness preceded death. She remained 
 sensible till near her death at 6 P. M. 
 
 On examination, the appendix caeci was quite divided about an inch from 
 the intestine, and it opened into a sloughy abscess, which extended behind 
 the bowel ; the abscess opened into the ascending colon by a round opening, 
 about the size of a sixpenny-piece. There was no tubercle in the lung nor 
 in the intestine, and no other ulceration in the intestine. There was no evi- 
 dence of enteric fever, nor of any foreign body having lodged in the bowel. 
 The mesenteric vein contained pus. The vena portae contained a clot, which 
 had formed a double layer upon the coats of the vein, and had allowed some 
 blood to pass in the centre of the vessel. There were numerous peripheral 
 abscesses of small size in the liver. The spleen was healthy, so also the 
 kidneys. 
 
 The diagnosis in this case was extremely obscure when she was brought 
 into the hospital. It was evident that there was acute disease of the abdo- 
 men, with peritonitis, but how it had originated was not clear. There had 
 been diarrhoea, but there was no proof of enteric fever, nor was there evi- 
 dence of phthisis or tubercular disease. Insidious disease of the appendix 
 led to ulceration, then to suppuration behind the caecum, and a second open- 
 ing formed into the bowel, at the ascending colon. Suppuration then ex- 
 tended into one of the branches of the mesenteric vein, and led to the ob-
 
 342 ON DISEASES OF THE CAECUM 
 
 ptruction in the vena portre and to the abscesses in the liver. The pyiemia 
 was the cause of the later symptoms and of death. 
 
 This case may be contrasted with one more recently under my care 
 in Guy's, in which equal obscurity attended the diagnosis. There 
 was acute inflammatory disease in the region of the caecum, but in 
 this instance the caecum, was pushed aside from its normal position 
 and the disease in the iliac fossa was produced by perforation of the 
 termination of the ileum, perhaps from enteric fever. 
 
 Many of these cases of perforation occur even at an earlier period 
 of life than those just recorded. In my notes 1 have cases at the age 
 of 12, 14, 19. &c., death generally taking place from the third to the 
 seventh day : but although the leading symptoms are very similar, 
 and well marked, each one has its own minor peculiarities. The de- 
 tection of foreign substances in the appendix, without any severe 
 irritation having been produced, is by no means uncommon ; thus a 
 pm was found with its head downwards, and its point extending into 
 the coats, half surrounded by fibrous membrane. Again, I have 
 observed an iron nail in the appendix, without injury having resulted 
 from its presence; shot, and various substances are sometimes thus 
 lodged. The presence of feces in the appendix is often the precursor 
 of ulceration and fatal perforation. In the volume of the ' Guy's 
 Reports' for 1856 there is a case of much interest, recorded by Dr. 
 Hughes, of strumous peritonitis and perforation of the caecum corning 
 on in a boy aged fourteen, after typhoid fever. Seven months after 
 fever, while at work, sudden and severe pain came on in the abdomen, 
 which subsided in a few days, but again returned, continuing for 
 several hours in each attack. When brought to Guy's the pain in 
 the abdomen was general, with tenderness, and there was much fe- 
 brile excitement. After several weeks the general distension sub- 
 sided, but a hard, tolerably defined mass was felt in the region of 
 the caecum. This hardness continued, and he had occasional attacks 
 of severe pain, sometimes with diarrhoea; hectic supervened, the 
 skin became hot, the stomach irritable, and he became exceedingly 
 restless, fretful, and distressed; the abdominal viscera moved en 
 masse; he sank about ten weeks after admission. 
 
 There was slight tubercular deposit in the lungs; but the abdomen 
 presented the usual appearance of strumous peritonitis; the disease, 
 however, was most marked in the region of the caecum, the anterior 
 surface of which was destroyed, and a fecal abscess had resulted ; the 
 termination of the ileum was also perforated. Other parts of the 
 small and large intestine were ulcerated. 
 
 The ulceration consequent on the typhoid fever in this child ap- 
 pears to have predisposed to slow organic changes of a strumous 
 character in the abdomen. 
 
 Cases of Cancerous Disease. 
 
 CASE CXXII. Cancer of the Ccecum. Abscess in the Groin William 
 
 J , set. 56, by trade a coach trimmer, of very temperate habits, had enjoyed 
 excellent health till he ruptured himself in carrying a heavy weight; he after-
 
 AND APPENDIX C.ECI. 343 
 
 wards had an abscess in the right groin. In October, 1855, he experienced 
 pain and sense of heat at the lower part of the abdomen, and then found a 
 swelling about the size of a walnut, which gave him great pain on pressure, 
 or on walking. The swelling enlarged day by day, but became less painful; 
 and night sweats came on. 
 
 On admission he had a cachectic appearance ; and in the right iliac region 
 was a hard swelling extending into the umbilical region ; it descended also 
 below Poupart's ligament on the right side ; the inferior part was firmer than 
 the upper; the pain was increased by pressure and during defecation. The 
 respiration was difficult, but the chest was normal ; the urine was healthy, 
 but there was pain after passing it. The appetite was tolerably good. He 
 was ordered to take a dose of castor oil; four leeches were appfied to the 
 tumor; and Dover's powder with gray powder were given night and morning. 
 Free action on the bowels took place, which lessened the abdominal tumor, 
 in fact it had almost disappeared ; but the tumor in the thigh remained hard 
 and tender. It became red, more swollen, and crepitant. Severe pain in 
 the thigh then came on, and a free incision was made into the abscess; about 
 a pint of fecal matter, with gas, was discharged. This fecal discharge with 
 pus continued very abundant ; the edges of the wound sloughed, and a second 
 opening formed near the crest of the ileum. The patient gradually became 
 prostrate ; and for more than a month before his death he had very trouble- 
 some diarrhoea. He died about three months after admission. 
 
 On inspection of the abdomen the general peritoneal surface was found to 
 be healthy; the small intestines were collapsed. There was an old inguinal 
 sac on the right side quite free and empty. Several coils of small intestine, 
 the lower parts of the ileum, were firmly adherent on the inner side of the 
 caecum, at the brim of the pelvis ; and the caecum itself formed the anterior 
 surface of a firm tumor. On carefully removing the caecum and intestine, it 
 was found that the posterior wall of the cascum was destroyed by carcinoma- 
 tous ulceration, and offensive fecal matter was poured out from beneath the 
 iliac fascia; and the abscess extended downwards to the opening on the thigh. 
 There was also an irregular nodulated growth extending from the mucous 
 membrane of the cascum, attached anteriorly near the valve, and surrounding 
 the intestine; the edges were exceedingly vascular, but not flocculent. The 
 section of the thicker portion near the ileum presented yellowish-white medul- 
 lary structure, and consisted of an aggregation of large nuclei, evidently 
 medullary cancer; near the margin, beautiful capillaries were observed dis- 
 tended with blood. At the posterior part some of the cellular tissue was 
 infiltrated. The coil of ilenm which was adherent to the caecum had an 
 irregular transverse opening into it, and was much injected. The remaining 
 part of the intestinal canal was healthy, so also the mesenteric and lumbar 
 glands. The liver was pale and somewhat fatty. The kidneys and bladder 
 were healthy ; so also the thoracic viscera. 
 
 The commencement of this disease was different from ordinary 
 caecal mischief. There was at first a small painful tumor in the 
 abdomen, which had more resemblance to cancerous growth, or dis- 
 eased gland, than cascal disease of a simple inflammatory character; 
 the disease was slow in its progress, hectic was developed, and the 
 patient ultimately sank from exhaustion. The course of the disease 
 beneath the iliac fascia was that followed in most cases of suppura- 
 tion in the iliac fossa. In other cases which I have witnessed of 
 ulceration commencing at the posterior surface of the csecum, and
 
 844 ON DISEASES OF THE CJ5CUM. 
 
 leading to extravasation into the cellular tissue of the iliac fossa, the 
 disease has generally been of a cancerous character. 
 
 CASE CXXIII. Colloid Cancer of the Caecum. Jaundice Ann C , 
 aet. 28, was admitted into Guy's Hospital, July 31st, 1860. She had resided 
 in service at Woolwich ; and her previous health had been tolerably good, 
 but the bowels had always been irregular. On July 22d she was seized with 
 vomiting, which continued till the time of admission, but was relieved by 
 milk and lime water. The vomiting came on in the evening, and was pre- 
 ceded by pain and soreness in the mouth ; pain then came on in the right 
 side. Since July there had been no appearance of the menses ; previously 
 she had suffered from dysmenorrhoea. On admission she was pale, and had 
 an anxious and distressed expression ; she was nervous and easily excited. 
 The pulse was compressible and the heart irritable; the chest was healthy, 
 and she had no cough. The abdominal muscles were rigid; and immediately 
 beneath the skin a defined, hard, and elongated tumor, placed somewhat 
 transversely, could be felt in the region of the cascum and ascending colon ; 
 the pain on pressure was severe, but was especially complained of when the 
 pressure was sudden. The part was dull on percussion ; the bowels were 
 easily acted upon. After food flatulent distension came on, and she often 
 complained of severe pain in the region of the crecum directly after swallowing 
 fluids. She was nervous and excitable, and the pain was manifestly increased 
 when attention was directed to the part. Dover's powder, and the steel and 
 aloetic pill afforded considerable relief, and she left the hospital on November 
 13th. She returned, however, in six weeks, much worse; jaundice had come 
 on a few days previously, and she was very ill. The mind was oppressed, 
 the pulse was very compressible, and she died in ten days from this hepatic 
 complication. 
 
 Inspection. The thoracic viscera were healthy. In the posterior wall of 
 the right lumbar and ileo-hypogastric regions the peritoneum was studded 
 with small yellowish tubercles of cancerous matter. The stomach was drawn 
 down by the great omentum, so as to be visible below the liver. The ileum 
 near the csecum became gradually thickened and rigid, from the growth of 
 cancerous matter of the appearance and consistence of old honey in a crys- 
 talline state. The ileo-caecal valve was obliterated ; the caecum and ascend- 
 ing colon were very thick and rigid ; the peritoneum over them was involved 
 in cancerous disease, and the muscular coat could not be distinguished. The 
 coats of the intestine were an inch in thickness just above the ctecum, and 
 the calibre of the bowel was much diminished in size ; at this part also the 
 mucous membrane was ulcerated for the space of several square inches. The 
 mesenteric glands were enlarged and infiltrated with cancerous matter. The 
 glands about the head of the pancreas compressed the common bile-duct. 
 The lumbar glands also were infiltrated. The kidney contained some cancer- 
 ous tubercles. The right ovary was enlarged to the size of an egg, and was 
 roughened and tubercular on the surface. The peritoneal veins at that part 
 of the pelvis were enlarged. The walls of the caecum and the last six inches 
 of the ileum presented a beautiful specimen of colloid cancer. The mucous 
 membrane was nearly half an inch in thickness, and of a gummy appear- 
 ance ; it presented delicate fibres forming cellular spaces, which were filled 
 with large nucleated cells ; portions of the cellular interspaces consisted of 
 very minute granules, as if from degenerating fibre ; numerous clusters of 
 granules were also observed. Beneath the thicker portion of the diseased 
 mucous membrane was a red layer, consisting apparently of degenerated 
 muscular fibre, or rather of cancerous tissue, in the place of the muscular, 
 and formed by an immense number of nucleated cells.
 
 AND APPENDIX CJECI. 345 
 
 The cause of death in this case, was the obstruction of the bile- 
 el nets by enlarged pancreatic glands. The patient was extremely 
 nervous and excitable, and at the onset of the disease it seemed 
 doubtful whether the symptoms arose from ovarian irritation. It 
 was, however, soon evident that there was organic disease of the 
 caecum or small intestine. The mischief was more circumscribed 
 than in ordinary cascal inflammation, and there was an absence of 
 febrile symptoms and of local peritonitis. It might have been 
 doubtful whether ovarian disease had set up. enlargement of the 
 lumbar glands; but the manner in which pain came on in the tumor 
 directly after food had been swallowed, pointed to intestinal mis- 
 chief; and the tumor appeared in her emaciated state to be very 
 superficial, immediately beneath the skin, and more distinct than it 
 would have been from enlarged glands ; neither was the growth in 
 the position of mesenteric or ornental tumors. 
 
 CASE CXXIV. Appendix Cceci in the Inguinal Canal. James C , 
 get. 16. The testes had not descended, and the appendix was adherent in the 
 inguinal canal ; the small intestine was fixed in the pelvis. The symptoms 
 of hernia came on, and an explorative operation was performed. Peritonitis 
 supervened, and after death purulent effusion was found in the abdominal 
 cavity. 
 
 These cases are recognized by surgeons as belonging to one of the 
 forms of irreducible hernia. 
 
 Intussusception of the ileum into the caecum and ascending colon 
 is of not unfrequent occurrence : and its symptoms might be mis- 
 taken for simple inflammatory disease of the caecum. This subject 
 will be again referred to in speaking of intussusception generally. 
 
 In many of the morbid changes of the caecum to which allusion 
 has been made, constipation is a more or less constant sign, and 
 there is danger of yielding to the temptation of administering pur- 
 gatives ; these medicines rarely effect the desired object until inflam- 
 matory irritation has subsided.
 
 346 
 
 CHAPTER XI. 
 
 ON DIARRH(EA. 
 
 DIARRHCEA consists in the abnormal frequency of evacuation of 
 the bowels, as defined by Cullen, "Dejectio frequens; morbus non 
 contagiosa; pyrexia nulla primaria:" and it arises generally, but 
 not exclusively, from an irritated condition of the large intestine. 
 
 It manifests itself in various forms, some of which have received 
 distinctive appellations, as Diarrhoea crapulosa, biliosa, mucosa, or 
 catarrhalis, dysenterica, and choleraica, to which might be added ner- 
 vosa, and colliqualiva. 
 
 Diarrhoea crapulosa is that state in which there is an unnatural 
 fluidity and excess of fecal excretion, in which the evacuations are 
 healthy in character, but in excessive frequency and fluidity; in 
 some cases very large quantities are discharged without any discom- 
 fort, but, on the contrary, with relief to the patient. This form of 
 diarrhoea should not be checked when it is a natural discharge ; but 
 more frequently it is the sequence of irritating and undigested food. 
 Too great a quantity may have been taken, and a portion of it may 
 have passed into the intestine crude and partially dissolved; or from 
 its insoluble character portions of the food, as the woody fibre of 
 vegetables and fruit, may have remained unchanged by the gastric 
 juice, and irritate the intestine. Again, active mental or bodily 
 exercise immediately after a rneal, which has been suitable both as 
 to quality and quantity, may interfere with the proper solution of 
 food, and lead to its hasty passage into the duodenum. 
 
 When the alimentary canal becomes in this way loaded with un- 
 dissolved ingesta, pain of a griping and twisting character ensues, 
 from irregular peristaltic action and from distension. The abdomen 
 becomes full ; the skin and complexion sallow ; the tongue is furred; 
 the pulse is compressible ; headache and giddiness are often present; 
 the sleep is disturbed ; the bowels act frequently and irregularly, 
 and the motions contain undigested substances, with fluid feces or 
 with firm scybala. Considerable soreness is at times experienced in 
 the course of the large intestine, and distressing tenesmus arises from 
 the irritation of the mucous membrane of the rectum. 
 
 The term lientary is used to designate the condition in which the 
 food is passed almost unacted upon, either by the gastric or intestinal 
 secretions, and in a very short time after having been taken. This 
 state arises from excessive irritability of the whole intestinal tract, 
 with disordered secretions; it is not unfrequent in children after 
 protracted diarrhoea, and gastro-enteritis. It is of common occur- 
 rence among the out-patients of large hospitals ; and in not a few 
 cases leads to a fatal termination.
 
 ON DIAKRHCEA. 347 
 
 Bilious Diarrhoea is also a form of disease produced by the effusion 
 of irritating substances into the intestine ; not, however, from with- 
 out, but from the liver, and possibly from the pancreas follicular 
 glands. 
 
 The secretion of the liver becomes either excessive in quantity, 
 or irritating in quality ; and the contents of the canal are apparently 
 hurried onward, and evacuated as frequent loose and bilious dejec- 
 tions. The causes of this state are various, and sometimes the 
 disorder of the liver is really secondary to an irritable condition of 
 the intestine itself, due to excess, especially of stimulants. Exposure 
 to cold and wet induces diseases of this kind, especially in the 
 autumnal season of the year. The symptoms are somewhat similar 
 to those previously mentioned; the pain is slight, unless. the disease 
 become aggravated; the tongue is furred; the complexion is sallow; 
 some febrile excitement is present with frontal headache ; pain in 
 the abdomen and in the hypochondriac region. This form of diar- 
 rhoea is sometimes epidemic, attacking considerable numbers exposed 
 to similar exciting causes ; and when severe, and accompanied with 
 colic or spasmodic pain in the abdomen and legs, and especially with 
 vomiting, it constitutes English cholera, and often leads to great 
 prostration of strength. The countenance becomes haggard, the 
 eyes appear sunken, the pulse is exceedingly compressible and 
 failing, the temperature below normal, the tongue is brown, and the 
 patient too frequently sinks exhausted, especially if very young, or 
 advanced in life, or if already prostrate from other disease. 
 
 Abnormal conditions of the bile tend to produce other modifica- 
 tions; thus, the motions in diarrhoea are sometimes in a state of 
 fermentation ; they are watery, frothy, and only contain fluid fecal 
 matter. This I have seen very prominently in a case of phthisis, 
 in which there was probably some ulceration of the intestine, when 
 the evacuations consisted of long shreds of mucus and casts composed 
 of columnar epithelium and nuclei. After a few weeks this con- 
 dition subsided under the use of cusparia, sulphuric acid, and opium, 
 with occasional starch injections, but it was followed by very severe 
 pain in the course of the colon, and by frothy, yeast-like evacuations. 
 For this state I used injections of charcoal, 1 3ij to about a pint of 
 thin barley-water, with great relief: the character of the evacuations 
 improved," and in a short time became naturally fecal, the pain 
 diminished, and the strength increased. I afterwards gave the 
 patient several grains of myrrh, twice or three times a day, with 
 manifest improvement, till she left the hospital several months later. 
 
 Diarrhoea sometimes occurs with an absence of bile in the evacua- 
 tions ; in jaundice this may be the case ; it is so in cholera ; and to- 
 wards the close of chronic disease, the liver may cease to pour put 
 its ordinary secretion. I have seen it in a patient slowly sinking 
 from the exhaustion consequent on diabetes, without phthisis. The 
 motions were in that case often quite white, like water frothy from 
 an abundance of soap. 
 
 ' See Dr. Theophilus Thompson's Lectures on Phthisis.
 
 348 ON DIARHIKEA. 
 
 There is, also, a form of diarrhoea arising from the inhalation of 
 noxious effluvia, which is closely allied to that just described ; the 
 fumes of sulphuretted hydrogen gas are absorbed by the lungs, and 
 through their minute capillaries enter the blood ; the gas is circu- 
 lated and acts as a poisonous agent on that vital fluid, and if con- 
 centrated, proves rapidly fatal; if less concentrated, it produces 
 headache, and frequently, also, diarrhoea. It appears, that not only 
 are the secretions of the liver and alimentary canal changed, but 
 that, by means of this excessive action of the abdominal viscera, the 
 poison is eliminated from the system. So rapid is this agent in its 
 action, that to be present for a short time, even a quarter of an hour, 
 in a dissecting room, will, in some persons, produce distressing diar- 
 rhoea. 
 
 In typhoid fever, and in phthisis, ulceration of the small intestine 
 is frequently found to be accompanied with diarrhoea; of these we 
 have spoken elsewhere ; in some of these cases, the large intestine is 
 involved, but in others, when the diarrhoea has been severe, such 
 has not been the case. It would appear that the continuity of struc- 
 ture with the ulcerated ileum, the irritating excreta, as well as the 
 changed and probably accelerated peristaltic action of the small in-, 
 testine, tend to excite over-action of the colon, and thus to set up 
 diarrhoea. 
 
 Catarrhal and mucous diarrhoea arises from a state of slight in- 
 flammatory disease, closely allied to ordinary coryza, affecting the 
 mucous membrane of the large intestine. The secretion is at first 
 checked, but afterwards greatly increased, and a watery feculent 
 mucus is discharged mixed with the ordinary feces. This state may 
 continue for several days, or even for a much longer period : the 
 motions are loose, and somewhat watery; and if the rectum be af- 
 fected, considerable tenesmus is produced ; the pain and febrile ex- 
 citement are slight, but the strength of the patient is reduced, and 
 he is unequal to his usual duties; the tongue is clean, the pulse is 
 compressible; the bladder sometimes sympathizes with this irrita- 
 tion, and a frequent desire to pass urine is induced ; in little girls, 
 also, a muco-purulent secretion often takes place from the vulva ; 
 redness of the parts is produced with smarting pain, and the idea 
 has sometimes been suggested that the child has been cruelly treated. 
 
 In this form of diarrhoea the evacuations contain a considerable 
 quantity of mucus, and a little blood is often observed ; these are 
 especially present when irritation occurs very low down in the rec- 
 tum, or is set up by hemorrhoids; and the mucus will sometimes 
 pass both before and after the dejection. 
 
 In infants the disease closely resembles gastro-enteritis, or it is, 
 perhaps, rather identical with it, but differing in degree, as a greater 
 or less part of the alimentary canal is affected ; in these cases the 
 whole tract sometimes becomes rapidly involved, and great, if not 
 fatal prostration, rapidly ensues. (See Muco-Enteritis.) 
 
 As the bilious diarrhoea, before mentioned, it is in very young or 
 aged subjects that catarrhal diarrhoea, or catarrhal inflammation of 
 the large intestine, leads to more serious disease, but it is also found
 
 ON DIARRH(EA. 349 
 
 amongst those in whom chronic or more exhausting disease has 
 existed. 
 
 This catarrhal diarrhoea not unfrequently becomes a chronic dis- 
 ease, the more severe symptoms cease, but still the bowels do not 
 act in their normal manner ; constipation often ensues, and after- 
 wards a fresh looseness of the bowels, and this alternation is often- 
 times repeated, or the more solid motions are followed by a discharge 
 of mucus coating the feces ; sometimes the mucus is passed in con- 
 siderable quantity after the evacuation, or it forms an elongated 
 flake or caste of the intestine. I have observed this condition fol- 
 lowing severe disease of the intestines of a dysenteric character, and 
 it is sometimes associated with a state of chronic congestion of the 
 liver ; again, it is often perpetuated by the presence of hemorrhoids, 
 and by ovarian disease. It may exist for many years without caus- 
 ing much derangement of health. 
 
 Morbid Anatomy. Many instances have been known of fatal diar- 
 rhoea in which the appearance of the mucous membrane has been 
 normal, its congestion has entirely disappeared, and a thin mucus 
 only has been found upon the membrane. But this is not always 
 the case, and there are several recognized pathological changes 
 which are frequently present. First of these, because most frequent 
 and therefore the more important, is a vivid injection in more or 
 less isolated patches. 
 
 2dly. When the diarrhoea has been chronic, the mucous membrane 
 is not unfrequently covered by a thick layer of mucus, and presents 
 a gray color. 1 have frequently examined membranes thus changed 
 (as before described ; see Duodenum and Caecum), and have observed 
 that the color arises from minute particles of dark pigmental matter 
 deposited in the substance of the mucous membrane. Prolonged 
 congestion is known to give rise to similar pigmentary changes in 
 many parts, as in the skin, liver, lung, heart, &c., and whenever 
 this pigmentary deposit occurs it is found to be due, as I have 
 described here, to grains of varying tint orange, red, brown, or 
 black. One must regard these grains as the remnants of actually 
 extravasated blood or to the arrest of some of the oxidizing or other 
 processes which the blood coloring matter probably undergoes in its 
 passage through the various tissues. 
 
 In the large intestine, this pigmental deposit is found in minute 
 circles around the follicles. 
 
 3dly. The mucous membrane, and also the connecting cellular 
 tissue, become thickened. 
 
 4thly. Minute ulceration, probably follicular, is found extending 
 through more or less of the length of the colon. These ulcerations 
 are about one-sixteenth of an inch in diameter, and present a minute 
 black zone around each of them. This state would be regarded by 
 many as the result of dysentery. 
 
 Dysenteric Diarrhoea. Purging is the most marked symptom of 
 dysentery, and the lesser degrees of irritation which we have con- 
 sidered under the term of catarrhal diarrhoea might be regarded as 
 a form of dysentery of the mildest character. In dysentery, how-
 
 350 ON DIARRHOSA. 
 
 ever, the diseased mucous membrane rapidly passes into a state of 
 ulceration, and blood is discharged with the fecal excreta. 
 
 In Choloraic Diarrhcea a thin, very abundant watery mucus is 
 discharged from the alimentary canal. The evacuation may have 
 very little color, and present the appearance of rice-water. It is 
 often alkaline in character, and consists of nuclei and epithelial cells 
 in various degrees of development. After death the membrane is 
 found to be entire, and pale or sodden ; the solitary and Peyer's 
 glands are enlarged. In many cases of uncomplicated cholera 
 which I have examined, no further morbid appearance was pre- 
 sented. 
 
 Of 'late years a belief in a fungous growth has been revived, and 
 the dejections of cholera have been said by Hallier and others to 
 contain specific spores. Some very careful and prolonged observa- 
 tions, however, by Drs. Lewis and Cunningham in India, controvert 
 this opinion. 
 
 The symptoms are those of rapid prostration, with pallor and 
 sunken eye ; the pulse is compressible, the tongue is cool, and the 
 voice is often scarcely audible ; the abdomen is collapsed, and the 
 urine is scanty in quantity; the stomach is often exceedingly irrita- 
 ble, so that everything is at once rejected from it; the alvine evacua- 
 tions are generally frequent, and of the character before mentioned; 
 and severe cramps in the legs and in the abdomen are often present. 
 This state may pass into one of profound collapse, even after one 
 evacuation of the character of rice-water, but as the prostration 
 subsides, in favorable cases, I have never observed the febrile excite- 
 ment which is secondary to true cholera. 
 
 Another kind of diarrhoea is that which has been correctly called 
 Serous, and which is frequently observed in albuminuria. A drop- 
 sical condition of the mucous membrane is induced, and the serous 
 exudation from the overcharged capillaries leads to watery discharge 
 into the colon, and thus to diarrhoea. This state of the mucous 
 membrane is precisely analogous to the oedema of the lungs, and to 
 anasarca of the cellular tissue in renal disease. So frequently is 
 diarrhoea present in these cases, that it may almost be regarded as a 
 symptom of the disease, and when moderate is beneficial in its results. 
 It is the action we often seek to produce artificially by powerful 
 hydragogue cathartics, so as to diminish the quantity of urea circu- 
 lating in the blood, and to relieve the oppressed kidney. All these 
 fluid evacuations contain urea, as does the gastric juice and the 
 mucus discharged from the lungs. 
 
 Another class of cases which can scarcely be placed among those 
 previously mentioned, arise from fright, from excessive mental agita- 
 tion, from want of food, and from exhausting disease ; the former 
 cases are of mental origin, the latter constitute what is sometimes 
 called "colliquative diarrhoea;" and the condition of the mucous 
 membrane corresponds to that of the skin, from which profuse 
 partial sweats break out. 
 
 In fright- the capillaries of the face become blanched, and the 
 blood leaves the whole of the surface; the cavities of the heart are
 
 ON DIAKRHGEA. 351 
 
 increasingly distended, hence tlifcdis.com fort there experienced, mill 
 the mucous membrane of the intestine is probably also engorged ; 
 therefore the discharge from the mucous membrane is to a "certain 
 extent beneficial in relieving internal congestion. The intimate con- 
 nection of the sympathetic nerve with the centres of thought and 
 feeling is the probable explanation of these instances of diarrhoea 
 following mental agitation. 
 
 In scurvy, purpura, starvation, &c., the altered character of the 
 blood leads to the effusion of serum, or blood, into the mucous mem- 
 brane, or into the canal itself, corresponding to the effusion into the 
 skin. In some fatal cases of purpura, the whole of the mucous 
 membrane of the alimentary canal is studded with spots of ecchy- 
 mosis. An interesting case of this kind occurred at Guy's Hospital 
 in 1856, in a young man who had been starved to death. 
 
 Discharge of blood, or melsena. Obstruction of the portal circula- 
 tion either from pulmonary, from cardiac, or from hepatic disease, 
 leads to great engorgement of the mucous membrane of the whole 
 alimentary canal ; and this congestion may cause hemorrhage from 
 the bowels. In examining the mucous membrane in these cases, it 
 is very common to find points of ecchymosis, and the capillary 
 vessels of the membrane much distended. Under a low magnifying 
 power we find the capillaries beautifully injected, with extravasated 
 blood between them, still, however, restrained by the unbroken epi- 
 thelial surface and its basement membrane ; if the rupture of this 
 membrane occur blood is extravasated. The discharge of blood 
 may be a symptom of various diseases; thus, ulceration is a fre- 
 quent cause of hemorrhage from the bowels, and the ulcer may be 
 located in any part of the canal; in the stomach and duodenum from 
 various causes ; in the small intestine in fever and in phthisis ; in 
 the colon in dysentery, &c. 
 
 The blood does not always present the same appearance ; if it arise 
 from hemorrhoidal vessels the blood will be florid, and precede or 
 follow the dejection; if it come from some higher part of the canal 
 it is incorporated with the feces; and when it has traversed a con- 
 siderable portion of the canal, it becomes altered by admixture with 
 the secretions from the mucous membrane. This is the case, to some 
 extent, when the blood is poured into the caecum, but is especially 
 so whenever it has been extravasated into the stomach ; the acids of 
 the gastric juice act upon the effused blood, so that it becomes black, 
 and when discharged from the intestine it resembles a pitchy fluid, 
 constituting true rnelaena. 
 
 The symptoms of diarrhoea have, perhaps, been sufficiently de- 
 scribed in mentioning its several forms; and they vary according 
 to the cause. In the simplest form there is neither pain nor consti- 
 tutional disturbance; in more aggravated cases there may be severe 
 colic, and febrile excitement ; and generally, unless there be hepatic 
 disturbance and derangement of the whole mucous tract, the tongue 
 is clean, it is then furred and injected, and in typhoid prostration 
 assumes a brownish color. The pulse is compressible, and the con-
 
 352 ON DIARRIICEA. 
 
 n \ ^ i ^ o I J 
 
 prostration is often voryjijnrming, especially in infants and 
 aged parsons, mid in SOUK; cases it leads to a fatal result. 
 
 11 It! is important carefully to mark 1 the character of the evacuations; 
 first, as to the admixture of undigested substances ; secondly, as to 
 the fluidity of the evacuations; a simple fluid state, with normal 
 excreta, indicates irritation of the mucous membrane in a slight 
 degree; thirdly, the presence of mucus is evidence of more severe 
 irritation of the colon; this is sometimes found in excessive quantity, 
 and is easily recognized by pouring the evacuation from one vessel 
 into another; fourthly, if more acute disease of the colon exist, de- 
 tached portions of feces are found floating on the fluid, which from 
 the rapidity of its discharge, and possibly also from intestinal changes, 
 is often frothy, from the admixture of air; fifthly, in severe diar- 
 rhoea, thin watery fluid may be discharged with scybala, and with 
 sedimentary portions of fecal matter; 1 sixthly, thin fluid, almost like 
 clear water, may be passed, as in some cases of albuminuria, from 
 an cedematous condition of the membrane, or like rice-water in 
 choleraic diarrhoea, or like soap-suds when with colliquative diar- 
 rhoea the hepatic secretion is also checked ; seventhly, the feces are 
 sometimes discharged in a state indicative of fermentative action, 
 and a frothy surface is produced of the appearance of yeast, and the 
 whole discharge closely resembles the matters occasionally ejected 
 from the stomach in obstructive disease at the pylorus; eighthly, as 
 to the color of the evacuation, we have evidence thereby of the 
 excess and of the paucity of bile, sometimes the stool being of a deep 
 brown color, at others almost as pale as chalk; ninthly, the color 
 may be changed by the admixture of such substances as logwood 
 administered medicinally, or blackened by steel medicines, the sul- 
 phide of iron having been formed; and tenthly, the color is a guide 
 to the detection of blood. Blood in the alvine discharges may be 
 only observable by microscopical examination ; but if in larger 
 quantity, the color varies from the ordinary appearance of blood to 
 the black pitchy stool of melasna, as we have before mentioned, 
 according to the position of the hemorrhage in the canal. The 
 green color of the discharges in the severe diarrhoea of children, we 
 believe, with Dr. Golding Bird, to be altered blood from an irritated 
 and perhaps aphthous surface. Again, in severe dysentery, thin 
 watery fluid, like the washing of beef, is sometimes discharged, con- 
 sisting of blood with mucus, and of imperfect epithelial elements. 
 To these dysenteric evacuations we shall have again to refer. Lastly, 
 the odor of the feces is not altogether unimportant; sometimes they 
 are intolerably fetid from rapid degenerative changes, at other times 
 they have scarcely any odor. In many instances the microscope 
 enables us to detect an excess of mucus, the presence of blood, the 
 rapid discharge of epithelial elements and nuclei, and other organic 
 and inorganic substances, which the unassisted eye would in vain 
 search for. We have elsewhere referred to the occasional presence 
 of phosphatic crystals upon the mucous membrane of the intestines, 
 
 1 Dr. Osborne "On the Examination of the Feces," 'Dublin Quart.,' 1853.
 
 ON DIARRH(EA. 853 
 
 and they are sometimes found in the alvine discharges, in simple as 
 well as in typhoid diarrhoea. The presence of fatty matters in the 
 evacuations was first noticed by Dr. Bright, in connection with dis- 
 ease of the pancreas; and the observations more recently made in 
 reference to the physiological effects of the pancreatic fluid have 
 directed increased attention to the subject. It must not be forgotten 
 that we sometimes find oleaginous substances discharged after the 
 administration of large quantities of milk and of cod-liver oil; thus 
 in one case masses of fat as large as filberts were sent to me by a 
 patient affected with phthisis, who had partaken of milk very freely; 
 still, the observation has been confirmed by subsequent observers, 
 that fatty matters are sometimes discharged in the alvine evacua- 
 tions in disease of the pancreas, and sometimes in extensive disease 
 of the mesenteric gland's. 
 
 The causes of diarrhoea have been partially referred to. 1st. The 
 most common cause of ordinary diarrhoea is exposure to cold and 
 wet ; standing in damp places ; allowing the legs and loins to become 
 damped and chilled ; sitting down upon the ground, and falling- 
 asleep in the open air; injudicious bathing; the habit of leaving off 
 flannel garments in hot weather, by which perspiration more rapidly 
 evaporates, and the blood is driven from the surface towards the 
 internal organs. 
 
 2d. Improper and indigestible food, unripe fruit, and an excess of 
 uncooked fruit ; salads, pastries, and much that modern cookery 
 produces, especially when an excess in quantity is combined with an 
 injurious quality. 
 
 In infants a fertile source of diarrhoea, often passing into severe 
 gastro enteritis, is the administration of unsuitable food, the injuri- 
 ous effects of which are greatly increased by exposure to cold. In 
 hospital and dispensary practice, this cause of disease is observed to 
 a frightful extent; at seven or eight months, even while the infant 
 is, in a great measure, nourished by the breast of the mother, meat, 
 raw vegetables, and fruits, sweets, almost ad libitum, are given ; and 
 a few months later we often find, that before the child has the power 
 of mastication, the mother gives the food of which she herself par- 
 takes, sometimes adding malt liquors and ardent spirits. The con- 
 sequences of this dietary are such as might be anticipated ; the food 
 passes onwards undigested, severe gastro-enteritis is induced ; and 
 the malady is often aggravated by a want of cleanliness, and by 
 exposure to night air and dampness. The mortality in London from 
 these causes is exceedingly great. In other infants the food, although 
 in itself pToper, is unsuited to the condition then existing, and per- 
 petuates diarrhoea ; or it may be, that the milk of the mother dis- 
 agrees with the child, from the impairment of her health. In such 
 subjects we occasionally find, that an alteration in the character of 
 the gastric juice of the infant leads to coagulation of the milk, and 
 to severe diarrhoea, with colic, &c., the stools containing portions oi 
 curdled and undigested milk, namely, oleaginous matter mixed with 
 casein. . 
 
 3d. Diarrhoea is set up by exhaustion, either from want of food, 
 
 23
 
 354 OX DIARRIKEA. 
 
 starvation and its attendants of misery, or as the consequence of 
 chronic disease. This form of diarrhoea is sometimes observed in 
 women who have nursed their infants too long. Enfeebled by bear- 
 ing children rapidly, their strength is additionally taxed by nursing 
 for twelve, fifteen, or eighteen months without proper nourishment 
 or invigorating air. The whole mucous membrane is affected ; the 
 nerve of organic life shows its ebbing powers ; the blanched cheek, 
 the dilated pupil, the desponding countenance, and impulses of a 
 mind verging on insanity, are symptomatic of this condition. There 
 is intense pain in the head, the heart is enfeebled, the pulse sharp, 
 and sometimes irregular; there is a distressing sensation of exhaus- 
 tion at the scrobiculus cordis, with severe pain in the back, and in 
 this state a very slight irregularity of food will sometimes set up 
 diarrhoea and vomiting. Cancerous and strumous disease of the 
 mesenteric glands, obstruction of the thoracic duct, chronic disease 
 of the pancreas, diabetes, &c., sometimes have uncontrollable diar- 
 rhoea as one of their latest symptoms. 
 
 4th. Epidemic causes. At some seasons of the year, in our own 
 climate during the spring and autumn months, diarrhoea of varying 
 severity is set up, and appears to arise from the condition of the 
 atmosphere, perhaps from germs of vegetable or animal growth. 
 
 oth. Endemic causes are more numerous, and with them may be 
 classed the diarrhoea arising from offensive drains, from decaying 
 animal and vegetable matters. Causes of this kind operate with 
 greater severity upon the young and enfeebled, upon the strumous 
 and ill-nourished. Many infants are thus affected with diarrhoea, 
 and with severe general gastro-eteritis. It is now well known, that 
 an impure water supply, especially if contaminated by sewage, will 
 lead to diarrhoea as well as to enteric fever, and probably to cholera. 
 Again, a general dampness of locality, as from a clay subsoil, will 
 set up, or will increase and perpetuate diarrhoea. We have wit- 
 nessed the removal into dry bracing air followed by cessation of the 
 . disease, and the return to the same district repeatedly cause its re- 
 currence. 
 
 6th. Excessive secretion of bile, and other diseases of the liver, as 
 well as disease of other intestinal glands, set up diarrhoea. 
 
 7th. Other causes are, tubercular disease of the mucous membrane 
 of the intestine and the mesenteric glands ; oedema and long-con- 
 tinued congestion of the mucous membrane ; mental agitation and 
 fright; ulceration of the small and large intestine, as in fever, 
 phthisis, &c. ; cancerous diseases ; purpura and scurvy ; large 
 draughts of water ; miasmatic disease ; poisons. 
 
 Prognosis. Diarrhoea is never altogether free from danger in aged 
 persons, or in very young children ; but the prognosis differs accord- 
 ing to its cause and character. If associated with chronic disease, 
 or an enfeebled condition of the system, it is often the immediate 
 precursor of death ; but when the cause can be removed, and the 
 subject is young, however severe the case may be, we should en- 
 courage the prospect of recovery. Many of such cases, when ap-
 
 ON DIARRHOEA. 355 
 
 parently quite in extremis, have gradually and almost miraculously 
 recovered. 
 
 The prognosis is unfavorable, when diarrhoea has been long con- 
 tinued, and is very severe in its character ; in some of these cases 
 scarcely any treatment appears to arrest the purging, and the patient 
 gradually sinks into a typhoid condition. 
 
 It may appear unnecessary to say any thing in reference to the 
 diagnosis of diarrhoea ; it is well, always, if possible, to ascertain 
 personally the character of the evacuations; since there may be 
 apparent diarrhcea, without the reality. I have seen starch enemata 
 used, when patients were greatly exhausted, and on inspection, found 
 the intestine loaded with solid fecal matter. In spinal disease, a weak 
 sphincter ani with involuntary defecation is often mistaken for diar- 
 rhoea, and I have known astringents continued for several months 
 ineffectively, whereas rest to the spine quickly relieved the malady. 
 A hardened mass of feces, which the patient is unable to expel from 
 the rectum, frequently leads to the repeated evacuation of small 
 quantities of fluid feces or of mucus, which is regarded as diarrhoea 
 or even dysentery ; the effort at expulsion is constant and painful, 
 but ineffective ; the removal of the mass at once checks the supposed 
 diarrhcea. Or again, in an exhausted state of the system, or during 
 epidemic diarrhoea, a single loose motion may require immediate 
 attention ; for the character rather than the quantity should be our 
 guide. In persistent diarrhcea it is important always to examine the 
 rectum, for I have frequently known cancerous disease entirely over- 
 looked from the want of digital examination. 
 
 Treatment. The primary object must be to ascertain the character 
 of the diarrhoea, and to remove, if possible, its cause. If food be 
 improper, to change it, arid administer such as shall be of the least 
 irritating kind. If the air be impure, to order removal to a healthy 
 atmosphere. If the mucous membrane and the secretions be dis- 
 ordered, to try and restore them to a healthy state. To check the 
 diarrhcea by various astringents and by rest. 
 
 Warmth. Warm baths, warmth applied to the feet, and flannel to 
 the abdominal parietes, a warm but pure air, &c., assist in checking 
 many of the simpler forms, and in diminishing those arising from 
 chronic disease. Local warmth may be attained by the application 
 of a hot fomentation, or poultice to the abdomen, or by such rube- 
 facients as a mustard poultice, or turpentine embrocation. 
 
 Food. In diarrhoea the least irritating and the most easily diges- 
 tible kinds of nourishment are advisable. Many of the forms of 
 amylaceous aliment, arrowroot, sago, are of this kind, and may be 
 given made with milk ; these are in themselves soothing applications 
 to irritated mucous membranes, whilst they serve as nourishment to 
 the system. Milk, rice, soaked bread and toast, lightly-boiled pud- 
 dings of flour and eggs, &c., may be also taken with advantage, and 
 in chronic diarrhcea suet and milk is often of great benefit. 
 
 The avoidance of stimulants, of rich and greasy food, of highly 
 seasoned dishes, of vegetables, especially when uncooked, of fruits, 
 &c., is essential ; and it is well in many cases to abstain for a short
 
 356 ON DTARBIKEA. 
 
 time from solid animal food altogether. The forms of animal food 
 which are most easily digestible are chicken, sweetbread, and some 
 forms of fish, as sole, cod, and whiting; then venison, mutton, and 
 beef; but much depends on the mode in which these viands are 
 dressed. When dried, salted, and cold, they require a much longer 
 period for their digestion, and portions often pass into the intestine 
 undissolved. Beef- tea sometimes appears to increase diarrhoea, when 
 veal and mutton broth can be taken with benefit. 
 
 Rest, and the avoidance of muscular excitement and sudden move- 
 ments, are very important in checking diarrhoea ; and in many 
 instances, especially in severe cases, a recumbent posture should be 
 maintained. In the erect position the gravitation of fluids increases 
 their rapid movement over the irritated mucous membrane. 
 
 Pure and dry air is very desirable ; many patients at once recover 
 when removed from a damp atmosphere to a dr,y and bracing one ; 
 and when the contamination of decomposing animal and vegetable 
 substances is setting up the disease, removal is still more important, 
 and is often essential to permanent restoration. In miasmatic dis- 
 tricts, diarrhoea may not only be rendered paroxysmal, but be per- 
 petuated by the marsh poison. 
 
 Many cases of diarrhoea will be cured by this attention to warmth 
 and diet, to rest and pure air; but other means often promote the 
 comfort and favor the restoration to health. 
 
 If the large intestine, and especially the rectum, be affected, much 
 benefit is derived from enemata. These are composed of various 
 ingredients, simple starch, thin gruel, and barley-water ; and to these 
 we may add tincture of opium and biborate of soda. Or they may 
 be made astringent, as decoction of oak bark with tragacanth, or 
 glycerine of tannin with water; or a very dilute solution of nitrate 
 of silver may be used ; an infusion of ipecacuanha has been favorably 
 recommended as an injection by Boudin and Chouppe. 
 
 To restore the diseased mucous membrane and to correct secretions. 
 The alkalies are of very great service in diminishing congestion, as 
 well as in rendering the secretions less irritating. Solution of potash, 
 lime-water, chalk, some salines, as chlorate of potash, bicarbonate of 
 potash, and nitrate of bismuth, act in this manner. 
 
 When the hepatic secretions are disordered, as shown by furred 
 tongue, and pale evacuations, the moderate use of mercurials is of 
 value, as gray powder or calomel^ combined with Dover's powder, 
 with soda or with opium; but we should strongly urge that mercu- 
 rials be very carefully administered, because in many forms of diar- 
 rhoea they tend greatly to aggravate the disease. It is only in some 
 cases, even with a foul tongue, and deficient hepatic secretions, that 
 we would recommend their use. 
 
 Demulcents. These act by directly sheathing the mucous mem- 
 brane ; the most important are those mentioned as food, but others 
 are of considerable utility, as acacia, tragacanth, linseed, liquorice, 
 glycerine, spermaceti, &c. 
 
 Castor-oil, Linseed-oil. These are of great value, when improper 
 food, retained secretions and scybala irritate the alimentary canal.
 
 ON DIARRH<EA. 357 
 
 They are combined with great advantage with the compound tincture 
 of rhubarb, and sometimes with a small dose of opium, "lv or x. 
 These remedies are of most service in some forms of dysenteric 
 diarrhoea, when scybala irritate the mucous membrane. 
 
 Ipecacuanha is a remedy which acts, apparently, on all the mucous 
 membranes, and is as valuable in disease of the alimentary as of the 
 respiratory mucous membrane. Ipecacuanha not only increases 
 the quantity of mucus but it mitigates inflammatory congestion. It 
 is of great service in the dysenteric diarrhoea of adults, and equally 
 so in the diarrhoea of infants. In the former, Dover's powder is 
 a valuable form for its administration, or the ipecacuanha may be 
 combined with astringents, as in the compound infusion of krarneria, 1 
 and the compound logwood mixture of the Guy's Pharmacopoeia, or 
 it may be administered alone as in the treatment of pure dysentery. 
 
 Astringents and Desiccants. These may be divided into several 
 classes. The saline, as chalk ; the vegetable, as tannic and gallic acids, 
 krameria, kino, catechu, logwood, Indian bael, cusparia, opium; me- 
 tallic, as sulphate of copper, acetate of lead, nitrate of silver, nitrate 
 of bismuth, &c. 
 
 Opium acts not only as an astringent, but also as a narcotic ; it 
 diminishes the secretion from the mucous membrane, and the peri- 
 staltic movement of the intestine, and it relieves the pain of colic. 
 It is of great value in diarrhoea, and may be combined with other 
 remedies, as with chalk and ipecacuanha; but, when irritating in- 
 gesta and disordered secretions perpetuate diarrhoea, opium and 
 astringents are not appropriate remedies. When the disease is 
 chronic, opium may be given with the more active vegetable astrin- 
 gents, catechu, krameria, and logwood, and sometimes very advan- 
 tageously with quinine. 
 
 The metallic astringents are combined in a similar manner with 
 opium and ipecacuanha, but are more frequently used in chronic 
 dysentery, and in tubercular ulceration of the intestine, than in sim- 
 ple diarrhoea. 
 
 Mineral Acids. Much has been written upon the use of dilute 
 sulphuric acid in diarrhoea; and its use has certainly been attended 
 with benefit, although not to the extent we were led to suppose. 
 Botli dilute sulphuric acid, and dilute nitric acid, are of value after 
 the more severe symptoms have passed off; they act at first possibly 
 by checking chemical and fermentative changes, and afterwards as 
 tonics to the relaxed mucous membrane. Combined with slightly 
 astringent and mucilaginous tonics, as with cusparia and simaruba, 
 or with calumba root and elm bark, they are of great service in 
 some cases. 
 
 When there is much pain, we may associate narcotics with other 
 remedies before mentioned. Spirit of chloroform and spirit of cam- 
 phor in small doses sometimes afford great relief, so also the tincture 
 of henbane; in other cases, simple carminative medicines are suffi- 
 
 1 Infusum Krameriae compositum. Infusion of Rhatany Root fl..5xj ; Ipecacuanha 
 Wine 3'Vj Tincture of Catechu 3i y -
 
 358 ON DIARRHCEA. 
 
 cient to relieve the pain, as ginger, cardamoms, &c., especially where 
 the diarrhoea is associated with flatulent colic. 
 
 In the colliquative diarrhoea of weaned children, Dr. I. F. Weisse 
 has strongly advocated the administration of raw meat, scraped and 
 reduced to a pulp, as we have previously mentioned in the remarks 
 on enteritis. 
 
 Leeches. The application of leeches to the anus is a remedy which 
 greatly relieves inflammatory congestion of the mucous membrane 
 of the large intestine, but it is one which we should scarcely recom- 
 mend, unless the disease assume a severe and dysenteric character. 
 
 Suppositories, composed of the compound soap pill or morphia, are 
 often of great service when there is distressing tenesmus which dis- 
 turbs the rest of the patient; and when it is undesirable to admin- 
 ister an opiate by the mouth, or inconvenient to use an enema. 
 Tannin may also in this way be conveniently used, so also bismuth. 
 
 In chronic mucous discharge from the bowels, we must first seek 
 to remove the disease of the liver, if such exist, by mild alteratives, 
 by taraxacum, and by nitro-muriatic acid. These remedies, also, 
 assist in relieving the chronic congestion and inflammation of the 
 intestine, and are more effective than astringents. It is well, how- 
 ever, to be assured that no polypoid growth, nor disease of the 
 rectum and sigmoid flexure, is setting up the disease. 
 
 If astringents be required in these instances, the oxide and nitrate 
 of silver, sulphate of copper with opium, or the vegetable astringents 
 just mentioned, may be used; and as enemata, glycerine of tannin 
 diluted with water, the solution of nitrate of silver (gr. x-xv to Oj 1 ), 
 the infusion of quassia, the decoction of oak bark, and the decoction 
 of poppies with or without the addition of borax, may be employed 
 with advantage. 
 
 In the treatment of choleraic diarrhoea, rest in the recurnl)ent 
 position, warmth to the abdomen and the feet, and gentle friction, 
 if muscular spasm distress the patient, are valuable remedies. A 
 full dose of chalk and opium with catechu and aromatic spirit of 
 ammonia should be given, and repeated in two or three hours, if 
 necessary. Demulcent nutriment, as mutton broth and arrowroot, 
 may be allowed: and if vomiting supervene, ice or cold water will 
 be beneficial. Dilute sulphuric acid has been sometimes used with 
 great advantage, and by some calomel has been freely given in these 
 cases, especially when vomiting has come on. When the collapse 
 of true cholera has attacked the patient, general experience does not 
 favor the free use of either opium or brandy; but to enter fully into 
 the treatment of cholera is foreign to our purpose. 
 
 The following cases of diarrhoea are of considerable interest: 
 
 CASE CXXV. Inanition. Diarrhoea John M , aet. 26, was admitted 
 into Guy's Hospital Dec. 17th, 1856, and died Dec. 20th. He had been a 
 sailor, and stated that he had had dysentery, but this was not satisfactorily 
 ascertained, on account of his prostrate condition. It appeared that lie had 
 been on board an American vessel from China to Liverpool, and arrived at 
 
 1 Trousseau.
 
 OX DIARRHCEA. 359 
 
 the latter place on December 6th ; he then came up to London. He informed 
 the nurse that there had been a mutiny on board, and that he had been put 
 in irons in the hold. He was in the most emaciated state ; the voice was 
 scarcely perceptible ; the pulse was exceedingly compressible, and the tongue 
 and mouth presented yellowish-white aphthous patches ; he had no vomiting, 
 but the stools escaped from him, and were white and very offensive ; the 
 respiration was easy, and the mind perfectly conscious. Milk was ordered. 
 The following day he was better, but sank on the third day after admission, 
 and was sensible till nearly the last. 
 
 Inspection, December 22, 1856 There were ecchymoses on both thighs, 
 and old cicatrices on the wrist and leg. The brain was less firm than normal ; 
 the lungs were collapsed and healthy. The heart was small. The liver was 
 healthy. The gall-bladder was not distended, and the spleen and kidneys 
 were healthy. The stomach presented gastric solution at the cardiac portion. 
 The small intestines were healthy. The large intestine was throughout of a 
 gray color, and was filled with dry, white feces. At the root of the mesen- 
 tery were several white strumous masses in the glands, but it could not be 
 found that the thoracic duct was obstructed. The urinary bladder was dis- 
 tended. 
 
 This case presents us with a well-marked instance of a man dying 
 from the effect of starvation. The diarrhoea was probably the result 
 of want of nourishment, of good air, and of light, &c.; so that sup- 
 plies having been cut off and the conditions necessary for reparation 
 excluded, the whole body wasted, and the spark of life graduallv 
 expired. 
 
 CASE CXXVI. Chronic Diarrhoea. Hysteria. Great Relief from 
 Tincture of Iron Georgiana B , aet. 40, a single woman, who had resided 
 in the Commercial Road, and had supported herself by her needle, applied at 
 Guy's Hospital May 23d, 1860, and was admitted under my care. She had 
 suffered from uterine ulceration. During eighteen months she had been 
 affected with diarrhoea, and when she had mental anxiety the disease increased 
 in severity. The slightest exertion produced perspiration. She was a tall 
 woman, extremely nervous, the eyes sunken, the countenance dejected. The 
 heart and lungs were normal. She complained of great pain in the abdomen, 
 on the right side below the liver, in the region of the ascending colon ; there 
 was tympanitic distension in the same region ; the bowels were opened six 
 times in twenty-four hours, but there was no evidence that blood had been 
 passed. She had not taken meat during several months Astringents of 
 different kinds were administered and enemata used, with only partial relief, 
 till the tincture of iron was given persistently for several weeks. The diar- 
 rhoea then subsided, and she left the hospital convalescent, stating that she 
 had not been so well for eight years. 
 
 This case appeared to be one of passive mucous diarrhoea in a 
 very hysterical subject, and the uterine irritation had tended to per- 
 petuate the disease. Astringents were less efficacious than prepara- 
 tions of steel, which diminished the nervous irritability and gave 
 tone and strength to the whole system. The regulated and more 
 generous diet which was given must not be overlooked ; and by per- 
 suasive measures she was induced to take a meat diet, which lessened 
 the fluid contents of the colon, and thereby increased the consistence 
 of the alvine discharges.
 
 360 
 
 CHAPTER XII. 
 
 ON DYSENTERY AND CATARRHAL INFLAMMATION OF THE COLON. 
 
 NUMEROUS authors, as Sydenham, Annesley, Parkes, Ballingall, 
 Sir J. McGrigor, and Morehead, have described the terrible forms of 
 this disease as they are manifested in tropical climates, and in mili- 
 tary campaigns, and as formerly seen in England. In our own 
 country, however, dysentery has very much diminished in severity 
 and in frequency, so that in its acute form it is rarely seen amongst 
 us, unless contracted in foreign climes, and then brought to our 
 shores. Still true dysentery occurs more commonly than some of 
 very great experience will admit ; sometimes it is the only disease 
 from which the patient suffers, and is quickly fatal ; or it is found 
 in association with a general inflammatory condition of other mucous 
 membranes ; or lastly, it aggravates varied forms of chronic disease, 
 or it causes their sudden termination. 
 
 Particular localities and periods of the year cause the manifesta- 
 tion of this disease, and its complication with others in a very 
 marked degree. This fact is shown by the observations of Dr. 
 Latham and Dr. Baly at the Millbank Prison ; and the greater 
 humidity of the atmosphere is probably the reason of the more fre- 
 quent occurrence of dysentery in the hospitals in Southwark than 
 elsewhere in London. When other diseases are complicated by dys- 
 entery a very important consideration is introduced into their prog- 
 nosis and treatment ; thus incipient phthisis may become altogether 
 hopeless, and in a very short time fatal, not from the severity of the 
 pulmonary affection, nor from tubercular disease of the intestines, 
 but from acute inflammation of the mucous membrane of the colon. 
 
 Abercrombie defined diarrhoea as purging, arising from irritating 
 substances in the canal, and from secretions poured into it ; and dys- 
 entery, as acute inflammation originating in the mucous membrane 
 of the large intestine. This distinction is probably, to a considerable 
 extent, correct ; but some forms of disease usually considered as 
 diarrhoea, arise from catarrhal inflammation of the colon and small 
 intestine, and after death may present scarcely any trace of abnormal 
 change. Dysentery is generally limited to the colon, and when 
 severe the disease rapidly passes into ulceration and sloughing, 
 unless from its extent, or the previous condition of the patient, it 
 prove fatal at an anterior stage, as in several of the fatal cases re- 
 corded in this chapter, which terminated before extensive ulceration 
 had taken place.
 
 DYSENTERY AND CATARRHAL INFLAMMATION OF COLON. 361 
 
 DYSENTERY. 
 
 Dysentery does not embrace every form -of inflammation of the 
 mucous membrane of the colon, and we would distinguish it from 
 catarrhal inflammation, confining the term dysentery to that more 
 severe inflammation which rapidly passes into ulceration. In 
 catarrh the condition of the mucous membrane is altered, as we 
 described in speaking of enteritis, the membrane is congested, and 
 the secretion is at first checked, afterwards it becomes excessive. 
 This state may soon subside, or it may continue for months, and 
 even for years. Like dysentery it may be brought on by endemic 
 causes, by cold and wet, and by unwholesome diet ; at the commence- 
 ment of a dysenteric attack the symptoms may at first be those of 
 acute catarrh of the colon, and on the subsidence of the dysenteric 
 ulceration, troublesome catarrh of the bowels may persist for a 
 lengthened period. 
 
 Dr. Lyon, in his Crimean report, has divided dysentery into two 
 forms, the exudative and the follicular. The former is, however, 
 probably the earlier stage, or that preceding ulceration and slough- 
 ing. The cases which have come under my own observation may 
 be divided, practically, into three classes : " 
 
 1. Those instances in which acute disease of the colon is the pri- 
 mary disease, and sometimes it terminates fatally in a short time. 
 
 2. Those cases in which dysentery is associated with inflammation 
 of other membranes and organs, as when bronchitis, laryngitis, and 
 pneumonia arise at the same time, and are produced apparently by 
 the same cause as the disease of the intestine ; in some instances the 
 disease is closely allied to pyaemia. 
 
 3. Those cases in which inflammation of the colon has hastened 
 the fatal termination of other more chronic disease. 
 
 Morbid anatomy. The dysenteric process is well described by 
 Rokitansky, who divides it into four stages, and considers that it 
 consists in inflammation of the mucous membrane of the colon, ter- 
 minating in severe cases in sphacelus. Dr. Parkes believes that, in 
 true dysentery, ulceration is always present, and attaches great im- 
 portance to the affection of the glands ; whilst Dr. Baly describes the 
 process as sloughing, rather than ulceration. Are we then to look 
 upon inflammation of the colon, in which there is no destruction of 
 the mucous membrane, as true dysentery ? It will be generally ac- 
 knowledged, that death may take place prior to the ulceration or 
 sloughing, although we rarely, if ever, find the mucous membrane 
 entire ; it is probable that the diseased condition is closely allied to 
 that of the pharynx in diphtheria; and, that in severe cases the 
 membrane rapidly sloughs, without anctecedent ulceration. 
 
 In the earlier stage of dysentery, the mucous membrane becomes 
 injected, oedematous, and thickened ; the mucus is scanty, and the 
 feces become adherent ; this condition may be universal in the colon, 
 or limited to the rectum, to the sigmoid flexure, or to the caecum. The 
 solitary glands will be found to be distinct, prominent and enlarged. 
 
 The" secretion from the membrane then becomes further changed,
 
 362 ON DYSENTERY AND 
 
 and a thin exudation, consisting of epithelium with a considerable 
 quantity of granular amorphous matter, coats the intestine. This 
 exudation is found in patches, or in lines, or it is spread generally, 
 upon the surface. It has been described as dipping into the follicles; 
 an appearance which I have myself observed, and it may also be 
 seen closely incorporated with the surface of the membrane, so that 
 it can only be separated by considerable violence. The color of the 
 exudation is generally of a greenish yellow ; but it varies somewhat 
 according to the character of the feces. On scraping off' the effusion 
 from the surface, the membrane beneath is found intensely congested, 
 and often superficially ulcerated ; oj, there may be merely minute 
 circular patches of ulceration, with portions of the false membrane 
 adhering at that part. This tendency to ulcerate, or to slough, 
 resembles diphtheritic disease in the pharynx and nares ; but the 
 character of the false membrane in the throat is more fibrinous than 
 that developed in the intestine. The muscular coat of the colon 
 appears thickened in this stage of dysentery, probably because it is 
 contracted ; and the submucous cellular tissue is often whitish and 
 distinct from inflammatory oedema. Dr. Baly, whilst describing this 
 epithelial degeneration, states, that in most cases these minute ad- 
 herent coverings on the surface of superficial erosions, or small ulcers, 
 consist of thin sloughs of the 'mucous membrane. He believes, that 
 in all cases, the destruction of the mucous membrane consists in a 
 process of mortification and sloughing, and not of simple ulceration ; 
 and that the disease commences in the solitary glands of the intes- 
 tines. Other parts, however, beside the solitary glands, are found 
 to be diseased ; but whether primarily or by extension, is matter of 
 opinion. Many instances of diarrhoea are observed, in which, after 
 death, the solitary glands are found enlarged, or minute points of 
 ulceration are presented ; the whole colon may be studded over with 
 minute ulcers, arising apparently in the glands, as is well shown in a 
 specimen in the Guy's Museum, to which reference has before been 
 made. Dr. Baly would probably consider these to be instances of 
 the dysenteric process in its mildest form, and that in other instances, 
 previously alluded to, more acute changes had spread from the glands 
 to the general surface of the membrane. 
 
 Dr. Morehead has in some cases observed diphtheritic membrane 
 effused in dysentery, and believes that the mucous follicles are more 
 frequently affected than the solitary glands. 1 
 
 In the third stage, we find ulceration, sometimes merely as minute 
 circular ulcers, but generally of a more extensive character; the 
 ulcers are often oval in form, and placed in the transverse axis of 
 the intestine ; and their edges are raised and injected, irregular and 
 undermined ; and their base is formed by the cellular or muscular 
 coats. These ulcerations gradually extend so as to coalesce, till at 
 last nearly the whole of the mucous surface is destroyed, except here 
 and there in prominent isolated portions, which become intensely 
 congested, and resemble polypoid growths. In severe cases the 
 
 Morehead, ' On Diseases of India.'
 
 CATARRHAL INFLAMMATION OF THE COLON. 363 
 
 whole colon, from the caecum to the rectum, is in this condition ; or 
 greater spaces intervene between the ulcers, which are only found 
 in the rectum, or in the sigmoid flexure, or in the csecum ; but gene- 
 rally the rectum and the sigmoid flexure are the parts most severelv 
 implicated. It sometimes happens, that the ulceration extends 
 through the muscular and the peritoneal coat, leading to fatal peri- 
 tonitis from perforation, but this is a rare occurrence ; or, the coats 
 of the intestine become sinuous abscesses, so that on dividing a 
 prominent portion of mucous membrane between two ulcers, several 
 drachms of pus escape. This extensive suppuration is very different 
 from the small local collections of pus, which sometimes form in the 
 substance of the mucous membrane after follicular and glandular in- 
 flammation, where small eminences about half an inch in diameter 
 are observed, covered by thin layers of mucous membrane. The 
 latter is a less general and less severe form of inflammation of the 
 colon, but one which I have several times observed. 
 
 The liver is generally found to be congested, and the gall-bladder 
 to be partially distended either with inspissated bile or orange-colored 
 mucus. The mesenteric glands are often somewhat congested : and 
 in some instances the ileum and the jejunum are both diseased, be- 
 coming intensely injected, partially ulcerated, and covered with 
 diphtheritic membrane ; Peyer's glands are also found to be con- 
 gested and enlarged; although never raised and infiltrated with 
 deposit, as in enteric fever. 
 
 Dr. Morehead gives an instance of fecal abscess, in the right iliac 
 fossa, from perforation of the cascum in dysentery. 
 
 If the acute symptoms have subsided, the injection is less deep in 
 color, and often becomes gray; the edges of the ulcers assume a 
 rounded and less prominent aspect; their surface has a smooth and 
 fibrous appearance; ulcerative action has been checked, and cicatri- 
 zation has commenced. The healing process may go on, so that the 
 cicatrix has an irregular and puckered appearance. The base of the 
 cicatrix is formed by fibro-cellular tissue, but the gland structure is 
 not reproduced. The contraction of the cicatrix sometimes produces 
 considerable constriction of the intestine, and occasionally tends to 
 fatal obstruction. Very frequently above the cicatrix all the coats 
 become hypertrophied, showing that there has been much impedi- 
 ment. Dr. WilKs has informed me of a case, and there are many 
 others now on record, in which the cicatrix presented a growth at its 
 margin, evidently of a carcinomatous character, indicating a greater 
 tendency to heterologous growth in the new than in a normal tissue. 
 
 In a fourth stage of dysentery the mucous membrane presents a 
 gray, ashy appearance, and considerable portions of it constitute 
 ragged and semi-detached sloughs. 
 
 Dysentery often terminates in complete recovery; at other times 
 death quickly supervenes from the severity of the disease ; or, 
 thirdly, it passes into a chronic state, which may continue with inter- 
 missions for several years. 
 
 Other seqmlse of dysentery are perforation of the intestine and 
 fatal peritonitis; fecal abscess; gradually increasing exhaustion from
 
 364 
 
 ON DYSENTERY AND 
 
 the destruction of the mucous membrane, and continued purging; 
 constipation, arising from the contraction of cicatrices leading to a 
 very troublesome and irregular condition of the bowels, and some- 
 times to fatal obstruction; pyasmia and suppuration in the substance 
 of the liver, from the absorption of pus, as described by Dr. Budd, 
 in his work on 'Diseases of the Liver.' This last result I have only 
 once observed at Guy's, in simple English dysentery, which is nearly 
 in accordance with the experience of Dr. Baly, at the Millbank Peni- 
 tentiary, and shows that whilst the disease may be the same in its 
 general character and pathology with tropical dysentery, there is 
 some modifying cause. 
 
 It must be borne in mind, however, that abscess in the liver may 
 occur without dysentery, and that the abscesses which are generally 
 found in pyaemia are different both in character and in position from 
 those observed in connection with tropical disease and with dysen- 
 tery; in ordinary pyaemia the abscesses are small, peripheral and 
 often numerous, in the hepatic abscess found with dysentery, the 
 abscess is often larger and it may be single; so also in the abscesses 
 following tropical hepatitis. Dr. Mayne in a very interesting article 
 in the Dublin 'Quarterly Review,' also mentions a state resembling 
 phlegmasia dolens as the occasional sequence of dysentery, and 
 speaks of spontaneous salivation as sometimes supervening after the 
 disease. 
 
 Symptoms. A sensation of coldness in the loins, chilliness, or 
 actual rigor, is followed by a loose evacuation from the bowels; this 
 alvine discharge is repeated, and the evacuations become scanty, and 
 are often accompanied with tenesmus, or a forcing sensation as if 
 the intestine retained its fecal contents. With this, there may be 
 slight pain or soreness in the iliac region or position of the trans- 
 verse colon, and even severe griping; febrile disturbance supervenes, 
 and the tongue has a whitish fur, or is injected at the tip and edges, 
 but the latter symptoms are often absent. In mild cases the ener- 
 gies and mental activity are unimpaired, but the face becomes pallid, 
 and the strength is not equal to accustomed duty. 
 
 This condition may continue for several days, the patient becoming 
 more feeble, the motions watery, or they contain mucus and blood, 
 and scybala are passed with pain. The countenance becomes hag- 
 gard, and expressive of distress, the skin clammy, and the pulse 
 compressible; the abdomen is collapsed, and tolerant of pressure; 
 . the pain is paroxysmal, and occasionally very severe, and vomiting 
 sometimes supervenes. 
 
 If the disease continue unchecked, the strength fails, the pulso is 
 rapid and compressible, and the eyes are sunken; the tongue is 
 brown, or it is dry and cracked; the motions are passed involun- 
 tarily, and often are of a greenish color, or they resemble the washing 
 of meat; the lower extremities are cold, and the hands and face are 
 covered with a clammy sweat; occasional cramps, with hiccough 
 and subsultus tendinum, come on; the patient is sensible, but speaks 
 in a feeble tone of voice, and at last dies, more suddenly, perhaps, 
 than those around him had anticipated.
 
 CATARRIIAL INFLAMMATION 'OF THE COLON. 365 
 
 These symptoms may only extend over a very few days or hours, 
 and sometimes are accompanied with much febrile disturbance, with 
 tenderness of the abdomen, and with a furred and brown, or red, dry 
 and glazed tongue. If the severity of the disease abate, the bowels 
 become more composed, and the patient rallies; or the diseased con- 
 dition returns with greater severity; for the first exhaustion is 
 scarcely recovered from before the strength is still further reduced, 
 and in this way the malady may extend over weeks, or months! 
 The patient then has a peculiar and characteristic appearance; he 
 is much emaciated; he has a sallow complexion; his mind is active, 
 but physical strength fails gradually, till at last he is obliged entirely 
 to take to his bed from a sense of utter prostration. 
 
 In the dysentery of the tropics, or the equally severe disease ob- 
 served in the hardships of war and after famine, the prostration is 
 more rapid, the disease more quickly fatal, and in some instances 
 has been accompanied with violent delirium. 
 
 In reviewing the symptoms of inflammation of the colon in its 
 severe forms, we have been struck with the occasional absence of 
 febrile symptoms, as indicated by a hot skin, furred tongue, or excited 
 pulse. The tongue, unless it be itself affected with local disease, 
 indicates the condition of all the nutritive functions, rather than 
 that of any isolated portions of the alimentary canal. The tempera- 
 ture in dysentery may remain about the normal standard or it may 
 be considerably raised, especially in those instances which are con- 
 nected with blood-poisoning. 
 
 If the peritoneum becomes inflamed, or if the extension of disease 
 to the muscular coat produces irregular muscular contraction, pain 
 often of a severe, griping, and of a paroxysmal character is the 
 result. The amount of pain appears to be greater in disease of the 
 small than of the large intestine, perhaps on account of its greater 
 mobility. 
 
 The character of the evacuations deserves particular attention. 
 They may consist of fluid feces containing scybala, or only of mucus 
 with blood. The mucus is often tenacious, and passed in considerable 
 quantity, with much tenesmus, forming a gelatinous mass, and is 
 occasionally accompanied with small scybalous masses. The dis- 
 charge becomes in severe cases thinner, greenish in color, and even 
 like spinach; or from the admixture of more blood it resembles the 
 "washings of meat." The inflamed colon, by its spasmodic contrac- 
 tion, prevents the discharge of the more healthy contents, which are 
 retained above the seat of disease; or they are passed very rapidly, 
 in a fluid state, whilst the pouches of the colon are filled with con- 
 solidated masses, which when discharged form the scybala previously 
 alluded to. 
 
 The cessation of the discharge of blood and of mucus, the absence 
 of tenesmus, and the presence of bilious fecal evacuation, are signs 
 of returning health. 
 
 The violent and often most distressing tenesmus is caused by the 
 involuntary action of the muscular fibres of the rectum, and by the
 
 306 ON DYSENTERY AND 
 
 abnormal sensibility of the lower bowel ; for where the latter part 
 is not affected the tenesmus is much less severe. 
 
 The sympathetic connection of the large intestine with the cerebro- 
 spinal system and with other organs, although of an intimate kind, is 
 less than that of the small intestine or of the stomach ; the function 
 of these parts is very different in relation to the vital processes. 
 The large intestine is an elongated receptacle for waste material ; it 
 is excretive in its function, although closely connected with the con- 
 dition of the blood, and affected by general causes; the small intes- 
 tine, on the contrary, whilst in part excretive, is more especially 
 connected with the absorption of nutritive substances, by its capil- 
 laries and its villi, and with the subsequent elaboration of chyle, by 
 means of the mesenteric and other glandular structures. Hence we 
 find less disturbance of the pulse, and of circulation generally, less 
 acute changes in the cerebral functions, and less modification of the 
 appetite, &c., in disease of the large than of the small intestine. The 
 urino-genital organs, however, sometimes sympathize in attacks of 
 dysentery, and we find the patient suffering from difficulty in mictu- 
 rition. 
 
 Cerebral symptoms have been described by many observers as 
 being present in the worst forms of dysentery, as stupor, delirium, 
 and typhoid symptoms closely resembling fever; but these symptoms 
 were not present in the cases that have come under rny notice, unless 
 associated with pneumonia; but it must not be forgotten that true 
 enteric or other fevers may be combined with dysentery. 
 
 Severe symptoms, indicative of great functional excitement of the 
 nervous system, were observed in the Millbank Penitentiary, such 
 as cramps, catalepsy, tetanus, &c. The peculiar condition of the 
 patients, depressed in mind, deprived of their wonted excitement, 
 and of the influence of their usual habits and associations, a spare 
 diet, &c., were probably, as Dr. Baly 1 states, the causes of the latter 
 symptoms. In some the cramps were as severe as in Asiatic cholera. 
 
 Intermittent and remittent fevers are sometimes associated with 
 dysentery, and increase the severity of the disease. Dr. MoreheaJ, 
 however, has rarely observed them. 2 
 
 Causes. Exposure to noxious and miasmatic effluvia appears to 
 be the most fertile source of the disease, especially when associated 
 with sudden changes in the temperature. If with the predisposing 
 cause of offensive effluvia there be associated exposure to cold and 
 wet, especially during the hours of night, if the common attendants 
 of poverty be present, as sleeping in damp rooms, clothing inadequate 
 to counteract the inclemency of the weather, diet improper and 
 scarcely sufficient to sustain life, intemperance, anxious and depress- 
 ing cares, we have ample exciting causes of dysentery; and many 
 of those who are thus attacked are also enfeebled by other disease, 
 as by struma, or phthisis. 
 
 The effluvia from drains and from decomposing organic substances 
 
 1 Baly on ' Dysentery.' ' Gulstonian Lectures.' 
 
 2 Morehead on ' Diseases of India.'
 
 CATARRHAL INFLAMMATION OF THE COLON. 367 
 
 are common causes of dysentery, and are sufficient alone to produce 
 the disease. 
 
 Dysentery often prevails after scarcity of food, and terrible mani- 
 festations of this fact have occurred in Ireland. The observations 
 there made by some of its most accomplished physicians, and the 
 valuable reports they have furnished, give some of the most faithful 
 descriptions which we possess of dysentery in its worst forms. I 
 refer to the labors of Drs. Mayne, Malcolm, Lalor, Harty, Young, &c. 
 
 In the active life of a soldier, especially in the tropics and in 
 marshy districts, these causes operate in all their intensity ; and the 
 disease thus manifested is more fatal than the field of battle itself. 
 Such has been the testimony of nearly all the writers on military 
 surgery and medicine. 
 
 Inflammation of the colon is, however, set up without any mias- 
 matic influence ; thus, from poisons, inflammation of the stomach 
 and the colon may be produced without the intervening small intes- 
 tine being affected ; so also from irritating ingesta and excretions 
 which appear in some instances to be the sole cause of the complaint. 
 Cold drinks in excess during summer heat also tend to produce dys- 
 entery. 
 
 Many believe in the contagious character of the disease. Thev 
 have found it to extend from one patient to another, to attendants, 
 or from house to house, &c. ; but it must be remembered, 1st, that 
 in many of these cases there is a general pervading atmospheric in- 
 fluence, miasmatic or otherwise ; 2d, that the effluvia from the dys- 
 enteric discharges are exceedingly offensive; 3d, that animal effluvia 
 are of themselves sufficient to induce the complaint ; 4th, that the 
 effect of night- watching, and of witnessing the rapidly fatal termina- 
 tion of the disease, is to depress the healthy tone, and weaken the 
 power of resisting the complaint. 
 
 The occasional similarity of dysentery to enteric fever, or the 
 occurrence of the two diseases at the same time and in the same 
 patient, do not warrant us in considering the one as of the same 
 character or type of disease as the other, namely, a blood disease 
 associated with special changes in the glands of the intestine. There 
 are few diseases that have not more or less of a constitutional origin, 
 and dysentery is doubtless of that character ; but while in some there 
 is evidence of a poison contaminating the blood, and leading to a 
 special train of symptoms, as in smallpox, or in pyaemia, there does 
 not appear to be any warrant for supposing that such is the case in 
 dysentery, more than in ulcerative stomatitis. Some cases of dys- 
 enterjr, as of pneumonia, doubtless arise from a diseased condition of 
 blood, whilst others are of a local character ; thus, pneumonia may 
 be produced by direct exposure to cold ; or, the blood may be in 
 such a condition from pyaemia and other septic changes, that it is 
 induced without any other exciting cause; in like manner some of 
 the cases of dysentery here recorded appeared to be produced by 
 irritation extending from the rectum ; others from direct irritation 
 caused by improper food ; while a third class arises from a morbid 
 condition of the whole circulating fluid.
 
 368 ON DYSENTERY AND 
 
 As far as our observations extend, we are disposed to agree with 
 the statements of Dr. Harty, in the 'Dublin Quarterly Review' 1st, 
 that genuine and simple dysentery is unattended with idiopathic 
 f jver, and is never of itself contagious ; 2d, that every form of the 
 disease when epidemic is a combination of simple dysentery either 
 with intermittent, remittent, or continued fever; and 3d, that the 
 form of dysentery which is combined with fever is alone contagious. 
 
 The Prognosis of dysentery is unfavorable when purging of blood, 
 and thin serous offensive discharge like the washings of meat con- 
 tinue ; when there is involuntary discharge from the bowels, with 
 great tenderness of the abdomen, vomiting, red and glazed tongue, 
 typhoid symptoms, irregular pulse, refusal of food, restlessness, and 
 great prostration of strength, or when these symptoms have con- 
 tinued for a considerable time, and one relapse has followed an- 
 other, without the patient in the interval regaining strength, but 
 retaining the same sallow and haggard expression ; when, also, 
 there are cerebral symptoms, as coma, delirium, or convulsions, we 
 judge unfavorably. On the contrary, when, on the removal of the 
 causes of the disease, the evacuations assume a healthy appearance, 
 and contain bile, when the pulse remains firm, and the prostration 
 becomes less, when the tenesmus ceases, and the patient gains 
 strength, we may give a cheering prognosis. 
 
 Diagnosis. There are several conditions which may, unless due 
 care be used, be mistaken for dysentery. 
 
 1. The discharge of blood from hemorrhoids, accompanied with 
 diarrhoea and prostration. Ordinary care alone is necessary to 
 guard against this error. 
 
 2. Disease of the rectum.^-The lower part of the rectum sometimes 
 becomes ulcerated, and leads to a discharge of mucus and blood with 
 tenesrnus, and with great anxiety and sympathetic nervous distur- 
 bance to the patient. It will be found in many of these cases, that 
 a small quantity of mucus or pus escapes from the rectum at irregu- 
 lar intervals. In organic constriction of the rectum, whether can- 
 cerous or otherwise, the bowels are sometimes in a loose condition. 
 
 8. Polypus in the rectum will produce like symptoms. Many of 
 these growths can. be detected by examination per rectum ; others, 
 however, are beyond the reach of the finger, and we can then only 
 decide by the clinical history of the case. In these instances healthy 
 feces are passed, but coated or followed by mucus or pus, and the 
 constitutional disturbance is less severe. 
 
 4. Fibro-celhdar ulceration. By this we mean a condition of rectum 
 which is not cancerous, but in which the mucous membrane is ulce- 
 rated and the coats of the intestine are converted into dense fibrous 
 tissue, and often syphilitic in its origin. 
 
 5. Some of the forms of diarrhoea resemble the earlier symptoms 
 of dysentery, but they are generally distinguished by the absence of 
 blood with mucus. In some cases, however, where there is disease 
 of the mesenteric glands, with persistent diarrhoea, and prostration 
 of strength, we are apt to believe that ulceration of the colon exists ; 
 the stools, however, are different; there is less of mucus, and no blood
 
 CATARRHAL INFLAMMATION OF THE COLON. 369 
 
 can be detected in the evacuation even by microscopical examina- 
 tion. 
 
 6. A feeble condition of the sphincter ani, and of the muscular coat 
 of the intestine, leading to the involuntary discharge of fluid feces, 
 might induce a belief in an abnormal condition of the mucous mem- 
 brane of the colon. 
 
 7. A mass of hard feces in the rectum which the patient is unable 
 to expel produces incessant straining, and is accompanied with the 
 almost constant discharge of mucus or fluid feces. This painful con- 
 dition is often mistaken for dysentery. 
 
 Treatment. Amongst the most important points for consideration 
 in the treatment of dysentery are the removal of all exciting causes, 
 and of the general conditions in which the disease has had its origin. 
 The patient should be clothed in flannel, and the temperature of the 
 body maintained, dampness and cold carefully warded off, improper 
 diet avoided, and, if possible, good and pure air inhaled. 
 
 Demulcents administered by the mouth have a long distance to 
 traverse before reaching the large intestine, but they nevertheless 
 act very beneficially by rendering the excreta poured into the colon 
 less irritating, and by thus soothing the diseased membrane. In this 
 way, arrowroot, linseed tea, mutton and veal broth, milk with suet, 
 rice milk, tapioca, &c., may be both grateful to the patient, and act 
 remedially, but fluid drinks should not be taken in great excess; 
 water alone has been used, although it is inferior to demulcent drinks. 
 By these simple means many attacks may be relieved, and the pa- 
 tients speedily recover. 
 
 The diet calls for much attention, equally in the early stages and 
 milder forms, as at a later period or in cases of a more severe char- 
 acter; but in the former it is often more difficult to persuade the 
 patient to follow our directions; being free from pain, the tongue 
 clean, the appetite craving, he does not at once see the importance of 
 using proper care. Any imprudence perpetuates and aggravates the 
 disease. Malt liquors and spirits should be abstained from. Meat 
 in a solid form is generally better avoided in the acute disease, but 
 when taken it should be in an easily assimilable form, and neither 
 richly dressed nor highly seasoned. 
 
 In protracted cases of dysentery, it is necessary to take animal 
 food, and it is very desirable in other ways to sustain the strength of 
 the patient as far as possible. For a short time, at least, it is well to 
 omit vegetables and fruit, especially when uncooked; but oranges, 
 grapes, &c., by supplying to the system that which is necessary for 
 the maintenance of sound action, without much indigestible product, 
 may sometimes be taken with great benefit in chronic dysentery, 
 although apples, and stone fruit, melons,. salads, &c., do harm. 
 
 Eest is important, and in very many cases the patient is too ill to 
 leave the recumbent posture; in the chronic disease also, fatiguing 
 muscular exertion and horse exercise must be avoided. It is useless 
 to attempt to treat a case of dysentery if the patient be allowed to 
 walk about, or to assume the erect position, for he ought to be per- 
 fectly quiet and in bed. 
 24
 
 370 ON DYSENTERY AND 
 
 Other remedies in most frequent use, have been opium, astringents, 
 both metallic and vegetable, ipecacuanha, mercurials, depletion, ene- 
 mata of various kinds, &c. 
 
 Opium is of almost universal application, but it cannot be given 
 indiscriminately, either alone or in combination; it acts partly by its 
 astringent properties, and partly as a narcotic, by its secondary influ- 
 ence upon the inflamed mucous membrane, through the sympathetic 
 system of nerves. It is often administered alone, but more frequently 
 m combination with ipecacuanha, as in Dover's powder; or with as- 
 tringents, as in the compound infusion of krameria, or compound 
 logwood mixture of Guy's; or in combination with mercurials, as 
 calomel and gray powder; and lastly, in enemata. When the excreta 
 are depraved, and cause irritation of the intestine by their presence, 
 no beneficial result is attained by seeking to check their removal by 
 astringents. 
 
 Mercurials. Calomel has been very largely and notoriously ad- 
 ministered in dysentery. In India 3j doses are described by Annesley 
 as productive of essential benefit ; others have now given up its use 
 altogether, in the severe dysenteries of the East. Its administration, 
 in more moderate doses, is often advantageous. In the earliest stages, 
 where the motions are of an unhealthy character, pale, or containing 
 hard and scybalous masses, it may be well to give a dose of calomel, 
 or of gray powder, followed by castor oil, guarded by opium ; or the 
 opium may be combined with the mercurial, as calomel with opium, 
 or gray powder with Dover's powder; in this way offending sub- 
 stances may be removed, and acrid excretions rectified and corrected ; 
 but it is, we believe, unwise and uncalled for, to persist in the use of 
 mercurials. We have no facts to show that the inflammation of the 
 mucous membrane is diminished by its action, but rather that it is 
 increased, and ulceration accelerated, although the abdominal glands 
 may be stimulated to a more healthy action. 
 
 Purgatives. Almost the same may be said of these remedies, as 
 of mercury. In the earlier stages of dysentery and dysenteric diar- 
 rhoea, when oftentimes irritating and crude materials are retained, 
 and equally irritating secretions are poured out, purgatives are of 
 great value; castor oil and linseed oil, with tincture of rhubarb, and 
 with small doses of tincture of opium, are old and valuable remedies 
 for this purpose. They may be repeated several times during the 
 day, with manifest improvement of the alvine evacuations, and relief 
 to the tenesrnus and the pain. This administration of a laxative 
 draught, followed by a full dose of Dover's powder, or chalk with 
 opium is the best treatment for ordinary dysentery at its onset. 
 Violent purgatives are, however, neither beneficial nor warrantable. 
 Ipecacuanha was introduced into Europe as a remedy for dysentery, 
 nearly 170 years ago, and has been used with success since that time; 
 large doses have been given without producing vomiting, as by Sir 
 J. Pringle, in gr. v, to 9j, and by Mr. Twining, with extract of gentian; 
 but much smaller doses are equally effective. Ipecacuanha appears 
 to have the same beneficial action in inflammation of the alimentary 
 as of the respiratory mucous membrane, in relieving the congestion,
 
 CATARRHAL INFLAMMATION OF THE COLON. 371 
 
 and in restoring healthy secretion. It is one of the most valuable 
 remedies in acute dysentery, and much larger doses can be tolerated 
 by the stomach if given soon after nourishment. It has been given 
 in various combinations, frequently with opium, and with vegetable 
 astringents, as kino, krameria, logwood, catechu, &c. 
 
 Astringents are of greater value in chronic than in acute dysen- 
 tery ; sulphate of copper, acetate of lead, oxide and nitrate of silver, 
 nitrate of bismuth, sulphate and pernitrate of iron, have all been used; 
 several of these act by their direct astringent property, others be- 
 come absorbed and are sedatives to the mucous membrane ; some of 
 these remedies have been used in combination with opium, as copper 
 and lead; others with considerable success as injections, and in that 
 way applied directly to the diseased surface; thus nitrate of silver 
 has been used as an enema by Trousseau, in the proportion of gr. x 
 to xv to a pint of distilled water ; so also borax in about 9j doses ; 
 in some cases I have used charcoal, 3ij, with Oss of thin gruel, with 
 evident relief. 
 
 Vegetable astringents are valuable remedies in the chronic disease, 
 and even in the acute stage after the removal of irritating excreta 
 and scybala, as krameria, kino, logwood, and catechu, tormentilla, 
 and sirnaruba; they are of especial service when given in combina- 
 tion, as ipecacuanha with catechu and krameria (Infusum Krameriae 
 Compositum. Ph. Guy's). Cusparia is a more stimulating astringent 
 and tonic, and is often of great benefit after the more active symp- 
 toms have subsided. Tannin and gallic acid have been used, and 
 may be given advantageously in doses of "ixx-xxx of the solution 
 in glycerine, with tt^x-xx of spirit of chloroform and water. The 
 rind of the pomegranate root is a favorite remedy with some, but it 
 is a less effective astringent than others just mentioned. I have tried 
 the Indian Bael in many instances of chronic dysentery, but I have 
 not seen it followed by the benefits which were anticipated from the 
 high encomiums given to it by practitioners in India. The solution 
 of potash, as well as the bicarbonate of potash, and the correspond- 
 ing preparations of soda, diminish intestinal irritation in the acute 
 disease ; they are best given, however, in combination with opium, 
 or henbane and astringents. 
 
 Earthy astringents. Chalk, alone or combined with opium and 
 astringents, is one of the ordinary remedies at the outset of dysen- 
 teric diarrhoea, and is frequently sufficient to check the purging; 
 but in many cases no form of astringent or sedative will serve to 
 restrain this symptom, whilst irritating excreta and other substances 
 are retained; and in others, so great is the extent of the disease, 
 that it is futile to attempt to check it by a grain or two of medicine 
 which acts locally, whilst the disease extends over many feet of 
 intestine. By demulcents, by removing the cause of the disease, by 
 rest, by correcting the general disturbance, and by sustaining the 
 patient during the degenerative changes which are in operation, we 
 must seek to shorten the morbid process and to restore health. 
 
 Mineral acids. After the urgency of the symptoms have subsided, 
 mineral acids, both sulphuric and nitric, appear to act beneficially
 
 372 ON DYSENTERY AND 
 
 on the mucous membrane in restoring healthy vigor. I have not 
 found the benefit from dilute sulphuric acid that some practitioners 
 have observed; still it is a remedy of value, and well deserves a 
 trial; and in chronic dysentery the nitric and nitre-hydrochloric 
 acids are often of service when combined with opiurn, and with the 
 milder vegetable astringents. Quinine. The combination of quinine 
 with Dover's powder, or with mineral acids and astringents, is pro- 
 ductive of considerable relief in those cases of chronic dysentery 
 which have been perpetuated and aggravated by residence in mias- 
 matic districts. 
 
 Warm enemata often afford very great relief by washing out the 
 lower part of the rectum, and by soothing the inflamed membrane; 
 in this way gruel, thin starch, and barley water may be used with 
 much relief; but their efficiency is increased by the addition of 
 tincture of opium. Borax and nitrate of silver are used, as we have 
 before mentioned, and sometimes charcoal; these agents and vege- 
 table astringents, as oak bark, have been more especially tried in 
 chronic dysentery. 
 
 Suppositories, composed of opiates or anodynes, or bismuth, afford 
 much relief to the tenesmus, but are less effective than enemata. In 
 the constipation which follows the cicatrization of dysenteric ulcers, 
 much relief is afforded by the use of sedatives with aperient medi- 
 cine, as by the colocynth and henbane with ipecacuanha, and by 
 belladonna with rhubarb and capsicum. 
 
 A change to more genial climate is often productive of the most 
 beneficial result; this applies especially to residents in India, and 
 to those who have contracted dysentery in our own country in damp 
 and miasmatic districts. 
 
 The following 39 fatal cases of dysentery were, with one. or two 
 exceptions, produced in our own country, and will illustrate the 
 causes of death in this disease; they indicate, 
 
 I. That dysentery of a most severe form arises in our own country, 
 and is not of unfrequent occurrence. 
 
 II. That the cause of death in some is the extent and severity of 
 the affection. 
 
 III. That others die from perforation and fecal abscess. 
 
 IV. That suppuration in some of the branches of the portal vein 
 and hepatic abscess follow some of the worst forms of English 
 dysentery. 
 
 V. That the constriction of the intestine sometimes leads to abscess 
 in the parietes and to artificial anus. 
 
 VI. That in the worst cases astringents and opiates are ineffective. 
 
 VII. That injections and demulcent remedies afford considerable 
 relief, and in mild cases will alone be sufficient ; but are inferior in 
 their efficacy to astringents and opium. 
 
 VIII. That rest even in mild cases is desirable. 
 
 Many cases have presented themselves, in my own practice and 
 spheres of observation, where these means checked the purging, and 
 restored health. 
 
 IX. That as far as can be judged, mercurial preparations, if con- 
 tinued, would have been injurious.
 
 CATARRHAL INFLAMMATION OP THE COLON. 
 
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 CATARRHAL INFLAMMATION OF THE COLON. 375 
 
 CASE CXXVII. Inflammation of Colon. Diphtheria of the Pharynx 
 
 Harriet S , aet. 28, was admitted July 18t'-, 1855, under my care. 
 
 She was a pale, thin woman, who had resided in the Borough, the wife of 
 a butcher, and she had been out of health for six months, with occasional 
 diarrhoea ; but during seven weeks she had become much worse. Her illness 
 came on after exposure to cold on entering a new house; she had great lassi- 
 tude, weariness, and severe pain in the limbs. These symptoms "increased, 
 and she was admitted into St. Thomas's Hospital, and whilst there she passed 
 blood and mucus from the bowels. She stated that her family were healthy, 
 but that she had previously had an attack of inflammation of the bowels. On 
 admission she had the appearance of a patient suffering from acute pneumonic 
 phthisis; the lips and nostrils were thin; the cheeks were sunken; the skin 
 was hot and clammy; the conjunctiva and skin generally were of a very 
 slight jaundiced color. Along the gums was a pale red line; the tongue was 
 coated with a yellow fur, dry and brown,' and at its centre there were several 
 aphtlious patches; the throat was dry and injected; she complained of diffi- 
 culty in swallowing, and it was painful to her to speak much. The pulse 
 was 112, soft and full. In the abdomen a large mass of the form of the liver 
 could be felt, extending nearly to the crest of the ileum, and across the 
 umbilical region. The abdomen was flaccid, but slightly tender on manipu- 
 lating the right hypochondriac region. The motions were passed involun- 
 tarily, and were slimy and of a green color; three or four were passed in an 
 hour. She was treated with astringents and opium, but gradually became 
 more prostrate, and died on the 23d. 
 
 On inspection, the pharynx, the posterior part of the tongue, the tonsils, 
 and the anterior part of the epiglottis were covered with a yellowish-white 
 crust ; this was very adherent to the lateral portions of the root of the tongue ; 
 and on the glossal surface of the epiglottis this membrane was so fixed that 
 it could not be washed off by water. The surface of the epiglottis beneath 
 it was much injected, but only towards the tongue. On examining a portion 
 of this substance it was found to consist of delicate interlacing torulae, some 
 jointed, and much resembling the torula cerevisia?; it was mixed with par- 
 ticles of fat. The larynx, internal surface of the epiglottis, trachea, and 
 bronchi were all free from disease. The lungs were healthy, so also the 
 pleura. The muguet did not extend to the resophagus, excepting at its upper 
 part. The heart and pericardium were healthy. 
 
 Abdomen There were old adhesions of the omentum. The stomach was 
 healthy, and on microscopical inspection its follicles were full of secreting 
 cells and granules, with a small quantity of highly refracting particles. The 
 liver extended to the right iliac region; it was exceedingly fatty, of pale 
 yellow color, and lighter than water. The gall-bladder was contracted and 
 empty; the weight of the liver 8 Ib. 6 oz. Spleen, corpuscles distinct, its 
 weight C>^ oz. 
 
 The peritoneum was healthy; there was a moderate amount of fat in the 
 mesentery, and the glands near the caecum were enlarged and somewhat 
 swollen. The intestines were moderately distended. On opening the colon 
 it was found to contain fluid feces; the whole mucous membrane was covered 
 by an adherent whitish layer, having a granular, almost villous appearance; 
 it was of a )ellowish-red color, which was more marked towards the rectum; 
 the mucous membrane was swollen, and in some parts presented small aphtlious 
 ulcers about a quarter of an inch in diameter. The submucous cellular tis- 
 sue was white and thickened; the muscular coat also appeared very thick 
 and distinct. The false membrane consisted of a blastema containing gran- 
 ules, highly refracting particles, and some cells, but no well-marked cells nor
 
 376 ON DYSENTERY AND 
 
 epithelium. The last foot of the ileum was much injected, and presented 
 M-vcral irregular ulcers, but no membrane similar to that in the ca-cum and 
 colon. 
 
 The kidneys were pale and large, their weight 11 oz. The uriniferous 
 tubes contained granules and oil particles. 
 
 This case of acute inflammation of the colon carne on gradually. 
 For six months the patient had attacks of diarrhoea, but for seven 
 weeks the symptoms were severe, and of the character of dysentery ; 
 the motions contained blood and mucus, and became afterwards green 
 and slimy. On admission into Guy's Hospital she was in a typhoid 
 condition, and almost dying. Her general appearance resembled a 
 case of pneumonic phthisis with dysentery, but there was no physi- 
 cal signs of phthisis. The astrjngents which were administered af- 
 forded only very temporary relief, and opium quickly produced torpor 
 the brain. 
 
 CASE CXXVIII. Diphtherite of the Colon. Dysentery. Chorea ' 
 Elizabeth H , aet. 7 years, was admitted into Guy's, February, 18^5. She 
 was a dark, strumous child, who five weeks previously, without apparent 
 cause, became affected with chorea; she improved under the use of sulphate 
 of zinc gradually increased, and purgatives had been required, for the bowels 
 were generally constipated. A few days before death diarrhoea came on with 
 prostration, and with symptoms very much resembling Asiatic cholera; the 
 motions consisted at first of blood and mucus, but afterwards of thin and 
 watery fluid. On the seventh day after the onset of the purging the child 
 died. 
 
 Inspection The eyes were much sunken. The cerebral veins were full 
 of partially decolorized clot, and the ventricles of the brain contained more 
 than the normal quantity of fluid. The lungs appeared healthy, except a 
 circumscribed patch at the middle of the\ left lung, where was a strumous 
 mass about the size of a hazel-nut, and some tubercles around it. The inner 
 aspect of the mitral valve was fringed with minute vegetations, firm, semi- 
 transparent, and surrounding the edge of the valve; the largest of them was 
 of the size of a pin's head. The inner surface of the tricuspid was slightly 
 roughened. The pericardium was healthy. The weight of the heart was 
 3 oz. 
 
 The stomach was healthy. In the jejunum a few of Peyer's patches were 
 visible and were injected ; in the ileum they were very distinct, and near 
 the caecum were covered with a delicate inflammatory deposit of lymph. 
 The large intestine was diseased throughout. The whole of the mucous 
 membrane was of a dark-green color, covered with a firm granular deposit of 
 lymph. The disease increased in severity from the caecum downwards. The 
 crecum was acutely inflamed, being of a red color, and the mucous membrane 
 was entire. Lower down the mucous membrane became green, and was 
 covered with inflammatory deposit ; and in the rectum the inner surface was 
 raised into folds or irregularly shaped eminences. In the descending colon, 
 when the adventitious product was removed, the tissue was seen to be swollen, 
 full of blood, and in some parts superficially ulcerated. The muscular coat 
 was much thickened. The kidneys were healthy. 
 
 This case was supposed to be one of Asiatic cholera, and, unless a 
 careful inspection had been made, it might have been so recorded. 
 The suddenness of the diarrhoea, the rapid collapse and prostration,
 
 CATARRHAL INFLAMMATION OF THE COLON. 377 
 
 closely resembled that disease. Other cases of cholera had occurred 
 about the time. The treatment used starch and opium injections, 
 &c., did not appear to have any effect upon the malady. 
 
 CASE CXXIX. Inflammation of the Colon. Hernia Ann H , aet. 60, 
 
 was a single woman, a servant, who had resided at Peckham, and she was 
 admitted into Guy's Hospital February 6th, 1857. For ten years she had 
 had hernia, but her general health was good. Five days before admission 
 the hernia came down, she was seen by a practitioner, and after taking croton 
 oil, various purgatives, shot, &c., was admitted into Guy's. She was much 
 depressed and collapsed; the symptoms were constipation, stercoraceous vomit- 
 ing, great pain in the abdomen, and some tenderness. A tolerably large 
 femoral hernia was found in the right inguinal region. A grain of opium 
 was given at once, and the hernia was reduced by taxis without difficulty. 
 On the following day, the 7th, the bowels were opened, and the patient felt 
 better. A grain of calomel and one of opium were administered, and repeated 
 every four hours ; and she was allowed beef tea. The diarrhoea continued 
 notwithstanding the use of various remedies, and she died from exhaustion 
 on the nineteenth day after the commencement of the illness. For some time 
 before death there was low muttering delirium, cold extremities, and an 
 almost imperceptible pulse. 
 
 Inspection was made a few hours after death. The body was much wasted, 
 and the eyes were sunken. The lungs and pleura were quite healthy, and 
 the lungs were collapsed ; the heart was small. 
 
 Abdomen The peritoneum was healthy ; the oesophagus was normal, so 
 
 also was the stomach ; the jejunum was congested, the valvulae conniventes 
 were covered with mucus. Eight feet from the caecum a portion of the ileum 
 about four inches long was of a deep purple color, and had evidently been 
 strangulated ; it appeared to be recovering. Below the strangulation the 
 ileum became much more congested, and for four feet from the cjecum the 
 intestine was acutely inflamed ; the mucous membrane was covered by a 
 yellowish-green adherent exudation, nearly a line in thickness, which was 
 with difficulty removed. The valvulae conniventes were exceedingly promi- 
 nent, rigid, and erect. The whole of the mucous membrane was much thick- 
 ened, the muscular coat more than a line in thickness, and the areolar tissue 
 very osdematous. 
 
 Section of the mucous membrane of a portion of the ileum in acute inflammation of the colon and 
 ileum, showing the surface covered with false membrane (diphtherite) and continuous with 
 mucous follicles. 
 
 On making a section of this portion of intestine, the exudation was found 
 to consist of cells and granules, and appeared to be quite continuous with the 
 follicles of the mucous membrane (LeiberkUhn's ; these follicles were
 
 378 ON DYSENTERY AND 
 
 ingly distinct, and were evidently distended to the utmost. It appeared that 
 the secretion from these follicles was changed by the diseased action, that it 
 was excessive in quantity, and abnormal in quality ; the form of the follicles 
 was retained by the exudation on the surface, as if it had been exuded 
 rapidly. The submucous cellular tissue was much thickened from inflam- 
 matory oedema. 
 
 The colon from the caecum to the rectum was still more diseased ; in the 
 caecum the mucous membrane had a reddish-gray color, with minute highly 
 injected points studding the surface ; some of these points presented a darker 
 colored centre, others were scarlet. In the place of others were minute 
 ulcers ; the mucous membrane being eroded ; the edges of the ulcers were 
 injected ; their surface whitish-gray, but there was no apparent slough. 
 In the ascending colon more of the mucous membrane was destroyed, and 
 elongated ulcers were found, about half an inch in length, with irregular, in- 
 jected or partially undermined margins, their base consisting of whitish 
 lymph-like exudation ; between these ulcers there were minute red points or 
 red mucous membrane covered with exudation. The whole of the colon 
 presented a similar appearance, even to the rectum. The appendix casci was 
 long, and at its extremity were about a half a dozen small shot. 
 
 The examination of the mucous membrane of the cajcum showed that the 
 minute red points were solitary glands. (The cut represents one of these red 
 
 Section of a solitary gland from tlie caecum, from the same, showing (a) the edges of a raised 
 portion intensely injected from distended capillaries ; (6) surface of mucous membrane covered with 
 diphtheritic granular membrane; (c) opening into the gland ; (d) small phosphatic crystals. 
 
 glands, having a deeply colored centre). The portion above the level of the 
 mucous membrane showed distended capillaries, and there was in the centre 
 an opening extending into the gland. In the gland were minute nuclei, and 
 a large nucleated cell was observed. It appeared probable, from the darker 
 color of the congested part, that the circulation in these capillaries had nearly 
 ceased, and that in a short time sloughing would have taken place. The 
 adjoining mucous membrane presented an appearance somewhat similar to 
 that found in the ileum, but the follicles were less distinct. Some crystals 
 were observed on the surface. 
 
 The liver was healthy, so also the spleen, kidneys, bladder, uterus, ovaries, 
 and the mesenteric glands ; in fact no disease was found except in the intes- 
 tines. The hernial sac was empty, and its opening nearly closed. 
 
 In this case there was acute inflammation of the whole of the 
 colon, and of several feet of the ileum; the changes were of a de- 
 generative kind, and rapid in their action. Was the disease dysen- 
 tery, or inflammation of a different kind ? In the caecum and colon 
 we found that the solitary glands were diseased, and that destruction
 
 CATARKIIAL INFLAMMATION OP THE COLON. 379 
 
 of the membrane had ensued ; but these glands were not the only 
 parts affected, the follicles and all the structures were diseased, as 
 we found with the follicles in the ileum ; the mucous membrane 
 and the muscular coat were oedematous. Very drastic purgatives 
 and violent means had been used at the onset of the disease, and 
 these probably contributed to the severity of the affection. The 
 bowels began to act very shortly after the 'hernia had been reduced, 
 and did not cease to act till death. As to the symptoms, they were 
 those of dysentery ; the stools consisted of blood and mucus, the 
 prostration became gradually extreme, the pain was sometimes 
 severe, but the patient did not suffer from the tenderness of perito- 
 nitis. The disease was probably, to a great extent, constitutional in 
 its character, but it was excited by direct irritation. 
 
 CASE CXXX. Dysentery. Ulceration of the Small Intestines. Perfo- 
 ration. Fecal Abscess. Peritonitis Edward B , aet. 39, was admitted 
 October 19th, 1853, and died November 8th. He had been a stout, hearty 
 man, living at Walworth, and a laborer in the London Docks. His health 
 had been unimpaired, and his habits of life regular. Six weeks before admis- 
 sion, he ate a considerable quantity of coarse sugar, and three days afterwards 
 he had diarrhoea, with copious liquid evacuations, and severe colic. This 
 state continued till admission ; he had become thin and weak, having been 
 unable to take any food since the commencement of his illness. On admis- 
 sion, the bowels acted every half hour. The evacuations were of a dark- 
 brown color, and no blood was passed. There was tenderness over the caecum 
 and descending colon ; he had no appetite, the mouth was dry and parched, 
 and he had considerable thirst ; he had nausea, but did not vomit. The 
 countenance was dejected, and the body emaciated and feeble. 
 
 The heart and lungs appeared to be healthy. The tongue became very red 
 and injected. Great prostration came on, and sordes formed on the teeth, 
 the purging continuing unabated. Kino, cusparia, opium, gallic and sul- 
 phuric acids, &c., were administered, with only slight relief. 
 
 Inspection eighteen hours after death. Chest With the exception of 
 calcareous induration at the right apex, the thoracic viscera were healthy. 
 The abdomen was collapsed. The intestines were contracted, but there was 
 universal moderate injection of the peritoneum, and the coils of the intestine 
 were united by h'brinous adhesions. On separating the abdominal parietes 
 from the sigmoid flexure, a part of the intestine was found to be perforated, 
 and all its coats destroyed for a considerable part of its circumference ; a 
 small fecal abscess had been formed. At the caecum also and rectum, ex- 
 travasation of feces was only prevented by external adhesions. The large 
 intestine was ulcerated in its whole length ; at the caecum were several trans- 
 verse patches of ulceration ; immediately above the caecum the mucus and 
 muscular coats were much thickened, apparently from older disease; beyond 
 this the mucous membrane presented a large slough, and nearly all the 
 mucous membrane was destroyed. Here and there were granular masses 
 like tubercles, or large portions which had become intensely congested, and 
 were raised above the ulcerated surface, giving it a polypoid appearance. The 
 sigmoid flexure and rectum were equally ulcerated ; in some parts the mucous 
 membrane only was destroyed, in others nearly all the coats. In the small in- 
 testine, about 8 inches from the caecum, the lining membrane was intensely 
 congested, and Peyer's glands presented several small aphthous old 
 The columnar epithelium was scanty, but numerous cells like mucus were
 
 380 
 
 observed. The mesenteric glands were enlarged. In the stomach were 
 several points of arborescent injection. The spleen was healthy ; the liver 
 fatty, and its weight was 4 Ibs. ; the gall-bladder was moderately distended. 
 
 The destruction of the mucous membrane of the colon in this case 
 was very great, both as to extent and depth ; fecal abscess had been 
 formed subsequent to the perforation. The disease lasted nearly 
 nine weeks, and the remedies did not at all check the symptoms. It 
 is probable that on admission (for the disease had then continued 
 for six weeks) considerable sloughing of the colon existed. 
 
 There was no evidence of any miasmatic influence nor noxious 
 effluvia, but the diarrhoaa and subsequent dysentery were produced 
 by the foolish excess of the patient. 
 
 CASE CXXXI. Ulceration of the Large Intestine. Perforation. Sub- 
 mucous suppuration. Pus in the Portal Vein, and Inflammatory Patches 
 
 in the Liver James T , set. 59 was admitted into Guy's October 12th, 
 
 1853, and died on the following day. He was a laborer in the London 
 Docks, and had had " bowel complaint" for two months ; the symptoms had 
 gradually become worse, and a week before his death he was confined to his 
 bed ; he had repeated purging of blood, and became much emaciated. 
 
 On admission the abdomen was tumid and tympanitic, but tolerant of pres- 
 sure; the skin was of a dingy color, an'd the tongue was red, glazed, and 
 dry; he was in a prostrate condition, and died the following morning. 
 
 Inspection fifty-seven hours after death. The body was spare. Chest 
 The pleura at the left apex presented a little cartilaginous thickening. There 
 was a white patch over the ventricles of the heart, the right side was distended 
 with clot, the left was empty; the mitral valve was thickened and slightly 
 contracted. 
 
 The peritoneum was universally inflamed, injected, and covered with 
 effused lymph. The cavity contained dirty fluid, green in color and of an 
 offensive feculent odor. On turning aside the large intestine, an opening was 
 found above the caecum. The whole length of the large intestine was ulce- 
 rated. These ulcers were transverse, and were generally about two inches 
 in length. The mucous membrane was ragged, and covered with a black 
 slough ; the circumference of these ulcers was thickened. In some parts the 
 mucous membrane was quite destroyed, and the intervening portions of 
 mucous membrane were oedematous. The peritoneal surface of the large 
 intestine was observed to be here and there of a yellow color; on making a 
 section at these parts, the subserous coat was found to be infiltrated with pus 
 extending from the submucous coat. These abscesses were situated on the 
 mesenteric side of the intestine. The mucous and muscular coats of the 
 rectum were much thickened, and at the lower part of the descending colon 
 was a puckered portion of intestine, ecchymosed and injected. 
 
 The small intestines were healthy. The stomach presented partial injec- 
 tion. The spleen and kidneys were healthy. The liver showed a thickened 
 layer of peritoneum at its lower border (attrition). On the convex surface 
 of the right lobe was an irregular congested portion about one inch in dia- 
 meter, and at its centre was a branch of the portal vein filled with pus. 
 Glisson's capsule was thickened; no apparent disease of the trunk of the 
 portal vein nor of the inferior mesenteric vein existed ; the liver generally 
 was fatty; weight 3 Ibs. 10 oz. 
 
 This was one of the most severe cases of inflammation of the in- 
 testine that I have seen ; large ragged abscesses extended throughout
 
 com- 
 
 CATARRHAL INFLAMMATION OF THE COLON. 
 
 the colon, and had led to perforation and to peritonitis. The - 
 mencing suppuration in the liver, and the pus in the portal vein 
 were confirmatory of the views first propounded by Dr. Budd and 
 now generally admitted, as to one of the causes of abscess of the liver 
 When admitted into Guy's the patient was in a dying condition but 
 the disease had existed for two months. 
 
 CASE XXXII. Dysentery. Perforation of Colon __ Sarah W , set. 34, 
 was admitted into Guy's Hospital April, 1874, after having been ill for three 
 months, and severely so for three weeks. She had resided at Huntingdon, 
 then at Lambeth, and was the wife of a fishmonger. Three months" pre- 
 viously she had had pitchy evacuations, evidently containing blood; but she 
 had been free from pain. Three weeks before admission she had profuse 
 purging; the evacuations contained blood, and scarcely any solid feces ; she 
 suffered much tenesmus and general pain in the abdomen; the pain was 
 occasionally aggravated, but was especially situated in the right iliac fossa. 
 Scybala were occasionally passed. There was febrile excitement, and before 
 death vomiting came on. 
 
 She took opium alone, then lead, ipecacuanha, and copper; mercurial in- 
 unction was used; leeches and blisters, &c., were applied to the abdomen. 
 Wine and suet and milk were administered. 
 
 Inspection The body was well nourished, and there was a considerable 
 amount of fat in the abdominal parietes. On opening the peritoneum, it was 
 found to be exceedingly dry; the transverse colon was adherent to neighboring 
 viscera by soft adhesions; the omentum extended to the pelvis, and on raising 
 it soft adhesions were found between it and the intestine, which were also 
 much injected at their points of contact with each other. In the left iliac 
 region, on drawing aside the sigmoid flexure, soft adhesions gave way, and 
 a small circular perforation was found; no extravasation had taken place. 
 In the right iliac fossa, the caecum was more firmly adherent ; and close to 
 the union of the vermiform appendix a long defined opening was observed, 
 but closed by adhesions. 
 
 There were also several perforations in the ascending and transverse colon 
 similarly closed; in other parts the peritoneum only was left. Perforations 
 had also taken place in the rectum, but no extravasation had followed from 
 any part. The vermiform appendix was healthy. The caecum and ascending 
 colon were distended and thickened. 
 
 On opening the whole length of the large intestines, the following appear- 
 ances presented themselves : Portions of mucous membrane which had escaped 
 ulceration were softened, and were of a greenish or red color ; large trans- 
 verse ulcers were found at other parts, their margins were defined ; in some 
 the peritoneum formed the base, and in nearly a dozen places the peritoneum 
 also was destroyed. Hard, dry scybala adhered in some parts. About six 
 inches above the caecum the intestine appeared somewhat contracted, and 
 large pouches were formed both above and below. The small intestines were 
 pale and no disease was observed in them ; they contained fluid feces. The 
 mucous membrane of the stomach was thickened and softened. The liver 
 was pale and soft. The gall-bladder was much contracted and adherent to 
 the colon ; it contained a small quantity of white, thick mucus, and crystals 
 of cholesterine ; the duct was blocked up by a gall-stone, which was about 
 half an inch in circumference. The spleen was larger than natural and it 
 was softened. The kidney presented an irregular contraction on its surface. 
 
 The lungs were emphysematous ; one or two consolidated lobules were
 
 382 ON DYSENTERY AND 
 
 situated at the apex. The heart was flabby; but, with the exception of slight 
 atlieroma, the valves were healthy. 
 
 In this case the most severe inflammation of the colon had been 
 set up, the coats of the intestine had sloughed, and numerous perfo- 
 rations had resulted. The disease had lasted for three months; but 
 a short time before admission it became much aggravated. It could 
 scarcely be expected that the administration of small doses of astrin- 
 gents could check such extensive degeneration; and it was evident 
 that the patient died, not from exhaustion, but from the severity of 
 the disease, and its extension to the peritoneum. 
 
 CASE CXXXIII. Chronic Bronchitic Phthisis. Cirrhosed and Larda- 
 ceous Liver. Contracted Abscess of Liver. Chronic Dysentery, and 
 Chronic Peritonitis. Thomas R , aet. 31, a soldier, or rather pensioner, 
 was admitted under my care Oct. 24th, 1856. He had been in the West 
 Indies as a soldier, and had been exceedingly intemperate in his habits, 
 spending all his money in rum, &c. He stated, however, that till three years 
 previously he enjoyed good health, but had had syphilis six or seven times, 
 and had been salivated five times ; and that when a child he had had ague. 
 
 Two and a half years before, while serving in Bermuda, he was exposed 
 to cold at night ; the following morning he had severe cold and cough ; but 
 did not report himself as ill for six months, having then gradually become 
 much worse. At that time he spat blood, and had night sweats, and had 
 great pain in the precordial region. He remained in hospital for nine 
 months, and left very little relieved. He subsequently went to the Crimea, 
 but was at once invalided, and sent to Scutari. Sixteen days before his 
 admission into Guy's his ankle became swollen, and dropsy rapidly increased. 
 
 He was a tall, emaciated man, with an exceedingly anxious, haggard ex- 
 pression ; the nails were clubbed ; the respiration was difficult and hurried ; 
 and he was almost in a dying condition. He complained of pain in the 
 chest and abdomen ; the respiration was 24 per minute, and he expectorated 
 much thick, greenish and rusty-colored mucus. 
 
 There were signs of advanced phthisis in both lungs. The abdomen was 
 hot and distended ; the superficial veins were enlarged ; fluctuation was very 
 perceptible ; the bowels were relaxed ; urine high-colored, non-albuminous, 
 sp. gr. 1.012. He gradually sank. 
 
 Inspection, Nov. 3d The body was much emaciated. The abdomen was 
 distended, but the enlargement of the superficial veins had disappeared. 
 Chest The lungs presented advanced disease, with some recent pneumonia. 
 
 Abdomen The peritoneum contained several gallons of fluid ; the intes- 
 tines were moderately distended. The peritoneum was opaque, slightly 
 granular, and very delicate bands were found between the intestine. The 
 liver was much contracted, nodulated, and its surface was opaque. On sec- 
 tion, an irregular cheesy mass was found, about three inches in length, ex- 
 tending from the surface of the liver into its substance, and surrounded by 
 slight fibrinous investment ; the surface was contracted. This mass appeared 
 to consist of two or three collections appended the one to the other. There 
 were numerous other small cheesy masses of smaller size, situated throughout 
 the liver, in the course of the portal branches. They were all apparently the 
 result of inflammatory action, or dried abscesses. The rest of the liver was 
 Bemi-transparent, and in many parts was lardaceous. The gall-bladder was 
 contracted. The spleen was enlarged and lardaceous. The kidneys were 
 healthy.
 
 CATARRHAL INFLAMMATION OF THE COLON. 383 
 
 Colon The whole of the colon presented irregularly healed ulcers, and 
 was granular and thickened ; and scarcely any healthy mucous membrane 
 was observable. Small circular, smooth spaces, evidently healed ulcers, 
 studded the whole surface. The coats of the intestine were thickened. The 
 ileum and stomach were healthy ; so also were the kidneys. The omentum 
 was adherent near the inguinal canal on the left side. 
 
 The original malady appeared to have been dysentery, contracted 
 in the West Indies, and it was followed by abscesses in the liver; 
 these abscesses dried, and probably constituted the cheesy masses 
 found after death, affording a remarkable instance of abscess of the 
 liver, and perhaps of pyasmia not at once fatal. The intemperate 
 and dissolute habits of the patient set up chronic fibroid disease in 
 the lungs. The lardaceous state of the liver was interesting in its 
 connection with syphilis and struma. The colon was filled with 
 cicatrices ; and they had led to partial obstruction, as shown by the 
 hypertrophy of the intestinal coats. 
 
 CASE CXXXIV. Chronic Dysentery. Hepatic Abscess. Pyeemia. 
 Abscess in the Brain and Lung Thomas D , aet. 25, was admitted Febru- 
 ary 14th, and died March 19th, 1855. He was a sailor, and had been for 
 two years in the East Indies. At Burmah he had ague and dysentery, 
 and was ill for several weeks ; and for two months he had had pain in the 
 side. , 
 
 On admission, he was sallow and generally cachectic. There was pain in 
 the right side ; the chest was dull ; and it was supposed from the history that 
 he had abscess in the liver. 
 
 On February 21st, when sitting by the fire, he fell down in a fit, and was 
 convulsed for several days ; he continued in a semi-conscious condition. On 
 the 28th, he could speak and give his name ; he continued apparently to im- 
 prove till the 14th, when he again fell into a semi-conscious state. On the 
 1 Gth he was able to sit up and take his breakfast ; but shortly afterwards 
 became quite insensible ; and had stertorous breathing, which continued till 
 death. It was observed throughout, that the right leg was weak, and at last 
 was paralyzed ; the right pupil was smaller than the left ; but a few hours 
 before death it became widely dilated. 
 
 Inspection twenty-four hours after death. Brain. The surface of the 
 hemisphere was dry; and at the base were slight adhesions between the 
 surfaces of the arachnoid. In the posterior lobe of the left hemisphere was 
 an abscess about the size of a hen's egg, containing thick, tenacious pus ; it 
 nearly reached the surface, and was surrounded with softened brain sub- 
 stance ; at the anterior part of the abscess was a clot of blood, also surrounded 
 by softened tissue. The abscess had broken into the left lateral ventricle at 
 its posterior corner; the left ventricle was filled with pus ; the right with 
 about 3j of clear serum ; the fourth ventricle was healthy. 
 
 In the chest were old and recent adhesions at the bases of both pleural 
 cavities. The bronchi were slightly inflamed, and contained muco-purulent 
 secretion. The base of the left lung contained a small abscess; the base of 
 the right was in a state of incipient pneumonia. 
 
 Liver In the right lobe, at the upper surface, were two chronic abscesses, 
 
 capable of holding about 3'iij of pus; the pus was thick and green; the walls 
 of the abscess were very thick, bounded by a smooth cyst, and firm tissue 
 about one-eighth of an inch in thickness; on the circumference of the abscess 
 a compressed vein was observed.
 
 38-t ON DYSENTERY AND 
 
 In the colon the mucous membrane was thickened; several well-marked 
 cicatrices were found in the ascending colon ; the mucous membrane was 
 puckered, and in some parts was of a slate color ; the muscular coat was 
 slightly hypertrophied. 
 
 It appears probable that the dysentery, which had been contracted 
 in Burmah, had led to abscess in the liver, and that this remained 
 passive for many months, producing hectic, with pain in the side, 
 &c., and at last, from some fresh exciting cause, new action was set 
 up, producing acute pyaemia, and abscess in the brain as the conse- 
 quence. Dr. Hughes diagnosed this course of morbid changes, which 
 was completely confirmed on inspection after death. 
 
 CASE CXXXV. Dysentery. Abscess of the Liver. Perforation of the 
 Diaphragm. Empyema John J , set. 32, admitted into Guy's Hospital 
 July 28th, 1858, under the care of Dr. Wilks. Till February, 1857, he had 
 been perfectly well, and went to the coast of Guinea; during two months he 
 remained on that coast, and had dysentery, producing much purging, with 
 tenesmus, and a discharge of a small quantity of blood. The dysenteric 
 symptoms continued for two months, and quite incapacitated him from work. 
 The symptoms came on suddenly, and were accompanied with severe pain ; 
 he took spirits for relief, but the following day pain again returned, with a 
 febrile condition, and with severe headache, &c., he was then completely laid 
 aside, and for a month was unable to take food. On June 14-th, he arrived 
 in London and had been under treatment till application at the hospital. 
 
 He was a man of fair complexion, slightly sallow, and emaciated. He 
 complained of pain in the right side, and had occasional rigors, but did not 
 suffer from cough ; the bowels acted regularly ; the tongue was slightly furred. 
 The abdomen was collapsed ; but there was pain in the right side of the 
 chest, which was uniformly dull; tubular breathing was audible, and on the 
 left side puerile respiration ; and it was evident that fluid effusion had taken 
 place into the right pleura. One week before death, his distress greatly 
 increased, and paracentesis thoracis was performed, and a pint of pus was 
 evacuated ; he died August 20th. 
 
 On inspection, the right pleura was found to be filled with several pints of 
 gray purulent fluid; the compressed lung being at the posterior and upper 
 part of the chest; a large opening in the diaphragm on the right side allowed 
 free communication between Ihe pleura and an abscess situated between the 
 liver and the diaphragm ; it was this abscess which had been opened by the 
 paracentesis. The left lung and the heart were healthy. In the abdomen 
 there were local adhesions between the intestines in various parts; at the 
 lower part of the ileum, and in the ascending colon, there was some recent 
 ulceration, and in some other parts a small quantity of granular lymph was 
 found covering the mucous membrane. In the crecuin were two large ulcers 
 of older date, with raised thickened edges, and the mucous membrane was 
 destroyed; towards the rectum the mucous membrane was of a slate color. 
 
 The large abscess above the liver was between the liver and the diaphragm, 
 and the capsule of the liver formed part of the walls of the abscess ; there 
 were several abscesses in the substance of the liver itself, and the whole of 
 the gland was filled with small deposits of pus. Many of the hepatic veins 
 wen- filled with clot and pus, the latter having apparently entered the veins 
 secondarily from the tissue; the liver weighed ( Ji Ibs. The spleen and kid- 
 neys were healthy.
 
 CATARRHAL INFLAMMATION OF THE COLON. 385 
 
 This was a case of great interest. Acute dysentery, which the 
 patient had contracted on the coast of Guinea, was followed by hepa- 
 tic abscess. This latter abscess extended to the surface of the liver, 
 and led to perforation of the diaphragm; the symptoms of pleuritic 
 effusion were then produced, and led ultimately to a fatal termina- 
 tion. Dr. Wilks had diagnosed the purulent collection, and deter- 
 mined to draw off the fluid: the trochar passed above instead of be- 
 neath the diaphragm;' but since the communication through the 
 diapraghm was perfectly free, the whole of the contents of the abscess* 
 and of the pleura could be emptied at the same time. There was 
 evidence of old disease in the mucous membrane of the colon. 
 
 CASE CXXXVI. Chronic Ulcer ati on of the Intestine. Dysentery. Cica- 
 trization. Contraction. Perforation. Abscess near the crest of the Ileum. 
 (From the Museum Records) A young man of intemperate habits, and 
 who had had syphilis, several years before death had a dysenteric affection, 
 on the subsidence of which his bowels were habitually constipated ; this state 
 was attributed to stricture of the rectum, which was felt at no great distance 
 from the anus. A bougie was passed with the effect of considerably dilating 
 the stricture. He subsequently went to America, but he did not prosper. 
 The death of his wife and other misfortunes were followed by declining 
 health. An abscess formed above the crest of the ileum, towards the pos- 
 terior part on the left side, and there was continual pain at that part ; after 
 the application of leeches several sinuses formed, diarrhoea came on, and he 
 wasted rapidly. 
 
 On inspection, except pleuritic adhesions, the thoracic viscera were healthy. 
 In the left iliac region the integuments were separated from the tendon of 
 the external oblique by sinuous ulceration. In that region, the intestines 
 Avere glued together ; the peritoneum and adjacent cellular membrane were 
 much thickened ; the rest of the peritoneum was healthy. In the sigmoid 
 flexure there were numerous traces of old ulceration, of a lightish green 
 color, the surface was uneven, and the structure of the intestine at the part 
 was thickened and condensed ; the calibre of the intestine was also much con- 
 tracted. There were three or four small perforations in the intestine at this 
 part ; the rectum was healthy, except immediately above the anus, where there 
 was considerable thickening with induration. This evidently depended on an 
 old ulcer, occupying about half the intestine ; and the part was of a leaden 
 color. The liver was much enlarged and fatty. The gall-bladder contained 
 some ropy mucus. The kidneys and the rest of the intestines were healthy. 
 
 This case is a very interesting one, for although the dysentery was 
 relieved, the cicatrization and subsequent contraction were followed 
 by constipation ; ulceration was set up above the points of contrac- 
 tion, and ultimately the intestine was perforated. The sinuses 
 opened near the crest of the ileum ; feces do not appear to have been 
 discharged ; but the case might easily have been mistaken for suppu- 
 ration from diseased bone. 
 
 The constriction in these instances arises from fibro-elastic tissue, 
 which becomes more dense than the original muscular coat ; it closely 
 resembles that found after the destruction of the skin in burns, and 
 has a similar disposition to contract. 
 
 II. Acute inflammation of the colon sometimes takes place in com- 
 25
 
 386 ON DYSENTERY AND 
 
 mon with diseases of other organs; and these cases present a marked 
 difference from those previously detailed. 
 
 Thus the thoracic viscera are affected with acute disease; the bron- 
 chial tubes and lungs are inflamed, and so, in fact, are almost all the 
 mucous membranes. The symptoms of disease of the chest are more 
 marked than those of the abdomen ; dyspnoea, cough, febrile excite- 
 ment are present with the physical signs of thoracic disease. The 
 countenance is anxious and flushed, the skin hot and dry, or clammy ; 
 the pulse becomes gradually more depressed, the tongue brown and 
 dry, and the patient is prostrate. These symptoms are accompanied 
 by dysenteric diarrhoea, which indicates a diseased state of the colon. 
 
 In some of these cases, the exciting cause of the inflammation of 
 the lungs and bronchi is also the cause of like disease of the mucous 
 membrane of the alimentary canal. In others, the symptoms appear 
 to be allied to those of pyaemia, and the affection of the colon is 
 merely another expression of the morbid state of the blood ; here 
 also, the indications of inflammation of the colon are not well marked. 
 Nearly all these cases are of a very severe character, and tend to a 
 fatal result. 
 
 In the treatment, the thoracic disease demands most urgent atten- 
 tion ; but it must be borne in mind, that the disease of the alimentary 
 canal tends still further to depress the powers of life; and we must 
 not add to the inflammation there existing, by the administration of 
 powerful drastic purgatives. 
 
 CASE CXXXVII. Dysentery. Pneumonia. Hydrencephaloid Disease. 
 Charles O , aet. 32, was admitted June 26, 1854, in an unconscious state. 
 He had been a blacksmith at Brixton. About six months previously, while 
 at work, he was seized with a fit,, which deprived him of speech for half an 
 hour, when he returned to his work ; and from that time he suffered from 
 pain in his head. At one time he was very sleepy and unable to work ; at 
 other times he became. excited, and his speech was affected. He continued 
 more or less at work till ten days before admission, when he seemed quite 
 lost, and he was taken home from his employment. He complained of pain 
 in his head and of giddiness, and was said to be suffering from inflammation 
 of the brain, and was bled. His symptoms increased, and when admitted he 
 spoke incoherently, and threw his arms and head about. He placed his hand 
 on his head, as if he suffered there. He was very pale, which was attributed 
 to loss of blood ; the pupils were dilated, and he had dysenteric diarrhoea. 
 For the next seven days he gradually became more prostrate ; he seemed for 
 a moment to return to consciousness, and then relapsed into an insensible 
 condition. July 3d. He was able to speak rationally ; the right pupil was 
 contracted, but the left was dilated ; he appeared paralyzed, but continued 
 sensible till his death, on the 5th. 
 
 Inspection, eighteen hours after death. Brain There was an increased 
 
 amount of clear serum in the membranes on the surface of the brain. The 
 brain substance was very pale and watery, its weight 2 Ibs. 14^ ozs. ; no 
 tubercle was discoverable. The ventricles contained an excess of fluid, 3 or 
 4 drachms each ; the central parts were not softened ; the microscope showed 
 no inflammatory corpuscles. There were a few purpuric spots on the pleura. 
 The lower lobe of the right lung was in a state of red hepatization, heavy, 
 soft, and ocdematous. Both apices contained a few groups of tubercles.
 
 CATARRHAL INFLAMMATION OF THE COLON. 387 
 
 Heart healthy. The whole of the large intestine, from the caecum to the 
 rectum, was in a state of acute inflammation. In the transverse colon were 
 isolated ragged ulcers ; these were close together in the ca?cum. In the sig- 
 moid flexure and in the rectum the whole surface was ulcerated, and covered 
 with a thick membranous exudation ; the muscular coat in some parts was 
 thickened. The spleen and liver were healthy ; the kidneys were large and 
 coarse ; the bladder presented a few spots, purplish in color and ulcerated in 
 the centre. 
 
 CASE CXXXVIII. Diphtherite of the Caecum and Colon. Bronchitis. 
 Pneumonia. Cirrhosis Charles G , ast. 34, was admitted, March 8th, 
 1854. He was a tall man, of dark complexion, and intemperate in his habits 
 of life. For three years he had served as a soldier in the East Indies. Five 
 days before admission he was taken ill, with febrile symptoms, cough, pain 
 in his side, and dark-colored expectoration ; dropsical effusion came on, and 
 subsequently jaundice. When first seen he was prostrate, comatose, and 
 restless ; the lips were dry and cracked ; there were sordes on the tongue ; 
 the skin was hot and dry, and slightly jaundiced ; the pulse was 156. There 
 were symptoms of pneumonia; pain was produced by pressure on the abdo- 
 men, and there were a few petechial spots. He became more comatose 
 before death. 
 
 Inspection, eight and a half hours after death. The body was jaundiced ; 
 numerous spots of purpura were observed on its surface, and on the leg was 
 a chronic ulcer. The trachea and right bronchus were granular and con- 
 gested. The lungs did not collapse ; the right was covered with a delicate 
 layer of lymph, the lower lobe was granular, consolidated, and of a yellow 
 color at the lower part. The left lung was healthy, but its lower lobe was 
 much congested. Over the left ventricle of the heart was an old adhesion, 
 about the size of half a crown ; the heart was thirteen ounces in weight, but 
 otherwise healthy. The whole of the mucous membrane of the stomach, 
 ileum, caecum, and colon, were much congested ; this congestion at the caecum 
 and colon became intense, and the folds were everywhere covered over with 
 a delicate diphtheritic layer. The liver was covered with false membrane ; 
 it was contracted, partially cirrhosed, and very firm, and was much congested 
 with bile. The gall-bladder contained 3-* f bile - The 8 P leen was lar o e > 
 soft, and pale, weighing 2 Ibs. The kidneys also were large, and much 
 congested. 
 
 CASE CXXXIX. Inflammation of the Colon and Rectum with false Mem- 
 brane, and superficial Ulceration, $c. Pneumonia. Entericat James 
 S , set. 20, was a laborer on the Sydenham Railway, who had lodged at 
 Norwood ; his habits had been temperate ; and his general health good ; he 
 was brought to Guy's July 18th, 1855. One month previously he had been 
 wet through, and experienced pain in his head and back ; a week afterwards 
 cough came on, and mucus was expectorated with blood, and these symptoms 
 increased till admission. His countenance was anxious and flushed, his 
 pupils dilated, the skin hot and dry, the tongue was covered with a thick fur; 
 the expectoration was viscid, tenacious, yellow, and rust-colored ; p^se 
 He was neatly depressed, lying on his back, and had tremor of the hands 
 and tongue, with occasional delirium. He had severe diarrhea ; there was 
 dulness of the chest, especially of the left lung, with general submucous crepi- 
 tation. He had the appearance of a person affected with typhoid fever, but 
 without the cerebral oppression. The symptoms of acute pneumonia becam 
 more marked, with rusty sputum and low muttering delirium.
 
 388 
 
 OV DYSENTERY AND 
 
 The prostration increased, and the parent gradually sank ; he died August 
 3d. There were no maculae on or after admission ; the diarrhoea did not con- 
 tinue after the first few days, nor was any blood discharged with the motions. 
 
 Inspection, August 6. The body was of moderate stature. Chest On 
 the right side there was an effusion of fibrin, and about a pint of bloody puru- 
 lent serum in the pleural sac. The lower lobe of the right lung was com- 
 pressed, the upper pneumonic ; the left pleura also was quite free from adhe- 
 sions ; the lower lobe was in a state of pulmonary apoplexy, the upper part 
 of the same lobe was very much congested and consolidated : it sank in 
 water. The pericardium contained several ounces of bloody serum ; the 
 heart was flabby, but was otherwise healthy. The abdomen was moderately 
 distended ; the peritoneum was smooth and healthy ; the stomach presented 
 advanced gastric solution, the mucous membrane at the cardiac extremity 
 being exceedingly thin ; the small intestine contained yellow, bilious fluid 
 feces ; in the last foot of the ileum the mucous membrane was gray, Peyer's 
 patches were slightly raised, and in a few parts presented irregular ulcera- 
 tion ; they had not, however, the raised swollen appearance common in 
 enteric fever. The caecum contained several small ulcers, and the whole 
 mucous membrane was of an iron-gray color ; the edges of most of these 
 ulcers were smooth and contracting ; the mucous membrane was thickened. 
 In the transverse and descending colon and in the rectum the whole of 
 the mucous membrane had a swollen, oedematous and almost viilous appear- 
 ance ; this was most marked towards the rectum. Studding the swollen 
 membrane with white patches of adherent lymph, in some parts merely con- 
 stituting a thin, delicate, but adherent membrane, in others forming a large 
 flocculent mass about three-quarters of an inch in length, firmly adherent to 
 the membrane ; there were numerous small ulcers scattered over these por- 
 tions of the intestine ; some with smooth, others with irregular and congested 
 margins ; some contained a small portion of false membrane, like a slough ; 
 from others large masses of false membrane could be detached. On tearing 
 off portions of this membrane, an injected granular surface or superficial 
 ulceration was observed. The submucous cellular tissue was white, thick- 
 ened, and oeJematous ; the muscular coat was contracted and distinct, and 
 
 Appearanre of inflamed colon; (a) false membrane composed of granule cells; (b) surface of a 
 portion of the colon beueath the false membrane ; (e) fullicle or crypt containing cells similar to 
 those compoi,ing the false membrane. 
 
 nearly one-eighth of an inch in thickness ; the mesenteric glands were en- 
 larged. On carefully examining portions of the false membrane, it was found 
 to consist of granular cells closely matted together with very little blastema ; 
 the cells were large and full of granules, some contained a faintly marked 
 nucleus ; but scarcely any columnar epithelium was observed. On examin- 
 ing the mucous membrane itself, small excavations were found to contain 
 similar cells. The liver and spleen were healthy.
 
 CATARRHAL INFLAMMATION OF THE COLON. 889 
 
 This diseased condition of the colon had led to the effusion of a 
 fibrin, and to the production of inflammatory cells, instead of the 
 ordinary columnar epithelium; the follicles and solitary glands had 
 become inflamed, and a subsequent continuation of this action pro- 
 duced superficial ulceration. The disease was of an inflammatory 
 character, and not only the follicles and glands, but the whole sur- 
 face of the mucous membrane was affected; the membrane thus 
 formed appeared more cellular than is sometimes observed. 
 
 The symptoms closely resemble those of enteric fever or typhoid 
 pneumonia. The irritation of the large intestine, as indicated by 
 the diarrhoea, appeared to be checked by the Dover's powder which 
 was given. The administration of alcoholic stimulants in a case of 
 this kind is a question of great difficulty ; the general symptoms 
 failing pulse, subsultus, &c. appeared to require their free use. 
 This case strongly favored the idea of a constitutional origin of the 
 disease, which resembled, if it were not identical with, enteric fever. 
 
 III. Another class of cases are those in which chronic disease has 
 slowly advanced for months or for years ; acute inflammation of the 
 alimentary canal is then set up, which in a short time leads to a 
 fatal termination. Cases of this kind are not of unfrequent occur- 
 rence, in which a patient is already broken down, as by incipient 
 phthisis ; there is already a disposition to the ulcerative disease of 
 the small intestine, so common in phthisis, when probably from fresh 
 exciting cause, acute inflammatory disease is set up, and diarrhoea, 
 which can scarcely be checked by any means, is rapidly fatal. This 
 inflammation, and the effusion of false membrane, may be confined 
 to the rectum or descending colon, or it may be found in the caecum 
 and ileum. Several cases of this kind have already been detailed in 
 connection with strumous disease of the intestine. 
 
 Catarrh of the Colon. 1 The mucous membrane of the large intes- 
 tine may be affected with catarrhal inflammation resembling that 
 which we have already mentioned as occurring in the small intes- 
 tine. It is seen both as an acute and as a chronic disease. In the 
 acute disease the mucous membrane is congested, and sometimes the 
 colon is deeply red ; one part only of the bowel may be thus affected, 
 the caecum, or the sigmoid flexure, or the rectum ; the follicles of the 
 intestine become enlarged ; the mucous membrane is swollen, arid the 
 mucus altered in character ; the feces a* first adhere to the membrane, 
 for the secretion is diminished, afterwards the quantity of mucus is 
 greatly increased, and it is recognized in post-mortem examination 
 upon the mucous membrane, and during life is seen to coat the feces, 
 or to be passed in abundance without the ordinary alvine discharge 
 in gelatiniforrn masses, or in shreds. Ulceration may ensue in small 
 patches, or in a deeper and more distinct form. 
 
 In chronic catarrh, the mucous membrane is found to be thickened 
 but sometimes it is atrophic and thin ; the color may be gray, and 
 we often find that a deep-colored gray zone may be found aro 
 
 See 'Remarks on Catarrhal Inflammation' in chapter on "Enteritis and Diar- 
 rhoea."
 
 390 ON DYSENTERY AND 
 
 the follicles ; due to pigmental deposit the result of long-continued 
 congestion. The mucus secretion varies according to the severity 
 and the chronic character of the complaint. The discharge may be 
 in small pieces, or it may constitute casts more or less complete of a 
 portion of the intestine. These casts may be several inches or even 
 a foot in length, 'and consist of mucus cells in a tenacious albuminous 
 basis, these casts and shreds especially in acute disease may have a 
 fibrillated appearance when examined under the microscope ; the 
 patient not unfrequently regards the mucous cast as the mucous 
 membrane itself, or as an intestinal worm. 
 
 Symptoms. In acute catarrh the symptoms are those of diarrhoea, 
 sometimes with tenesmus, when the rectum is affected, and then even 
 with the discharge of blood ; there may be febrile excitement, and 
 uneasiness in the abdomen, but in many cases there is no fever, the 
 tongue may be clean, the skin cool, and the pulse quiet ; if the ex- 
 creta be irritating, there is often a good deal of smarting pain at the 
 orifice, and the mucous membrane may be protruded.. Flatulent 
 distension of the abdomen and dyspnoea are also observed. 
 
 In chronic catarrh, diarrhoea is usually the prominent symptom ; 
 it may continue in varying degrees for months or even for years, 
 and it often alternates with constipation ; if the strength fail, then 
 the pulse becomes compressible, and the tongue dry and brown or 
 glazed. When the rectum is affected, as it generally is, when 
 mucous casts are passed, the pelvic viscera closely sympathize with 
 the morbid action ; in men we find irritation of the bladder, in 
 women disturbance of the uterus, vagina and ovaries, as well as of 
 the bladder. This sympathy is observed in young children, acute 
 catarrh of the rectum may be the cause of vaginitis, and lead to the 
 supposition that the child has been maltreated. We would, how- 
 ever, remark that the converse is also true, that stricture and disease 
 of the bladder and prostate will in men set up excessive irritation 
 even resembling dysentery; and in women, dysmenorrhcea, and 
 ovarian congestion may be the cause as well as the result of inflam- 
 mation in the rectum. 
 
 The patients who suffer from this chronic discharge of mucus are 
 generally in a cachectic state, pale, and more or less emaciated ; the 
 bowels are irregular, sometimes confined, at other times affected 
 with diarrhoea ; and there are. occasionally intervals of several weeks 
 or months between these mucous discharges of flakes and casts. 
 During their passage a sense of distress and faintness, and even actual 
 syncope may be produced, with severe colic; the pulse is compres- 
 sible, the tongue may be clean or furred, and the appetite uncertain; 
 the rnind is generally irritable or dejected, and sometimes almost 
 melancholic and hypochondriacal. 
 
 The neuralgia is often very severe, sometimes coming on two or 
 three hours before the bowels act, at other times following the motion. 
 The pain also is great, it may extend up the spine or pass into the 
 pubes ; sometimes it is compared to the cutting of an instrument, at 
 other times the sense is that of painful burning. These painful sen- 
 sations may be quite independent of any pressure at the anus, and
 
 CATARRHAL INFLAMMATION OF THE COLON. 391 
 
 may continue in a more severe form after the primary irritation in 
 the bowels has subsided. The disease is often very obstinate and it 
 may last not only for months, but even years. 
 
 As to the causes of this disease, if seems in some instances to be 
 produced by catarrh commencing in the small intestine, or it may 
 be the sequence of acute or chronic dysentery. The irritation of a 
 polypoid growth in the rectum or in the sigmoid flexure may induce 
 it, or the mischief may be due to the irritation of hemorrhoids. The 
 portal congestion often associated with malarious fevers predisposes 
 to this form of mucous congestion. Sometimes hard retained feces 
 may set up catarrhal irritation, so that mucus in considerable quan- 
 tities may be passed, or thin feces ; in these cases there is a constant 
 and painful effort to evacuate the bowels, and the malady is mis- 
 taken for diarrhoea or dysentery. 
 
 In those instances which do not proceed from disease of the rectum 
 or of the sigmoid flexure, as haemorrhoids, polypus, &c., nor are the 
 sequence of acute dysentery, we have generally found, either that 
 long-continued congestion of the vena portae. or irritation of the 
 urino-genital organs has produced or at least perpetuated the disorder. 
 In young women, it may be induced by painful menstruation and 
 ovarian disease: in men, by prostatic disease, calculus, &c. 
 
 The disease is a remedial one, and the prognosis may be favorable 
 when the irritating causes can be removed, when a patient will 
 submit to well-regulated dietetic regimen and careful habits of life, 
 and when, for a sufficient time, he will persist in the use of proper 
 medicinal measures. - 
 
 Where disease of the rectum is present, and local and general 
 means are unavailing, the help of the surgeon may be required to 
 remove an irritating growth or haamorrhoid. If the latter be present, 
 the bowels should be regularly acted upon by the confection of senna 
 and of black pepper ; the gall ointment may be locally applied or we 
 may use an astringent wash; at the same time the diet must be 
 carefully regulated and hepatic congestion avoided. It is, however, 
 to the chronic form of mucous discharge that we here especially 
 refer, and in this, careful attention to the diet and to the state of the 
 skin is especially needed ; a nourishing but unstimulating diet should 
 be taken, and, if possible, stimulants altogether avoided. Although 
 mercurial medicines, in aperient or in very small 'doses, sometimes 
 afford considerable temporary relief, we have often found the distress 
 greatly increased by them ; and, we have seen greater benefit accrue 
 from the use of nitro-hydrochloric acid with henbane and vegetable 
 infusions, as of calumba or carscarilla. If the bowels be loose, kra- 
 meria, with ipecacuanha and tincture of catechu, may be used, or 
 quinine with Dover's powder. When aperients are necessary, a 
 small dose of colocynth may be given with Dover's powder, or of 
 castor oil with tincture of rhubarb, but aloes and the more powerful 
 purgatives are injurious. The sulphur confection or the compound 
 confection of senna may be used ; but enema of oil with gruel, or 
 decoction of poppies may be sufficient to act on the bowels. Astrin- 
 gent injections are sometimes of service, but are unavailing if portal
 
 392 DYSENTERY AND CATARRHAL INFLAMMATION OF COLON. 
 
 congestion or pelvic irritation continue. In dysmenorrhoea and 
 ovarian disease, absolute rest, at least for a time, is necessary, and 
 the avoidance of tight corsets is indispensable. Dr. Clark 1 recom- 
 mends astringents, as alum, the pernitrate and the sesquichloride of 
 iron, &c., but it is often better to soothe the irritated mucous mem- 
 brane by the injection of borax with poppies, or of nitrate of bismuth 
 with morphia and gruel, or morphia suppositories with belladonna 
 may be used. If hardened feces be retained they must be got rid of 
 by the use of gentle aperients, or by the injection of several ounces 
 of oil followed by soap and water, but if necessary they must be 
 removed mechanically. 
 
 See some interesting remarks on this subject by Dr. Andrew Clark, 'Lancet,' 
 December, 1847.
 
 393 
 
 CHAPTER XIII. 
 
 ON TYPHOID DISEASE OF THE INTESTINE. 
 
 IN enteric fever diseased action of a special kind takes place in 
 the glands of the intestine. This state passes through very definite 
 conditions, and has been described by Eokitansky as the typhoid 
 process. Dr. Stewart, Sir W. Jenner, and others have pointed out 
 the essential difference in the signs of typhoid and typhus fever, and 
 that it is only in the former disease that we find an abnormal condi- 
 tion of the intestine. The glands especially affected are those at 
 the lower part of the ileum, namely, Peyer's or the aggregate glands; 
 the solitary glands also become involved, and the lymphatic glands 
 of the mesentery are enlarged, congested, and swollen. The ques- 
 tions naturally arise, In what does this state consist? Is it a neces- 
 sary sign of fever? What are the indications of the typhoid state 
 of the glands, and what is the course which the disease pursues? 
 
 The intestinal disease consists in an abnormal and excessive growth 
 in the glands just mentioned, and the product effused is composed of 
 a blastema, which as it undergoes but little development quickly 
 degenerates, and consists of an immense aggregation of granules, 
 and of some large cells containing nuclei. 
 
 Soon after the commencement of the fever the glands are swollen 
 and enlarged, and the mucous membrane becomes more vascular 
 than usual. As the fever advances the glands are raised sometimes 
 two or three lines above the surface of the membrane; about the 
 fourteenth day of fever the product either becomes absorbed, or 
 ulceration takes place, or the gland sloughs; a few days later the 
 slough is found to have separated, and an irregular nicer occupies 
 its position; the muscular coat is exposed; and the margin of the 
 ulcer is ragged and congested. If the patient do well, this ulcera- 
 tion, of greater or less extent, gradually heals, a cicatrix is formed, 
 and the health is slowly restored ; the convalescence extends over 
 several weeks, and is interrupted, it may be, by relapses consequent 
 on this condition of the intestine, or by a repetition of the process in, 
 hitherto unaffected glands. The glands nearest to the ileo-cohc 
 valve are those which are most severely affected; and sometimes 
 the whole valve itself is converted into a slough, and the disease 
 extends to the glands in the caecum. 
 
 The mesenteric glands slowly assume their normal condition; but, 
 in some instances, the hyperaemia thus induced tends to the excessive 
 development of cellular structure, which may undergo caseous de- 
 generation. 
 
 In the examination of the intestines after death from fever, we 
 find the process of glandular disease in various stages in the same
 
 304 ON TYPHOID DISEASE OF THE INTESTINE. 
 
 subject; the glands may be merely swollen and raised, or the slough- 
 ing process may have commenced in small points, or the whole of 
 the glands may be converted into sloughs, which are partially de- 
 tached, and stained by feces; the glands nearest to the caecum may 
 be in this latter state, whilst others further removed from that part 
 are, in earlier stages of the same process, either beginning to slough 
 or merely swollen and raised. In some cases, when death has taken 
 place several months after fever, we have found cicatrices, without 
 ulceration; the disease had been cured. A very interesting case of 
 this kind occurred at -Guy's Hospital under the care of Sir Win. 
 Gull. A young man was admitted, having the ordinary symptoms 
 of enteric fever, with the indications of ulceration of the intestine; 
 he appeared to convalesce favorably, but about three months after- 
 wards he was seized with typhus, and died in a few days. On in- 
 spection, there was no injection of the mucous membrane of the 
 ileum, but only cicatrices. 
 
 As a consequence of this diseased action the whole of the mucous 
 membrane and even the deeper tissues become inflamed; the intes- 
 tine, from its enfeebled muscular power, readily yields to any dis- 
 tending force; the peritoneum is sometimes injected, and we find in 
 many cases a delicate, fibrinous exudation upon it; again, the mucous 
 coat often becomes ulcerated, so also the muscular, till at last only 
 the semi-transparent peritoneum is left ; this also in many instances 
 sloughs, and a minute opening takes place in the peritoneum, leading 
 to rapidly fatal peritonitis; and even when the peritoneum is not 
 actually perforated, transudation is frequently found to take place, 
 so as to produce acute disease of the serous membrane. 
 
 Tuberculosis, although not a necessary sequence, frequently follows 
 this fever; changes, such as those just referred to, may take place in 
 the mesenteric glands ; tubercles may be deposited in the substance 
 of the mucous membrane, and ulceration follow ; tubercular disease 
 of the peritoneum may take place; and, lastly, phthisical disease of 
 the lungs and other structures may supervene. 
 
 The symptoms which are especially associated in enteric fever 
 with this condition of intestine, and which alone have to be con- 
 sidered in this work on abdominal diseases, are that the abdomen is 
 full and rounded, and on pressure in the region of the caecum a 
 gurgling sound is produced, with more or less pain; diarrhoea is 
 generally but not always present; for sometimes the bowels are 
 confined, even when the ulceration is severe; the evacuations are of 
 loose consistency and of an ochre color, and they often contain blood 
 and portions of sloughy membrane; the pulse is compressible, the 
 tongue is red and injected, and it becomes dry or cracked; there is 
 often also a circumscribed flush on one or other cheek ; the brain, 
 too, is more depressed than in other cases. If perforation takes 
 place there is sudden severe pain in the abdomen with collapse, and 
 death then generally ensues in five to ten hours. 
 
 The symptoms of typhoid fever are sometimes so slight, even with 
 existing ulceration of the intestine, that the patient is able to walk, 
 and does not appear much enfeebled. I well remember a case of
 
 ON TYPHOID DISEASE OF THE INTESTINE. 395 
 
 this kind, attending, and continuing to attend, as an out-patient at 
 Guy's Hospital for three weeks, under the care of one of my col- 
 leagues. About the twenty-third day, a short time after admission 
 into the hospital, when I first saw him, perforation of the intestine 
 had taken place into the peritoneal cavity, and death quickly fol- 
 lowed; and in other cases, when the severity of the fever has passed, 
 and the patient has apparently begun to convalesce, having regained 
 power and mental energy, after some indiscretion of diet, or an 
 attempt to move from the bed, perforation takes place, and the 
 bright, beaming hope of returning health is lost in the terrible fore- 
 shadowing of speedy death. These are painful cases, trying to the 
 physician, who has encouraged the hopes of the patient and his 
 friends, and still more so to those who are thus deprived of kindred. 
 Perforation takes place from the third to the sixth week, and until 
 this period is passed the greatest care should be used in allowing 
 changes of food, or increased muscular movements; for among the 
 fatal cases of enteric fever a large majority die from this perforation 
 of the intestines. 
 
 The hemorrhage from the intestine in fever may be exceedingly 
 severe and generally results from sloughing at the affected part and 
 from perforation of minute vessels; it is in my experience rarely 
 fatal, 1 but it may lead to great exhaustion and may retard convales- 
 cence, sometimes hemorrhage is followed by rapid subsidence of the 
 febrile symptoms and by speedy recovery. Ulceration, however, is 
 not the only cause of hemorrhage, for we find that bleeding some- 
 times takes place from the stomach and from the kidneys, even in. 
 cases that terminate favorably. 
 
 The general symptoms and treatment of fever, and the question 
 whether there be any essential difference between typus and typhoid 
 fever, are not within the sphere of this work ; the able manner in 
 which they are discussed by Drs. Stewart, Jenner, Wilks, Peacock, 
 Murchison, &c., and earlier by Bretonneau, Louis, Broussais, Bouil- 
 lard, Chomel, Christison, &c., render any mention of these points 
 unnecessary. 
 
 Treatment. The question may, and has been raised, How far diar- 
 rhoea is beneficial ; and whether we ought at once to check it ? We 
 may be assured that purgatives are injurious, especially those of an 
 active or drastic character. The disease of the intestine has been 
 often aggravated by the injudicious administration in the early stage, 
 of jalap and scammony, of senna, and the like; so also mercurials 
 tends not only to increase the subsequent depression, but to aggra- 
 vate the ulcerative action. It is often beneficial to act on the bowels 
 and on the liver by a mild mercurial purge, as gr. iij of Hydrargyrum 
 cum Greta followed by a rhubarb draught or by castor -oil, when 
 there is disorder of the abdominal viscera ; but all irritation of a 
 prolonged kind must be avoided. When the diarrhoea is continuous, 
 it should be checked by enemata of starch, or by the administration 
 
 1 Murchison, however, states that of 60 cases of hemorrhage 32 died, or 53.33 per 
 
 cent.
 
 306 ON TYPHOID DISEASE OF THE INTESTINE. 
 
 of chalk with opium, or vegetable astringents ; but in reference to the 
 use of opium, it is well to be on our guard, lest the cerebral oppres- 
 sion be increased and a state of coma be induced thereby. When 
 hemorrhage takes place, the acetate of lead is sometimes of service, 
 or vegetable astringents, as kino, catechu, logwood, krarneria, or the 
 glycerine of tannin. 
 
 We must strongly urge extreme caution in the return to solid and 
 highly nutritious food ; and equally important is it that, during the 
 severity of the fever, and for many subsequent days, no muscular 
 exertion should be attempted, but absolute rest in the recumbent 
 position maintained. The attention to these means would have 
 saved many valuable lives ; and few diseased conditions require such 
 constant watchfulness in the maintenance of rest, and the frequent 
 administration of mild nutritious aliments. 
 
 Ammonia and serpentary may be given ; and in some, quinine 
 proves of service, especially where there is any sign of miasmatic 
 influence; but in other cases quinine may reduce the temperature 
 and promote convalescence. The judicious administration of wine 
 in fever is one of the most difficult questions in practice ; many are 
 benefited by it, whilst others appear to do well without it : a failing 
 circulation, especially in advanced life, as shown by a compressible 
 character of the pulse and a feeble action of the heart, show that its 
 free use is required ; other indications for the employment of stimu- 
 lants are dryness of the tongue, prostration of strength, a dusky con- 
 dition of the skin, the presence of petechiae, &c. In many cases, if 
 too long postponed, patients will sink, however freely wine may 
 afterwards be given ; and, on the contrary, I have witnessed in others 
 that a reduction of quantity, or the entire cessation of the adminis- 
 tration of wine and ardent spirits, has been followed by moisture of 
 the tongue, and the abatement of all the febrile symptoms. 
 
 In some cases of enteric fever the pyrexia is reduced by the 
 cautious use of cold water, either as a bath or by sponging; but 
 where there is evidence of severe intestinal affection, great caution 
 must be used lest perforation be induced or fatal collapse ensue. 
 
 CASE CXL. Enteric Fever. Peritonitis Henry H , jet. 23, died on 
 
 the twenty-third day of fever; and on the day before death he had symptoms 
 of peritonitis ; he had previously had syphilis, and was in a cachectic state. 
 
 On inspection, there was acute peritonitis; but no perforation could be 
 found; there was very extensive ulceration of the ileum and caecum, affecting 
 both the solitary and Peyer's glands; in one or two places the muscular coat 
 was also destroyed. The liver, spleen, and kidneys were healthy. 
 
 In this instance, acute peritonitis was set up, although complete 
 perforation had not taken place; in some parts, however, the serous 
 membrane only was left entire; and there can be little doubt that 
 transudation had resulted in the acute serous inflammation. 
 
 CASE CXLI. Enteric Fever. Perforation of Intestine in the Seventh 
 Week Joseph C , set. 17, was admitted August 18th, 1858, and died Sep- 
 tember 1st. He had been residing at Woolwich, and six weeks before admis-
 
 ON TYPHOID DISEASE OF THE INTESTINE. 397 
 
 sion had suffered from fever, with much diarrhoea. The day before he was 
 brought to Guy's he said to have' had a discharge of blood from the bowels. 
 On admission he was pale, emaciated, and almost pulseless; scarcely any 
 complaint of pain was made, but he had an anxious and distressed counte- 
 nance ; the abdomen was moderately distended ; he rallied slightly, but sank 
 a week afterwards. 
 
 Inspection. Chest The pleura was healthy; the lungs were pale, and 
 distended ; the heart was healthy. Abdomen The intestines were distended ; 
 the peritoneum contained about two pints of offensive pus, which was collected 
 in the depending parts; there was scarcely any adhesive lymph, and no adhe- 
 sions; but the general peritoneal surface was slightly opaque. About eight 
 inches from the caecum there was a sloughing opening into the ileum, capable 
 of admitting the tip of the little finger; and a second opening of rather smaller 
 size was situated nearer to the csEcum. On the mucous surface of the ileum 
 at its lower part, were the remains of ulcers; many of them cicatrizing, their 
 edges were smooth and gray; the floor of the ulcers was formed in several 
 instances by smooth submuscular areolar tissue on the peritoneal surface; 
 these remains of ulcers covered nearly the whole of this part of the intestine. 
 There were also several ulcers in the caecum ; the rest of the intestine was 
 healthy. The liver was discolored on its surface, but it was otherwise 
 healthy; the spleen was slightly enlarged; the kidneys were healthy. 
 
 The comparative absence of pain in this case was explained by 
 the great prostration from which the patient suffered. The great 
 care required after typhoid ulceration of the intestine is shown in 
 this instance; for six weeks had elapsed, and many of the ulcers had 
 healed before fatal rupture of the intestine and peritonitis took place. 
 It is probable that injudicious diet or increased muscular exertion 
 had led to the perforation of the ileum. 
 
 CASE CXLII. Enteric Fever. Perforation of the Ileum John C , 
 aet. 28, was admitted in a dying state into Guy's Hospital. He stated that 
 he was well till the previous evening, when he was seized with acute pain in 
 the abdomen; and on admission he had the symptoms of peritonitis. He 
 died in a few hours. 
 
 On inspection, the body was found to be well nourished. The abdomen 
 was distended ; the whole surface of the intestines was covered with fecal 
 matter, and the end of the ileum was perforated ; the lower part of the ileum 
 was ulcerated, as in typhoid fever, and one of these ulcers had given way; 
 there was deposit in Peyer's glands, and the mesenteric glands were enlarged 
 and softened. The liver was healthy, so also the kidneys. The spleen was 
 large, soft, and of a dark color. 
 
 The patient seemed to have been so far convalescent from a mild 
 attack of fever as to consider himself well, when fatal perforation 
 of the ileum took place. The appearance of the intestine was pre- 
 cisely that found in typhoid fever, and there was no indication that 
 the ulceration was of a strumous character.
 
 398 
 
 CHAPTER XIV. 
 
 ON COLIC. 
 
 BY the term colic we mean a severe twisting pain in the abdomen, 
 about the region of the umbilicus, without inflammatory action, 
 generally with constipation, but sometimes with looseness of the 
 bowels and vomiting. Internal strangulation of the intestine and 
 intussusception are sometimes considered as more aggravated and 
 severe forms of colic on account of the pain which is a prominent 
 symptom in many cases; but the former may be in its early stages 
 altogether free from pain, until distension and violent peristaltic 
 action set up inflammation, which involves all the coats of the intes- 
 tines; unless, therefore, we consider some forms of colic to be free 
 from pain, in some of its stages, we cannot regard fatal obstruction, 
 arising from displacement and internal strangulation, as a form of 
 the disease. 
 
 Dr. Copland divides colic arising from functional disorder of the 
 bowels into four classes: 
 
 1. Flatulent, nervous, or spasmodic colic. 
 
 2. Colic from an injurious character of the food. 
 
 3. Colic from morbid secretion, or retained excretions. 
 
 4. Colic from lead. 
 
 This division appears to be a just and useful one; for each class 
 indicates widely different conditions, which require different treat- 
 ment. 
 
 In flatulent colic the intestines become distended with flatus; 
 severe twisting pain comes on round the region of the umbilicus; if 
 the pain be severe, the patient becomes cold, and a clammy sweat 
 breaks out; the pain extends to the back, and the severity of the 
 pain is relieved by a change in its position, but especially by eructa- 
 tion, or by the discharge of flatus from the rectum; during the 
 severity of the pain, the pulse becomes depressed, feeble, and ir- 
 regular. 
 
 In nervous and spasmodic colic there is less distension of the abdo- 
 men although it may be slightly tympanitic; the pain extends to 
 each side and to the back, and is sometimes situat.d across the 
 chest. The removal of pain from one part to another, and especially 
 the discharge of flatus, as in the flatulent colic, afford relief. The 
 abdomen is, however, tolerant of pressure, and pain is occasionally 
 relieved by this means. There is, also, an anxious expression of 
 countenance, with coldness and clamminess of the surface, and with 
 depression of the pulse, if the pain be severe. The collapse has even 
 been mistaken for ruptured intestine, so complete may be the pros- 
 tration ; in colic, however, the collapse entirely disappears in a few
 
 ON COLIC. 399 
 
 hours; in perforation, it soon terminates in death. The tongue is 
 not generally affected, and it may be clean or furred; the evacuations 
 from the bowels also may be as in health, but in most cases they 
 will be found to deviate from their normal condition. In the nervous 
 colic of hysteria, the urine is abundant and limpid. In the spas- 
 modic colic of gout the urine contains an excess of lithic acid, and 
 may be turbid and sca'nty. 
 
 Causes. Flatulent colic is observed in nervous and hysterical 
 subjects, and' is produced by the rapid evolution of gases from the 
 contents of the alimentary canal, whilst in some cases it appears to 
 arise from change in the secretions of the mucous membrane itself. 
 In the intemperate, and in gouty patients, the chylopoietic viscera 
 are often in a congested and morbidly excited state; and in these 
 cases a very trifling cause will produce intense colic. 
 
 In patients reduced by exhausting diseases, by loss of blood, by 
 the too long continuance of farinaceous and fluid aliments,. as also 
 by over lactation, we find that colic of this kind is readily induced. 
 
 The exciting causes are alarm and fright, exposure to cold and 
 wet, especially of the lower extremities, food not in itself indigestible, 
 but taken when the powers of digestion are diminished, either from 
 an enfeebled condition, or from the state of the nervous system. 
 
 Diagnosis. There are several conditions for which this functional 
 colic may be mistaken, and which are important to remember. 
 
 Perforation of intestine is generally known by the intensity of the 
 collapse : it is exceedingly unusual for collapse at all approaching in 
 severity to that produced by ruptured intestines to arise from func- 
 tional colic, although it is sometimes the case. During the passage 
 of a calculus from the gall-bladder or from the kidney, intense pain 
 is produced; but the position of the pain, the character of the vomit- 
 ing, and in the latter case, the pain and retraction of the testicle, 
 and blood in the urine, enable us to distinguish these diseases from 
 ordinary colic. 
 
 In disease of the spine, severe and sometimes intense pain is pro- 
 duced in the abdominal parietes, but this pain has generally less of 
 the twisting pain of colic, and may be traced in the course of the 
 spinal nerves; sometimes, however, it is more diffused in character, 
 and the patient can scarcely be persuaded that the cause is not within 
 the abdomen. 
 
 Aneurism of the abdominal vessels and abdominal tumors are 
 sometimes the cause of intense suffering, but the character of the 
 pain, and the presence of a tumor with other signs afford easy diag- 
 nostic marks of their true character. 
 
 In peritonitis there is exquisite tenderness of the abdomen, whilst 
 in colic the pain rarely amounts to more than a diffused soreness, and 
 pressure can often be borne. 
 
 In tubercular and chronic peritonitis flatulent distension of the 
 abdomen is associated with soreness or tenderness, less severe than 
 in ordinary peritonitis ; and these conditions may, in the early stages, 
 be mistaken for simple colic; this is important, because by an over 
 active plan of treatment disease may be accelerated; afterwards,
 
 400 ON COLIC. 
 
 \vhen the intestines are matted together, and attacks of peritonitis 
 are set up, the pain and tenderness come on in severe paroxysms, 
 when they are less likely to be mistaken for simple colic. It is only 
 in the early conditions of this disease, and especially in young people 
 of nervous and excitable temperament, that there is liability to such 
 mistake. 
 
 The distinguishing marks between colic and hernia need not be 
 dwelt upon ; for the presence -of an external tumor, with constipation 
 and stercoraceous vomiting, can only be mistaken for simple colic 
 by great carelessness ; and in every case of colic, even before severe 
 vomiting has come on, it is well always to examine the patient for 
 hernia. In intussuception also, intense recurrent pain in the ab- 
 domen of a twisting character is sometimes associated with diar- 
 rhoea, and I remember a case in which this malady was mistaken 
 for colic produced by irritating substances ; this idea was strength- 
 ened by the occurrence of the attacks of pain on the days when the 
 patient was visited by his friends. Flatulent distension of the 
 stomach is sometimes a severe and even fatal disease, but the dis- 
 tension and tympanitis are great, and the form of the abdomen is 
 characteristic. The intense pain arising after poisons, as from mine- 
 ral acids, &c., is associated with violent vomiting ; but the suffering- 
 is especially experienced in the mouth and gullet, and has other 
 symptoms which we need not now mention. 
 
 Our prognosis in flatulent and spasmodic colic is generally favora- 
 ble, but it must be more guarded when we have had evidence of 
 previously existing disease, or where the collapse is great in a patient 
 who has been affected with gout. 
 
 Treatment. The ordinary treatment in colic, often before the 
 patient is seen by a practitioner, is to administer some hot brandy, 
 and water; and if the disease be of the simple kind, which we have 
 described, the symptoms may be thereby relieved ; but in peritonitis, 
 in hernia, in perforated intestine, no treatment can be worse, for it 
 takes from the patient the chance of recovery. Opium, gr. i-ij, 
 and laudanum, are the most useful remedies in severe functional 
 colic, and may be given either alone or with ether ; chloroform in 
 doses of Rv with or without camphor, chloric ether also, and the 
 salts of morphia, may be advantageously administered. Warmth 
 should be applied to the abdomen by means of hot water, hot flan- 
 nels, poppy fomentation, &c., and sometimes a mustard poultice or a 
 hot flannel sprinkled with turpentine, or spongio-piline previously 
 wrung out of hot water and sprinkled with chloroform and bella- 
 donna liniment, mixed in equal parts, may be employed to relieve 
 severe pain. 
 
 When the bowels are inactive, and when no indications of acute 
 disease, hernia, or internal obstruction exist, a warm saline purge 
 may be given, but some practitioners prefer a dose of calomel, with 
 gr. j or ij of opium, or colocynth with henbane, or castor oil with 
 the tinctures of rhubarb and opium. Again, enemata are sometimes 
 of much service in emptying the colon, and thus may entirely relieve
 
 ON COLIC. 401 
 
 the disease ; castor oil and oil of turpentine, colocynth and rue, may 
 each be employed in this manner. 
 
 If the attacks be less severe, but repeated, and if the patient be 
 exhausted and anasmic, steel and quinine may be combined with 
 henbane and with mild aperients. At the same time many of the 
 vegetable bitters calumba, cascarilla, gentian may be prescribed 
 with the aromatic spirit of ammonia, with henbane, with the car- 
 bonated alkalies of soda, potash, or magnesia, &c. In hysterical 
 subjects the compound assafoetida pill and aloes, musk, or myrrh 
 may be used; and some practitioners employ valerian, castor, sumbul, 
 and the essential oils, to relieve the painful and flatulent distension 
 of the abdomen. 
 
 The diet should be of a form easily digestible, but sufficiently 
 varied, and neither bulky nor entirely of a fluid kind. 
 
 When a gorged state of the portal system exists, from an excess 
 of aliment and of stimulants, it is well to abstain from alcohol in 
 every form; but this abstinence is the more difficult to attain, because 
 the colic is itself often relieved by fresh doses of ardent spirits. So 
 also in gout, an excess of animal food and of stimulants aggravates 
 the disease, but the patient may be so enfeebled as to require the 
 continuance of stimulants in a well regulated manner; and in in- 
 stances of colic with exhaustion, from over lactation, loss of blood, 
 great mental alarm, &c., alcoholic stimulants are of great value. 
 
 2. Colic arising from the injurious character of th? food. This 
 disease has many symptoms in common with the colic just described ; 
 but its cause is different, and also its mode of relief. 
 
 Severe pain comes on in the region of the scrobiculus cordis and 
 umbilicus, sometimes with flatulent distension, two or three hours 
 after eating. Vomiting occasionally supervenes ; and it may be, if 
 the food is of an injurious character, either in itself or from the 
 idiosyncracy of the patient, that diarrhoea is set up. The tongue 
 is whitish and furred, or enlarged, and red papillae are observed 
 through the fur, or it is injected at the tip and edges. The pain is 
 followed by a soreness of the abdomen, which may persist for several 
 hours or days. The pulse is compressible, and the respiration is less 
 free than normal. This condition may pass into that of diarrhoea, 
 or of enteritis; or, after vomiting, and the discharge of unhealthy 
 evacuations from the bowels, the patient may be restored to health. 
 
 This form of colic is often associated with disturbance of the 
 cerebral functions, and severe pain in the head, dimness of sight, 
 irritability of temper come on; or it may set up disturbance of the 
 skin, producing urticaria and roseola, and in children of strophulus 
 and other lichenous eruptions. 
 
 If the injurious diet be persisted in, the colic may cease, but other 
 conditions consequent on general impaired nutrition may be set up. 
 
 The exciting causes are salads, cold drinks, acid and fermenting 
 wines, raw fruit, especially stone fruit, mussels, and so-called shell 
 fish, the imperfect mastication of food, either from bad teeth or 
 hurried meals; the latter cause is especially found m those who are 
 actively engaged in business, or who from choice or necessity posl 
 26
 
 402 ON COLIO. 
 
 pone the meal till the frame is almost exhausted. Severe colic of 
 this kind is sometimes produced by mushrooms, especially where 
 other forms than the edible agaricus are taken, and dangerous and 
 alarming symptoms may follow. 1 
 
 In other cases the diet may be of good quality, but improperly 
 administered ; thus the most severe colic may be produced by giving 
 cold milk to young children. Sudden prostration of strength, pain, 
 a sunken eye, vomiting, and afterwards diarrhoea are produced, and 
 .the motions indicate the uudissolved state of the food taken. 
 
 In the diagnosis of these cases, equal care is necessary as in flatu- 
 lent colic, for the same conditions may mislead in each ; it is well 
 also to remember that hernia, perforation of the intestine, peritonitis, 
 intussusception, and enteritis may produce many of the symptoms of 
 this form of colic. Ordinary care will in most cases enable us to 
 detect external hernia; the pain of peritonitis and that from perfo- 
 rated intestine is more severe in kind, and different in character from 
 that of ordinary colic. Enteritis and intussusception may follow as 
 the consequence of intestinal irritation of the kind just described, 
 but the symptoms of these are of greater duration than those of 
 simple colic; and when due to the administration of irritating 
 poisons, the examination of the vomited matter is an essential 
 element in forming a correct opinion as to the nature of the case. 
 
 Treatment. If vomiting have come on, and irritating matters 
 have already been freely ejected, the symptoms of disease often 
 subside spontaneously, if not soothing demulcents may be given ; 
 but if pain and nausea continue, an emetic is of service. Action 
 from the bowels should be insured by saline aperient medicines, as 
 the carbonate of magnesia, the sulphate of potash, the tartrate of 
 soda, or by a free mercurial purge ; and demulcents, as arrowroot, 
 milk, rice, mutton or veal broth, &c., should constitute the only 
 diet; the administration of saline medicines, with antispasmodics, 
 sedatives, and anodynes may be necessary for a short time, and opium 
 may be required to check the irritated action which has been set up, 
 but opium should not be given whilst irritating substances continue 
 to disturb the intestine. 
 
 3. Colic from retained secretions and morbid excretions. 
 
 When severe pain comes on with diarrhoea and with dark bilious 
 evacuations, a state of disease is produced which is closely allied to 
 the bilious diarrhoea and English cholera, which we have previously 
 noticed. The severe pain in the region of the umbilicus may be 
 associated with violent vomiting and purging, without being caused 
 by any impropriety of diet. The patient sometimes becomes pros- 
 trate, the motions fluid, the surface cold, the pulse compressible, and 
 in a very short time he is brought to extreme collapse, resembling 
 Asiatic cholera. This, in its most severe form, constitutes the 
 English cholera that is found to prevail each autumn in our own 
 country. But there are less degrees of this condition ; the vomiting, 
 pain, and purging may be more moderate, the tongue furred and in- 
 
 1 Taylor on 'Poisons.' Christison on 'Poisons.'
 
 Otf COLIC. 403 
 
 jected, whilst the prostration is less. Again, in other instances, 
 severe pain in the abdomen of the character of colic is present, with- 
 out any purging or vomiting, but with a sallow complexion, with 
 furred tongue,, pain in the head, oppression of the mind, and impaired 
 physical energies. 
 
 In some cases the prostration is so severe that the patient suc- 
 cumbs ; but more generally, I may say in most cases, the symptoms 
 subside, and are followed by speedy recoverv. 
 
 Causes. In the autumnal season there is much greater liability 
 to this disease, on account of the sudden variations in temperature 
 to which persons are often exposed. The exhalations from decaying 
 animal and vegetable produce, the effluvia from drains, also induce 
 this form of colic. In miasmatic districts, and in damp localities, 
 there is still fnore liability to this state, and so great may be the 
 predisposition, that a very slight excitement is sufficient to set up 
 the disease. 
 
 The most frequent cause, however, is disturbance in the function 
 of the liver, whether from intemperance, indiscretion in diet, mental 
 disquietude, &c. ; and whatever leads to congestion of the portal 
 system tends to induce colic upon slight exciting causes. Attacks 
 of this kind are often designated " spasms." 
 
 In infants it is exceedingly common to have colic from retained 
 and from morbid secretions; pain is produced, as shown by the 
 drawing up of the lower extremities, the cry is almost incessant, 
 there are green or watery evacuations, containing portions of coagu- 
 lated milk or undigested food, the countenance is anxious and dis- 
 tressed, and the sleep is disturbed. If this condition continue, it 
 extends so as to affect the mucous membrane of the stomach, and is 
 then associated with violent vomiting, so as to constitute gastro- 
 enteritis ; rapid prostration may ensue, and death may quickly 
 follow, or more slow muco-enteritis or intussusception may super- 
 vene ; and in some older children a less serious, but a troublesome 
 disease, prolapsus ani, is occasionally produced. 
 
 In the diagnosis, the remarks made in reference to the other 
 descriptions of colic are equally applicable ; and in the severer forms 
 the disease approaches in character to cholera. 
 
 Our prognosis must be a guarded one, for although most cases 
 recover, still in some, especially in infants, an untoward result follows, 
 and the patient becomes perfectly prostrate and dies. 
 
 Treatment. It must be remembered that the effect of the vomiting 
 and purging in these cases is to remove the offending matters from 
 the alimentary canal, so that many cases, if left to themselves, 
 recover. In milder cases the pain, the vomiting, and purging are 
 entirely removed by the administration of arrowroot, or by the in- 
 jection into the rectum of thin starch. If offending substances and 
 secretions are retained, castor oil with tincture of rhubarb, and with 
 opium, afford great relief, repeated as need be; and it is in this con- 
 dition, antecedent to the aggravated forms of Asiatic cholera, that 
 we may expect to derive benefit from the plan of treatment recom- 
 mended by Dr. Johnson. Some administer magnesia with good
 
 404 ON COLIC. 
 
 effect, calcined or carbonate, with a little conium or henbane; and 
 gray powder, with Dover's powder, or calomel with opium, may be 
 given so as to remove the abnormal contents of the intestine, and to 
 check the pain of the colic. If, however, the pain and diarrhoea 
 continue, it is well to give absorbent alkaline medicines, with astrin- 
 gents, as chalk with catechu and opium, or kino, krameria, logwood, 
 tormentilla, &c., and to repeat the starch injections, or injections of 
 oak bark. 
 
 In the subsequent prostration, mineral acids, the sulphuric, nitric, 
 hydrochloric acids, with vegetable tonics, are of great service in 
 restoring tone to the mucous membrane. The sulphuric acid lias 
 been much used in this form of diarrhoea, and we have already 
 alluded to its use. The secretions from the mucous membrane of 
 the small and large intestine are of an alkaline character, and when 
 the membrane is irritated, these are poured out in greater quantity, 
 forming an unusually thick covering to the membrane; in this state 
 the mineral acids correct the secretions by their astringent effect on 
 the capillaries, checking the further secretion of watery mucus, and 
 they assist the removal of that already formed. The solution of 
 potash, and the alkalies generally, have a soothing influence upon 
 the mucous membrane of the alimentary canal, and I think are of 
 greater service than acids in the early stage of this form of colic and 
 diarrhoea. If there be persistent pain warm applications, as pre- 
 viously described, should be applied. 
 
 Food should be very sparingly administered, and only of the most 
 bland form, as arrowroot, rice, tapioca, veal or chicken broth ; if the 
 strength fail, we must add brandy, or some other ardent spirit. 
 
 4. Lead colic. Till attention was drawn to the subject of lead 
 poisoning, the colic arising in the wine and cider districts was attri- 
 buted entirely to the character of the fluids drunk; this is still 
 known to be in a great measure the case; but, since the observations 
 of Sir George Baker, on the effects of poisoning by lead in its several 
 forms, we are able easily to distinguish the effects of lead poisoning 
 from other forms of colic. 
 
 The patient exposed to the influence of lead becomes of a sallow 
 and anaemic aspect, his muscular development is diminished, and his 
 mental capabilities are somewhat enfeebled; if colic come on, he 
 experiences severe pain in the abdomen, at first moderate, but after- 
 wards becoming intense, and of a twisting and grinding character 
 about the umbilicus; the abdomen is contracted, and the patient 
 experiences relief by firmly compressing the abdomen with his 
 hands, or even across a chair; the bowels are obstinately constipated, 
 the abdomen is neither tender nor hot, but hard and contracted; nor 
 is there generally any vomiting, but the patient writhes with the 
 severity of the pain; the tongue may be clean or furred, the pulse 
 is feeble, but not increased in frequency, and the urine is pale. 
 After some hours the severity of the pain subsides, but it may again 
 return during the next night, or after taking food. The severe colic 
 is sometimes accompanied by cerebral disturbance, but this is a rare 
 occurrence, although severe cephalalgia or epilepsy may precede or
 
 ON COLIC. 405 
 
 follow colic, as another of the effects of lead poisoning; so also 
 paralysis of the extensor muscles of the forearm may be produced. 
 The colic may, also, be associated with severe cramps and pains in 
 the extremities; the constipation sometimes gives place to diarrhoea, 
 but still the pain continues, or rather severe soreness, occasionally 
 aggravated into intense suffering. On examining the gums we find 
 along the edge a deep blue dotted line composed of minute particles 
 of sulphide of lead. This sulphide is formed by the sulphuretted 
 hydrogen produced by decomposing food, lodged "bet ween the teeth, 
 reacting on the lead circulating in the capillaries. The deposit takes 
 place around the small capillary vessels of the papillae of the gum as 
 shown by Dr. Fagge, but by abrasion it becomes exceedingly super- 
 ficial. This line is a very distinctive sign of lead poisoning, even 
 when the abdominal symptoms are insufficient to guide us tcTa cor- 
 rect diagnosis. It rarely occurs that, colic produced by lead termi- 
 nates fatally, unless associated with other diseases. In a case pre- 
 viously referred to, lead colic was associated with chronic ulceration 
 of the stomach, which led to perforation and a fatal result. We 
 sometimes find that paralysis of the hands or wrists, and epilepsv 
 are coincident with the colic; it is unusual to have paralysis of the 
 ankles, but such a case I have seen. 
 
 The proximate cause of lead colic is not known, whether it arises 
 from irregular peristaltic action of the muscular coat of the intestine 
 or from paralysis of one part, and spasmodic contraction of another. 
 In those cases which I have examined, and in others recorded, no 
 abnormal appearance was found in the intestine. The manner in 
 which the lead enters the system is, in some cases, very obscure, but 
 generally it is sufficiently manifest. Drinking fluids from leaden 
 vessels which are not covered with any protective carbonate, &c., 
 and acid drinks as cider, &c., from leaden vessels, are the common 
 modes of its introduction ; but lead colic is most frequently observed 
 in plumbers, painters, typefounders, &c., men who are constantly 
 employed in handling lead, and who breathe an atmosphere contami- 
 nated with minute particles of it. It appears probable that in the 
 mixture and using of paints containing lead there is still greater lia- 
 bility to its absorption ; the oil contains minute particles of the metal, 
 and its ready inhalation is effected. In many instances the want of 
 proper cleanliness in washing the hands before taking food, and in 
 changing the clothes, very much aggravates the liability to poisoning 
 by lead. It is sometimes, however, difficult to ascertain how the 
 metal has entered the system. Dr. Addison mentions a publican 
 who was thus poisoned by drinking in the morning, as his first 
 draught, the ale which had remained in the leaden pipe during the 
 night. Several instances have been know where lead was found in 
 the snuff which the patient had been in the habit of taking. It has 
 sometimes been produced by the medicinal use of acetate of lead; 
 but Dr. Thompson has shown that there is less liability to this effect 
 being produced when the lead is combined with opium, or given 
 with dilute acetic acid. 
 
 The diagnosis of lead colic is sufficiently clear when ordinary cau-
 
 406 ON COLIC. 
 
 tion is used, the lead line along the gums, with pain relieved by 
 pressure, and the contracted abdomen, distinguish the disease ; but, 
 as before mentioned, it may be associated with chronic ulcer of the 
 stomach, with hernia, &c., which obscure the diagnosis, and may lead 
 to a fatal result. 
 
 In uncomplicated lead colic we may give, especially in the earlier 
 attacks, a favorable prognosis. 
 
 Treatment. The indications of treatment appear to be sufficiently 
 plain in this disease to relieve the pain, to act on the bowels, and 
 to remove lead from the system. For the relief of the pain, opium 
 and chloroform are the best remedies and may be administered freely; 
 to act on the bowels, croton oil with opium, or calomel witli opium, 
 or castor oil and laudanum, or the sulphate of magnesia with corn- 
 pound infusion of roses and henbane may be used ; or we may 
 administer injections of castor oil or colocynth ; warmth should be 
 applied at the same time to the abdomen. 
 
 In relation to the subsequent treatment, we should not be content 
 with the subsidence of the colic as long as the patient retains his 
 sallow and anaemic aspect, and has a lead line along the gums. 
 Iodide of potassium has been used, and it has been found that the 
 urine contained lead during its administration ; this I have often 
 attempted, but unsuccessfully, to verify. Considerable benefit has 
 been found in dropped hands from rubbing iodine ointment into the 
 paralyzed parts, 1 and still more by the use of electricity and galvan- 
 ism locally applied. An insulated water bath has been recommended, 
 the patient in the bath being connected with one pole, the sides of 
 the bath with the other. It is stated, that the lead is removed from 
 the body of the patient, and deposited upon the walls of the bath ; 
 but I have not seen electricity applied in this manner ; the only 
 opportunity in which I have known galvanism used in colic, to 
 excite the bowels to action, was in the case associated with gastric 
 ulcer; the existence of the gastric ulcer was not known, and fatal 
 peritonitis followed. Warm baths, perfect cleanliness, bracing air, 
 and preparations of steel, after the removal of the lead, are of great 
 service ; but a considerable time is required for the system to become 
 completely free from the poison. 
 
 The prophylactic treatment is an exceedingly important consider- 
 ation to those employed in the use of lead. The importance of per- 
 fect cleanliness, of changing the clothes, of not partaking of the 
 meals in the workshop are now generally acknowledged, although 
 they are not acted upon as their cogency demands. 
 
 A drink containing dilute sulphuric acid with lemon juice is a 
 useful preventive against absorption of lead for those who are ex- 
 posed to its influence. 
 
 1 'Medical Times and Gazette,' May, 1857.
 
 407 
 
 CHAPTER XY. 
 
 ON CONSTIPATION. 
 
 WASTE and repair are necessarily connected with the performance 
 of every function of the human body ; and the various excretory 
 organs are the channels by which the waste materials are separated 
 as substances no longer of any benefit, and the retention of which 
 becomes increasingly detrimental to the whole economy. 
 
 The large intestine may be looked upon as an important excretory 
 organ, as well as a channel for the separation of effete material ; and 
 the removal of its contents is as necessary for the continuance of 
 human life, as the separation of carbonic acid from the lungs in 
 ordinary respiration. 
 
 The colon is well adapted for the purpose of excretion, and by its 
 arrangement serves as a reservoir, which by its distension permits 
 of an occasional, rather than a continuous, discharge of its contents. 
 
 But in this periodical movement of the intestinal canal there is 
 great difference in individuals ; and the variation within the bounds 
 of health is much greater than is usually supposed ; with some, and 
 perhaps by far the larger number, an action of the bowels takes 
 place once every day, or it may be two or three times, although 
 either condition may be consistent with health ; on the contrary, 
 with others, it may be that an action every second or third day is 
 the normal condition ; and the usual period may be even extended 
 to every fourth or seventh day. This variation must be borne in 
 mind, otherwise, in the attempt to produce what is considered bene- 
 ficial, an abnormal condition may be set up, and comfort and health 
 lost in striving to bind all to the same universal law. 
 
 Much, however, may be acquired by habit; regularity maybe 
 attained ; or inattention and want of care may induce a condition 
 which will almost baffle any subsequent effort to remedy. Pre- 
 mising that the healthy action in one may be disease in another, we 
 may define constipation to be a less frequent action of the bowels 
 than is the healthy condition of each individual. Ordinary consti- 
 pation arises from "the insufficient contraction of the muscular coat 
 of the intestine ; the canal becomes more and more distended, and 
 with each increase in the circumference of the tube greater power is 
 required to force onward its contents. I have sometimes observed 
 a colon so enlarged in obstinate constipation by distension and con- 
 sequent loss of power, that it has measured as much as twelve to 
 fifteen inches in circumference ; the power which must have been 
 necessary to propel the contents must have been enormous. And it 
 appears probable that in this extreme distension, a state closely allied 
 to paralysis of the muscular parietes is the result ; sometimes, how-
 
 408 ON CONSTIPATION. 
 
 ever, this gradual distension is the effect, rather than the cause of 
 paralysis. 
 
 A second effect of constipation is that the lateral pouches of the 
 colon formed by the circular and longitudinal bands of muscular 
 fibre, become more and more distended, and being thus filled out, 
 their contents are removed from the central current, and become 
 impacted, while the bowels act with some degree of regularity ; these 
 impacted feces may frequently be felt as tumors through the abdomi- 
 nal walls, alarming the patient, but disappearing under judicious 
 treatment. 
 
 Pouches of the colon sometimes become of considerable size, and 
 are generally surrounded by the circular fibres of the canal ; but not 
 ^infrequently these fibres yield, and the mucous layer projects, 
 covered only by the peritoneum, thus forming a mere elongated sac, 
 filled with mucus, or more frequently with feces. The orifices of 
 these small sacs are surrounded by the hypertrophied circular and 
 longitudinal fibres, and their contents remain almost shut off' from 
 the intestinal canal. These pouches are the result of constipation, 
 the muscular fibres become hypertrophied, and their efforts to propel 
 onward the contents of the canal lead to these hernial protrusions. 
 
 I have most frequently observed pouches in connection with the 
 sigmoid flexure ; but they, probably, occur at any part where the 
 longitudinal fibres form a triple band rather than an uniform layer. 
 In one case they were situated about every half inch, forming a 
 double row on each side of the colon. No muscular fibres could be 
 detected in several of them, beyond the immediate vicinity of the 
 mouth of the sac ; they consist merely of mucous membrane, sub- 
 mucotis tissue, with fat and peritoneum. They have latterly been 
 observed in the smaller intestine where they usually occur at the 
 mesenteric attachment of the bowel. These pouches do not appear 
 to produce any symptom, nor do they lead to dangerous results. A 
 remarkable case of this kind I observed in a patient, aged sixty-two, 
 who died from cancerous disease of the liver and lungs, with bron- 
 chitis and emphysema. The sigmoid flexure and rectum were con- 
 tracted, and presented numerous pouches, some of which were half 
 an inch in length ; they were arranged in two rows about one inch 
 apart; these pouches consisted of mucous membrane and perito- 
 neum; the circular muscular fibres were placed between them, and 
 the longitudinal fibres on either side, and both of these fibres were 
 hypertrophied. The pouches were filled with mucus and feces. There 
 was neither ulceration nor evidence of cicatrix, but it appeared that 
 the constipated bowels, to which the patient had been subject, had 
 led to unequal pressure and saccular distension, or hernioe of the 
 mucous membrane. Appearances of this kind, though in less degree, 
 are by no means uncommon in the colon, especially towards its 
 termination. 
 
 Continued distension of the colon with solid contents alters its 
 position ; this is especially observed in the transverse colon, and in 
 the sigmoid flexure ; the convexity of the former becomes greatly 
 increased, and the double curve of the latter is rendered more evi-
 
 ON CONSTIPATION. 409 
 
 dent. The attachment of the great omentum, and the ready separa- 
 bility of its layers, appear to be especially designed to allow of free 
 distension of the transverse colon, but a continued pressure increases 
 the curve, till at last it may form a large sigmoid flexure, reachino- 
 nearly to the brim of the pelvis. Increased curvature of the trans- 
 verse colon is of common occurrence, but sometimes its malposition 
 seems to be congenital; thus \ve have seen the descending colon 
 passing downwards in close contact with the ascending, and then 
 terminating in a transverse colon, which was situated at the brim of 
 the pelvis, thus connecting the descending colon with the sirnoid 
 flexure. 
 
 The most important result arising from continued constipation is 
 the retention within the blood, or the reabsorption into it of mate- 
 rials which are essentially excrementitious. The excrementitious 
 portion of the bile is not removed, and the functions of the liver are 
 imperfectly performed; the blood of the whole portal system is 
 rendered more or less impure; the complexion becomes changed, 
 sallow and muddy; the brain does not act with its wonted energy, 
 and there is a manifest diminution in the elasticity of both the mind 
 and bodv. 
 
 The functions of other viscera become disordered, and the en- 
 larged and distended colon interferes mechanically with the healthy 
 action of adjoining viscera. The caecum and ascending colon may 
 press injuriously upon the ilio-hypogastric and genito-crural nerves, 
 leading to severe neuralgic pain over the crest of the ilium or groin; 
 and pain of this kind may be mistaken for rheumatism, lumbago, 
 and sciatica, whilst it entirely disappears when mechanical pressure 
 on the nerves has been removed. This pressure is, however, more, 
 frequently exerted on the left side by the sigmoid flexure than by 
 the ciecum on the right; the veins of the lower extremity and the 
 testicle or ovary may become pressed upon, and oedema of the feet 
 and varicose veins result; by the distended transverse colon the 
 stomach is interfered with, and its movements are to a certain ex- 
 tent crippled. 
 
 In reference to the causes of constipation, the first to be mentioned 
 is original peculiarity of habit, or idiosyncrasy; that such peculiarity 
 does exist cannot, I think, be doubted, although it must not be con- 
 sidered as disease in the same light as constipation arising from 
 organic change. 
 
 A second cause is an abnormal condition of the abdominal walls. 
 The contraction of the parietal muscles is an important aid in defe- 
 cation, and their tonic contraction assists the peristaltic action of the 
 intestines. The constipated condition of the bowels in diseased and 
 fractured spine may be explained in part by this cause, namely, 
 paralysis of the parietal muscles. Diminution of contractile power 
 also arises from degeneration of the muscles themselves, and from 
 excessive development of fat; and sometimes the contraction of these 
 muscles is checked by pain, either of a neuralgic character, or from 
 local inflammation, as boils, fascial abscess, carbuncle, &c. Inactivity, 
 or sedentary life, tends to produce constipation in the same manner.
 
 410 ON CONSTIPATION. 
 
 How different the condition, when many hours are spent day after 
 day in nearly the same position, from that of active muscular exer- 
 tion? Contrast the mechanic, where the whole frame is in constant 
 movement, with the overworked sempstress; the clerk, sitting for 
 hours over the desk, with one engaged in active out-door occupation; 
 the professional or literary man, almost deprived of walking exercise, 
 to another in the full enjoyment of it. The muscular exertion of 
 walking, horse-riding, various athletic exercises, or other means by 
 which the muscles of the abdominal walls are brought into play, are 
 thus essentially necessary for maintaining good health. 
 
 A third cause of constipation arises from the alteration of the 
 secretions poured into the large intestine. These secretions, or rather 
 excretions, arise from the mucous membrane of the large intestine 
 itself, from the small intestine, from the liver, and from the pancreas, 
 and they undergo various changes; thus a congested condition of 
 the liver and of the portal system of veins, induces modification of 
 the whole chylopoietic viscera, for the vena portas receives its 
 branches from the large and small intestines, stomach, &c. ; hence 
 also a state of congestion of the liver not only checks the formation 
 of bile, but it interferes with normal secretions from other parts, 
 often diminishing them in quantity, and altering them in quality; 
 in this manner we have constipation from hepatic disturbance, and 
 from the intemperate use of alcoholic liquors; thus also in jaundice, 
 constipation is generally the result, the motions become clayey, white, 
 and exceedingly offensive. 
 
 Diseases of the lungs and heart, which interfere with the free 
 circulation of the blood, render the right side of the heart engorged ; 
 and as a necessary consequence of this distension, the liver and the 
 whole portal system are congested, the secretion from the mucous 
 membrane becomes scanty, and constipation is the result. This 
 constipation increases the original disease of the heart, and the 
 remark is often made by those who are the subjects of chronic dis- 
 ease of the lungs and heart, as chronic bronchitis, emphysema, 
 asthma, and valvular disease of the heart, that as soon as the bowels 
 become confined, they experience increased discomfort. 
 
 A state which may be called chronic catarrh of the mucous mem- 
 brane is sometimes induced from this congestion of the portal system 
 and constipation very frequently follows ; but another cause of this 
 altered secretion arises almost from an opposite cause, namely, a di- 
 minished supply of blood to the mucous membrane. The secretion 
 is scanty, but from a different reason ; in the former case, secretion 
 is checked by engorgement of the vessels with blood ; in the latter, 
 by a diminished supply. 
 
 The various excretory organs are closely connected the one with 
 the other. The excretions from the lungs, the skin, the kidneys, the 
 alimentary canal, are intimately associated. Their nicely adjusted 
 balance continues during health, but if one becomes greatly in excess 
 the others consequently, and almost in that proportion, suffer; thus 
 excessive secretion from the skin diminishes secretion from other 
 parts. The box of rhubarb pills is often carried by the pedestrian
 
 ON CONSTIPATION. 4H 
 
 and why ? The muscular exercise and action of the abdominal 
 muscles should induce increased action; and such would in many 
 cases happen if the exercise were moderate ; but if persisted in so as 
 to induce free perspiration, with rapid molecular changes in the mus- 
 cles, blood is actually withdrawn from the alimentary canal to the 
 skin and muscles; the internal secretions become diminished, and 
 constipation results. A similar condition is observed when exces- 
 sive action of the kidneys carries off the aqueous portion of the blood 
 too freely. The kidneys act less when the skin energetically per- 
 forms its function ; and on the contrary, when the warm air of sum- 
 mer is suddenly changed to a cold, chilly temperature, the action of 
 the skin is checked, and increased renal secretion is induced. We 
 have already alluded to this in our remarks on diarrhoea and dysen- 
 tery ; for the sudden interference with the action of the skin often 
 induces those diseases; hence autumnal diarrhoea, and the severe 
 dysenteries of hot climates. Cerebral congestion, over-anxiety of 
 mind, extreme mental occupation, act also in this manner, as well as 
 more directly upon the nervous condition of the alimentary canal. 
 There is increased circulation of blood in the brain, and less in the 
 abdomen ; for great excitement of the cerebrum is associated with 
 diminished activity in the nerve of organic life. 
 
 Constipation is also induced by general anaemia, and loss of blood; 
 and very frequently in spanasmia or poverty of blood, as in the chlo- 
 rosis of young women. The condition of the blood is here the pri- 
 mary cause of other secondary changes. There is inactivity or 
 irregular muscular exertion, and the secretions are imperfect both in 
 their character and quantity. 
 
 A fourth cause of constipation is a diseased state of the coats of 
 the intestine itself. I have already alluded to the secretion from the 
 mucous membrane, and especially refer here to the condition of 
 the muscular layer, and to the nervous supply of the alimentary 
 canal. 
 
 The muscular layer, in a state of health, contracts from slight di- 
 rect stimulus upon the contents of the canal, but this contractile 
 power is liable to various modifications ; sometimes it is excessive, 
 leading to the immediate expulsion of the contents, but more fre- 
 quently it is deficient, leading to constipation. This inactivity 'may 
 arise from the muscular coat having been unwisely excited to action 
 by improper means as by the injudicious use of purgatives, either 
 from their habitual continuance or from their powerful character; 
 and the muscular coat is left in such a state that it will not contract 
 from the normal stimulus, whilst the diminution of contractile power 
 is increased by the constipation with which it is associated. The in- 
 testine becomes distended, the calibre increases, and the muscular 
 fibre, which could easily propel the contents of a cylinder one to two 
 inches in diameter, is unable to do so when the cylinder is increased 
 to three or four inches in diameter, and the canal many times its 
 normal size. A state of actual paralysis of the muscular fibre of the 
 intestine may be thus induced, in the same manner as the urinary 
 bladder, when enormously distended, is unable to expel its contents .
 
 412 ON CONSTIPATION. 
 
 Repeated doses of blue pill and black draught, of violent purgative 
 medicines, of mercurials, &c., render the whole coat of the intestine 
 ina relaxed and enfeebled condition ; the mucous membrane is debili- 
 tated, the muscular fibre is inactive, and partially paralyzed. I do 
 not mean for a moment, that such remedies are not frequently at- 
 tended with marked relief to existing morbid conditions; but, the 
 continued use of them leads to chronic disease, which is perpetuated 
 as well as induced by the remedy itself, although in some cases this 
 is borne with apparent impunity. 
 
 Dr. Billing related to me an instance of a lady, who for thirty 
 years took a grain of calomel every night; and a colleague of his 
 own at the London Hospital for more than thirty years had taken 
 the same quantity daily after dinner. 
 
 It is, I believe, universally acknowledged that the long-continued 
 habit of taking snuff irritates the fauces and epiglottis, producing 
 cough, &c. Nor is dyspepsia the only further ill effect of this habit; 
 the irritating particles extend along the whole length of the alimen- 
 tary canal. Several inveterate snuff-takers have complained to me 
 of the irritable state of the bowels; and it appeared that the mucous 
 membrane was unnaturally stimulated and irritable. The oft-re- 
 peated stimulus leads to an enfeebled condition of the mucous mem- 
 brane, to a loss of contractile power, as well as of healthy secretion 
 and of nervous stimulus; as regards the stomach, dyspepsia is the 
 result; in the intestine, it leads to diarrhoaa or constipation; in some 
 cases the rectum is principally affected, and either the feces are 
 retained so as to form an impacted mass, which the bowel is unable 
 to propel; or, if the excreta be fluid, the same weakness allows the 
 contents to pass rapidly to the sphincter, which is itself so enfeebled 
 as to be unable to restrain an involuntary discharge. Snuff may 
 actually be seen among these excreta. 
 
 Drinking excessively of cold water induces an enfeebled, relaxed 
 condition of the mucous membrane of the alimentary canal. 
 
 Cicatrices of the mucous membrane after ulceration, as in dysen- 
 tery, lead to contraction and diminution of the canal; they cause 
 mechanical obstruction, and interfere with regular peristaltic action. 
 Tumors, or any growths pressing upon either small or large intes- 
 tine, may induce constipation in a similar manner; but we defer 
 entering into the causes of insuperable constipation, arising from cica- 
 trices, till we speak of ileus. With these cases also we shall consider 
 other more serious causes of constipation, namely, cancerous and 
 fibroid growths, tumors connected with the intestine, or pressing 
 upon it, and the various forms of internal strangulation and intus- 
 susception, &c. 
 
 In speaking of constipation arising from diminished secretion, we 
 have alluded to cerebral disease, and cerebral congestion, from over 
 anxiety and mental work. Various causes often co-operate in these 
 instances; a sedentary life and diminished muscular exertion, are 
 associated with changes in the secretions and with diminution of 
 contractile power of the intestine. In many diseases of the brain,
 
 ON CONSTIPATION. 413 
 
 the abdomen becomes collapsed, as if the healthy tone of the parts 
 was lost. 
 
 In diseases or injuries of the spinal cord, this relation between the 
 nervous system and the alimentary canal is still more evident; the 
 bowels are constipated, and action is often induced with difficulty; 
 not only from paralysis of the parietal muscles, but from diminution 
 of the contractile power of the intestinal muscular layer, as well as 
 from change in the secretions of the mucous membrane. The paraly- 
 sis is painfully shown in these cases by the want of control over the 
 sphincter muscle; for the motions escape involuntarily. 
 
 In advanced life the feeble contraction of the parietes, the dimin- 
 ished excitability of the intestinal muscular coat, and the necessarily 
 less active life, often produce constipation, which is increased by the 
 nervous alarm of the patient at the non-action of the bowels. 
 
 Constipation is also a sign of inflammation of the peritoneal in- 
 vestment of the intestines; the muscular coat becomes involved, and 
 ceases to contract with energy. This is a wise and beneficent pro- 
 vision, to which we have already referred. 
 
 Constipation also is induced when defecation is painful, as in in- 
 flamed haemorrhoids, in ulceration of the rectum, and in diseases of 
 adjoining parts. So severe is the pain in some cases, that action of 
 the bowels is prevented by the sufferer, who is unwilling to undergo, 
 or rather is desirous to postpone to the latest period, that which 
 produces such intense suffering. It is a merciful provision that in 
 health such necessary actions are free from pain. 
 
 It sometimes happens that a spasmodic constriction of the alimen- 
 tary canal, especially the rectum, induces constipation ; in most 
 cases, however, it will be found that there is associated with this 
 spasmodic contraction some direct cause of irritation at the part, as 
 a minute fissure or ulceration of the mucous membrane, disease of 
 the bladder or uterus, &c. 
 
 A. fifth cause of constipation may be the state of the contents of the 
 large intestine. The feces having become hard and impacted, remain 
 like a foreign body, and are only removed with considerable diffi- 
 culty. The character of the food may have been such as to induce 
 this impaction ; for many cases are recorded of substances which 
 have been taken habitually, as brown coarse bread, leaving the un- 
 digested parts to become agglutinated ; so also with calcined magne- 
 sia, taken medicinally day after day; undigested meat, ligamentous 
 tissues, arteries, fish bones, human hair, may form these concrete 
 masses ; and amongst lunatics stones and pebbles which have been 
 s\vallowel may thus become impacted. 
 
 It is in the lower part of the large intestines that feces generally 
 become thus hardened ; although it sometimes takes place to a less 
 degree in the caecum, and in the ascending and transverse colon. 
 
 Sixthly. Mechanical obstructions have been cursorily alluded to 
 in reference to tumors, as affecting the coats of the intestine ; and it 
 is of very common occurrence in pregnancy and ovarian growths, 
 to find that direct pressure is exerted upon one or other part of
 
 414 ON CONSTIPATION. 
 
 the colon, so as to interfere with regular and free action of the 
 bowels. 
 
 Symptoms. Constipation manifests its effects on the brain by in- 
 ducing torpor of the mind with diminished energy and activity ; the 
 sleep is disturbed, and not refreshing, the mind easily agitated, and 
 often melancholic. There is also a general malaise, which renders 
 the patient unwilling to undergo ordinary exertion and fatigue ; 
 pain in the head, sometimes at the forehead, at other times in the 
 occipital region, is often present; and when diseased arteries of the 
 brain, or other predisposing causes of disturbed cerebral circulation 
 exist there is not unfrequently vertigo, with disturbed vision, hazi- 
 ness, sparks before the eyes, muscae volitantes, ringing noise in the 
 ears (tinnitus aurium); and occasionally there is momentary loss of 
 consciousness. 
 
 When disease of the heart exists marked symptoms of disturbance 
 in the circulatory organs are sometimes produced ; the most frequent, 
 perhaps, is irregularity of the pulse, and uncomfortable palpitation 
 of the heart ; and the pulse is generally compressible. As to the 
 respiratory organs, dyspnoea is not unfrequently induced by the im- 
 pediment to free action of the diaphragm. Pain, especially across 
 the sternum, is often ascribed to the chest, whilst it really arises from 
 distended colon. 
 
 The abdomen is full, and sometimes masses of a round and hard 
 character can be felt in the course of the colon, simulating morbid 
 growths, which when perceived, cause alarm to the patient; this 
 state of partial impaction may exist, although there is daily action 
 from the bowels, a central channel being left, or fluid feces pass 
 around the obstruction ; the tongue is flaccid and indented by the 
 teeth, showing an atonic state of the muscular fibre. 
 
 Various neuralgic pains are often induced, from direct pressure 
 upon the nerves, sometimes in the right hypochondriac regions; 
 frequently over the crest of the ileum in the course of the ilio-hypo- 
 gastric nerve, and in the course of the genito-crural, to the groin and 
 the testicle. 
 
 Aching pain in the loins and in the lower extremities arises from 
 interference with the free return of blood ; and beside this symptom, 
 a varicose condition of the veins is induced or aggravated ; and con- 
 sequent oedema is produced. A similar condition of the hernor- 
 rhoidal veins is also the result of habitual constipation ; and all the 
 discomfort attendant on hemorrhoids follows. Irritation of the 
 adjoining pelvic organs is sometimes excited, as irritability of the 
 bladder. 
 
 It has been stated, that a distended transverse colon may exert 
 pressure on the duodenum, so as to lead to symptoms of dyspepsia; 
 such an effect is exceedingly doubtful, but when adhesions have 
 taken place between the first portion of the duodenum and the colon, 
 great distension of the latter then exerts pressure ; generally, how- 
 ever, these symptoms are due to the imperfect separation of execreta, 
 and to congestion of the portal system. - 
 
 Diagnosis. The diagnosis of constipation may be considered as
 
 ON CONSTIPATION. 415 
 
 generally sufficiently clear, but the various secondary symptoms 
 may lead to serious misapprehensions. As to impacted feces in the 
 course of the colon, they have very often been mistaken for tumors; 
 but their local character, mobility, and general symptoms serve to 
 distinguish them. This discrimination is more easy in the ascending 
 or transverse colon; but in the descending colon, and especially in 
 the sigmoid flexure, the diagnosis is more difficult. Cancerous ob- 
 struction at the sigmoid flexure is very insidious, and gradual consti- 
 pation is its principal symptom ; but local pain, and a small, firm, 
 hard tumor at that part are very diagnostic of an obstruction of this 
 kind. Impacted feces, however, in the rectum and sigmoid flexure, 
 sometimes become so firm and immovable, that the symptoms mav 
 closely resemble organic disease; weeks may be passed without, an 
 evacuation, and gradually severe symptoms result, as vomiting, and 
 occasionally extreme pain. A careful examination will, in most 
 cases, render the diagnosis easy, and the patient perseverance in 
 injections and mild aperient remedies will be effective ; we do not 
 find in simple impaction of feces that the stomach becomes so irri- 
 table as in organic strangulation. A hardened mass in the rectum 
 produces the repeated discharge of fluid feces or of a clear mucus, 
 which is often mistaken for diarrhoea; and whenever these symptoms 
 occur, it is most important to make a digital examination. 
 
 A case is recorded by Mr. Staniland, 1 of a patient, aet. 73, who had 
 habitual constipation, so that, during the last five years of her life 
 the bowels were only acted upon once in every two months; after 
 being confined for four months and eight days they were very freelv 
 acted upon; seven months then elapsed without any pain or evacu- 
 ation. Some weeks before death she had a fall, which produced 
 very severe pain in the region of the caecum, and led to local inflam- 
 mation, gangrene, and fecal extravasation into the peritoneum. The 
 intestines were found enormously distended with feces, the transverse 
 colon was nine inches in diameter, and the sigmoid flexure ten and 
 a half; the rectum six inches. A remarkable instance of constipa- 
 tion of nearly four months' duration, after fever, is recorded by Mr. 
 Gay, in the 'Pathological Transactions' of 1854. The patient, set. 6, 
 recovered. 
 
 The treatment of constipation is a subject of great interest, because 
 it is one which so frequently tests the skill of the practitioner. A 
 knowledge of the habits and diet is essential to us in devising means 
 of cure; thus regular exercise, when the life has been sedentary, and 
 especially walking or horse exercise, is of paramount importance. 
 It is true that the beneficial effect of pure air may be otherwise 
 obtained, but not all its good effects ; for carriage exercise is not alone 
 sufficient. The practice of riding in many of the crowded convey- 
 ances which hurry to the city day by day, becoming wearied by 
 standing, or quietly sitting at the desk, and when exhausted return- 
 ing home in a close omnibus, or railway carriage, is sufficient to 
 induce discomforts of a hundred kinds, without the addition of the 
 
 i ' Medical Gazette,' p. 246. 1832-1833.
 
 41G ON CONSTIPATION. 
 
 anxieties of life; and this mode of life in a greater or less degree is 
 everywhere observed. An actual distaste for or aversion to walking 
 may be easily acquired, and the beneficial effect of such exercise is 
 forgotten. 
 
 It is very desirable to promote constant regularity in the action 
 of the -bowels; with many persons, an early movement before or 
 after breakfast, removes discomfort for the rest of the day; with 
 others, though less desirable, the time immediately before going to 
 bed is chosen. 
 
 The character of the food is an important consideration ; sometimes 
 injury is done by taking more than the frame requires, and the 
 stomach can digest; or by too great sameness in the diet, for variety 
 is required; not that at each rneal numerous forms of food should 
 be taken and satiety induced by the niceties of the culinary art ; 
 but, an admixture of animal and vegetable food is necessary, and a 
 change in them is requisite. 
 
 Vegetable food contains a large quantity of indigestible material 
 and of alkaline salts which stimulate the alimentary canal, so that 
 when there is a tendency to constipation, a free use of this form of 
 diet may be sufficient to remove it ; thus, brown bread acts by the 
 irritating character of the indigestible parts of the grain. Again, 
 gentle palpation of the abdomen, kneading of the parietes with the 
 palms of the hands, has sometimes induced action. The bracing 
 tonic effect of a shower-bath, or in a less degree of cold sponging, 
 when it is not contra-indicated, may obviate constipation. These 
 means produce their effect by the increased action of the abdominal 
 muscles; but another agent acts in a similar manner, namely, elec- 
 tricity. A galvanic current transmitted through the abdominal 
 walls induces a very speedy action, or rather emptying of the colon ; 
 it has been sometimes recommended in the constipation of painter's 
 colic. I have used it with manifest advantage in paralysis. A case 
 of partial paraplegia, in which injections did not act satisfactorily, 
 and drastic purgatives were undesirable, was treated by a galvanic 
 current passed through the abdomen every morning ; in a few hours 
 a free evacuation was produced without any discomfort. This agent, 
 which has been employed to excite contraction of the uterus, may be 
 frequently used with benefit in constipation. 
 
 Medicines, directly purgative, may be divided into several classes 
 those which are : 
 
 1. Laxatives. Manna, figs, prunes, raisins, fruits, brown bread, 
 cold water. 
 
 2. Aperients. Castor oil, almond oil. cod-liver oil. 
 
 3. Saline purgatives, as magnesia, sulphate of soda, and of potash, 
 saline waters, bitartrate of potash, &c. 
 
 4. Mild purgatives. Senna, rhubarb, aloes, mercurial medicines. 
 
 5. Drastic purgatives. Jalap, colocynth, gamboge, scarnmony, tur- 
 pentine, croton oil, elaterium. 
 
 Inspissated bile has been used as an aperient, from the idea that 
 the excrementitious portion of bile is naturally purgative in its 
 action ; but although ten or fifteen grains may act as an aperient,
 
 OX CONSTIPATION. 417 
 
 and assist in unloading the intestine, it is an offensive and less satis- 
 factory remedy than others which we possess. These remedies act 
 on different portions of the intestine and in various ways ; thus 
 mercurial purgatives stimulate all the secretions, both those of the 
 liver 1 and of the mucous membrane ; senna, and saline purgatives 
 act on the small intestine, and render the evacuations more 3 fluid ; 
 aloes, and the drastic purgatives act on the colon ; rhubarb has an 
 astringent as well as purgative effect, and sometimes irritates and 
 offends the stomach. Some aperients stimulate the intestine to in- 
 creased peristaltic action and excite griping pain. The action of the 
 salines is partly due to exosmotic current from the capillaries of the 
 intestine, thus leading to the effusion of fluid in a greater extent 
 into the canal than is absorbed from it. 
 
 The rapidity of the action of aperients is also very diverse. The 
 
 _ salines act quickly, especially if given with a considerable quantity 
 
 of diluent fluid. Aloes is slow in its action, and requires several 
 
 hours to produce any effect. Drastic purgatives are often followed 
 
 by much trying irritation in the rectum, and by tenesmus. 
 
 Strychnia, or nux vornica, is a valuable remedy in constipation; 
 it excites the muscular coat to contraction, at the same time that a 
 tonic effect is produced on the mucous membrane. It is well to 
 combine with it purgatives and sedatives, as aloes, and henbane, &c. 
 Preparations of steel often act as purgatives in the same manner. 
 
 Podophyllin, from the Podophyllum peltatum, the May apple or 
 mandrake, has been long used in the United States ; in doses of gr. 
 J-j, it acts as a mild purgative, producing an evacuation from the 
 bowels slowly, but efficiently and often without pain. I have ob- 
 served it act thus favorably in chronic ulcer of the stomach ; in 
 large doses it produces violent vomiting and purging ; thus in an 
 instance in which a nurse, contrary to directions, gave seven to ten 
 grains, severe colic, vomiting and dysenteric diarrhoea followed, but 
 subsided in a few days. The tincture of podophyllin, gr. j, with 5j 
 of rectified spirit, is a convenient mode of administering this purga- 
 tive. 
 
 The use of glysters is too frequently neglected in ordinary consti- 
 pation ; but, their beneficial effect is now more generally acknow- 
 ledged ; some act simply by irritating and distending the intestine, 
 thus exciting it to contract ; as warm water and gruel ; purgative 
 substances may be added, as soap, castor oil, colocynth, turpentine, 
 and rue ; the last two are especially used when constipation is asso- 
 ciated with flatulent distension of the intestines. The excessive use 
 of glysters even of the mildest kind, as water and gruel, and espe- 
 cially when they are administered in large quantities, induces dis- 
 tension of the rectum, and an unreadiness to act without the wonted 
 stimulus. 
 
 I cannot leave the subject of the use of purgatives in ordinary 
 constipation, without speaking of the injurious effect of their indis- 
 
 1 The results obtained by the Committee of the British Medical Association appear, 
 however, to show that mercurial medicines do not increase the actual flow of bile in 
 the lower animals. 
 27
 
 418 ON CONSTIPATION. 
 
 criminate and injudicious use; to some the use of a dinner pill or 
 ;iii aiu-rifiil at night, is constant, year after year; in others a slight 
 discomfort leads to the use of the blue pill or black draught, or to 
 still more active agents. Temporary relief is afforded by powerful 
 purgatives, but the delicate mucous membrane of the intestinal tract 
 is weakened, a state of chronic catarrh is induced, and the very con- 
 dition sought to be removed is aggravated tenfold. In enfeebled 
 persons, violent purgative medicine has in very many cases induced 
 excessive prostration, and even fatal results; and, in them, it is easy 
 to excite a state of irritation which it is almost impossible to subdue. 
 
 The administration of vegetable tonics, with mild purgative medi- 
 cines, and with ammonia, is often of great utility; a valuable pre- 
 paration of this kind is the compound gentian mixture of the London 
 Pharm.; it contains senna, gentian, orange and lemon peel, ginger, 
 and tincture of cardamoms. The combination of aloes and rnyrrh is 
 a preparation of a somewhat similar kind, the tonic effect of the 
 myrrh is associated with the purgative of the aloes. Purgative 
 medicines sometimes act more beneficially in combination; as slight 
 mercurials, when the secretions of the liver are imperfect, with aloes, 
 rhubarb, and colocynth. 
 
 The addition of an anodyne or carminative, as hyoscyamus, Dover's 
 powder, the essential oils, &c., with more active remedies, is benefi- 
 cial in removing their irritating character, and in preventing the 
 griping pain sometimes induced by them when given alone; thus 
 the compound gamboge pill, and compound colocynth pill with hen- 
 bane, act as efficient but tolerably mild purgatives, emptying the 
 large intestine; or the purgative may be sheathed by mucilaginous 
 and oleaginous substances, as rhubarb with linseed oil. Belladonna 
 will often act as a purgative when administered alone, as gr. J of 
 the extract; it appears to induce this action by lessening spasmodic 
 irritation. 
 
 In infants, constipation is sometimes an exceedingly troublesome 
 affection; the repetition of castor oil is trying, and even injurious; 
 an old-fashioned remedy is that of exciting the intestine to contract 
 by introducing a very small glyster pipe into the rectum, or a por- 
 tion of soap cut into a conical shape; magnesia may be given in a 
 tasteless form, the calcined, or citrate, &c., or sometimes a small 
 quantity of gruel will excite the bowel to slight action; in any case, 
 however, irritating medicine must be avoided. It is difficult to 
 over-estimate the injurious effect in children of repeated doses of 
 calomel, of jalap, &c.; muco-enteritis is induced, and sometimes 
 fatal results follow; scammony with milk is a convenient remedy in 
 some cases, but it must be used with caution. 
 
 In the aged, enfeebled either by a life of activity or by declining 
 strength, the intestines lose their normal power of wonted contrac- 
 tion; to use drastic purgatives is out of the question, and a constant 
 change of milder aperients is necessary. The mildest laxatives may 
 suffice, as a draught of cold water, prunes, figs, roasted apples, brown 
 bread, manna, the confection of senna, or the compound rhubarb 
 pill, alone or with henbane, so the compound colocynth pill, and
 
 ON CONSTIPATION. 419 
 
 scammony pill with henbane and Dover's powder, or a few grains of 
 dried rhubarb with capsicum and soap, may be given with each 
 principal meal; and to these, in some instances, very minute doses 
 of strychnia are added, with considerable benefit. The arnmoniated 
 tincture of guaiacum is sometimes useful as a stimulant to the colon, 
 or the powdered resin of guaiacum combined with the confection and 
 syrup of senna, or may be confection of sulphur. 
 
 When the muscular coat of the rectum loses its contractile energy 
 the contents sometimes become so impacted and hardened as subse- 
 quently to withstand the most powerful efforts at expulsion ; purga- 
 tives, and even copious injections, are insufficient to soften the hard 
 contents, and mechanical assistance has in not a few cases been re- 
 quired. Hard masses may be retained in the colon and rectum even 
 although there be repeated action of a fluid kind ; for, laterally, 
 fluid may pass, especially after purgative remedies, whilst scyba'la 
 are still retained. In advanced life, in spinal disease, in constipation 
 after powerful purgatives, this state is occasionally present, but it 
 has in rare cases been witnessed in very early life. Warm copious 
 injections, whilst enteric irritation is avoided, will suffice to relieve 
 most of these impactions, but it is well to precede the soap or gruel 
 injection with several ounces or even a pint of warm salad oil, if the 
 obstruction be severe. 
 
 Concretions may form in the intestines from deposit upon extra- 
 neous substances, from impacted biliary calculi, but more frequently 
 they consist of hardened feces, or of the undigested portions of food 
 and medicine, as from oatmeal, brown bread, &c. Dr. Harley, in 
 an interesting communication on this subject to the Pathological 
 Society, in 1859, records an instance of concretion consisting of starch, 
 taken to relieve dysentery; another of benzoin, which had been 
 taken to improve the voice, and had formed a concretion as large as 
 a bean. Again, large quantities of magnesia have been found as a 
 mass in the colon, and portions of string have become impacted in 
 like manner. 
 
 Foreign bodies of considerable size sometimes pass through the 
 whole intestinal canal without producing any injurious symptoms, 
 as coins accidentally swallowed, stones taken by maniacs ; in other 
 cases they are retained at the sphincter and require mechanical 
 assistance in their removal, as fish-bones, &c., placed across the 
 intestine. 
 
 In a remarkable instance in which a sailor swallowed clasp-knives, 
 several were discharged from the bowels, and one was found fixed 
 transversely in the rectum ; the case is recorded by Dr. Marcet, in 
 the 'Medico-Chirurgical Transactions,' and the thickened stomach, 
 with the fragments of the blades found on examination after death, 
 are preserved in the Museum of Guy's Hospital. The patient was 
 an American sailor, aged 23, who, in June, 1799, swallowed four 
 clasp-knives ; three were discharged from the bowels. In March, 
 1805, he swallowed fourteen knives in two days ; in December, 1805, 
 he swallowed fifteen to twenty more ; making thirty-five swallowed 
 at different times. His health became impaired; he vomited the
 
 420 ON CONSTIPATION. 
 
 handle of one, and passed portions of the blades of others; and in 
 MM rch, 1809, he died in a state of extreme exhaustion. The oesopha- 
 gus and stomach were dilated and thickened, and in the latter, there 
 were numerous blades of knives partially dissolved. In the abdo- 
 men there was a general discoloration of the intestines ; one blade 
 was found perforating the colon opposite the kidney, but without 
 extravasation of feces ; another blade was transversely fixed in the 
 rectum.
 
 421 
 
 CHAPTER XYI. 
 
 ORGANIC OBSTRUCTION INTERNAL STRANGULATION INTUSSUSCEPTION 
 CARCINOMA OF INTESTINE. 
 
 VARIED conditions, leading to insuperable constipation, have fre- 
 quently been indiscriminately associated together, under the terra 
 ileus ; and, whilst we are willing to acknowledge, that very great 
 difficulty is connected with the correct diagnosis of these cases, we 
 believed that when a full history of the symptoms can be obtained, 
 careful examination will enable us to divide them into several classes, 
 and to make an approximate diagnosis, not only as to the character, 
 but as to the position of the obstruction. Each minute circumstance 
 is important in assisting the correct diagnosis of these cases, the 
 accurate detail of previous symptoms, the mode of attack, the posi- 
 tion of the pain, the vomiting, the relative severity and period of 
 commencement of these symptoms, the state of the abdomen, the 
 general appearance of the patient, the quantity of the urine, &c. Dr. 
 Barlow has drawn attention to several of these conditions, and has 
 shown the importance of ascertaining the period of the commence- 
 ment of the vomiting 1 and the condition of the renal secretion. 
 
 Organic obstruction of the bowel may be conveniently divided into 
 several classes. 
 
 1. Those cases in which the cause of the obstruction is external to 
 the bowel comprising : 
 
 Bands of adhesion. 
 
 Diverticula. 
 
 Adherent appendix ceeci. 
 
 Twists of the bowel or displacement. 
 
 External tumors and enlarged glands. 
 
 Internal hernia : 
 
 Diaphragmatic. 
 
 Meso-colic. 
 
 Ornental. 
 
 Obturator. 
 
 Pelvic. 
 
 2. Those cases in which the cause of the obstruction is in the 
 changed coats of the intestine. 
 
 Intussusception. 
 
 Polypoid growths. 
 
 Cancerous disease. 
 
 Cicatrices. 
 
 Contraction following inflammation or injury. 
 
 1 'Guy's Reports,' 1844. Clinical cases. Practice of Medicine.
 
 422 INTERNAL STRANGULATION. 
 
 Peritonitis and enteritis. 
 
 Prolapsus ani. 
 
 Inflamed hemorrhoids. 
 
 3. Those cases in which the obstruction is due to the contents of 
 the bowel. 
 
 Concretions. 
 
 Foreign bodies, gall stones. 
 
 Impacted fec6s. 
 
 In the consideration of the pathology of the first class of cases, 
 those in which the obstruction is external to the bowel, we have first to 
 notice the obstruction produced by bands of adhesion. 
 
 These bands are of various kinds, sometimes like a thin cord 
 under which a coil of intestine may have passed or round which 
 the intestine may have twisted ; at other times they are broad, 
 and may be the cause of obstruction by having become perforated 
 or by allowing the intestine to pass through them, but more fre- 
 quently the obstruction is due to traction upon the band by disten- 
 sion of the part above. Thus, in an instance under my care, there 
 was a broad band extending from nearly the whole of the ascending 
 colon to the mesentery; years had passed with only slight pain 
 when the knee and thigh were strongly flexed, but when the caecum 
 became greatly distended after improper food, the traction upon the 
 band led to complete and fatal obstruction. Bands are generally 
 the result of inflammatory action, and may extend from one coil of 
 the small intestine to another, from the small to the large intestine, 
 from the sigmoid flexure to the caecum, from the small intestine to 
 the pelvic viscera, as the uterus or ovary ; again a portion of adhe- 
 rent omentum may constitute the constricting band. The inflam- 
 mation may have taken place during infantile or even during foetal 
 life, and it is always important to inquire minutely into the clinical 
 history in these cases. 
 
 The part of the small intestine most frequently strangulated either 
 by loops, bands, or adhesions, is the lower portion of the ileum ; the 
 colon is sometimes constricted by old inflammatory bands, but the 
 sigmoid flexure is that part which we find most commonly diseased, 
 and very frequently the disease there is of a cancerous character; 
 sometimes the constriction is twofold, as in an instance under the 
 care of Dr. Bees, in Guy's Hospital, in which a band constricted the 
 upper part of the jejunum, and a second band the ileum. 
 
 The constricting medium may however arise from congenital mal- 
 formation, and be produced by diverticula. During foetal life the 
 ornphalo-mesenteric duct extends from the intestine to the umbilicus, 
 and a portion of this duct may remain as a pouch passing from the 
 ileum a few inches from its union with the caecum. At the extremity 
 of this pouch an adhesion of varying length may fix it either to the 
 mesentery, to the umbilicus, or to a coil of intestine, and thus become 
 a constricting band. Remains of this duct may be free from the 
 ileum, but attached at the navel. 
 
 The appendix cseci, as we have before remarked, varies greatly in 
 its position and in its length. It is sometimes several inches long
 
 INTERNAL STRANGULATION. 423 
 
 and free, so that it may pass over a coil of intestine, and if inflam- 
 matory adhesion take place it may become a constricting band; we 
 have known the lower part of the ileum completely bound down in 
 this manner. 
 
 Tivists of the bowel and displacement frequently become the cause 
 of obstruction, and the intestine may be looped in a complicated 
 manner. Eokitansky gives three forms of twisting of the intes- 
 tine: 1, upon its _ own axis; 2, upon the mesentery; and 3, upon 
 other coils of the intestine. The small intestine may easily become 
 thus twisted, and the caecum is sometimes so freely movable that it 
 may be twisted round into the left hypochondrium, as in a case 
 recorded in this chapter. Again, the sigmoid flexure, especially in 
 aged persons, where there has been previous constipation, will bend 
 upon itself, and fall over into the pelvis. The sigmoid flexure then 
 forms an acute angle opposite to the brim of the pelvis, and the 
 contents will not pass; the distension of the upper part of the bowel 
 increases the obstruction. 
 
 The pressure of enlarged glands and of abdominal tumors is an 
 occasional source of insuperable constipation. An ovarian tumor 
 may exert considerable pressure on the bowel, but if a coil of intes- 
 tine has become fixed by inflammatory adhesion the obstruction may 
 be rendered complete. It is more frequent to find that tumors which 
 cause fatal obstruction are of a cancerous character; in a case under 
 the care of one of my colleagues, numerous enlarged glands pressed 
 upon the intestine and produced a double obstruction, one affecting 
 the lower part of the intestine, and the other the duodenum, in which 
 latter part the bowel passed between two enlarged glands which 
 compressed it on either side. 
 
 By internal hernia we mean those forms of the disease in which 
 the intestine does not protrude in the ordinary channels as through 
 the umbilicus, the inguinal canal, or the femoral ring, but in posi- 
 tions where it is either entirely hidden by the soft structures, or 
 concealed in the abdomen; thus hernia may take place through the 
 diaphragm, but many of these cases are from direct violence and a 
 fatal result at once ensues; the protrusion may be through the meso- 
 colon, through the oinentum or the mesentery; or again through the 
 obturator foramen, the ischiatic notch, or through the recto- vaginal 
 pouch, or lastly through the foramen of Winslow, or behind the 
 peritoneum. 
 
 A second division is that in which there is change in the coats of 
 the intestine itself. Such is the case in intussusception; and also in 
 cancerous disease of the bowel whether of the large or small intestine. 
 Polypi of varied form and size grow from the mucous membrane, 
 especially in the rectum and sigmoid flexure; these growths some- 
 times induce intussusception, but they may themselves produce ob- 
 struction. The cicatrices which follow ulcerative action may cause 
 occlusion, for not only is the bowel narrowed at that part, but spas- 
 modic contraction may ensue and render the partial obstruction 
 complete ; in this way we have observed an ulcer in the small intes- 
 tine lead to fatal result. After dysentery the cicatrices are still
 
 424 INTERNAL STRANGULATION. 
 
 more decided, and constipation even of an insuperable character 
 may ensue; malignant deposit sometimes takes place at the seat of 
 the cicatrix. The same kind of contraction may be induced by 
 previous inflammation whether the result of injury or not. 
 
 In peritonitis and enteritis, the coats ot the intestine are enfeebled 
 by the inflammatory process : they are unable to contract and to 
 propel onwards the contents, hence constipation that is apparently 
 insuperable is the result; a greater mistake can scarcely be made 
 than to administer purgatives in these cases, and to try and induce 
 action from the bowels. In procident conditions of the rectum, pro- 
 lapsus ani, and in inflamed haemorrhoids, fatal constipation may some- 
 times result; the pain is so severe that the patient will not allow 
 the bowels to act; and vomiting and extreme prostration may come on. 
 
 A third class includes those cases in which the obstruction arises 
 from the nature of the contents of the bowel ; we have already 
 referred to concretions of various kinds, and to foreign bodies, stones, 
 fish bones, portions of hair and string. It is not usual, however, 
 for these substances to cause fatal obstruction, and, indeed, it is re- 
 markable how foreign bodies will pass along the intestinal tract with 
 comparatively little irritation, such as coins of varied sizes, nails, 
 pins, even small spoons, &c. 
 
 Gall stones of very large size occasionally obstruct the bowel; we 
 remember fatal obstruction from a gall stone impacted in the com- 
 mencement of the jejunum, and in another case which we have 
 recorded, the gall stone was gradually working its way onward to 
 the colon, it had reached the lower part of the ileum, when death 
 took place from hemorrhage. There are many instances on record 
 of this kind of obstruction. Fecal accumulation rarely if ever 
 causes fatal obstruction, though death may arise from the violent 
 remedies employed, as from strong purgatives or as when the injec- 
 tions of very large quantities of fluid have been followed by fatal 
 collapse. 
 
 \Vhen the obstruction is complete, the intestine above the part 
 becomes distended, and when the disease is chronic, the muscular 
 coat becomes hypertrophied. In chronic obstruction, especially in 
 the lower part of the colon, the distension becomes very great, and 
 the colon attains an enormous size. The coats of the intestine at 
 the seat of the stricture become greatly congested ; there is intense 
 venous repletion ; the mucous membrane becomes purplish in color, 
 enteritis supervenes and afterwards ulceration. The inflammatory 
 action extends to the peritoneum, so that it is very rare to find a 
 case of fatal obstruction without peritonitis ; sometimes merely a dry 
 and congested state of the serous membrane exists, in others lymph 
 is effused, and in many there is perforation. The perforation of the 
 intestine is often observed at the seat of the constriction, and is most 
 marked at its upper limit; but in diseased rectum and sigmoid flex- 
 ure, it will be frequently found that perforation has taken place, not 
 only at the constriction, but at the eoecurn. The ulceration of the 
 mucous membrane in these instances is also peculiar; it is somewhat 
 similar to that presented by the skin which has been overstretched, 
 and affected with erythematous inflammation and superficial ulcera-
 
 INTERNAL STRANGULATION. 425 
 
 tion. It is, in instances where the obstruction is primarily from the 
 mucous membrane, as in cancerous growth, that peritonitis is most 
 slowly developed. Where all the coats of the intestine are in- 
 volved, as in many cases of internal strangulation, the vessels of the 
 mesentery become also obstructed, oedema is produced, and in a 
 short time gangrene follows. 
 
 In the records of the Guy's post-mortem room during twenty-three 
 years, there have been nearly 8000 examinations (7934), and twenty- 
 five instances of fatal obstruction by bands are described. 
 
 In 10 a peritoneal band extended from the mesentery to some 
 other part. 
 
 In 5 there was an omental band. 
 
 " 2 a band from the vermiform appendix. 
 
 " 5 diverticula ilei. 
 
 " 3 various; in one there was an arch from the mesentery; in 
 a 2d, the pedicle of an ovarian tumor; and in the 3d, the neck of an 
 internal hernial pouch formed the constricting medium. 
 
 From the whole number of post mortems just mentioned there were 
 114 cases of intestinal obstruction, including strictures of various 
 kinds ; there were intussusceptions 17 times. Twisting of volvulus 
 8 times. Obstruction by bands 25 times. Adhesions and contrac- 
 tions 20 times. 
 
 The latter class included various conditions, such as chronic 
 tubercular peritonitis twisting upon old adhesions, one case of ob- 
 struction some time after recovery from intussusception, and two 
 other cases were from a malposition or malformation. 
 
 As regards the symptoms produced in these several conditions we 
 find, that the instances of internal strangulation and acute obstruc- 
 tion of the bowels, from twisting or compression, differ from those 
 produced by intussusception and from the more gradual disease due 
 to cancerous growth, and we may take these three as examples of the 
 several varieties we have just enumerated. 
 
 Abercrombie 1 describes cases of ileus in which no cause of strangu- 
 lation nor obstruction was detected after death, and he believed them 
 to arise from distension, or " simple derangement of action" of the 
 intestine; thus he states, "that distension appears to constitute a 
 morbid condition which inay be fatal without passing into any 
 farther state of disease;" and again, that "ileus does not appear to 
 be necessarily connected with obstruction in any part of the canal ; 
 for we have seen it fatal without obstruction, and we have seen 
 everything like obstruction entirely removed without relieving the 
 symptoms." He mentions other instances in which adhesions had 
 formed without sensible diminution of the calibre of the intestine, 
 and which were followed by the symptoms of insuperable obstruc- 
 tion ; in the former we believe that either enteritis was present, or 
 the bowel was twisted; in the latter that spasmodic contraction 
 rendered a partial impediment complete ; and the author just men- 
 tioned writes, "I admit, however, that there may be irregular con- 
 
 1 Abercrombie on ' Diseases of the Stomach and Intestine.' Third edition.
 
 426 INTERNAL STRANGULATION. 
 
 tractions of portions of the intestine, analogous to that to which the 
 term spasm is usually applied, and that these may form the first 
 step in that chain of derangements of the harmonious action of the 
 canal which leads to an attack of ileus." 
 
 Internal strangulation. The general symptoms of this condition 
 are pain, gradually increasing distension of the abdomen, constipa- 
 tion, generally of an insuperable character, vomiting at first bilious, 
 afterwards stercoraceous ; and after a longer or shorter period peri- 
 tonitis, prostration, and death. 
 
 Pain. In many cases of internal strangulation there is a sudden 
 catch in the bowels, as of some displacement, and the patient can 
 place the hand on the exact part, which generally indicates the seat 
 of disease, although we may afterwards find that distension and other 
 causes have led to considerable alteration of its original position. 
 When a portion of intestine has slipped under a band of adhesion, 
 or into a hole of omentum or mesentery, this character of pain is 
 observed, but when there has been a twist of the intestine the pain 
 is generally more gradual in its development, and for many days 
 may be entirely absent. The most obscure cases are those of inter- 
 nal strangulation, in which there has been chronic partial constric- 
 tion, when from indiscretions in diet, or other causes slight enteric 
 irritation has led to spasmodic constriction at the part ; in these 
 cases the pain closely resembles ordinary colic. Tenderness of the 
 abdomen may be absent for many days ; in some instances the peri- 
 tonitis does not come on till nearly the close of life, when it is due 
 to a state of continued and extreme distension of the intestine, and 
 to ulceration of the mucous membrane extending to the serous coatj 
 but where there has been sudden strangulation, the serous membrane 
 is more quickly implicated, and the symptoms bear a closer resem- 
 blance to those of ordinary external strangulated hernia. If the 
 strangulation be in the small intestine, either near the caecum, or in the 
 jejunum, the pain will generally be found to be in the region of the 
 umbilicus ; where the colon is involved the position of the pain is in 
 the course of that part of the intestine, and often marks its precise 
 seat ; thus, in diseases of the sigmoid flexure, the pain will generally 
 be found in the left iliac fossa or in the left groin. 
 
 Peristaltic movements. Tympanitis. Unless the obstruction be 
 very high in the alimentary canal, as in the case recorded with dis- 
 ease of the duodenum and of obstruction twenty inches from the 
 pylorus, the abdomen gradually becomes distended, and tympanitic 
 on percussion. The enlarged coils of intestine may be observed 
 through the stretched parietes, and the peristaltic movements are 
 often clearly perceptible, especially in obstruction of the colon. If 
 the ileum, or the commencement of the ascending colon be con- 
 stricted, the distension is central in its character, and is less evident; 
 but if the descending colon, sigmoid flexure, or rectum, then the 
 portions of the large intestine above the seat of disease become 
 greatly distended ; they may be observed in the peculiar outline of 
 the abdomen, and the tympanitic resonance extends to the loins; 
 where, however, the obstruction arises from portions of twisted large
 
 INTERNAL STRANGULATION. 427 
 
 intestine, as of the caacum or sigmoid flexure, we find that there is 
 some deviation from the general character just mentioned ; an enor- 
 mously distended caecum may be twisted over to the left hypochon- 
 driurn, and constitute a prominence in that region. It is, however 
 not to be considered that a constant rule is laid down, for a greatly 
 distended small intestine may occupy the position of the transverse 
 colon. 
 
 Vomiting. The character of the vomiting, and the period at which 
 it has commenced, especially when irritating and powerful purgative 
 medicines have not been administered, are important guides to our 
 diagnosis. If the obstruction be sudden, and be situated in the 
 small intestine, the vomiting comes on very quickly, in from half 
 an hour to two or three hours; if it be high in the jejunum, the 
 vomited matters are of a bilious character, but if near to the caecum 
 they may assume a fecal odor, and be completely stercoraceous. In 
 one instance, in which the obstruction arose from a band of adhesion 
 high up in the jejunum, the vomiting was so sudden as to resemble 
 that produced by cerebral disease; and this view of the case was 
 favored by the partial insensibility of the patient. In the case 
 recorded of twisted caecum, where the obstruction was near the ter- 
 mination of the ileum, so fully fecal was the character of the vomited 
 fluid that it was for a time supposed that a communication existed 
 between the stomach and the transverse colon. When the large 
 intestine is the seat of disease, as in cancer of the sigmoid flexure, 
 and of the rectum, &c., several days sometimes elapse before vomit- 
 ing supervenes; the time is, however, much accelerated if powerful 
 drastics are given. In the latter state, also, the vomiting is more 
 easily checked by the administration of remedies, as of ice and 
 opium. As to the immediate cause of stercoraceous vomiting, Dr. 
 Brinton, in his valuable remarks in the 'Encyclopaedia of Anatomy,' 
 has suggested that the peristaltic action is not in itself reversed, but 
 that the contents of the bowel are propelled onwards in their normal 
 manner till the obstruction is reached, when the fluid assumes a 
 central retrograde direction, thus producing a double 'current, a 
 parietal or onward, and a central or reverse current; this retrograde 
 movement continues till the vomited matters are of the same char- 
 acter as those found at the seat of stricture. It would, however, 
 seem, from the character of the ejection, that the intestinal tract is 
 emptied in the order of its anatomical arrangement, first the stomach, 
 then the duodenum, jejunum, and lastly the ileum. During the 
 latter stage of the disease if the patient become insensible, regurgi- 
 tation of the stercoraceous vomit sometimes takes place into the 
 trachea and bronchi. 
 
 Hiccough is also more severe and more speedily produced in the 
 strangulation of the small than of the large intestine. It must be 
 borne in mind, that the vomiting and hiccough are sometimes ex- 
 treme in peritonitis, especially where the serous membrane of the 
 stomach is involved. 
 
 Urine. Dr. Barlow has drawn especial attention to the amount 
 of urine excreted, as a sign of the seat of obstruction ; that where
 
 428 INTERNAL STRANGULATION. 
 
 the obstruction is high in the canal, as in the jejunum or ileum, 
 absorption is partially checked, the renal blood supply is thereby 
 considerably diminished, and a small quantity of urine is excreted ; 
 if, on the contrary, the rectum or sigmoid flexure be occluded, nearly 
 the whole of the capillaries of the alimentary canal are free to absorb 
 fluid, and thus the blood contains more watery constituents, and the 
 urine is abundant. This is a symptom deserving our attention, but 
 it is not a certain one; several cases among those illustrative of 
 disease of the sigmoid flexure had scanty urine among their earlier 
 signs, and we shall find that the amount of urine is in inverse pro- 
 portion to the quantity of fluid vomited ; that if in obstructed colon 
 powerful drastics have been administered, and speedy vomiting in- 
 duced, or peritonitis quickly set up, the urine will be found to be 
 small in quantity ; if peritonitis take place the condition of the abdo- 
 minal sympathetic may lead to cessation of secretion from the 
 kidney as well as from other glands. The fluid character of the 
 contents generally observed in the distended intestine above the 
 seat of stricture is to be remarked, and is an indication that no 
 remedies are needed in these cases to render the feces more watery, 
 but that the spasmodic state of the diseased bowel, in addition to 
 the mechanical impediment, is the immediate cause of the obstruc- 
 tion, and often prevents a drop of fluid or any gas from passing the 
 stricture. 
 
 State of the rectum, Dr. Barlow has here also brought his diag- 
 nostic acumen to bear on the elucidation of the symptoms presented. 
 He has shown that in intestinal obstruction suddenly produced, the 
 rectum retains its natural power of contraction, and will be found to 
 be empty ; if the disease be of gradual formation, that it is more 
 patulous and readily yields to injections. To a certain extent this 
 is the case, but the symptom is one upon which we cannot rely. 
 The intestine below the obstruction is generally contracted, though 
 sometimes after the occurrence of the strangulation or other occlu- 
 sion, a fecal evacuation may take place, or be removed after injec- 
 tion from below the seat of stricture, thus giving a delusive hope of 
 recovery, or misleading in diagnosis. Mr. Charles H. Moore has 
 proposed the injection of fluid into the colon, as a means of enabling 
 us to detect the position of the obstruction, the extent of the dulness 
 on percussion in the loins being carefully noticed ; and that in this 
 way fluid may be forced into the ascending colon, and indicate that 
 the disease is above that part. 
 
 The discharge of blood, or of offensive mucus, has been mentioned 
 by Mr. Gorham 1 as a very frequent sign of intussusception ; and it 
 may be here remarked that it is important in all cases of this kind 
 to make a careful manual examination of the rectum, as well as of 
 all the parts in which hernia may occur. By this simple means im- 
 pacted feces, inflamed hemorrhoids, cancer of the rectum, prolapsus 
 ani, suppuration in the pelvis, each of which may lead to symptoms 
 of insuperable constipation, may be diagnosed. 
 
 1 ' Guy's Hospital Reports.'
 
 INTERNAL STRANGULATION. 429 
 
 In internal strangulation there may be no excitement of pulse nor 
 any febrile disturbance ; the patient may be free from distress ex- 
 cept that the abdomen is distended, and the bowels do not act ' the 
 mind may be perfectly clear, but there is generally some anxiety of 
 expression; day after day may pass in this way, till prostration, 
 with hiccough and peritonitis supervened. We often find that the 
 bowels act when sphacelus of the strangulated intestine takes place; 
 the friends of the patient suppose that the urgent symptom, consti- 
 pation, being relieved, all will be well ; the bowels may act copiously, 
 but on examination the patient may be cold and nearly pulseless ; 
 he is in a dying state, although the mind is clear and perfectly con- 
 scious. The period at which a fatal result ensues is liable to great 
 variation. In sudden strangulation of the small intestine we some- 
 times find that death takes place in five to seven days ; whilst in 
 other cases, especially in obstruction of the colon, several weeks may 
 elapse, and the patient may remain free from pain and distress till 
 about forty-eight hours before death. Cases, however, recover 
 when the patient has been apparently in a hopeless state ; the bowels 
 act, the tympanitis subsides, and the strength soon returns; some- 
 times, however, after the development of favorable symptoms, a re- 
 lapse takes place, and the obstruction leads to a fatal result. 
 
 Intussusception is that condition in which one portion of the intes- 
 tine passes into another, as the finger of a glove drawn within itself. 
 In this state there need not necessarily be entire obstruction, unless 
 congestion, effusion, and inflammation close the canal completely. 
 The section presents us with three layers of intestine ; two mucous 
 and two serous surfaces being opposed to' each other, and in the 
 centre are placed the ordinary mucous surfaces. It is said that there 
 is sometimes a second involution of the intestine from below, passing 
 in an opposite direction ; or that the only involution may be from 
 below upwards. The occurrence of such a condition must be very 
 rare, and obstruction from it still more so. The mesentery attached 
 to the involuted portion is also drawn in, and by its traction the 
 central portion of intestine becomes somewhat curved laterally, and 
 the opening of the most depending part is observed to be linear. 
 The vessels of the portion of intestine thus incarcerated become en- 
 gorged, and may render the obstruction complete ; the whole of the 
 folds involved become swollen and deeply congested, and blood is 
 extravasated into the substance of the mucous membrane, as well as 
 into the mesentery ; in a short time both the serous and the mucous 
 surfaces become inflamed, and an effusion of lymph takes place ; the 
 opposed serous surfaces become adherent, and so to a less degree the 
 mucous surfaces ; bloody serum and mucus are effused into the canal, 
 and this discharge per rectum is a diagnostic sign of intussusception. 
 If life be prolonged, and the intussusception continue, the serous 
 surfaces at the opening or upper part are rendered adherent ; the 
 contained intestine becomes gangrenous, and is often detached as a 
 slough. In this way many inches of intestine may be discharged 
 per rectum ; in one instance as much as forty-four inches of large 
 intestine were evacuated ; in another, which terminated favorably,
 
 430 INTERNAL STRANGULATION. 
 
 and the specimen of which is in the museum at Guy's, the whole of 
 the caecum and ascending colon were thus passed. If the adhesions 
 be disturbed or broken down after the slough has separated, fecal 
 abscess may be the result. In some instances the intussusception is 
 restored; more frequently, more and more intestine is forced in, 
 symptoms of internal strangulation supervene, and death results from 
 perforation into the peritoneum, or from peritonitis set up by the 
 direct extension of disease from the strangulated part. It must not, 
 however, be supposed that the passage is always occluded ; such is 
 sometimes not the case, and even diarrhoea may be produced. It 
 would seem that the intestine maybe thus incarcerated within another 
 fold, without being strangulated. The case recorded by Dr. Hughes, 
 in the Guy's Reports, was of this kind ; so also those of Mr. Phillips 
 in the 'Medical Gazette;' and still more remarkably a specimen 
 exhibited by Mr. Hutchinson at the Pathological Society, in which 
 the symptoms extended over seven months. 
 
 The position of intussusception may be solely in the small intes- 
 tine, but more frequently a portion of ileum passes into the caecum 
 at the valve, the valve being pushed onward and forming the most 
 dependent part ; and lastly, the intussusception may consist only of 
 one portion of colon within another ; the cascurn and ascending colon 
 may become so involuted as even to reach the rectum. It would 
 appear that in intussusception in the colon, constipation is less con- 
 stant as a sign of disease. 
 
 According to the following tables from Dr. Brinton's Croonian 
 Lectures, recorded in the ' Lancet,' 1859, it would seem that ileo- 
 caecal intussusception is the most frequent variety ; this may be the 
 case, if we exclude the numerous instances of intussusception which 
 take place during the time the patient is in articulo mortis. 
 
 Intestinal Obstructions (excluding Hernia). 
 
 Frequency, 1 in 280 deaths (from 12,000 promiscuous necropsies). 
 
 Intussusception . . . . . . .43 
 
 External (bands, &c.) . . . . . .32 
 
 Parietal (Strictures, &c.) . . . . . .17 
 
 Torsions . . . . . .. . .8 
 
 100 
 
 Varieties, relative frequency per cent, (from 600 necropsies of obstruction). 
 Intussusception, varieties of, per cent. 
 
 Ileo-caecal . . . . . . . .56 
 
 Ileac . . . . . . . . .28 
 
 Jejunal ........ 4 
 
 Colic . . . . . . . . .12 
 
 100 
 
 In nearly 8000 post-mortem records at Guy's Hospital, there are 
 17 cases of fatal invagination. Ileo-cagcal 10, ileac 5, rectal 2, one 
 of these due to villous growth. 
 
 The number of intussuscepted portions also varies much, being 
 sometimes single, but in young persons, and especially infants, it is 
 exceedingly common to find numerous parts so aflected, from six to
 
 CANCEROUS DISEASE. 431 
 
 twelve, or even more. Some of these, however, are probably pro- 
 duced immediately before death ; there is absence of all symptoms 
 of strangulation, and in the intestine itself neither congestion, effu- 
 sion, nor ulceration exist ; they are most frequently observed in 
 inflammatory disease of the brain, and hydrocephalus. 
 
 The symptoms of intussusception are those of colic with constipa- 
 tion; sudden local pain is produced in the bowels, followed by 
 vomiting, constipation, prostration, haggard expression of counte- 
 nance, failing pulse, distension of the abdomen, stercoraceous vomit- 
 ing, peritonitis, and death. It is exceedingly difficult to distinguish 
 this condition from ileus arising from internal strangulation and 
 local enteritis ; but after a time there may be discharge of blood and 
 mucus from the involuted portion, which materially assists in form- 
 ing a correct diagnosis. In intussusception, a firm mass may often be 
 felt at the seat of pain, which is not the case in ordinary internal 
 strangulation. In intussusception of the small intestine the tumor 
 may be central, whilst in ileo-colic and colic involution the mass will 
 be in the course and position of the colon. The sudden onset of the 
 pain, its subsidence and paroxysmal aggravation are indications of 
 this form of obstruction. It has been before mentioned that diar- 
 rhoea sometimes supervenes, especially where the large intestine is 
 affected ; and it is occasionally noticed where the disease is of a 
 chronic character. In seeking to arrive at a correct diagnosis,' it is 
 well always to examine the rectum. 
 
 The cause of this abnormal involution appears to be sudden and 
 spasmodic contraction of a portion of intestine, impelled onwards 
 into a part which is less contracted or altogether flaccid. It occurs 
 at all periods of life, but it is much more frequent in youth and 
 infancy. 
 
 The prognosis, although very unfavorable when we have well- 
 marked indications of the existence of intussusception, is not without 
 hope, and we have seen almost hopeless cases recover. In some the 
 intestine is restored to its normal state ; in others, the strangulated 
 bowel sloughs off', the canal becomes free, and the divided intestine 
 unites. 
 
 Cancerous Disease of the Intestine. Cancer of the stomach is a 
 disease of frequent occurrence j but cancer is more rare in other 
 portions of the alimentary canal. We have Already described in- 
 stances of it as affecting the duodenum and the caecum, and other 
 portions of the small intestine and of the colon are occasionally thus 
 diseased; still the rectum and the sigmoid flexure of the colon are 
 the parts of the intestine most frequently affected, and it is to the 
 latter, that we direct especial attention as a seat of obstruction. 
 
 The termination of the sigmoid flexure appears to be particularly 
 prone to this form of disease, and many of those cases which are 
 described as cancer of the upper third of the rectum are at this part, 
 and have been pushed down into the pelvis by the obstruction pro- 
 duced. It is a peculiar form of disease that we find thus developed; 
 not the extensive deposit with glandular infiltration, though this is 
 sometimes the case, but a modification of scirrhus. There is a growth
 
 432 CANCEROUS DISEASE. 
 
 from the mucous membrane, the muscular fibre is infiltrated and 
 contracted, and the calibre of the intestine is diminished. The glands 
 are frequently not at all affected, and in this respect it closely re- 
 sembles epithelial cancer. The constriction of and growth in the 
 intestine are sometimes circular, sometimes one side is much more 
 affected than the other. On examining the condensed part we find 
 fibrous tissue, and some elongated nuclei; but the growth from the 
 mucous membrane presents more of the elements of cancer. These, 
 however, are not like the ordinary epithelial cancer elements, but 
 many of the cells are large columnar epithelium, with a large nucleus, 
 the growth being modified on account of its situation on a columnar 
 epithelial surface, an instance of the differentiation of abnormal 
 growth. 
 
 Medullary and colloid cancer sometimes affect this part, so also 
 lymphoma and adenoma, but their course is different from that of 
 scirrhous disease. In medullary cancer the ulcerative process ex- 
 tends through the coats of the intestine more rapidly, and instead of 
 intestinal obstruction we have fecal abscess, either in the iliac fossa, 
 or within the abdominal cavity itself, or a communication may take 
 place with the bladder. In the rectum similar forms of disease are 
 presented, which occur in its several parts : and scirrhus of this part 
 leads to contraction, thickening of the external tissues, and obstruc- 
 tion of the intestinal canal. Medullary cancer, on the contrary 
 causes ulceration and communication with the other pelvic viscera, 
 with the vagina, bladder, or uterus, so that all the viscera become 
 matted together into one mass. The rectum also frequently becomes 
 involved, by the extension of disease from the uterus and vagina, 
 leading to terrible manifestations of disease and suffering. Epithelial 
 growths of a cancerous character arise from the mucous membrane 
 of the rectum, as well as from the sigmoid flexure, and they lead 
 slowly to obstruction or to exhausting diarrhoea. 
 
 Where the coats of the intestine are thus diseased, the intestine 
 above the stricture becomes gradually distended, the mucous coat is 
 thickened, and the muscular hypertrophied, so as to be in some cases 
 a quarter of an inch in thickness. The extent of these changes varies 
 much, and in chronic and slowly progressive disease they are more 
 manifest. The distension of the intestine also produces inflammation 
 and ulceration of the mucous membrane above the stricture, and it 
 leads in many cases to perforation; this condition of ulcerative ero- 
 sion is sometimes very extensive, at a considerable distance from the 
 seat of obstruction ; thus we find perforation of the caecum taking 
 place in obstruction of the sigrnoid flexure. 
 
 Cancerous disease of the ascending or transverse colon takes place 
 more rarely, and appears to be produced by some local exciting 
 cause, as the cicatrix of an ulcer, or by a blow ; still it is far from 
 infrequent. In a case of colloid cancer of the stomach we observed 
 a similar state of the ascending colon, but in a less advanced con- 
 dition. 
 
 Mr. Birkett, in the 'Pathological Transactions,' has recorded a 
 remarkable case of vascular villous growth from the colon near the
 
 CANCEROUS DISEASE. 
 
 433 
 
 liver; the growth was covered with epithelium, and its cancerous 
 character was very doubtful. It was taken from a man, aged fifty - 
 eight, who a year before his death had had pain in the abdomen 
 and diarrhoea. Two months before admission into Guy's, he had 
 had constipation and pain, and when brought to the hospital he had 
 symptoms resembling strangulated hernia, with constipation of one 
 week's duration ; he had had a scrotal hernia, and the sac still 
 remained. The caecum could be seen distended, and so also the 
 ascending colon, as far as the liver, where there was pain on pres- 
 sure ; the descending colon could not be felt. Mr. Birkett explored 
 the hernial tumor, but no intestine was within it. The propriety of 
 opening the ascending colon was discusssed ; but the patient died 
 four days after admission. (See Prep, in Guy's Museum, 1854 65 .) In 
 another instance a blow on the hypochondrium was followed by a 
 cancerous growth, which led to fecal abscess and to perforation of 
 the jejunum. 
 
 Carcinoma of the stomach sometimes extends to the transverse 
 colon; such was the case in one of the instances we have recorded 
 of disease of the stomach ; but although there was fecal eructation, 
 no stercoraceous vomiting occurred. Drs. Gairdner and Murchison 
 have shown the important diagnostic indications of this symptom in 
 communication between the stomach and intestine. 1 It is more 
 common to find disease of the colon extending into the stomach 
 than the reverse, namely, disease of the stomach into the colon. 
 
 The ileum and jejunum are very rarely affected with primary 
 scirrhous and medullary cancer; they are sometimes involved in 
 cancer of the mesenteric glands; but we have never observed in- 
 superable obstruction thus produced. 
 
 During the last 16 years 45 cases of stricture of the intestine have 
 occurred at Guy's, as shown by the post-mortem records: 
 
 General narrowing from disease of the peritoneum 
 
 extending into the coats of the bowel 
 Of the small intestine 
 
 caecum and ascending colon 
 
 hepatic flexure 
 
 transverse colon 
 
 splenic flexure 
 
 descending colon 
 
 sigmoid flexure 
 
 rectum 
 
 2 
 
 1 
 
 2 
 
 3 
 
 2 
 
 1 
 
 4 
 
 10 
 
 20 
 
 45 
 
 Symptoms. In scirrhous disease of the sigmoid flexure, if we pos- 
 sess a history of all the symptoms, the nature of the malady may 
 often be correctly shown. There is slight pain, fixed in character, 
 and remaining for a variable period, in the left iliac fossa, with con- 
 stipation, or an irregular condition of the bowels: after one or two 
 attacks of this kind, with several months or years between them, 
 the constriction becomes narrowed to such an extent that a very 
 slight increase renders it complete. The bowels again are confined, 
 
 28 
 
 ' Edinburgh Monthly Journal.'
 
 434 CANCEROUS DISEASE. 
 
 the patient feels uncomfortable from their loaded condition; the 
 abdomen is gradually distended, vomiting coines on, and the symp- 
 toms of insuperable obstruction follow. The vomiting occurs mur.h 
 later than in obstruction of the small intestine, unless powerful 
 drastic purgatives have been administered; the secretion of the 
 urine continues free, and the patient may appear in comfortable 
 health, except that the bowels have not acted. After ten or twelve 
 days, however, if no evacuation ensue, the colon becomes much en- 
 larged, its distended coils can be seen through the parietes, and 
 there is tympanitis in both lumbar regions; the urgent peristaltic 
 movements may be detected through the parietes; at last ulceration 
 takes place above the seat of stricture, and leads to fatal peritonitis 
 and extravasation, or peritonitis arises from the enormous distension, 
 and the more general inflammation of the coats of the intestine. 
 Sometimes, with judicious treatment, after symptoms of threatening 
 peritonitis, the bowels are acted upon, and the patient is for a short 
 time spared; even diarrhoea will occasionally supervene; the patient 
 then continues much enfeebled, and after a few months sinks ex- 
 hausted, or another attack of constipation terminates fatally. 
 
 The same symptoms of insuperable obstruction sometimes arise in 
 medullary and colloid cancer ; but, as before stated, they less fre- 
 quently terminate in complete occlusion. The intestines become 
 united together, ulceration extends through the coats, local peritoni- 
 tis and fecal abscess are the result, with severe pain and hectic fever, 
 or the cancerous ulceration may extend into the iliac fossa and sup- 
 puration may burrow down beneath Poupart's ligament, as in dis- 
 ease of the caecum, or the disease may form a communication with 
 the bladder. 
 
 There is much less pain in cancerous disease of the sigmoid flex- 
 ure than of the rectum, because the parts are more free, there is less 
 pressure on the nerves, and the adjoining structures are less involved. 
 If the rectum be affected, the constipation and difficulty of defecation 
 is more constant; the pain produced is often intense, especially where 
 the lower third is affected. The feces become flattened ; this may be 
 the case when the sigmoid flexure is the part diseased, but it is less 
 liable to occur, for the feces can be retained for a sufficient period in 
 the rectum to reassurne their ordinary character. In the later stages 
 of cancerous disease of the rectum, and in the fibro-cellular thickening 
 and contraction of its coats, diarrhoea instead of constipation may 
 occur ; I have seen several such instances, and Nelaton refers to this 
 liquid condition of feces and their free separation as not unfrequent 
 in syphilitic disease. Tactile examination may detect disease at the 
 lower part of the rectum, but not at its upper third. The extension 
 of disease to the bladder, vagina, and uterus, leads to most distress- 
 ing complications, and special symptoms are produced. In obstruc- 
 tion of the alimentary canal as we have before said, the rectum should 
 always be examined. 
 
 The symptoms of cancerous disease of the ascending or transverse 
 colon are of the same kind as we have just described, but it is more 
 easy to detect a hardness or tumor produced by the growth in the
 
 CANCEROUS DISEASE. 435 
 
 intestine. In many instances there is severe pain at the seat of the 
 obstruction at an early stage, and this pain I have in several in- 
 stances noticed as being produced as soon as fluids have been taken; 
 diarrhoea is sometimes present, or it alternates with constipation. 
 Again, we do not find that the transverse colon becomes distended 
 and tympanitic across the abdomen; nor that there is the same reso- 
 nance in the left lumbar region. These indications, however, must 
 be used with great caution, because the distension of the small intes- 
 tine may lead to the presence of enormous coils, which may easily 
 be mistaken for an enlarged colon. The suggestion of Mr. Moore 
 may be tried, namely, the injection of water into the colon and the 
 examination of the amount of dulness produced. The intestine, how- 
 ever, in some cases, becomes so contracted below the seat of stricture, 
 as not readily to yield to the injection of water, and we might be led 
 to a very incorrect diagnosis if we trusted to this means alone. 
 
 In many patients who are, affected with cancerous obstruction of 
 the sigmoid flexure, there is but little emaciation or appearance of 
 cancerous cachexia. They may be well nourished, and apparently 
 in health ; generally, however, there has been some indication of dis- 
 ease, as shown by troublesome constipation, an occasional fixed 
 pain, and sometimes by a discharge of mucus from the rectum. 
 
 These forms of scirrhous cancerous disease rarely occur in early 
 life; at that period it is more likely to be medullary or lyrnphadeuo- 
 matous in character; but there are exceptional instances in this 
 respect. 
 
 The position at which the sigmoid flexure becomes affected is at 
 the brim of the pelvis, where it is -more liable to temporary com- 
 pression. It is also at that part where the triple longitudinal mus- 
 cular band assumes a continuous character around the intestine. 
 
 Diai/nosix. In our remarks on internal strangulation, we have 
 already pointed out the diagnostic value of many of the symptoms 
 presented. The varied causes of obstruction must be also borne in 
 mind ; comprising not only the forms of internal strangulation, of 
 intussusception, and of cancerous disease, but the presence of tumors, 
 of enteritis or peritonitis, the impaction of feces or of foreign bodies, 
 tumors connected with the uterus or ovaries, and hemorrhoidal 
 tumors. In intussusception there is generally more pain resembling 
 colic, there is the discharge of bloody mucus, and a tumor can fre- 
 quently be felt at the affected part: and in not a few cases the in- 
 volved bowel may be detected by examination per rectum. In 
 internal strangulation the vomiting is more severe, the onset more 
 sudden than in cancerous disease, and frequently something has been 
 felt to have given way or slipped; there is a great resemblance to 
 the symptoms of ordinary hernia; the small intestine is the part that 
 is generally thus strangulated; and then, whilst the vomiting is 
 more early and severe, the abdomen is less distended, and the course 
 of the colon cannot be so easily traced. In impacted feces alone, 
 unless some foreign body be also present, the symptoms rarely, if 
 ever, become so urgent, and are scarcely ever fatal. In speaking of 
 constipation, we have quoted a case from the ' Medical Ga/stte,'
 
 436 TREATMENT OF INTERNAL OBSTRUCTION. 
 
 where after seven months of fecal obstruction, the patient had a fall, 
 and peritonitis was produced ; she had had attacks of constipation 
 of two months' duration, for four years. In simple fecal retention, 
 after a whole month has elapsed, we may find very little discomfort, 
 and the distension not extreme in degree. In cancerous disease of the 
 sigmoid flexure, the gradual character of the obstruction, the seat of 
 pain, the distension of the abdomen without tenderness, the abund- 
 ance of urine, the late period at which vomiting occurs, are the 
 principal signs; and many of these cases closely resemble simple 
 fecal impaction. In the one we shall probably find that injections 
 per rectum will be effective, and after a time they will be followed 
 by relief: in the other, the injection will in a short time be returned, 
 only a small quantity can be thrown up, and no fecal contents are 
 evacuated. 
 
 The early tenderness of the abdomen distinguishes enteritis and 
 peritonitis in most cases ; and recto-vaginal examination serves to 
 remove other sources of diagnostic difficulty. 
 
 Treatment. If after the administration of mild aperient medicines, 
 or even without their use, it has been ascertained with tolerable 
 certainty, that constipation from one or other of the causes we have 
 described exists, it is exceedingly unwise to employ active treatment. 
 Purgatives of all kinds are better avoided, and the use of drastic 
 measures will tend to aggravate the sufferings, to shorten life, and 
 to remove the possible chances of recovery. 
 
 The administration of opium is now known to be attended with, 
 beneficial results, and frequently with partial, if not with permanent 
 relief. By this means the peristaltic action is checked, spasmodic 
 contraction diminished, and the opening which previously would not 
 allow the passage of flatus, will suffer fluid feces to escape. Solid 
 opium may be given, as in the soap and opium pill. Some combine 
 calomel with the opium, but we prefer opium alone, for the mercurial 
 medicine increases depression ; it probably hastens perforation, and 
 extravasation is less likely to be limited by adhesion after its action. 
 
 Drastic purgatives, as colocynth, croton oil, scammony, mercurials, 
 &c., stimulate and excite the intestine to greater contraction ; vomit- 
 ing of a stercoraceous character is set up more quickly or is increased, 
 and ulceration or fatal peritonitis is speedily produced. Electricity, 
 which is a valuable remedy in simple constipation, is here produc- 
 tive of injury to the patient. 
 
 If there be any indication of local peritonitis, leeches should be 
 applied, and rest in the recumbent posture enjoined. The diet should 
 be spare, and of a fluid, unirritating, and non-stimulating kind. If, 
 however, we find great prostration, it is well to give brandy or wine, 
 when they can be taken. 
 
 Enemata are of great value in removing fecal concretions from the 
 rectum, and below the seat of the stricture ; and are sometimes 
 followed by the discharge of flatus, affording great relief to the 
 patient. In this way warm water, soap, castor oil, or turpentine in- 
 jections may be used ; and several ounces of simple olive or linseed 
 oil thus thrown into the rectum sometimes afford considerable relief.
 
 TREATMENT OF INTERNAL OBSTRUCTION. 437 
 
 Injections of this kind are most effectually administered by means 
 of an O'Beirne's long tube ; care, however, must be used lest the ex- 
 tremity of the tube turn upon itself. The simple introduction of an 
 enema tube, and its retention for a short time, may excite the lower 
 bowel to contract, and cause the expulsion of flatus, thus relieving 
 the painful distension. In some instances, it is well to use nutrient 
 enemata, which may serve to prolong the exhausted powers of life 
 for a short period. Great care is necessary in the use of the long 
 tube; we have known perforation, abrasion of the intestine, and 
 fatal peritonitis induced by it, and in one instance emphysema. The 
 mucous membrane of the bowel is softened and the parts adherent; 
 in the case in which emphysema was produced the patient passed 
 the enema tube through an ulcer into the cellular tissue. 
 
 By the use of these means, when the patient is almost in extremis, 
 an evacuation may be passed, and recovery take place. In some 
 cases, after the continued use of opium, diarrhoaa is produced and 
 may become so severe as to require remedial measures. 
 
 Change of position has in some instances appeared to produce 
 benefit, and has been followed by recovery ; but whilst this may 
 sometimes occur, we have witnessed the injurious effect of moving 
 the patient when the peritoneum is intensely congested, and per- 
 haps inflamed from the great distension : death has in several in- 
 stances quickly followed. 
 
 The application of cold water, of ice, or the exposure of the sur- 
 face of the abdomen to the air, has been sometimes advantageously 
 tried. In one of the cases which I have narrated, the patient said, 
 whilst the abdomen was exposed, that he felt that something had 
 slipped, and in a short time an abundant fecal evacuation was passed, 
 and recovery took place. In another case obstruction had gone on 
 for many days, the mischief appeared to be in the small intestine, 
 so that colotomy could not be performed, and a fatal result was 
 anticipated, when the application of a bag of ice to the abdomen 
 was followed by free action of the bowels. The patient, a woman 
 of middle age, left the hospital comparatively well. 
 
 In the absence of relief by these means, the question of surgical 
 interference becomes one of anxious consideration ; after death from 
 internal strangulation, the obstruction has been found so simple in 
 character, that with great facility it might have been divided, and 
 perhaps the life saved. In several instances, Mr. Hilton attempted 
 this mode of relief, with an amount of success which subsequent 
 operators have confirmed; but it must be borne in mind, first, that 
 the peritoneum is already inflamed, or in a state of intense conges- 
 tion, and that general peritonitis is very likely to follow ; secondly, 
 that there is great difficulty in the diagnosis, and that some recover 
 from apparently a dying condition. A very interesting communica- 
 tion on this subject was read at the Hunterian Society, by Mr. 
 Hutchinson, to which we must refer, and to the papers of Mr. Hil- 
 ton, in the Guy's Reports of 1852. The operation of opening the 
 colon in the loin has in many cases prolonged life ; it has been espe- 
 cially performed in cancerous disease of the rectum, to relieve either
 
 438 TREATMENT OF INTERNAL OBSTRUCTION. 
 
 the obstruction or the severity of the pain, and in other cases, where 
 we have indications of obstruction in the sigmoid flexure, it may be 
 employed with much success. In the case recorded by Mr. Hilton, 
 in the paper just referred to, the relief was exceedingly marked, 
 and the life of the patient prolonged for several months ; of late 
 years numerous successful cases have been recorded by Curling, 
 Bryant, Maunder, and others. In many instances I have witnessed 
 the value of this operation ; sometimes for the relief of ulceration of 
 the colon extending into the bladder; in one, several years ago, the 
 patient was reduced to extreme emaciation and distress from the 
 presence of feces in the bladder. Mr. Bryant opened the colon, the 
 patient regained strength, and the opening in the loins is of only 
 slight discomfort to him. In another case, cancerous disease of the 
 bowel led to the same distressing complication, colotomy relieved 
 the suffering and prolonged life for several months. Last year a 
 patient, aged 54. consulted me for dyspeptic symptoms on January 
 24th ; organic disease was suspected ; he had become thinner, suf- 
 fered from pain after food, and flatulence, sometimes from vomiting, 
 the bowels were inactive. On March 4th the bowels had not acted 
 for a fortnight, there was great distension ; the coils of the intestine 
 were visible, and peristaltic movement was distinct ; there was 
 vomiting, but no pain. Opium with belladonna was given, and 
 injections of oil, and afterwards of soap and water were used. Colo- 
 tomy was recommended if the bowels did not act. He was brought 
 to Guy's on March 13th, the bowels acted freely after admission, but 
 still the abdomen remained distended. Remedies were used to re- 
 lieve this flatulent distension, but the bowels again became confined, 
 and it was evident that the danger was imminent; a fatal result was 
 feared, when Mr. Davies Colley, on April 6th, performed colotomy. 
 The urgent symptoms were relieved, and after a few days feces 
 were passed by the rectum, and the patient left the hospital com- 
 paratively well on May 5th. In a valuable paper by Mr. Caesar 
 Hawkins, in the ' Transactions of the Royal Medical and Chirurgi- 
 cal Society,' the result of the operation of colotomy in forty-four 
 cases of stricture of the colon or rectum is recorded; in ten cases 
 death took place withiu forty-eight hours, in twenty-one within five 
 weeks, and thirteen recovered ; of these six died in six months, and 
 nine survived more than one year. 
 
 The colon in its ascending or descending part may be opened in 
 many cases with facility, without dividing the peritoneum. Mr. 
 Maunder has proposed opening the small intestine through the peri- 
 toneum, and has successfully performed such an operation. My col- 
 league, Mr. Bryant, has also successfully performed similar opera- 
 tions ; in one case the patient survived eighteen months. In many 
 cases, however, these operations have been deferred so long, that 
 peritonitis has already arisen from the extreme distension and the 
 skill of the surgeon is then placed under the most disadvantageous 
 circumstances. 
 
 In the treatment of intussusception, every possible means should be 
 employed to quiet the propulsive action of the intestine; but much
 
 INTERNAL STRANGULATION. 439 
 
 good may^be effected by local means. If the bowel be felt in the 
 rectum, it may sometimes be returned by the introduction of a 
 bougie, or of a candle: and in other cases gentle distension by the 
 injection of warm water, or inflation by air, has apparently produced 
 a return of the bowel. Mr. Hutchinson has suggested operative in- 
 terference in these cases, by opening the peritoneum and withdraw- 
 ing the invaginated bowel ('Med.-Chir. Transactions,' vol. Ivii); in 
 other cases in which the operation has been performed, even in 
 recent cases, it has been found that the bowel could not be withdrawn ; 
 out of eight cases two have been successful, one under Mr. Hutchin- 
 son, and the other under Mr. Howse, six have proved fatal. 
 
 CASES OF INTERNAL STRANGULATION. 
 
 CASE CXLIII. Internal Strangulation of the lleum. Band of Adhe- 
 sion Elizabeth B , set. 52, was admitted, March 10th, 1857, into Guy's 
 Hospital. She was a married woman, thin, of sallow complexion, and had 
 had a family. For twenty years she had had occasional pain in the left side, 
 the bowels had generally been confined, but she had not had any attack like 
 that for which she was admitted. 
 
 On March oth, five days before admission, after breakfast, she experienced 
 a sudden pain in the abdomen ; it commenced about the navel, but soon ex- 
 tended over the whole abdomen ; vomiting came on an hour afterwards ; the 
 bowels had been open slightly the same morning, but had been confined on the 
 previous day. From that time no evacuation took place, the vomiting con- 
 tinued, the abdomen became, tympanitic, and moderately distended, and there 
 \v;i> slight tenderness. The pain in the abdomen cams on in paroxysmal at- 
 tacks, but was generally absent when she remained quiet ; the vomited mat- 
 ters continued bilious, and the urine abundant. 
 
 On March 10th, the countenance was expressive of considerable distress, 
 but was calm and resigned ; the eyes were sunken ; the abdomen was slightly 
 prominent in the centre, but not laterally ; it was tympanitic, but free from 
 tenderness ; the pulse was sharp, the respiration normal, and the urine was 
 abundant. Purgatives had been given, and enemata administered, but she 
 had vomited the former. 
 
 She was ordered calomel and opium of each gr. j every six hours, a soap 
 injection to be administered, and a linseed poultice to be applied to the ab- 
 domen. 
 
 March 12th. The countenance was more haggard, and the eyes more 
 sunken ; the vomited matters were thick, green, and offensive, but not ster- 
 coraceous ; the pulse was more compressible ; the abdomen was in the same 
 state as far as external appearance, and it was still free from tenderness ; 
 there had been no relief from the bowels, and no flatus passed ; the urine con- 
 tinued abundant ; she had had a restless night, and suffered occasionally from 
 hiccough. 
 
 14th. There was no improvement. There was neither pain nor tender- 
 ness in the abdomen, nor was it more distended ; she was not disturbed by 
 vomiting, but was partially under the influence of opium, which had been 
 continued without calomel ; nutrient enemata were used. 
 
 17th She died, rather less than twelve days from the time of strangula- 
 tion. 
 
 Inspection took place about twelve hours after death. On opening the 
 abdomen, the small intestines were found moderately distended, but on the
 
 440 INTERNAL STRANGULATION. 
 
 fingers being passed towards the pelvis the strangulated bowel gave way, and 
 some fecal extravasation took place; the peritoneum was inflamed; it was 
 dry, and deep red lines existed at the points of contact of the intestine; the 
 stomach and transverse colon were moderately distended; the small intestine 
 was still more enlarged. In the pelvis several coils of small intestine were 
 found almost black in color; there was iV-cal extravasation, hut this probably 
 only took place after death; at the site of the right internal abdominal ring, 
 was a roughened and injected state of the peritoneum, as if adhesion had 
 existed ; and there was a similar condition also on the right side. On turning 
 aside the small intestine, a firm band of adhesion, round and dense, was found 
 to extend from the region of the caecum to the margin of the pelvis, at the 
 termination of the sigmoid flexure ; through this loop several coils of ileum 
 had passed, and had become strangulated. The band of adhesion passed from 
 the mesentery of the ileum to the mesentery of the sigmoid flexure, and it 
 appeared to be the free perforated margin of the latter mesentery; the band 
 was thin, and contained vessels; and it was doubtful whether it was really 
 a band of inflammatory adhesion, or a part of the sigmoid mesentery, which 
 had become thinned and perforated, and so presented an abnormal and free 
 edge. The strangulation was four feet from the caecum, and nearly two feet 
 in length. The mesentery of the strangulated part was infiltrated with blood ; 
 its peritoneum was almost black, and in several parts it was sloughing. The 
 mucous membrane at the upper end of the strangulation presented an exten- 
 sive slough, and the coats were destroyed; at the lower end the sloughing 
 was rather less extensive and advanced. The coils of intestine contained 
 within the adhesion were united by moderately firm lymph. 
 
 The appendix caeci was perfectly free ; below the band the small intestine 
 was contracted, so also was the sigmoid flexure, but the transverse colon was 
 moderately distended with flatus. The stomach was not at all dissolved ; but 
 the whole of the mucous membrane was intensely congested with very minute 
 arborescent vessels. 
 
 The liver, kidneys, and spleen were healthy. In the lower lobe of the 
 left lung there were several lobules, in a state of red and gray hepatization ; 
 and the whole of that lobe was in a state of early pneumonic consolidation ; 
 the other lung was healthy. The heart was normal ; its right cavities were 
 filled with blood. 
 
 In this case, it is probable that a portion of intestine had been 
 encircled by the band for some time, for adhesions had evidently 
 existed between that part of the ileum and the parietes near the 
 inguinal canal, and occasional pain had been experienced in the 
 abdomen; the distension of the incarcerated part and the intrusion 
 of other coils led to strangulation. 
 
 It was diagnosed before death, that the obstruction was in the 
 small intestine, from the moderate distension, the short time that 
 elapsed before vomiting came on, and the character of the ejected 
 matters. The quantity of urine did not assist us here ; the vomiting 
 was moderate, because purgatives and irritants were avoided ; the 
 distension also was rather in the central part of the abdomen, and 
 the transverse and descending colon could not be traced, as in ob- 
 structed sigmoid flexure. As to the treatment, I believe it was 
 most judicious after admission into Guy's Hospital, and that life was 
 by that means prolonged for several days, and the patient spared 
 intense suffering. The opium quieted the peristaltic action and
 
 INTERNAL STRANGULATION. 441 
 
 violent vomiting, and if the latter had continued perforation would 
 probably have taken place at an early period. 
 
 In reference to opening the abdomen, if it had been attempted at 
 a very early period, the band might perhaps have been divided, but 
 during the latter days of life the intestine was in a semi-gangrenous 
 state, and the operation would probably have been hastily termi- 
 nated by the rupture of the strangulated bowel. 
 
 CASE CXLIV. Internal Strangulation. A Loop of Small Intestine 
 passed into a hole in the Great Omentum J. D , aet. 45, was apparently 
 in the enjoyment of good health till Monday morning, November 29th. On 
 that day lie alighted suddenly from a chaise ; at the same moment he felt sudden 
 pain in the abdomen, low down in the right iliac region; about noon he began 
 to vomit, and the vomiting recurred frequently. He had never suffered from 
 any irregular action of the bowels, and had previously had good health. He 
 was bled, and calomel with purgatives administered, without any effect. Ene- 
 mata were returned with fecal odor. On the third day the abdomen was 
 moderately distended, but free from tenderness; the pulse was 84; and the 
 tongue was injected and fissured. There had been no action from the bowels, 
 and the vomiting continued. 
 
 On the fourth day, there was no change in the symptoms ; he was placed 
 in a warm bath, and water injected into the rectum. Whilst in the bath he 
 became much worse, collapse came on, and death followed in five hours. 
 
 Inspection The peritoneum contained thin fecal fluid. The coils of the 
 large intestine were lying in front of the omentum, which descended into the 
 pelvis. The small intestine was adherent to the anterior abdominal parietes, 
 and air was found to escape from a perforation in the small intestine. A 
 loop of ileum, six inches from the caacum, together with the mesentery, had 
 passed through an opening in the great omentum, and had led to the fatal 
 strangulation and subsequent perforation. There was no ulceration in the 
 whole of the canal. 
 
 In this case we had sudden occurrence of symptoms ; the position 
 of the pain indicated the seat of the disease, and the vomiting came 
 on a few hours after pain, indicating an affection of the small rather 
 than of the large intestine. The case showed that, although the ab- 
 domen was free from pain and tenderness, the movement required to 
 place the patient in a warm bath, and the injection of warm water 
 into the rectum, were not free from danger; they hastened fatal per- 
 foration and peritonitis ; how much more easily would such an effect 
 have followed from more sudden and violent exertion. 
 
 CASE CXLV. Internal Strangulation of the last eighteen inches of the 
 Small Intestine by means of a Diverticulum from the Ileum, fatal after 
 thirty-eight hours Henry W , aet. 19, had been employed as a lead and 
 color manufacturer in Tooley Street ; he had had colic a year previously, but 
 at the time of admission into Guy's Hospital no trace of lead existed on the 
 gums. He was of pale complexion, with light hair, and he enjoyed his usual 
 health till Sunday, July 28th, at 7 P. M., when soon after drinking some 
 beer he was seized with pain at the lower part of the abdomen, towards the 
 right side. About an hour after this he had moderate action of the bowels. 
 Sickness came on about 9 o'clock, and during the night he vomited whatever 
 he took. An injection, administered before admission, came away with 
 scarcely a tinge of feculent matter. He was brought to Guy's at 10 P. M.,
 
 442 INTERNAL STRANGULATION. 
 
 July 20th, and placed under Dr. Barlow's care, in an almost pulseless state ; 
 pulse 144, the face and extremities were cold, there was frequent eructation, 
 the abdomen was rigid, tyrnpanitic, and very tender on pressure ; the tongue 
 was flabby ; no urine had passed ; and his respiration was entirely thoracic. 
 
 At 9 A. M., on the day after admission, the abdomen was tense, slightly 
 hollowed out in the right hypochondriac region, arid tender on pressure. He 
 was very restless, turning from side to side in bed, and his legs were occa- 
 sionally drawn up. He had passed a disturbed night, with the same symp- 
 toms as on admission ; his pulse could scarcely be felt. Shortly after-tins he 
 was allowed by the nurse to rise up in bed, became faint, and died in about 
 half an hour, thirty-eight hours after the commencement of the pain. 
 
 On examining the abdomen, several pints of bloody serum were found in 
 the peritoneal sac. The whole of the small intestine was much distended ; 
 but several coils, corresponding to the last eighteen to twenty-four inches of 
 the ileum, were in a state of approaching gangrene. The latter portion had 
 become strangulated by a diverticulum from the small intestine, about one 
 and a half inches in length, and by a band passing from the mesentery to 
 the ca?cal end of this pouch. The large intestine was less contracted than is 
 generally observed in such cases. There was evidence of general peritonitis, 
 lymph being effused between the coils of the intestine. The mucous mem- 
 brane was continued into the pouch, and much imperfectly masticated cocoa- 
 nut, and the remains of gooseberries, which had been eaten on the morning 
 of the attack, were found in the intestine. The remaining viscera were 
 healthy. 
 
 This case is worthy of being recorded as presenting peculiar diffi- 
 culties in diagnosis; for whilst the urgent vomiting, the state of the 
 abdomen, and the mode of the attack, pointed it out as one of me- 
 chanical obstruction, the great depression and rapid termination 
 seemed to refer it to rupture of the bowel. These latter peculiar! 
 ties, however, probably arose from the extent and completeness of 
 the strangulation leading to speedy gangrene. Although the pain 
 was situated towards the right side, the symptoms were not those 
 usually presented by caecal mischief. The first indication of disease 
 was pain resembling colic after taking some malt liquor, and it is 
 probable that the indigestible substances which he had eaten tended 
 to excite distension and irritation of the mucous membrane. A slight 
 constriction of the canal may become so increased by irregular peri- 
 action and over-distension as to become complete ; thus a patient 
 may for years suffer from slight attacks of pain and from irregularity 
 of the bowels, till after some indiscretion in diet he has a recurrence 
 of pain and vomiting with constipation ; no tenderness of the abdo- 
 men may be present, but rigidity of the abdominal muscles; the 
 vomiting may continue, no further action from the bowels take place 
 but hiccough, rapid prostration of strength, and death speedily follow. 
 The diagnosis in such a case is beset with difficulty. Abercrombie 
 records several instances of this kind, where there was adhesion 
 without apparent narrowing of the canal, existing probably for yc.-irs, 
 till, from some unknown cause, complete and fatal obstruction took 
 place; and cases repeatedly present themselves in which organic dis- 
 ease of great extent has existed for a considerable period, and symp- 
 toms of obstruction are manifested only a short time before death.
 
 INTERNAL STRANGULATION. 443 
 
 CASE CXLVI. Internal Strangulation of a large part of the Small 
 Intestine. Death on the fifth day. Edward J. T., set. 27, was admitted 
 under the care of Dr. Rees into Guy's Hospital, October llth, 1861, and 
 died on the 14th. He was a spare man, with a rather sallow and anxious 
 expression, and his eyes were sunken. The skin was cool ; he stated that he 
 was quite well till Wednesday, the 9th, when, having returned to his work 
 after dinner, sudden pain came on in the abdomen, close to the umbilicus ; he 
 sent for a dose of castor-oil, which at once produced vomiting ; the vomiting 
 continued till his admission on Friday. The rejected matters had the ap- 
 pearance of fluid feces, but the fecal smell was not very manifest. The 
 tongue was clean, the pulse compressible ; there was no evidence of external 
 hernia; the abdomen was rather small, and there was no distension of the 
 colon : neither was there any tenderness, nor tumor, nor hiccough. Calomel 
 and opium were given, and, after an injection, flatus was discharged ; after a 
 second injection flatus and some fecal matter were passed : the pain ceased ; 
 during the twenty-four hours a pint of urine was passed. On the 14th col- 
 lapse came on, and in a few hours death took place. 
 
 On inspection, the lungs were found in a healthy state ; the heart was 
 small, the right side was flaccid, the left was firmly contracted. On opening 
 the abdomen a band of adhesion was at once seen constricting a large portion 
 of the small intestine. The general peritoneum was clear, smooth, and 
 shining; the constriction was formed by a hole near to the centre of the 
 omentum, the edges of which were thickened; and the ends of the constrict- 
 ing fold were adherent to the brim of the pelvis. The stomach and about six 
 feet of the jejunum were distended; the rest of the jejunum and the ileum. 
 nearly to the caecum had passed through the opening. The constricted part 
 was contracted ; its peritoneum was partially inflamed, and in one part soft- 
 ened, but there was no perforation. The colon was small and empty. The 
 kidneys and the liver were healthy. 
 
 The symptoms of strangulation in this case were suddenly de- 
 veloped; and it was evident that the small intestine was the affected 
 part, from the early period at which vomiting came on, the absence 
 of distension of the abdomen, and the small quantity of urine which 
 was passed. I have usually regarded the passage of flatus as a hope- 
 ful symptom, but in this case it had not its usual favorable import; 
 however, the strangulation was at that time either not complete, or 
 the flatus merely came from below the incarcerated intestine. The 
 early period at which death took place was probably due, in part, to 
 the great extent of the strangulated bowel, which amounted to the 
 whole of the ileum and part of the jejunum; but the cause of the 
 sudden collapse, a few hours before the fatal termination, could not 
 be ascertained, for no perforation existed, and the strangulated por- 
 tion only had its peritoneal investment inflamed. The omentum had 
 first become adherent, then atrophied and perforated, and on sudden 
 movement or distension the bowel passed through the opening. 
 
 CASK CXLVII. Internal Strangulation. Old Peritoneal Adhesions. 
 Peritonitis. Suppuration John D , aet. 33, a laborer, was admitted 
 under Dr. Wilks's care into Guy's Hospital June 8th, 1860. Till the previous 
 Sunday, June 3d, he had felt in good health ; and on the following day, at 
 1 A. M., he was seized with pain in the abdomen, and vomiting shortly came 
 on. Aperient medicines were given, and the vomiting increased in severity; 
 the ejecta became stercoraceous ; but no action of the bowels took place. He
 
 444 INTERNAL STRANGULATION. 
 
 had a sallow and anxious expression of countenance when he was brought to 
 Guy's; the abdomen was moderately distended, and rather tense; there was 
 slight pain; an injection on the previous day had brought away some fecal 
 matter, but he was not sure that any flatus had passed; the urine was scanty; 
 the tongue was slightly injected and furred; the pulse was compressible. A 
 grain of opium was ordered every four hours; and a warm poultice was applied. 
 On the 9th the countenance was less anxious; but the eyes were sunken ; the 
 pulse quiet, the skin normal, the abdomen was not distended, and the muscles 
 were hard and rigid, especially around the umbilicus, where he complained 
 of pain; there had been no action from the bowels, nor had any flatus been 
 passed; the urine was moderate in quantity; the vomiting of offensive matter 
 continued. On the llth, as there was no improvement, Dr. Wilks directed 
 that he should be placed in a warm bath, and cold water poured upon the 
 abdomen. On the 12th the patient was in greater distress, and in more 
 severe pain ; he had had no sleep, for as soon as he dozed he was at once 
 awoke by sudden pain darting through him: the pulse was 100, hard; the 
 tongue was rather dry, the vomiting more severe, and stercoraceous ; the 
 abdomen was ruot distended, and still rigid; the pain was especially situated 
 in the umbilical region and about the caecum. Opium gr. j was continued 
 every four hours; and a long tube was passed and water injected into the 
 bowel. On the 13th he was in still greater pain. Six pints of water had 
 been thrown up three times; and the dulness consequent on the injection 
 extended apparently as far as the caecum ; some scybala were brought away, 
 and the vomiting became less. 
 
 On the 16th he had not vomited for three days; on the previous day a six- 
 pint injection was again thrown up, and some scybala passed; flatus was 
 discharged; the pulse was quiet, the skin cool; the urine was abundant; he 
 had suffered during the morning from severe twisting pain in the region of 
 the umbilicus, and the pain continued; but his general expression was much 
 improved more cheerful and less haggard ; he was able also to take beef 
 tea. To continue the opium. 
 
 During the afternoon of June 16th, on the thirteenth day of obstruction, 
 the bowels acted. On the 17th the bowels acted twice. On the 18th he 
 was cheerful, but suffered occasional pain in the abdomen. In a few days 
 he was considered sufficiently well to leave the hospital. 
 
 On October 17th, 1869, he was admitted into St. George's Hospital, under 
 Dr. Fuller's care, and 1 am indebted to the kindness of Dr. Dickinson for 
 the following report: The abdominal pain had never entirely left him since 
 he had been in Guy's Hospital. "When admitted (October 17th) he was 
 much emaciated and sallow. The abdomen was somewhat tympanitic, and 
 slightly painful, but not tender. The bowels were regular; the motions pale. 
 He was weak and occasionally had cramp in the abdomen; his strength 
 failed, the tongue became red and glazed, and the pulse rapid. On the 8th 
 he was more prostrate, and the pulse quick and irregular. Vomiting came 
 on and continued all day. leaving him at last faint and sinking, in which 
 condition he died, in full possession of his faculties." 
 
 ''The inspection was made sixteen hours after death. The body was much 
 emaciated ; the abdomen very tympanitic. The brain was healthy. There 
 were extensive old pleural adhesions on both sides. The lungs and heart 
 were healthy. All the opposite surfaces of the peritoneum were closely united 
 by old adhesions. In front the parietal peritoneum was thus united to the 
 great omentum, which was of great density and much thickened by old in- 
 flammation. It was closely adherent below to the walls of the abdomen near 
 the pelvis, so that on dissecting off the abdominal walls, nothing else was
 
 INTERNAL STRANGULATION. 445 
 
 seen. On cutting through the omentum, a large collection of thin fetid pus 
 was found bathing the intestine; there could not have been less than a quart 
 of this fluid. The small intestines were much convoluted, and in some places 
 greatly distended ; they were vascular, and their surfaces smeared in many 
 places with recent lymph. Besides these, there were old adhesions between 
 neighboring coils. The small intestines were carefully traced down from the 
 stomach (which was itself collapsed, but healthy), but no trace of obstruction 
 could be found either in it or in the large intestine. The coats of the bowel 
 were in many places much thickened, so as to resemble tripe. No morbid 
 condition of the mucous membrane was anywhere found. The mesenteric 
 glands were healthy, and near the ileo-caecal valve was a large chalky mass, 
 which apppeared to have originated in a diseased gland. The liver and 
 kidneys were healthy." 
 
 When this patient was under the care of Dr. Wilks he was suffer- 
 ing from the symptoms of internal strangulation of the small intestine, 
 as shown by colic, with constipation and stercoraceous vomiting, &c. ; 
 and from the subsequent inspection, which revealed the presence of 
 old peritoneal adhesions, it would seem probable that the obstruction 
 arose from this cause, namely, the pressure of adhesions, perhaps 
 rendered complete by enteric inflammation. The thickening of 
 several portions of intestine indicated the presence of chronic im- 
 pediment in the transit of the fecal contents. The cause of death 
 appeared to be exhaustion from recurrent peritoneal attacks, termi- 
 nating in suppuration. The advantage of an opiate plan of treat- 
 ment, with enemata, was shown in the subsidence of the severe 
 symptoms of the first attack. 
 
 CASE CXLYIII. Lead Colic. Internal Strangulation of the Intestine 
 from old disease of a Mesenteric Gland, and subsequent Fibroid Contraction. 
 ( Reported by Mr. George Eastes.) Charles S , set. 29, was admitted into 
 Guy's Hospital, under Dr. Rees's care, November 8th, and died on the 20th. 
 He had been a painter by trade, but had left that occupation to become a 
 chimney-sweep, seven or eight months before his last illness, on account of 
 the attacks of colic from which he suffered; but even when a child he fre- 
 quently suffered from pain in the abdomen. The first attack of this sort 
 occurred three years previously, but that had been preceded by many threat- 
 enings; the next was twelve months later; in six months more, the colic 
 came on a third time ; and from that time he had repeated attacks, the inter- 
 val of freedom from pain lessening in duration; so that during five months 
 prior to admission, he was quite laid aside, on account of the abdominal pain 
 and distress being almost constant. During the latter part of his illness he 
 had been much annoyed by vomiting; this symptom had harassed him con- 
 tinually, and it had generally come on about two hours after food, of what- 
 ever kind it might be ; the bowels were meantime costive, so as only to be 
 opened by injection ; the pain gave him no rest, by night nor by day, and 
 it was accompanied by gurgling and spasm of the abdominal walls; the peri- 
 staltic movement of the intestine became visible. The patient described the 
 passage and quantity of urine as free. He did not suffer from headache, nor 
 from pain in the joints; but he had a well-marked lead line on his gums. 
 His complexion was dark, and he had a large quantity of black hair; his 
 countenance was anxious ; the conjunctivas were dingy; the tongue was red 
 at the tip and edges ; the pulse 68. The abdomen was not tender during 
 the intervals of quiet ; but as soon as the pain came on, the rectus muscle
 
 446 INTERNAL STRANGULATION. 
 
 \\n< drawn up into distinct knots, and then the abdomen became so tender 
 tluil lie could not bear even the bedclothes to rest upon him. He was not 
 always sick, but generally vomited for a day or two at intervals of two or 
 three months. The appetite was pretty good, but for four months he had 
 taken only bread and arrowroot; meat was almost certain to produce vomiting 
 soon after taking it. His bowels were much constipated, acting only every 
 three or four days; and the evacuations were hard and scybalous. There 
 was slight difficulty in micturition, and the urine contained lithatcs. 
 
 The bowels acted slightly on two occasions during the next twelve days, 
 but the pain and vomiting continued more severely, and he died November 
 20th, after a night of agonizing pain. 
 
 The inspection was made thirty-six hours after death. The thoracic vis- 
 cera were healthy. Abdomen: there was general and acute peritonitis; nearly 
 the whole of the ileum and jejunum were almost of a black color, and greatly 
 distended, and in several parts the peritoneal surface had ulcerated, exposing 
 the muscular coat, apparently from distension. The small intestine was 
 drawn backward towards the spine from contraction of the mesentery; and 
 on examining the ileum, near to the CEecum, a hard mesenteric gland pro- 
 jected into the intestine, and had led to fibroid thickening and contraction ; 
 at this part the muscular coat of the ileum was much hypertrophied, and 
 projected, like a nodule, into the intestine; it closely resembled thickening 
 of the pylorus from fibroid degeneration ; the hypertrophy of 'the muscular 
 coat extended some distance up the ileum, and contrasted remarkably with 
 the thin muscular coat below the stricture; the mucous coat was also thick- 
 ened, and slightly ulcerated $ the peritoneal coat presented the ulceration 
 before mentioned; the colon was contracted. The other viscera were healthy. 
 
 The constriction in this instance apparently originated in disease 
 of one of the rnesenteric glands during early life, fibroid thickening 
 took place at that part of the mesentery, which led to partial and 
 afterwards to fatal occlusion and peritonitis. The intense colic from 
 which the patient suffered, was produced by the irregular peristaltic 
 and spasmodic efforts to overcome this obstruction ; attacks of colic 
 appear to have come on in early life, before he had adopted the trade 
 of a painter ; afterwards, it is probable that the lead aggravated them. 
 . The circumstance of chronic poisoning by lead and the blue line 
 along the gums tended to obscure correct diagnosis; the intensity of 
 the colic, however, the intolerance of pressure, and the supervention 
 of peritonitis, were all opposed to simple poisoning by the absorption 
 of lead. 
 
 CASE CXLIX. Mechanical Obstruction terminating favorably after 
 seventy-eight hours For many of the particulars of the following case I am 
 indebted to my friend Sir William Gull. 
 
 J. S , set. 33, a coal porter on a wharf, rose on the morning of the 26th 
 June, 1850, in his usual health, and before going to his work, went, as his 
 habit was, to stool, and had a good evacuation from the bowels. About half 
 an hour afterwards, whilst stooping to fill a sack, he was suddenly seized with 
 a sharp pain across the abdomen in the hypogastric region, accompanied by 
 a sense of constriction. He was obliged to leave his work and to go home ; 
 in a short time he began to vomit, and after the attack was unable to pass 
 anything downwards. He was treated by Mr. Mitchell, of Deptford, but 
 without effect, and on the evening of the following day, forty hours from the 
 accession of the symptoms, he was sent to the hospital with a note, saying
 
 INTERNAL STRANGULATION. 447 
 
 that no hernia could be found, but that an internal obstruction was suspected. 
 The assistance of Mr. Cock was obtained, who examined all the outlets, but 
 could detect no protrusion. On admission he had the usual symptoms of 
 strangulated hernia, urgent vomiting, anxious countenance, pulse rather fre- 
 quent; the temperature of the surface was depressed, the abdomen rigid, and 
 rather tumid, and slightly tender on pressure, urine small in quantity, and 
 high colored. He was ordered a grain of opium every four hours, and to 
 abstain from relieving his thirst. The report of the third day at noon was, 
 that he had passed a restless night, vomiting continually. He was seen early 
 in the morning, everything was interdicted, even to cold water, and he was 
 then better, the paroxysms of pain in the abdomen being less urgent. As he 
 was under the influence of opium the dose was diminished to half a grain, 
 and a copious enema of salt and water was thrown by a long flexible tube into 
 the rectum ; it passed up readily, but without bringing away any feculent 
 matter. In the evening he was restless, his countenance was anxious, the 
 vomiting and other symptoms continuing as before. 
 
 Fourth day, eight o'clock A. M He vomited during the night in con- 
 siderable quantity; the abdomen was tense, and coils of distended intestine 
 could be partially traced, the peristaltic action rendering them prominent, 
 with increase of pain in the abdomen, of which he complained bitterly. His 
 countenance was still expressive of great anxiety, and the features were 
 shrunk. He had passed about half a pint of urine, clear and well colored; 
 the pulse was accelerated, and diminished in power. He was ordered to go 
 on with the opium. During the morning his abdomen was exposed for some 
 time, whilst a sketch was made of its peculiar form, and the position and 
 direction of the prominent convolutions, in order to determine more accu- 
 rately the precise seat of obstruction ; when suddenly, about noon, he expressed 
 himself relieved, saying, that "something had given way within him," and 
 this feeling was quickly followed by a copious flow of liquid feces inundating 
 the bed. From this time he steadily recovered, the vomiting and hiccough 
 at once subsided, and the face acquired a cheerful expression. 
 
 V. 
 
 Certainly no cases present a less promising prognosis than those 
 of mechanical obstruction of the intestines, nor has the enterprise of 
 modern surgery yet succeeded in diminishing their mortality. The 
 case here recorded presented points of no common interest; that it 
 was one of mechanical obstruction there can be but little doubt, and 
 if so, we had an instance of its spontaneous removal, and it answers 
 in the affirmative the question whether we can hope for a successful 
 result in mechanical obstruction without surgical interference. From 
 what we have seen in hospital practice, there is reason to believe 
 that irregular peristaltic action following upon indigestible food, is 
 not an uncommon cause of internal displacement ; but in the case 
 here recorded, it came on after a night's fast, and before any rneal 
 had been taken in the morning. The patient rose as well as usual ; 
 the bowels acted according to his daily habit; he went to his work 
 in good health, but whilst in a stooping position the pain came on. 
 It need not be mentioned, that there was neither history nor trace of 
 lead in the system, nor indeed were the symptoms such as arise from 
 poisoning by that mineral. The only remedy trusted to in the treat- 
 ment was opium, but the happy termination of the case whilst the 
 abdomen was exposed to the cold air, renders it probable that 
 moderation of temperature had somewhat to do with the result. The
 
 448 INTERNAL STRANGULATION. 
 
 application of cold has been suggested in such cases, and has much 
 in theory to recommend it, and it might be expected, in conjunction 
 with opium, to effect all that mere treatment can effect. For, sup- 
 pose a portion of intestine to have insinuated itself under any acci- 
 dental band in the abdomen, by what means can we so well hope to 
 liberate it, as by reducing its volume, and by allaying the vomiting? 
 I would also suggest whether opium suppositories would not some- 
 times more efficiently promote the latter object than opium in the 
 stomach. Of the opiate plan of treating intestinal obstruction too 
 much cannot be said. It has both reason and experience on its side; 
 and yet in the reports daily given of such cases, purgatives form 
 generally the early part of the treatment ; and they are persevered 
 in until the stomach will bear them no longer, serving only to ex- 
 haust the patient and to increase the symptoms. This case also 
 shows the importance of abstaining from food, which not only dis- 
 tends the bowel, but increases the peristaltic movement and augments 
 the pain. 
 
 CASE CL. Internal Strangulation and Constipation. Subsidence of 
 Symptoms. Death from Phthisis (From the Museum Records.) William 
 H , a man of middle age, was admitted into Guy's in 1829. There was 
 obstinate constipation, vomiting of a stercoraceous character ; but no hernia 
 could be detected. The symptoms gradually subsided, but the patient died 
 from phthisis several months afterwards. 
 
 On inspection, there were vomicae in the lungs. The intestines were ir- 
 regularly contracted. The appendix cieci was bound by adhesion to the 
 brim of the pelvis, and several bridles of adhesions extended to portions of 
 small intestine at this part ; one of them was very long, and had apparently 
 led to constriction, and to the previous symptoms of strangulation. No 
 ulceration of the intestine existed. 
 
 Tumors sometimes become developed in the mesentery, and act as 
 either the predisposing, or as the direct cause of mechanical obstruc- 
 tion. Among the records of the inspections at Guy's, is that of a 
 boy, aged seventeen, who, after a blow on the abdomen, two years 
 previously, had gradual distension of the abdomen, fluctuation, vom- 
 iting, and constipation. The jejunum was found to be enormously 
 distended. One portion of the mesentery near the commencement 
 of the ileum contained numerous tubercles, supposed to be cancerous, 
 and the contraction around these had led to obstruction; other tuber- 
 cles were situated in the pelvis. 
 
 CASE CLI. Colic, Simulation of internal Strangulation. Recovery 
 A young man, set. 22, badly nourished, who had resided in Rosemary Lane, 
 was admitted August 21st, into Guy's Hospital. He was pale and despond- 
 ing, and had been suffering severely during eight days. He appeared to 
 earn a scanty livelihood as a porter, and on August 14th, after taking his 
 breakfast in his usual health, he lifted about f cwt. upon a cart, when he felt 
 a sudden pain below the left hypochondriac region ; he, however, went to his 
 work, but was taken back, " doubled up," as he described it ; after a few 
 hours, vomiting came on, and both pain and vomiting continued till admis- 
 sion ; he had not had any action from the bowels, although repeated doses of 
 medicine had been taken, nor had there been any hiccough. He complained
 
 INTUSSUSCEPTION. 449 
 
 of severe pain across the umbilical region ; the abdomen was neither hot, nor 
 tender on pressure ; there was some distension laterally, and in the position 
 of the transverse colon, otherwise it was contracted. The tongue was clean 
 and pale ; the pulse eighty, and tolerably iree in volume. He had passed 
 but little urine, and neither blood nor mucus from the bowels. There was 
 no hernia, but along the gums a dirty line which somewhat resembled lead. 
 
 For three months he had been a teetotaller, and he had had occasional 
 pain in the abdomen, but no constipation. 
 
 A soap injection was administered, and calomel gr. v, with opium gr. iss, 
 given as a pill. On the 22d and 23d there was no relief from the bowels, 
 no medicine was administered. On the third day after admission the bowels 
 acted slightly, castor-oil was then given, and was followed by more active 
 remedies. The bowels acted, and he left the hospital in a few days com- 
 paratively well. 
 
 This case was probably one of colic, in which the symptoms came 
 on suddenly after exertion; it resembled internal strangulation, but 
 the abdomen never became distended; the importance of not allow- 
 ing too active a plan of treatment was also shown, the vomiting be- 
 came much less after the purgative medicines had been left off; the 
 calomel and opium with enemata were used once; and on the third 
 day the bowels were acted upon. 
 
 CASES OF INTUSSUSCEPTION. 
 
 CASE CLII. Colic. Lumbrici. Diarrhoea. Intussusception of the 
 Kenin and Ascending Colon into the Descending Colon. This case is fully 
 reported by Dr. Hughes in the ' Guy's Reports' of 1856. 
 
 Daniel D , set. 14, was admitted into Guy's, February 27th, 1856, under 
 Dr. Hughes's care. He had resided near the Tower, and had assisted his 
 father as a tailor. His previous health had been very good till seven weeks 
 before admission, when he was exposed to severe cold, and the following 
 morning he was seized with acute pain in the abdomen, which continued for 
 several hours ; the pain returned on the following day, and similar paroxysms 
 took place till admission, but at uncertain periods. The attacks generally came 
 on towards evening, and sometimes twice in the day. He was free from pain 
 from the 21st to the 25th, when he took some castor oil, and from that time he 
 suffered from tenesmus, vomiting after meals, and loss of appetite. He de- 
 scribed the pain as a twisting and tearing of his intestines principally about 
 the umbilicus, and he detected " lumps" in the abdomen, which disappeared 
 on the subsidence of the paroxyms, during which he lay with his legs curled 
 up and his hands on the abdomen ; the duration of the pain varied, and was 
 frequently relieved by passing flatus. In the intervals he felt well. The 
 appetite was capricious, and sometimes excessive. The bowels were open 
 twice a day, the motions semi-fluid or scybalous. On admission he was 
 much emaciated ; the expression of countenance was one of distress ; there 
 was a white fur on the tongue, and the pulse was weak and compressible. 
 Shortly after admission he voided an ascaris lumbricoides with some mucus. 
 Calomel gr. v and opium gr. -| were given, and were followed by a senna 
 draught. Poppy fomentations were applied, and milk diet ordered. 
 
 Repeated paroxysms of severe pain came on during the next fortnight ; 
 but in the intervals he was able to go about the ward. Calomel and opium, 
 purgatives and enemata were ordered ; diarrhoea then supervened with tenes- 
 mus. On March loth he was suffering from severe pain, the tongue was 
 29
 
 450 
 
 INTUSSUSCEPTION. 
 
 coated with a white fur, and the pulse was quick and compressible. The 
 abdomen was distended ; coils of intestine were visible, and there was tender- 
 ness. He vomited a considerable quantity of green bilious fluid, and the 
 alvine evacuations were of a dysenteric character, consisting of bloody mucus 
 without fecal matter. Notwithstanding treatment by sedatives and demul- 
 cents, no relief was obtained ; the vomiting became more severe ; another 
 lumbricus was ejected ; and on the 23d the symptoms of peritonitis became 
 suddenly aggravated, and he died on the following day, twenty-seven days 
 after admission, and eleven weeks after the commencement of the attack. 
 
 Inspection The body was badly nourished. The lungs and heart were 
 healthy. The abdomen was considerably distended. On opening the peri- 
 toneum the descending colon was found to be enormously enlarged and full ; 
 so also the sigmoid flexure, which made a great curve nearly to the right side 
 of the abdomen. The transverse colon could be traced in a similar state to 
 the right side of the median line ; it was thrown into transverse folds, and the 
 ileum was found within it. The caecum and ascending colon were entirely 
 
 Position of intestines in a case of intussusception of csecum and ascending colon into descending 
 colon and sigmoid flexure ; the commencement of the rectum is drawn from its position, to show the 
 translated bowel within. 
 
 intruded. The rest of the ileum was much distended ; a great part of the 
 jejunum, however, was collapsed, and situated behind the transverse colon 
 and stomach, in the position described, as the sac of the lesser omentum. It
 
 INTUSSUSCEPTION. 451 
 
 f d\ \ F f~ r~ f"i'~~ (~i r ~Tt-cr*r~r\-f\ 
 
 occupied this position either from the 'congenital looseness of the J colon, or 
 from its meso-colon having been drawft askle by the intnssuiSceptiOiF; 'tlitsr 
 foramen of Winslow was normal. The general peritoneum was intensely 
 injected, and was covered with lymph, and there was general acute perito- 
 nitis ; the small intestine, however, which was situated behind the stomach, 
 was not inflamed. 
 
 The stomach contained semi-feculent fluid ; but the duodenum was normal. 
 Several lumbrici were found in the jejunum ; the ileum presented towards 
 the commencement of the intussusception an ulcer about half an inch in 
 diameter, much congested at its margin ; the intestine was full of yellow fluid 
 feces. On tracing the intestine onwards the lower part of the ileum, the 
 caecum and ascending colon were found in the descending colon. It could be 
 felt within the large bowel, and readied into the rectum, within a few inches 
 of the anus. On opening the sigmoid flexure and rectum, the termination 
 of the intussuscepted portion was observed, almost black, but surrounded by 
 semi-fluid feces ; the apex of the invaginated portion was very tense, its 
 opening, which would admit the little finger, was marked by a fissure towards 
 one side on account of the contraction of the mesentery. Turning aside the 
 bowel it was found to be convex and twisted from the dragging of the mesen- 
 tery, and at the concave side was a large irregular ulcer at the most tense 
 portion. In the sigmoid flexure, which was considerably distended, was a 
 small opening into the peritoneal cavity, which has set up general peritonitis; 
 at the other extremity of the intussuscepted portion the finger could be easily 
 passed round the bowel, although there was commencing adhesion for the 
 effusion of lymph. The liver, spleen, kidneys, &c., were healthy. 
 
 This case was one of peculiar interest, on account of the obscurity 
 of the disease; the colic appeared to be due to the lumbrici, but the 
 severity of the symptoms, the intense pain, the purging of bloody 
 mucus, the almost incessant vomiting, and the distended coils of in- 
 testine, indicated a more serious abdominal lesion. The disease lasted 
 eleven weeks, and it is probable that the intussusception continued 
 during that period, at first perhaps slight in extent, but gradually 
 increasing to a greater degree. The canal did not become entirely 
 occluded till near the fatal termination ; and it is possible that the in- 
 tussusception may have become partially restored with the relief of 
 the symptoms, and at each fresh paroxysm the intestine may have 
 been pushed further onwards. The cause of death was peritonitis, 
 consequent on rupture of the sigmoid flexure ; and the exciting cause 
 of the intussusception was probably the irregular peristaltic action 
 consequent on the lumbrici associated with unusual and perhaps con- 
 genital freedom of the caecal mesentery. As far as can be judged by 
 a post-mortem consideration of treatment, opium was the most de- 
 sirable remedy, with rest, bland nutriment, and the avoidance of any 
 purgative medicines.; but with such an extensive intrusion of intes- 
 tine no remedy would probably have been effective; the injection of 
 fluid at an early period might have been effectual in reducing the 
 invaginated bowel, but the gangrenous condition of the inclosed 
 bowel had a reparative tendency, which in like cases has often re- 
 sulted in the recovery of comparative health. 
 
 I have observed instances in which symptoms very similar to those 
 manifested in this case have gradually subsided, and the patient
 
 452 nO INTUSSUSCEPTION. 
 
 / v <! * T i : Pi "-i.0 ^ L"> ^ I ! I N a j n -r\ T< 
 
 vered ; such a case occurred under my colleague, Dr. Fagge, in 
 
 ,: in' 'which tlio pstjHleiftti tH^seqUently died from a twist of the 
 bowel at the point where an old intussusception had become adhe- 
 rent to the abdominal wall. 1 
 
 CASE CLIII. Intussusception. Recovery. Ccecum and the whole of the 
 Ascending Colon passed per Rectum. (See Prep, in Guy's, 1875.) W. 
 P , ait. 6, a patient of Mr. C. King's, in 1852. The previous health of the 
 child had been good, till he was attacked with oedema and discoloration of 
 both legs; these symptoms soon subsided, but constant vomiting came on, 
 with constipation and pain, and with tenderness of the abdomen, particularly 
 in the right iliac region ; these urgent symptoms remained for four days, 
 when convulsion and insensibility ensued. He remained in this condition for 
 twelve hours, apparently dying ; on the two following days he was a little 
 better; the vomiting ceased, but constipation continued ; during the next four 
 days there was no cliange. Eleven days after the seizure, and five days after 
 the cessation of the vomiting, he had an evacuation from the bowels, and the 
 caecum with the vermiform process and the ascending colon were discharged; 
 when passed, the cylinder of the intestinal slough was complete. In a few 
 days the leg became gangrenous, and was removed by Mr. Hilton. The 
 child did well, and completely recovered. 
 
 The symptoms of colic, in this as in the previous case, were very 
 severe, and the recovery of the child very remarkable after the re- 
 moval of the whole of the caecum and ascending colon. It must 
 also be noticed that constipation of an insuperable character was not 
 one of the earlier symptoms; there was evident impairment of the 
 general health of the child, as shown by the oedema and discoloration 
 of the legs, followed by gangrene ; and it was suggested that unwhole- 
 some food, as ergotized bread, might have produced the disease. In 
 cerebral irritation, also, we find a disposition to irregular peristaltic 
 action of the intestine, and frequently after death from hydrocepha- 
 lus numerous portions of invaginated intestine are observed ; here, 
 however, the abdominal symptoms preceded the cerebral. The fol- 
 lowing cases present several points of great interest connected with 
 this subject. 
 
 An emaciated man, set. 28, under the care of Mr. Benjamin Phil- 
 lips, 2 had been resident in a miasmatic district. He had suffered 
 occasionally for weeks from an obscure affection of the digestive sys- 
 tem ; the abdomen was hard and tympanitic; there was frequent 
 nausea, but vomiting rarely took place ; the alvine evacuations were 
 sometimes frequent and fluid, at other times they were natural; 
 leeches were applied to the abdomen ; the diarrhoea and nausea con- 
 tinued, the evacuations became greenish, and contained blood ; and 
 an elongated mass was found occupying the left iliac fossa. The pa- 
 tient had a constant disposition to sleep ; and he died seven days after 
 coming under Mr. Phillips's care. 
 
 1 The seat of constriction was over the right sacro-iliac joint ; here the enormously 
 distended ileura went to the wall of the abdomen, and became lost for half an inch 
 just before its junction with the caecum. The two edges of bowel thus left, on open- 
 ing the intestine, were found to be raised, red, and well defined, and a seam in the 
 mesentery led to this point. 
 
 * 'Medical Gazette.'
 
 INTUSSUSCEPTION. 453 
 
 On inspection there was found to be acute peritonitis, and invagi- 
 nation of the caecum and ileum into the transverse and descending 
 colon. Several inches of the invaginated intestine were gangrenous, 
 and the serous surfaces of the inclosed bowel were adherent; perfora- 
 tion had taken place. 
 
 In another case, reported by the same gentleman, the patient, set. 
 31, had suffered for many months; the skin was sallow; he was ema- 
 ciated, and had a tympanitic state of the abdomen, with tenderness 
 in the course of the descending colon and sigmoid flexure. In the 
 left iliac region a tumor could be felt, considered by some to be im- 
 pacted feces. On inspection there was general peritonitis, the caecum 
 and ascending colon were not visible, and a cylindrical tumor was 
 found in the iliac fossa; "two inches of the small intestine had pene- 
 trated into the caecum; this turned upon itself, and was then introduced 
 into the ascending colon, which in turn had passed into the transverse 
 colon, and all these parts thus disposed had reached the left iliac 
 fossa." Several perforations had taken place. 
 
 In a case reported by Mr. Jon. Hutchinson, in the 'Pathological 
 Transactions,' the symptoms of colic had existed for several months, 
 and the patient, a young man, had sometimes swung himself on the 
 steps of a ladder, as the only means of relieving the pain. The in- 
 vaginated portion of intestine was found adherent, and the appear- 
 ances evidently indicated that it had been so intruded for a conside- 
 rable period. 
 
 CASE CLIV. Constipation. Subsequent Perforation. Peritonitis. In- 
 tussusception Restored? (From the Museum of Records.) M. S , get. 60, 
 ten or twelve days before application had experienced sudden violent pain in 
 the abdomen, with constipation : vomiting came on, but no hernia could be 
 detected ; by avoiding medicine the vomiting subsided. A dose of croton oil 
 produced an evacuation, but without relief to the symptoms ; the bowels 
 were afterwards moved by castor oil ; the symptoms of peritonitis returned, 
 and the patient quickly died. On inspection a portion of small intestine was 
 found, dusky and lurid, and patches of lymph were observed ; on moving the 
 intestines feces escaped. The discolored portion was from six to seven 
 inches in length, and the mucous membrane was dark ; the mesentery was 
 also slightly discolored, and greenish at that part. A defined line marked 
 the diseased portion. 
 
 The appearances presented in this case were either those of an 
 intussusception restored, which was the opinion of one who had had 
 very great experience in pathology ; or, 2dly, of internal strangula- 
 tion ; or 3dly of local enteritis, as we have previously mentioned in 
 speaking of that disease ; or, 4thly, of a twist of the intestine on the 
 mesentery, which had become partially restored. The last sugges- 
 tion was, perhaps, the most probable. There was no evidence that 
 either external or internal hernia had existed ; and whilst it is very 
 probable that cases of intussusception are restored, we scarely feel 
 warranted in asserting that invagination had taken place in this 
 instance. 
 
 The following case is a remarkable one, as indicating one of the 
 sequences of intussusception. It is from the ' Medical Gazette' :
 
 454 INTUSSUSCEPTION. 
 
 A patient, aet. 65, had constipation, violent pain in the bowels, and 
 vomiting; in four days the pain ceased. It had commenced on 
 August the 26th ; on the 31st there were several offensive dejections, 
 and on September 5th forty -four inches of intestine were evacuated. 
 The patient survived forty days. 
 
 On inspection the sigmoid flexure was wanting, and the caecum 
 and colon, seventeen inches in length, opened into a large fecal 
 abscess, into which the rectum passed. 
 
 CASE CLV. Phthisis. Intussusception of the Ileum. Peritonitis 
 James H , aet. 16, a pale boy, was admitted into Guy's Hospital, May 23d, 
 1860. For a year he had suffered from cough and phthisical symptoms. 
 Eight, days before admission he complained of pain in the abdomen, which 
 was accompanied with vomiting. The pain commenced in the region of the 
 caecum, but the tenderness was at first slight ; this symptom afterwards in- 
 creased, and became more general as the indications of peritonitis were de- 
 veloped. There was great restlessness, and persistent bilious vomiting. The 
 bowels acted once after injection, but there was no discharge of blood. 
 Death took place on June 1st. 
 
 On inspection, phthisical vomicae were found at the apices of both lungs ; 
 and the lower lobe of the left lung was in a state of recent hepatization. In 
 the abdomen, both small and large intestines were distended ; there were 
 some lines of injection at the margins of contact between the intestinal coils. 
 A foot from the caecum all the coats of the small intestine had sloughed 
 through up to the mesentery ; but extravasation had not taken place to any 
 great extent, although no adhesions had formed. It was at once seen that 
 the sloughing had arisen from intussusception of the ileum ; and several 
 inches of separated intestine were in a sloughy state. The sigmoid flexure 
 and the parts below the intussusception were not collapsed, but were partially 
 distended with flatus. 
 
 CASE CLVI. Intussusception of Ileum. Perforation. Peritonitis John 
 S , aet. 17, was admitted into Guy's Hospital, under Dr. Barlow's care, 
 September 17th, 1857, in a moribund state, and died in an hour or two. It 
 was stated that he had suffered from insuperable constipation for a fortnight, 
 with increasing distension of the abdomen and vomiting. The first symptom 
 had been inaction of the bowels two weeks previously ; and after that time 
 he had only the smallest evacuation after injections. On admission there 
 was peritonitis and fecal vomiting. The body was that of a strong, muscular 
 man ; the abdomen was much distended and tympanitic. 
 
 On inspection, the thoracic viscera were found to be healthy. There w r as 
 acute peritonitis, but only a small quantity of lymph had been effused. The 
 small intestines were much distended, but the large were contracted. The 
 obstruction was at once seen to be an intussusception at the lower part of the 
 ileum ; and upon raising this portion an opening was seen in the gut, and 
 fecal matter was escaping ; a small quantity only of fecal matter was at first 
 seen, so that the perforation probably remained nearly closed by being in 
 contact with an adjoining coil, although the whole calibre of the intestine 
 was torn through. The intussusception was found to be at three feet from 
 the caecum, and consisted in four to five inches of the ileum which had passed 
 into a lower portion. The contained part was in a state of slough, and was 
 in shreds, as if it would soon have become detached. At the upper orifice 
 some firm adhesions existed between the serous surfaces, but at the point of 
 constriction these had separated. The opening of the lower part was almost
 
 INTUSSUSCEPTION. 455 
 
 closed, so that a probe could be scarcely introduced. The serous surfaces 
 were closely adherent at the margin, where they passed the one into the 
 other ; and upon cutting through the included part the serous surfaces were 
 seen in like manner to be connected by lymph ; and, as a considerable space 
 existed, the lymph uniting them was of some thickness ; the interior mucous 
 passage was almost closed, only just admitting a probe. All the small intes- 
 tines, as well as the stomach, were filled with fluid fecal matter, which in 
 general appearance could not be distinguished from that in the colon. 
 
 This patient was dying when admitted, and there were no symp- 
 toms to enable us to distinguish this case of intussusception from one 
 of internal strangulation of the intestine. It is possible that, had 
 rest been enjoined and proper treatment adopted from the first, the 
 contained slough might have been discharged without the separation 
 of those adhesions on which the safety of the patient depended. 
 
 CASE CLVII. Intussusception of Si y moid Flexure. External Protru- 
 sion. Symptoms of Strangulation. Peritonitis. Death Catharine F , 
 a;t. 25, was admitted into Guy's Hospital, June 18th, 1857, and died on the 
 28th. She was a single woman, and in the October before her death began 
 to suffer from prolapse of the anus ; the prolapse was returned, but again 
 came down, and from mistaken modesty she had neglected her complaint. 
 Three weeks before admission the bowel came down, and she was unable to 
 return it, and at the same time constipation ensued. Still no advice was 
 sought, and on admission she was found to suffer from strangulation ; the 
 bowels had not been moved for three weeks. The intussuscepted bowel lay 
 for several inches outside the anus, but could be easily replaced, although the 
 strangulation was not thereby overcome. 
 
 She died on the 28th, ten days after entering the hospital. The body was 
 spare ; the abdomen was tynipanitic, but not excessively distended. There 
 was acute general peritonitis. All the intestines were slightly distended, and 
 full of fluid feces. Nothing abnormal was found till the pelvis was ex- 
 amined, where, low down behind the uterus, an intussusception was found, 
 and at first it seemed so near to the anus as to be merely a prolapse ; when, 
 however, the intestine was removed it was found that the proximity to the 
 anus arose from dragging down of the intestine, for when stretched out the 
 invaginated part did not reach the anus by three inches ; measuring from the 
 line of constriction to the anus was nine inches, and the invaginated part 
 measured half this length, making the commencement of the inverted bowel 
 eighteen inches from the anus, and therefore in the sigmoid flexure. The 
 invaginated part was sloughing, and, as usual, slightly curved on itself by 
 the dragging of its attachment. The other viscera were healthy. 
 
 These instances of intussusception present us with symptoms of 
 severe colic, with vomiting and constipation, and often with tumor; 
 2dly, they show that the pain and other symptoms are often parox- 
 ysmal; 3dly, that the constipation is not always constant, but on the 
 contrary, that diarrhoea is sometimes present; 4thly, that the dis- 
 charge of blood and mucus occasionally takes place; 5thly, that the 
 causes of death are perforation and acute peritonitis, or secondary 
 fecal abscess; and 6thly, that the disease is cured by restoration of 
 the parts, and sometimes by sloughing and separation of the invagi- 
 nated portion.
 
 456 CANCEROUS DISEASE. 
 
 CASES OF CANCEROUS DISEASE. 
 
 CASE CLVIII. Columnar Epithelioma of the Sigmoid Flexure, with 
 Cancerous Infiltration of Glands near the Gall-bladder Ralph G , get. 
 44, a stout, plethoric man, who had served for fifteen years in the police 
 force, had been employed at the station house, so that his life was a seden- 
 tary one. He had had good health, with the exception of slight attacks of 
 rheumatism, till one year before admission, when, after taking less than his 
 usual exercise, his bowels became confined ; he had, however, generally a 
 motion every three days. 
 
 He was admitted into the hospital, under my care, July 3d. 
 
 On June 20th he passed a solid stool, small in quantity, but without strain- 
 ing or pain ; from that time nothing had been passed. He did not feel any 
 uneasiness till the 23d, when he felt pain and a sense of weight in his abdo- 
 men, and he vomited slightly. These symptoms passed off, but afterwards 
 returned. He had hiccough at night, and his sleep had been disturbed ; the 
 appetite had failed, his abdomen had swelled", and he had some dyspncea. 
 Before admission he took various aperients, and had an injection of turpen- 
 tine, but without effect. 
 
 July 3d. The abdomen was much swollen, measuring forty and a half 
 inches in crcumference ; it was most prominent in the position of the trans- 
 verse colon, and tympanitic. This tympanitic resonance could be traced in 
 the course of the colon, nearly to the sigmoid flexure. At that part he had 
 slight pain, and stated that some months before he had had a similar attack. 
 He had not had any discharge of blood, mucus, nor of air, per rectum; there 
 was no pain on manipulating the abdomen, nor any increase of temperature; 
 the pulse was quick and sharp, 98 ; the respiration was accelerated, the skin 
 was perspiring, the tongue had a white fur upon it. A turpentine enema was 
 ordered at once, and the soap and opium pill, gr. v, three times a day. 
 
 4th. Vomiting took place at 5 A.M., the pulse was strong, 86; the skin 
 cool ; he had had no vomiting since the morning. The pills were continued, 
 and he was to have a rue injection. 
 
 5th He passed a considerable evacuation and felt much easier. He after- 
 wards had some sleep, and was able to take some food ; the pulse was feeble, 
 116; tongue more brown. 9 P. M Calomel gr. xij, were ordered to be 
 taken, and the rue injection to be repeated. 
 
 6th Passed a small quantity of faeces. The prostration of strength and 
 tymranitic distension increased; there was no further action of the bowels, 
 although the long tube was used ; the patient became restless, the pulse rapid, 
 but he did not suffer from severe vomiting. Opium was continued. The 
 urine was moderate in quantity and high colored. 
 
 2 P. M Mr. Birkett could not detect anything on examination per rec- 
 tum, and did not think the symptoms of insuperable obstruction sufficiently 
 severe to warrant surgical interference. 
 
 9 P.M The patient appeared in the same condition as in the morning, 
 he was prostrate and was covered with clammy perspiration. The patient 
 gradually sank, and died 2.30 A.M. on the 8th, nineteen days after the com- 
 mencement of the symptoms of obstruction. 
 
 Inspection twelve hours after death. The rigor mortis was well marked. 
 The abdominal parietes contained a considerable layer of integiimental fat. 
 The abdomen measured round the umbilicus three and a half feet. On opening 
 the peritoneal cavity it was found to contain about three pints of opaque 
 serum mixed with shreds of lymph ; the peritoneum was much injected, and 
 was covered with spots of lymph. Both small and large intestines were
 
 CANCEROUS DISEASE. 457 
 
 enormously distended ; this was especially marked in the caecum and colon, as 
 far as the sigmoid flexure, where was the seat of obstruction ; the sigmoid 
 flexure was distended and bound to the walls of the abdomen, the intestine 
 then turned inwards towards the promontory of the sacrum, where it became 
 suddenly narrow at its union with the rectum. Externally the constricted 
 mass felt hard, and after removal it was found that an ordinary probe would 
 scarcely pass. The obstruction was nearly an inch in length ; on placing it 
 in water the surface was quite flocculent, resembling villous cancer. The 
 intestine, both above and below, was healthy; above, was a large quantity of 
 fluid feces ; below, small scybalous masses. Near the gall-bladder were 
 several glands infiltrated with cancerous product. The other organs were 
 healthy. 
 
 The microscopical examination of the diseased growth presented 
 cells resembling columnar epithelium, but of greater size, and con- 
 taining large nuclei. The whole of the flocculent surface was com- 
 posed of cells of this kind, but no large cells, such as are usually 
 found in epithelial cancer, were observed. They appeared rather to 
 be modified columnar epithelium. The muscular coat of the intes- 
 tine at that part was much contracted. The diagnosis in this case 
 was from the first clear ; the gradually increasing constipation, ab- 
 sence of pain, resonance, so far as the sigmoid flexure, with previous 
 slight pain at that part, and the normal quantity of urine, all tended 
 to show that the obstruction was at or about the sigmoid flexure. 
 It was a matter of regret that, in a case so favorable for surgical 
 assistance, such means were postponed till fatal peritonitis came on ; 
 but the apparent mildness of the symptoms, the absence of vomiting, 
 on account of the non -administration of drastic purgatives, led some 
 to the supposition that the disease arose rather from impacted feces 
 than from an insuperable obstruction. The development of glands 
 infiltrated with cancer near the gall-bladder was an interesting fact 
 with this form of disease, which appeared to be of the character of 
 epithelial cancer, in which there is less tendency to glandular infil- 
 tration. 
 
 CASE CLIX. Cancer of the Sigmoid Flexure. Perforation Sarah 
 O , set. 42, was admitted November 18th, 1856, and died the following day, 
 at 8 A. M. In July she had received a fall, and on August 5th experienced 
 pain in the region of the sigmoid flexure of the colon. The pain gradually 
 extended over the whole abdomen ; injections were administered which pro- 
 duced evacuations from the bowels, several days before admission. 
 
 AVhen brought to Guy's Hospital she was too ill to give any definite state- 
 ment in reference to herself. The countenance was anxious, the pulse was 
 small and compressible. The abdomen was very much distended, and when 
 exposed the position of the transverse colon was more prominent than other 
 parts, and was tympanitic. The pain and tenderness were general ; vomiting 
 was very distressing ; an abundant quantity of urine was passed. Opium was 
 given, and a warm poultice was applied ; but she died the following morning. 
 
 Inspection was made about six hours after death. The thoracic viscera 
 were quite healthy. The peritoneum was much injected, and the intestines 
 appeared dry, from a delicate stratum of lymph upon them. 
 
 The colon was very much distended as far as the sigmoid flexure ; the small 
 intestines also were moderately distended. The stomach was healthy. Near
 
 458 CANCEROUS DISEASE. 
 
 the end of the ileum there was considerable congestion and several ulcers ; 
 these ulcers, however, were much more extensive in the crccum. The caecum 
 was enormously enlarged, and there was very general transverse ulceration, 
 exposing the circular muscular fibres, as if ulcerated from over-distension; 
 in some parts the muscular coat also was destroyed, and slight perforation had 
 taken place in one spot, but without extravasation of feces ; the gut was more 
 than nine inches in circumference. The appendix was filled with mucus, 
 which was very slightly acid ; and it was adherent in the long axis of the 
 colon. The descending colon was very much distended as far as the brim of 
 the pelvis, where it became suddenly contracted ; and this part was adherent 
 to the uterus and to a coil of small intestine. On separation the intestine 
 was found to be drawn in at that part, and hardened. On opening it, the 
 little finger could be passed, and the canal above was filled with fluid feces ; 
 at the constriction there were vascular prominent growths, corresponding 
 almost to the position of the longitudinal bands ; the section had a yellowish 
 color, and showed that both the muscular and mucous coat were involved. 
 On careful microscopical examination the surface was found to present a few 
 villous processes, and the mass consisted of abundant nuclei and many com- 
 pound nucleated cells, resembling some forms of medullary cancer ; above the 
 constriction was a smooth round opening, extending through the coats of the 
 intestine into the peritoneum, but adhesions had formed between the uterus 
 and coils of small intestine, so as to prevent extravasation. The constriction 
 was seventeen inches from the anus ; below the stricture was some dry fecal 
 matter. The other abdominal viscera and glands were healthy. 
 
 CASE CLX. Cancerous Disease of the Sigmoid Flexure. Ecchymosis of 
 Stomach. Ulceration of the Ileum. Contracted Mitral Valve. Ellen II , 
 set. 53, was admitted November 7, 1855. She was a married woman, with- 
 out family ; she had been living at Shepherd's Bush, and was greatly ema- 
 ciated. 
 
 Seven months before admission she had had severe pain at the lower part of 
 the abdomen, and was compelled to desist from work ; the pain came on four 
 or five times a day ; the bowels were confined, but had previously been regular. 
 The motions were then very scanty, except after injections ; she had some- 
 times had severe vomiting, and at times offensive matter was rejected ; the 
 urine had always been abundant. 
 
 The abdomen on admission was very large and tympanitic, but it was most 
 prominent in the umbilical region ; the tongue was clean ; the pulse WHS 
 small and very compressible. No abdominal tumor could be felt ; and there 
 was no tenderness. On admission enemata were administered, and purga- 
 tives, which latter aggravated the symptoms. November 24th, opium was 
 given, gr. j every six hours. This was followed by marked improvement, 
 the stomach became quiet, and she was able to retain food. 
 
 November 30th She was not so well, and complained of severe pain in 
 the stomach ; the tongue was small and contracted ; the bowels were opened 
 freely; enemata had been administered, and opium given. 
 
 December 19th She was much better ; the abdomen was supple, not dis- 
 tended ; and the bowels were open ; she was free from pain, and had a good 
 appetite ; she took some porter and a chop, and wine. Opium gr. j was con- 
 tinued. The bowels afterwards again became constipated ; the abdomen be- 
 came painful, and the strength failed. She sank on January 8th. 
 
 January 9th Inspection, 2.30 P. M., seventeen hours after death. The 
 body was extremely emaciated ; the eyes were sunken ; the abdomen was 
 greatly distended. The parietes of the abdomen were thin. On opening the
 
 CANCEROUS DISEASE. 
 
 459 
 
 peritoneal cavity, an enormously distended transverse colon was found to 
 occupy the whole anterior region of the abdomen ; from the liver it passed 
 down to the brim of the pelvis, then ascended nearly to the scrobiculus cordis, 
 before it formed a second smaller curve, and became the descending colon. 
 The large intestine was distended as far the termination of the sigmoid flex- 
 ure. Along the margins of the dis- 
 tended coils of intestine were lines of 
 injection, and between some of the foils 
 were delicate flakes of lymph. At the 
 commencement of the rectum the in- 
 testine was contracted ; and a drawing 
 in of the coats of the intestine gave the 
 part an irregularly puckered appear- 
 ance ; although thus contracted, the 
 intestine at that part was readily mov- 
 able. The whole of the colon was dis- 
 tended with fluid bilious feces ; at the 
 constricted part the intestine would 
 only admit an ordinary quill ; the con- 
 striction was one inch in breadth, 
 raised, nodular, and deeply injected ; 
 the superficial portion was soft, and of 
 a grayish color ; this rested on firm iron 
 gray structure, and minute masses of 
 yellowish fat ; the muscular coat was 
 drawn in and lost at this part ; but in 
 the colon, both above and below the 
 stricture, it was distinct. 
 
 On careful examination of this part 
 the surface was smooth, and presented 
 columnar epithelium, nucleated cells, 
 and elongated nuclei (a) ; beneath the 
 mucous membrane, which was itself 
 dense, changed in character and 
 fibrous, was a considerable quantity of 
 firm, fibrous tissue, arranged at right 
 angles with the intestine (6), and leav- 
 ing interspaces filled with nuclei, but 
 without nucleoli (e) ; still deeper, mus- 
 cular fibre could be detected. There 
 was no structure of an ordinary carci- 
 nomatous character. The nuclei were diiferent from ordinary nuclei, not 
 having well-defined cell-wall or nucleoli. They appear like a coagulated 
 blastema, in course of development into a fibrous structure. 
 
 In the termination of the ileum was an ulcer affecting nearly the whole of 
 one of Peyer's patches, and the mucous membrane was entirely destroyed, 
 but the disease was of a different character from that in the colon ; the rest 
 of the small intestine was healthy. The stomach contained some black mucus 
 adherent to the membrane. At the cardiac extremity was a raised, black 
 patch, covered with white substance, but merely affecting the mucous mem- 
 brane, probably from thrombosis. The follicles were evident, and slightly 
 blackened from the blood which they contained; but at the upper part of the 
 membrane, where the capillaries were more numerous, there was an almost 
 uniform black color ; it appeared that before death ecchymosis had taken place 
 
 4.OQ 
 
 Obstruction of the sigmoid flexure by cancer- 
 ous growth ; (a) columnar epithelium and nu- 
 clei ; (b) fibrous tissue beneath the mucous 
 membrane; (e) interspaces filled with nuclei; 
 (c) surface of mucous membrane composed of 
 dense fibre tissue.
 
 460 CANCEROUS DISEASE. 
 
 from the capillaries, and that after death the blood had become changed by 
 the action of the gastric juice. At the lesser curvature was another black 
 patch, but without the white substance on the surface ; there, too, tLe follicles 
 were beautifully distinct, some being marked out by being filled with changed 
 blood ; and that which had exuded from the superficial capillaries was black- 
 ened. The white substance consisted of cells and crystals. There was con- 
 traction of the mitral valve ; but the liver, kidneys, and other viscera and 
 
 glands were healthy. 
 
 
 
 In this case the obstruction was diagnosed to be at the sigmoid 
 flexure, but the general emaciation led to the belief that there was 
 more general infiltration of the glands. This was not the case, but the 
 distension had produced ulceration of the ileum ; nutrition was much 
 impaired, and the diseased condition of the mitral valve interfered 
 with the healthy action of the heart. The opium acted well, and its 
 use was followed by marked improvement, and by action from the 
 bowels ; the administration of purgatives increased the vomiting and 
 prostration. 
 
 CASE CLXI. Cancer of the Liver, of the Lumbar Glands, and of the 
 Sigmoid Flexure Robert W , aet. 32, was admitted September 19th, and 
 died October 16th. He was a patten maker, and had lived in the Borough. 
 Four months previously he had begun to feel pain ; there were symptoms of 
 indigestion, and afterwards severe pain in the right side. He became ema- 
 ciated, but the abdomen was enlarged ; the liver could be felt very distinctly 
 on the right side, and nearly reached to the crest of the ilium. The pain in 
 the right side and across the abdomen became more severe, and he gradually 
 sank. There was no indication of disease of the sigmoid flexure observed 
 during life. 
 
 Inspection was made twenty-seven hours after death The body was spare, 
 and slightly jaundiced. The chest was healthy, with the exception of the 
 base of the right lung, where was a large patch about three inches in diameter, 
 white in color, situated on the surface of the pleura, and about one-eighth of 
 an inch in thickness; this consisted of cancer, extending through the dia- 
 phragm from the liver; there were a few tubercles in the neighborhood; and 
 one of the glands of the neck was infiltrated with cancer. The lungs, 
 bronchial glands and heart were healthy. 
 
 Abdomen The peritoneum contained about three pints of serum and pus; 
 the liver was 9^ Ibs. in weight, and towards the diaphragm had the appearance 
 of a large abscess ; the surface was irregularly contracted from the develop- 
 ment of masses of cancer. On section, nearly the whole gland was found to 
 be involved, with scarcely any intervening gland structure ; and these can- 
 cerous masses presented nearly every stage of degeneration ; some had a soft, 
 yellow centre, others a dark green slough, and in some the centre was semi- 
 fluid. The lumbar glands were infiltrated; and at the termination of the 
 sigmoid flexure was a small fecal abscess; the walls of the intestine were 
 ulcerated, broken down, and infiltrated with cancer, and some of the contents 
 had become extravasated among the cancerous exudation. 
 
 Here there was no marked constipation ; the cancer was medullary 
 rather than scirrhous or epithelial ; there had been some pain in the 
 part, but no obstruction. The patient was evidently wasting from 
 organic disease ; the liver was known to be affected, and so slight 
 were the symptoms of disease at the sigmoid flexure, that they were
 
 CANCEROUS DISEASE. 461 
 
 scarcely noticed, although it is probable that the disease commenced 
 at that part. 
 
 CASE CLXII. Cancerous Ulceration of the Sigmoid Flexure of the Colon. 
 Constipation For the particulars of the following case I am indebted to my 
 friend Sir W. Gull. The preparation is in the Museum at Guy's (1854 35 ). 
 
 Mrs. H ,set. 60, in May, 1854, had an attack of diarrhoea, and a similar 
 attack had occurred some months previously; from that time she had been 
 troubled with flatulence and pain in the abdomen. The diarrhoea was re- 
 lieved, but the pain continued. On July the 22d she had constipation, which 
 was not removed by the use of castor oil, rhubarb, &c. There was no vomit- 
 ing, the pulse was quiet and the tongue clean. Vomiting came on, on the 
 24th. The examination of the rectum discovered a hard mass high up in the 
 recto-vaginal space. Opium and ice removed the symptoms. After five days 
 the bowels were relieved, and she then went on very well till September 20th, 
 when the bowels again became obstructed ; enemata were used, and opium 
 was administered; croton oil was rubbed into the abdomen. Purgatives were 
 occasionally given, but in vain; after five weeks of complete constipation, 
 symptoms of peritonitis came on, and she died. The operation of opening 
 the descending colon was proposed, but the patient would not consent. 
 
 In this case diarrhoea alternated with constipation, a condition 
 which is not unfrequent in disease of the sigmoid flexure. 
 
 CASE CLXIII. Cancer of the Sigmoid Flexure. Obstruction. Relieved. 
 Gradual Exhaustion Richard C , set. 32, was admitted under Sir W. 
 Gull's care, July 2d, 1854, and died September 3d. He had been troubled 
 with symptoms of obstruction for five months, his abdomen often becoming 
 distended, and again diminishing after escape of flatus. Various remedies 
 were given, and with considerable success (quinine and opium). The bowels 
 became freely acted upon, but the patient became gradually wasted, and at 
 last sank. 
 
 Inspection, twenty hours after death. The heart and lungs were healthy. 
 The abdomen was enormously distended on account of the size of the large 
 intestine; the omentum was drawn upwards. The small intestine was much 
 enlarged ; but the caecum and colon were enormously so. Just within the 
 hollow of the sacrum was the constriction, which could be felt as a hard 
 lump about the size of a hen's egg. The disease occupied four inches of the 
 canal, and consisted of epithelial cancer. The walls were much thickened, 
 and in the cellular tissue around was hard tissue of a scirrhous character. 
 The interior of the gut was ulcerated, and upon it were a few vascular 
 fringes. The mesentery contained a few hardened glands. The walls of the in- 
 testine were considerably hypertrophied. The remaining viscera were healthy. 
 
 This case was an exceedingly interesting one, showing the benefi- 
 cial and marked effect produced by judicious treatment. On admis- 
 sion there appeared but little probability that the obstruction would 
 be overcome; the opium which was administered with quinine, so 
 far allayed the intestinal action and spasmodic contraction, that feces 
 slowly passed the stricture, and for a time there appeared probability 
 of recovery. 
 
 CASE CLXIV. Colloid Cancer of the Sigmoid Flexure. Artificial Anus 
 in the Groin. Pleuro-pneumonia Thomas C , ast. 56, had had severe 
 pain in the course of the ureter, and it was supposed that he had renal calcu-
 
 462 
 
 CANCEROUS DISEASE. 
 
 lus. On admission it WHS evident that there was an abscess forming in the 
 iliae region ; this reached slowly below Poupart's ligament, and was allowed 
 to open itself. The patient became more and more prostrate, and a few 
 days before death troublesome diarrhoea came on. 
 
 The inspection was made seven hours after death. The body was rigid 
 and much emaciated; on the left side, below Pou part's ligament, and at the 
 crest of the ilium, were two openings about a quarter of an inch in diameter, 
 the surrounding skin being thin and red; a probe passed for several inches 
 along the course of the crest of the ilium, and a discharge of feculent pus 
 proceeded from the wound. There was pneumonia at the base of the left 
 lung. The heart only weighed seven ounces, the valves were atheromatous, 
 and the muscle fatty. 
 
 Abdomen The parietes were rigid; the intestines were collapsed; two 
 bands of omentum were adherent at the sigmoid flexure. The stomach was 
 low down, and much distended; its mucous membrane was mammillated ; 
 the secreting cells were granular; the pylorus was healthy. The mucous 
 
 Colloid cancer of the sigmoid flexure X 4 diam. ; (a 6) columnar epithelium; (c) nuclei with 
 granular blastema ; (d) large cells, with large nuclei, and some with several nuclei in them; (e) 
 intervening delicate tissue ; (/) elongated fibre cells. 
 
 membrane of the cascum and colon were of a gray color. The colon was 
 contracted ; at the commencement of the sigmoid flexure was a hard mass 
 resembling scybala; on opening this the calibre of the intestine was almost 
 obliterated by an irregular growth from the mucous membrane, which in-
 
 CANCEROUS DISEASE. 463 
 
 volved the whole circumference of the gut, and would only admit the little 
 finger at the upper margin ; it was rounded, foliated, and extended in one 
 part an inch up the descending colon ; the lower margin was of the same 
 kind, but more intensely congested. The In-eadth of this diseased portion 
 was from one to three inches; the intermediate part was ulcerated, and a 
 communication passed at the posterior part into an irregular sinus, behind 
 the fascia covering the quadratus lumborum ; this sinus was filled with fecu- 
 lent pus, and burrowed downwards along the crest of the ilium to the open- 
 ings in the skin. On making a section of the growth, it was found to be soft, 
 of a yellowish-white color, and had a striated appearance, and fluid could be 
 compressed from it; several parts presented transparent gelatinous masses of 
 colloid cancer. The whole of the mucous and muscular coats were involved 
 and destroyed ; and the muscular tissue of the quadratus lumborum was filled 
 with round isolated masses of colloid growth, separated by bands of muscular 
 fibre. The surface of the growth presented columnar epithelium, some cells 
 of normal size, others much enlarged ( b) and containing single or double 
 nuclei; some of these cells were oblong; the principal portion, however, of 
 the growth was composed of large nuclei, about 1000th to 1500th of an inch 
 in diameter, with distinct nucleoli, and closely packed together with very little 
 intervening blastema (c) ; there were some large cells containing several 
 nuclei (d). On the field were numerous masses resembling inflammatory 
 granule cells (e). The intervening tissue consisted of delicate fibres, arranged 
 so as to form cells (e) ; and in some parts presenting elongated cells (f). 
 There was no doubt as to its cancerous character; and there were a few 
 small infiltrated glands in the neighborhood of the cancerous growth. On 
 the surface of the liver, both on the right and left lobes, the peritoneum was 
 thickened from attrition ; the liver was fatty and coarse. The spleen Avas 
 soft, its corpuscles were visible. The kidneys were atrophied, and contained 
 a few cysts ; they were 8^ oz. in weight. 
 
 In this case, the examination of the feces or the discharge might 
 have detected cancer, but no tumor could be felt; there was no marked 
 constipation, but pain in the course of the ureter was the principal 
 symptom. 
 
 CASE CLXV. Cancerous Disease of the Sigmoid Flexure. Diarrhoea. 
 
 Perforation. Fecal Abscess Elizabeth S , aet. 55, was admitted into 
 
 Guy's Hospital, March 29th, 1854. She was a married woman, but had had 
 no children. She was much emaciated, and for three years had ceased to 
 menstruate. On admission she had a hot and dry skin ; the abdomen was 
 tender ; the pulse was sharp and frequent. She had had pain in the hypo- 
 gastric region, with vomiting and purging, and the stools had contained 
 blood. The diarrhoea became more severe, and there was increased tender- 
 ness and pain at the lower part of the abdomen ; the evacuations contained 
 inflammatory product. She died on May 16th, severe purging having con- 
 tinued. 
 
 On inspection the lungs and heart were found healthy. A cancerous 
 growth was situated above the sigmoid flexure ; and there was ulceration of 
 the new growth. The calibre of the intestine was contracted, and there was 
 thickening of the mucous and muscular coats of the descending colon. The 
 omentum was adherent to the large intestine at that part, where a large fecal 
 abscess had formed, from the giving way of the descending colon above the 
 seat of stricture. The liver was small and fatty. The kidneys were small 
 and atrophied.
 
 464 CANCEROUS DISEASE. 
 
 This case is one of much interest, as showing an occasional mode 
 of fatal termination of cancerous disease of the intestine; and that 
 after ulceration has taken place at the seat of stricture diarrhoea may 
 come on. Here, however, the intestine had also given way, and had 
 led to peritonitis, and the formation of fecal abscess. 
 
 CASE CLXVI. Cancerous Disease of the Rectum. Old Hernia In the 
 ' Guy's Reports' for 1850, Mr. Birkett has recorded a case of insuperable 
 constipation arising from stricture at the upper third of the rectum, and asso- 
 ciated with scrotal hernia. The patient was forty-nine years of age, and for 
 fourteen years he had had hernia. The bowels had been rather constipated. 
 On June 13th he could not reduce the hernia, and applied at one of the 
 London hospitals. On the 18th he was admitted into Guy's. There were 
 slight symptoms of strangulation, but the hernia was reduced, and he felt 
 greatly relieved. On the 21st he came to the hospital, suffering very severe 
 pain in the abdomen, with tympanitis; the voice was weak, and the counte- 
 nance was expressive of great anxiety ; the pulse was small and frequent, and 
 the extremities cold. There was a swelling in the left side of the scrotum, 
 and although the patient did not complain of pain, there was much dragging, 
 with sense of tightness across the abdomen ; it was decided to make an ex- 
 ploratory operation. No intestine was found in the sac, and the internal 
 ring was perfectly free. He died on the 26th, nine days after the last alvine 
 evacuation. On inspection, there was a general peritonitis, and at the com- 
 mencement of the rectum there was a vascular growth from the mucous mem- 
 brane, with thickening of the submucous tissues, which had led to complete 
 occlusion of the canal. The hernial sac was perfectly free. 
 
 Great obscurity existed in this case; examination per rectum could 
 not have reached the stricture, and the whole attention of the patient 
 was to the hernia. The symptoms, however, were more gradual in 
 the onset than ordinary strangulated hernia. 
 
 CASE CLXVII. Cancerous Disease of the Transverse Colon. Fecal Ab- 
 scess. Mary N , aet. 40, living at Whitechapel, was admitted September 
 19th, 1856. Two years previously she had been pushed by her husband 
 from the top of the stairs, and violently struck her abdomen across the ban- 
 ister. She felt great pain in her loins when she recovered herself, and was 
 unable to assume the erect posture, but felt more easy in the semi-upright 
 position. The abdomen became distended, and a large hard swelling was felt 
 in the left hypochondriac and iliac regions. This tumor gave her great pain 
 on stooping, and she was unable to bear any pressure upon it. She had 
 vomiting and diarrhoea. The tumor continued in the same state for about a 
 year ; but at that time it became enlarged, and there was great pain across 
 the loins ; she frequently vomited and had diarrhoea. The urine occasionally 
 became scanty, and she had headache, vertigo, and loss of appetite. She was 
 a woman of dark complexion, and was much emaciated, cachectic, and 
 slightly jaundiced ; a tumor was felt in the left iliac and hypochondriac re- 
 gions ; it was tender on pressure, and appeared to be felt in the loins ; 
 the bowels were relaxed, the urine dark colored, but it did not contain any 
 pus. The diarrhoea continued with occasional vomiting till death, on the 
 18th October. 
 
 Inspection was made on the 20th. The body was slightly jaundiced. The 
 thoracic viscera were healthy, but colored with bile. 
 
 On opening the abdomen, the peritoneum was healthy, except towards the
 
 CANCEROUS DISEASE. 465 
 
 left side, where the tumor was observed, which had been felt during life in 
 front of the kidney. There were adhesions firmly uniting several coils of 
 intestine together. On separating them, which could be done without 
 tearing the intestine, a feculent cavity was found, bounded above by the 
 transverse colon, where it joins the descending colon, and by the greater 
 curvature of the stomach ; behind, by the pancreas ; below, by several coils 
 of jejunum. 
 
 The transverse colon presented an irregular opening about three inches in 
 circumference, the edges of the opening were thickened, stained by adherent 
 feces, infiltrated with cancerous product, and in some parts were half an inch 
 in thickness. The pancreas at its lesser extremity, and some of the adjoin- 
 ing glands, were infiltrated with cancer ; the stomach, though adherent, was 
 not affected. At the lower part of the abscess two coils of the jejunum were 
 firmly adherent, and were perforated ; one, by a transverse opening extend- 
 ing about half across the intestine, the edges of which were everted and much 
 ejected ; the other, by a smaller opening. The mucous membrane of the 
 jejunum generally was injected, and covered with mucus. The stomach and 
 remaining parts of the intestine were healthy, so also were the liver and kid- 
 neys. The uterus, ovaries, and glands were healthy. 
 
 The disease was here of a strictly local character. The examina- 
 tion of the growth showed that it consisted of nuclei resembling those 
 found in cancerous disease, and the general appearance was very 
 strikingly that of cancer ; still no other part was affected. The blow 
 which she had received at this part set up inflammatory disease, and 
 it is probable that a cancerous action subsequently ensued; ulcera- 
 tion then took place, and a fecal abscess formed. 
 
 The diagnosis was difficult ; the position of the tumor was that 
 usually found in disease of the glands about the kidney, but no ab- 
 normal condition of the urine existed. The vomiting was less per- 
 sistent, and the diarrhoea more severe than is usually observed in 
 cancerous disease of the stomach ; but although the colon was thus 
 extensively diseased, constipation did not occur. 
 
 CASE CLXVIII. Carcinoma of the Rectum, of the Ovaries, and of the 
 Peritoneum. Acute Peritonitis. Scirrhus Ann S , aet. 26, admitted 
 March 26th, was a married woman, living at Dockhead, and her youngest 
 child was two and a half years old. For one year she had had difficulty in 
 the passage of the alvine discharges. She was exceedingly ill on admission, 
 and no connected history could be obtained ; the lowest part of the rectum 
 was sacculated, and about two inches upwards a stricture was found, through 
 which a catheter could be passed. She suffered considerable pain, but no 
 vomiting; she gradually sank, and died April 13th. 
 
 Inspection seventeen hours after death. The body was very much emaci- 
 ated. At the apices of the lungs there was slight pneumonic consolidation, 
 with a little chalky deposit. The heart was small, and without fat. 
 
 Abdomen. The intestines were distended. The peritoneum was intensely 
 injected, and the coils of the small intestine were matted together. The 
 mesentery was shortened. The great omentum was contracted into a firm 
 mass, and was nodulated ; nearly the whole of the peritoneum was minutely 
 studded with small white tubercles ; these were very numerous upon the 
 peritoneal surface of the stomach. The sigmoid flexure and the upper part 
 of the rectum were very much distended. 
 30
 
 466 CANCEROUS DISEASE. 
 
 On taking out the large intestine, a growth was found about three inches 
 from the anus, having a semi-cartilaginous hardness. On its inferior surface 
 the infiltrated mucous membrane had a double lip-like appearance, and was 
 considerably raised. In the centre of the growth, all the coats of the intes- 
 tine were destroyed, and were infiltrated with heterologous deposit. The 
 mucous membrane had a yellowish-white appearance on section ; beneath it 
 was a firm, white fibrous product, mixed with iron-gray pigment ; still lower, 
 fat with firm tissue. The whole of the external cellular membrane was semi- 
 cartilaginous. On microscopical examination, the mucous membrane was 
 found to consist of a delicate cellular tissue of nucleated fibres, interlacing 
 and leaving spaces filled by elongated and reniform nuclei ; a few cells were 
 observed, but their cell walls were very imperfect ; the submucous tissue was 
 very beautifully composed of a series of bands of fibre tissue, with intervening 
 columns of nuclei; at the upper part these bands of fibres formed series of 
 arches. The muscular coat of the intestine above the stricture was much 
 hypertrophied. In the sigmoid flexure above the stricture were one or two 
 superficial ulcers or abrasions. The descending colon was filled with solid 
 bilious feces, but was otherwise healthy. The csecum and small intestine 
 were also healthy as to their mucous membrane. The whole of the cellular 
 tissue about the ovaries was thickened, white, and infiltrated ; both ovaries 
 also were infiltrated with cancer, and one mass was of a yellowish color, as if 
 degenerating. The uterus, vagina, and bladder, were healthy. The liver 
 was fatty. The stomach and spleen were healthy. There was no infiltration 
 of the lumbar nor of the mesenteric glands. The kidneys and supra-renal 
 capsules were healthy. 
 
 The disease in this case began apparently in the rectum, and ex- 
 tended from it, by continuity of structure. It was of a scirrbous 
 character rather than epithelial, and although the obstruction was so 
 great as only to allow a goose-quill to pass, no vomiting was pro- 
 duced by the constipation; the reverse would have been the case if 
 violent drastics had been administered. The character of the pain 
 in this instance was more severe than we find in disease of the sig- 
 moid flexure ; there was direct pressure on the nerves of sensation, 
 and the disease extended to the adjoining structures. The growth 
 could be felt on rectal examination, so that there was no difficulty in 
 the diagnosis. 
 
 CASE CLXIX. Epithelioma of Rectum. Contraction and Obstruction. 
 Artificial Anus in the Loins. Diseased Appendix Cceci. Fecal Abscess. 
 Mary P , get. 48, was admitted into Guy's Hospital, October 7th, 1859. 
 She had suffered from constipation for three weeks, accompanied with vomit- 
 ing, and great abdominal distension. She was a thin person, having an 
 aged, haggard expression ; and when brought to Guy's she was in such a 
 condition that life was despaired of for many hours. The abdomen was much 
 distended, but free from pain, and there were resonance and distension in the 
 loins. On October 8th, Mr. Bryant made an incision into the left loin, and 
 opened the descending colon ; thin feces were abundantly discharged ; the 
 operation was performed without unusual difficulty, but the patient gradually 
 sank, and died on October 19th, at midnight. 
 
 The inspection was made fifteen hours after death. The body was very 
 thin, and the abdomen collapsed ; the peritoneum in some parts had lost its 
 shining surface, but there was no evidence of general peritonitis. The peri- 
 toneum covering the iliac fascia on the left side was thin and green, and
 
 CANCEROUS DISEASE. 467 
 
 nearly perforated. The rectum passed directly up to the caecum, then turned 
 to the left along the brim of the pelvis ; at the angle was a small fecal abscess, 
 bounded by the rectum, caecum, and by a portion of small intestine ; it con- 
 tained the appendix, which was obliquely truncated near the ceecum by ulcer- 
 ation; there was a contracted portion of rectum about the centre of the 
 concavity of the sacrum, having the appearance externally as if girt with a 
 portion of string. On opening the bowel it was found to be nearly occluded; 
 it was ulcerated on its inferior aspect; and above, it had a raised, slightly 
 vascular fringe; there was no enlargement of glands. The opening into the 
 descending colon was well situated ; it was about one inch in length ; the 
 mucous membrane had united to the muscle immediately beneath ; but 
 beyond that, near the skin, the tissues were in a state of slough, and feces 
 had burrowed down under the fascia, so as to occupy the whole of the iliac 
 fossa; this fecal abscess nearly perforated the peritoneum, and extended into 
 the labinm on the left side, where was a small opening. The bladder was 
 distended. The liver was pressed down ; a white thickened patch existed on 
 its surface. 
 
 This patient was too prostrate to allow of reparative changes 
 after the operation had been performed, so that fecal extravasation 
 took place in the loin; the disease in the rectum was of a local kind, 
 and the operation was skilfully performed; still, not only was sur- 
 gical help deferred too long, for when first admitted she was almost 
 dying, but the fecal abscess arising from a perforated appendix caeci, 
 would in itself have led to a fatal termination. 
 
 CASE CLXX. Cancer of the Jejunum, and of the Mesenteric Glands. 
 Softening of the Spinal Cord. Paraplegia Samuel S , aet. 15, was ad- 
 mitted into Guy's Hospital under Dr. Rees's care, December 17th, and died 
 on the 31st. After a fatiguing march, in a rifle corps, five weeks previous 
 to the commencement of his illness, he began to suffer from "pins and 
 needles" in his legs, followed by weakness and complete paraplegia. The 
 respiratory muscles became involved before death. A tumor was felt in the 
 lower part of the abdomen, near the anterior and superior spinous process of 
 the ilium on the right side; but neither history of abdominal pain nor any 
 distressing abdominal symptom was made out during life. The bowels acted 
 without purgative medicine; the motions, however, were discharged involun- 
 tarily. 
 
 On inspection, the spinal membranes were found to be clear, but rather 
 more adherent than usual ; the vessels also appeared very full of blood ; and 
 at the upper part of the dorsal region the cord had a diffused ecchymosed 
 appearance, several points of extravasated blood were also found. In the 
 lumbar and lo\ver part of the dorsal region the cord was hard, but at the 
 upper part it became soft, and in some parts semi-diffluent; one or two spots 
 were more prominent than others in this softened portion. 
 
 Abdomen The peritoneum was healthy ; the omentum was spread down 
 
 to the pelvis, and was adherent near the right iliac region to a hard mass, 
 about three inches in circumference, consisting of an erLirged and infiltrated 
 mesenteric gland ; a distended coil of jejunum was adherent at the part to 
 the omentum. The caecum was free and empty, and was situated behind 
 and a little to the right of the growth just mentioned. On removing the 
 intestine and opening the distended portion opposite to its mesenteric attach- 
 ment, it was found to consist of about six inches of jejunum dilated into a 
 large sac ; at the entrance into this sac the mucous membrane was infiltrated 
 with cancerous product, so that the valvulae conniventes were hard and
 
 468 CANCEROUS DISEASE. 
 
 prominent ; a similar state also existed at the outlet of this sac ; in some 
 portions of this distended bowel the coats were very much thinned, as if 
 about to perforate into the peritoneum. The mucous membrane of the jeju- 
 num, however, was entire. A mesenteric gland in the centre of this coil of 
 jejunum was infiltrated with medullary cancer; it was very soft and pale in 
 color; other glands were infiltrated in a less degree; and one or two near 
 the pancreas were also enlarged. The growth in the jejunum consisted of 
 yellow cancerous matter infiltrating the coats of the intestine. In another 
 portion of the jejunum there was a white, hard mass, opposite to the mesen- 
 teric attachment, about one inch in length, and one-eighth of an inch in 
 thickness, consisting of cancerous infiltration into the submucous cellular 
 tissue, but the mucous membrane was entire. The colon, stomach, duodenum, 
 and pylorus were healthy. The liver and spleen were fissured, but free from 
 disease; there were several cancerous masses in the kidney, and the epididy- 
 mis was enlarged. The lumbar tubercles in glands were normal. The left 
 lung was solidified at its base. 
 
 The spinal mischief led to a fatal termination, but the case is 
 remarkable not only in the form and situation of the cancerous 
 disease, but in the comparative absence of symptoms of abdominal 
 mischief. No obstruction took place in the intestinal tract, and the 
 peritoneum was not involved. If, however, life had been prolonged 
 for a short time, the more extensive affection of the mesenteric 
 glands and the implication of the peritoneum would soon have led 
 to well-marked indications of abdominal disease. 
 
 CASE CLXXI. Cancerous Ulcer of the Colon opening into the Duode- 
 num. Diarrhoea. Vomiting Ann S , aet. 47, a greengrocer, who had 
 worked hard, and drank freely ; her father died from phthisis, but with the 
 exception of an attack of acute rheumatism, and of erysipelas ten years be- 
 fore her last illness, she had enjoyed good health. Five and a half years 
 before admission she had free access to a fruit garden, and partook of fruit 
 to excess ; severe diarrhoea and depression followed. Eighteen months after- 
 wards the skin became slightly jaundiced, and her medical attendant found a 
 tumor about the size of a hen's egg immediately above the superior spinous 
 process of the left ilium. She had also suffered from haemorrhoids, and 
 from tapeworm. When she applied for admission at Guy's Hospital, Novem- 
 ber 15th, 1859, she was pale and had a careworn appearance; there was 
 brown discoloration of the abdomen, neck, thighs, and elbows, the gums 
 were pale, and the tongue was clean. The resonance of the chest was good, 
 and the respiration was healthy. The pulse was 90, and compressible. The 
 abdomen was supple and resonant, excepting in the region of the caecum, 
 where a rounded, uneven and hard tumor could be felt, about the size of a 
 turkey's egg. There was slight dulness at that part, but no pain except 
 when pressure was made, or when a deep inspiration was taken, or after 
 swallowing fluids ; pain extended also in the course of the ilio-hypogastric 
 nerve, reaching as far as the trochanter, and also back to the spine ; on pres- 
 sure, also, the pain was produced in the inguinal region of the opposite side. 
 The bowels were relaxed, and mucus was passed in the motions ; the urine 
 was of light color, of sp. gr. 1015, and free from albumen and sugar. There 
 was good appetite ; nausea was present, but no vomiting. Eight leeches 
 were applied, and a poultice ; the spermaceti mixture given, and Dover's 
 powder with gray powder every night. The pain was relieved by the leeches, 
 but on the 24th it again became very severe, and the bowels were relaxed.
 
 CANCEROUS DISEASE. 469 
 
 The leeches were repeated, and calomel and opium, of each gr. j, given every 
 night. 25th The pain was less, but there was tenesmus and diarrhoea ; an 
 enema of starch with tincture of opium was administered. On the 30th, 
 leeches were repeated to relieve the pain, and opium was given. 
 
 On December 4th, there was diarrhoea, and the swelling had increased, 
 extending upwards ; vomiting came on. Logwood mixture (G. P.) was 
 given. On the 7th, sickness was relieved by brandy and soda-water. The 
 symptoms partially subsided, and she left the hospital on January 31st. 
 
 She was readmitted on March loth, 1860. Fifteen days before, at 3 P. 
 M., she had an inclination to go to stool, but before she could reach the closet 
 she felt something give way in the abdomen, and a profuse discharge of very 
 fetid pus took place from the bowels. The tumor diminished in size ; the 
 bowels continued relaxed, and for one week there was blood in the evacua- 
 tions ; she seemed low and weak ; there was no appetite, but considerable 
 thirst ; there was pain in the tumor before and after the discharge, emacia- 
 tion was manifest, the mouth became sore and aphthous, and the urine con- 
 tained lithic acid. When admitted, she was emaciated, and her countenance 
 was anxious and distressed ; there was a deep flush on the cheeks ; the eyes 
 were sunken and hollow, the tongue was morbidly red, glazed and cracked, 
 and there was aphthous ulceration at the tip ; the skin was hot and dry. 
 The abdomen was soft. There was undue prominence over the right ilium ; 
 and pain with tenderness was present at the epigastrium, as well as in the 
 right hypochondriac and iliac regions ; the tumor which had been felt so long 
 was resonant on percussion. The hepatic dulness extended two inches below 
 the sternum ; the appetite was bad, and she complained of thirst and nausea ; 
 the bowels were moved ten to twelve times, and the motions consisted of very 
 fetid brown fluid, containing scarcely any solid matter, and no blood. The 
 urine was scanty. The compound decoction of krameria was given every 
 six hours, with brandy, milk, arrowroot, &c. 
 
 March 25th For two days obstinate vomiting tried the patient ; it in- 
 creased in severity, and came on after any exertion, and after taking food ; 
 rapid prostration followed, and death. 
 
 On inspection, the thoracic viscera were found to be healthy. In the ab- 
 domen, the ascending colon was firmly fixed in the right loin, and it was 
 adherent to the surface of the liver ; but the liver and kidneys could be re- 
 moved without interfering with the diseased part. On opening the colon 
 there was found in the ascending part, just above the caecum, a large carcino- 
 matous ulcer, as large as the palm of the hand ; it was circumscribed and 
 surrounded by raised edges of morbid structure. In some parts of the dis- 
 eased tissue the edges were undermined, so that bridles of tissue passed 
 across. At the bottom of the ulcer was a large hole, through which the 
 middle finger could easily be passed, and entered at once into the duodenum. 
 On opening the duodenum the perforation was seen within it ; the hole was 
 as large as that in the colon, but its edges were merely fringed by the new 
 growth. The duodenal opening was near the pylorus, and opposite to the 
 common bile duct, so that the bile might have at once passed into the colon. 
 The contents of the intestine, both small and large, were of a pale slate 
 color, showing the absence of bile. The liver was very fatty, and it was 
 lighter than water. The kidneys were healthy. The omentum was adherent 
 to the right ovary, and the Fallopian tube was adherent to the ovary. 
 
 In this case there was evidence of chronic disease of the caecum 
 or of the colon, as shown by the gradually increasing tumor; the 
 pain increasing at once on drinking fluids was very manifest. The
 
 470 CANCEROUS DISEASE. 
 
 enteric irritation was propagated to other parts of the intestine, and 
 diarrhoea was produced; this in connection with pain was, for a long 
 time, a very troublesome symptom. About a month before her 
 death, at the time that something was felt to have given way in the 
 abdomen, the opening into the duodenum was probably suddenly 
 made, and from that time vomiting was a more constant symptom; 
 there was no evidence, however, by stercoraceous vomiting, that 
 fecal matter passed from the colon into the duodenum. As to the 
 cause of the disease of the colon, it is possible that the primary 
 irritation of the intestine after partaking of a large quantity of fruit, 
 might have determined the seat of the disease; this, however, is 
 very doubtful. From the first, the treatment was in a great meas- 
 ure palliative rather than strictly remedial; but much may be done 
 in these cases to diminish the sufferings of the patient and to prevent 
 the rapid extension of the disease. 
 
 CASE CLXXII. Ulceration of the Colon. Intestinal Obstruction from 
 Contraction of the Transverse Colon. Cancer ? Dysentery. Constipation. 
 Diarrhoea. (For the following case I am indebted to my friend Dr. Wilks). 
 David B , set. 72, was a rather spare man, of middle stature, and with 
 a yellowish complexion, but he had never been abroad ; his habits had been 
 rather intemperate He stated that his general health had been tolerably 
 good, until within the last few years, during which he had suffered at fre- 
 quent intervals from diarrhoea, with colic in the abdomen, and often from 
 painful defecation. His bowels were at times so irritable that, after .swallow- 
 ing only a cup of tea they acted immediately and almost before he could reach 
 the closet-; these symptoms became increasingly severe. Nine years pre- 
 viously, also, he had received a blow in the left groin, which produced u 
 femoral hernia ; it was reducible, and, with a truss, did not give him much 
 inconvenience. 
 
 On August llth, 1855, he complained of diarrhoea, stating that his bowels 
 were relaxed several times during the day, and that he suffered at times from 
 severe pain in the abdomen ; the pulse was full, 75 ; the tongue was clean ; 
 the appetite was good ; and, excepting the symptoms just mentioned, he 
 seemed to be in good health. He was ordered chalk mixture with aromatic 
 confectian three times a day. 
 
 On the 14th, the bowels were less relaxed, but the pain in the abdomen 
 was augmented ; and sulphuric ether, with tincture of opium, was given in 
 pimento water every four hours. 
 
 On the 16th, the abdominal pain had greatly increased, it was nearly con- 
 stant, but at intervals became more severe ; there was no tenderness on pres- 
 sure at any particular part, but the greatest amount of pain was felt about 
 the umbilical region ; the bowels had not been open for two days. The con- 
 stipation was relieved by purgatives, but there was return of severe colic, and 
 vomiting and tympanitis came on. He gradually became prostrate, and diar- 
 rhoea supervened before death on the 29th. 
 
 Inspection. August 30th The body was spare, but not much wasted. 
 The abdomen only was examined. There was no recent acute peritonitis. 
 The intestines were distended, injected and covered with a slight exudation 
 of lymph. The seat of stricture was at once seen to be the middle portion 
 of the transverse colon, exactly in the median line of the body; the omen- 
 turn was found abnormally adherent to this portion of the intestine, and a 
 dark-colored, hard-looking substance was recognized ; this formed the con-
 
 CANCEROUS DISEASE. 471 
 
 stricted portion of the intestine, and both above and below it there was con- 
 siderable dilatation. On removing this portion of the intestine, the disease 
 was felt as a hard tumor situate in the substance of the organ, and producing 
 the constriction. Although the exterior continuity of the bowel exhibited a 
 considerable falling in at this part, its lessened calibre was not so manifest 
 from the exterior as from the interior. When the intestine was opened, its 
 channel was found to be so reduced in size that it would only admit a goose quill. 
 On laying the whole of it open, the diminished passage was found to be owing, 
 not only to the external peritoneal puckering, but to the hypertrophy of the 
 subserous cellular tissue, and of the muscular coat, and to a raised spongy 
 condition of the mucous membrane. When spread out, the diseased surface 
 occupied a space not much larger than that of a five-shilling piece. The 
 mucous membrane was red, highly vascular, and completely separated from 
 the healthy surrounding structures, not only by its color, but by its highly 
 raised margin, which was considerably above the level of the adjacent mucous 
 membrane. It had a soft, spongy appearance, and the muscular coat beneath 
 was much hypertrophied. The microscope showed the surface of the struc- 
 ture to be composed of highly vascular branching villi. The surface was 
 covered over with an abundance of columnar epithelium. More deeply seated 
 was found a delicate fibre tissue, with a number of small nucleated cells, of a 
 shape resembling ordinary or abortive epithelium. The caecum and ascend- 
 ing colon, as well as the lower part of the descending colon and the rectum, 
 contained numerous ulcers in various stages of healing ; most of them were 
 quite healed, and presented only cicatrices. There were large irregular shaped 
 portions of mucous membrane, of a dark blue or slate color, which seemed to 
 have been ulcerated, and caused a considerable puckering of the surface. 
 In the caecum and rectum the general calibre of the intestine was much 
 altered in shape by the contraction, and also by the hypertrophy of the mus- 
 cular coat, which was very considerable in the caecum. The liver contained 
 no cancerous disease, nor did any of the abdominal glands. 
 
 Simple acute disease of a dysenteric character took place in this 
 patient, ulceration followed, and, at the seat of one of these ulcers, 
 a villous growth was developed, which led subsequently to con- 
 striction ; the coats of the intestine at that part were hypertrophied, 
 showing that the obstruction had existed for some time. As to the 
 nature of the growth, although no strictly cancerous product was 
 found, and although no glandular disease was present, its villous 
 character and cellular substratum showed that it belonged to the 
 class of growths designated as cancerous. The first symptoms were 
 those of dysentery, as shown by the diarrhcea and the discharge of 
 mucus; but as the disease extended to the deeper structures, and 
 spasmodic contraction took place at the seat of the villous growth, 
 the obstruction became complete, till vomiting even of a stercora- 
 ceous kind was set up; and it was only as the strength of the patient 
 failed that the constriction yielded and the bowels acted; diarrhcea 
 then came on, and continued till death. In the treatment of the 
 patient, the increase of the symptoms after purgative medicines, and 
 their relief after the administration of opium, were well marked. 
 
 These instances show, that with care the several forms of internal 
 strangulation may be generally distinguished, when we have the 
 whole of the symptoms before us ; that whilst over-active and inju-
 
 472 CANCEROUS DISEASE. 
 
 dicious treatment increases discomfort and hastens a fatal termina- 
 tion, much may be done for the relief of the patient, and valuable 
 lives may thereby be prolonged. These are not the cases for do- 
 nothing practice ; the proper use of enemata, of such diet only as can 
 be borne without injury, opium, rest, and other means to which we 
 have referred, will mitigate suffering even where cure is impossible.
 
 473 
 
 CHAPTER XVII. 
 
 SUPPURATION IN THE ABDOMINAL PARIETES. PERFORATION OF THE IN- 
 TESTINE FROM WITHOUT. ABSCESS IN THE ABDOMINAL PARIETES EX- 
 TENDING INTO THE INTESTINE. FECAL ABSCESS. 
 
 PERFORATION of the coats of the small intestine ranks in the order 
 of frequency next to perforation of the stomach ; the colon is, how- 
 ever, perforated more frequently than is generally supposed. These 
 perforations of the intestinal tract divide themselves into two great 
 classes : 1st. Those which arise from disease commencing in the in- 
 testine itself, and to which we have referred in numerous instances, 
 as perforation of the ileum in typhoid fever and in phthisis; of the 
 caecum and its appendix ; of the colon in dysentery, in cancerous dis- 
 ease, and in several forms of insuperable constipation. 2d. Those 
 in which the perforation is from without, or from the extension of 
 disease from adjoining structures. These latter cases constitute an 
 important and an exceedingly interesting class of diseases ; and the 
 following causes of external- perforation may be enumerated: 
 
 1. From the peritoneum, as in strumous peritonitis and localized 
 peritoneal abscess. 
 
 2. From disease of the stomach, as ulceration and cancer, extend- 
 ing into the transverse colon. 
 
 3. From hydatids and abscess of the liver, thus forming a means 
 of escape into the small or large intestine. 
 
 4. From calculi in the gall-bladder, setting up ulceration of the 
 duodenum or of the colon. 
 
 5. From abscess in the spleen. 
 
 6. From abscess in the kidney. 
 
 7. From abscess in the abdominal parietes and loins opening into 
 the intestine. 
 
 8. From diseased ovary communicating with the caecum, colon, or 
 rectum. 
 
 9. From cancer of any of the abdominal organs extending into the 
 intestine. 
 
 10. From extra-uterine foetation. 
 
 11. From one portion of intestine opening into another, as the ap- 
 pendix into the rectum. 
 
 12. From blows, and external injury. 
 
 In many of these forms of disease last enumerated, various and 
 characteristic symptoms precede the perforation of the peritoneum 
 and of the intestine ; thus, the signs of cancerous disease of the sto- 
 mach arise some time before fecal eructation or vomiting indicate 
 extension into the colon. In hydatid disease of the liver a rounded 
 tumor, of slow formation, is detected, having often a peculiar vibra-
 
 474 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 tory thrill, and without general disturbance, before the occurrence 
 of local peritonitis takes place, and the hydatids are discharged either 
 by the mouth or with the evacuations per rectum. 
 
 In gall-stone very severe pain arises in the region of the gall-blad- 
 der with vomiting and often with jaundice, before ulceration takes 
 place, and perforation be made into the duodenum or into the colon. 
 Peritoneal adhesions generally prevent severe inflammation of the 
 serous membrane. 
 
 In abscess of the spleen the symptoms are more obscure, and con- 
 stitute part of a general constitutional disturbance, till perhaps the 
 discharge of pus by stool indicates that a communication has been 
 formed with the transverse or descending colon. 
 
 In abscess of the kidney, and pyelitis, there is purulent urine; 
 but when there is suppuration external to the tunic of the gland the 
 symptoms are more obscure. 
 
 In ovarian and cancerous tumors tactile examination will detect 
 them. Some of these forms of disease are more obscure than others, 
 but when fecal abscess is the result there is considerable uniformity 
 in their character ; severe local pain arid tenderness come on, with 
 hectic fever, and steadily increasing prostration; and when the ab- 
 scess is not limited by adhesion, a rapidly fatal result occurs. 
 
 Suppuration in the parietes of the abdomen is frequently observed, 
 and simulates deeply-seated mischief; and for a short time consider- 
 able obscurity may attend it. (the symptoms are generally of an 
 acute character; considerable pain and febrile excitement precede 
 inflammatory oedema of the skin, and while the effused products are 
 bound down by firm fascial investments the symptoms closely re- 
 semble caecal disease, and local peritonitis ; in fact every part of the 
 abdominal parietes presents us with disease on the surface, resem- 
 bling deeper injury, and the structures beneath sympathize with the 
 external disease. Thus jaundice may come on with abscess in the 
 right hypochondrium, constipation and distended bowel may be found 
 in cases of inflammation behind the ascending or descending colon. 
 Movement of the bowel induces pain and delay in the passage of the 
 contents. In the hypochondriac regions suppuration connected with 
 the costal cartilages and ribs simulates abscess of the liver, empyema, 
 hydatids, diseased gall-bladder, or corresponding disease of the spleen; 
 in the right and left iliac regions abscess in the parietes may be mis- 
 taken for affections of the caecum and sigmoid flexure of the colon ; 
 in the lumbar regions, for renal and spinal disease; in the umbilical, 
 for strumous and cancerous disease ; arid, lastly, in the hypogastric 
 region, pelvic cellulitis, for ovarian and uterine disease. 
 
 Simple suppuration in the parietes generally tends to the surface, 
 and the abscess is opened or it is discharged spontaneously, and in 
 many cases recovery takes place, unless the disease be associated 
 with pyaemia, or occur in cachectic subjects ; sometimes the suppu- 
 ration spreads extensively among the muscles ; it extends also in 
 d"epth, and gradually produces local peritonitis, or discharges itself 
 into some of the viscera. Thus abscess about the kidney opens into
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 475 
 
 the colon, that in the iliac regions into the sigmoid flexure or 
 caecum. 
 
 The most fertile sources of these forms of parietal suppuration are 
 blows and falls. I have observed them from blows, from pressure 
 on the abdomen, and from falls on the back, &c. In pyaemia and in 
 cachectic subjects very trifling causes appear to be sufficient to lead 
 to this disease. A rupture of the muscular fibre is followed by ex- 
 travasation of blood, and suppuration may supervene. 
 ^ Diagnosis. The pain will generally be found to be very super- 
 
 sial ; but m many instances, at an early stage, before any inflam- 
 matory oedema has been produced on the skin, and whilst the disease 
 is confined beneath the fascia of the abdomen, there is much obscurity 
 in the diagnosis ; and after pus is discharged, it must be remembered 
 that a fecal odor does not necessarily imply communication with the 
 intestine; for transfusion of the gaseous contents of the intestine, 
 when there is tolerably close contact, may cause the contents of an 
 abscess to have a fecal smell. In the diagnosis, it is important to 
 bear in mind the remark we have just made as to the sympathv of 
 adjoining viscera. We refer to the production of jaundice in disease 
 in the right hypochondrium. Abscess below the diaphragm often 
 leads to congestion and inflammation of the pleura and lung which 
 may be mistaken for the primary disease. 
 
 In reference to the treatment this early obscurity is of no great 
 moment, for at that period, rest, warm cataplasms, local depletion, 
 and counter-irritation, are equally applicable to local peritonitis as 
 to parietal inflammation. When suppuration has actually taken 
 place, the sooner the pus is evacuated the less likely is it to burrow 
 among the flat muscles and fascia of the abdomen ; and even in 
 abscesses, fecal or otherwise, extending secondarily to the parietes, 
 unnecessary delay is sometimes made in discharging their contents. . 
 The rule is, I believe, a correct one, to open these abscesses verv 
 early. 
 
 CASE CLXXIII. Suppuration external to the Sigmoid Flexure of the 
 Colon, opening on the Anterior Abdominal Parietes, and communicating 
 with the Intettine. Elizabeth R , *t. 39, 'a widow, who had supported 
 herself by dressmaking, was admitted into Guy's Hospital, under my care, 
 in March, 1855. Till a fortnight before admission she had enjoyed good 
 health, when she felt pain in the back, which extended to the shoulders and 
 knees. The greatest pain, however, was in the course of the ilio-hypogastric 
 nerve. These symptoms were accompanied with considerable febrile excite- 
 ment. In a few days the pain, which had simulated rheumatism, ceased, 
 and she gained strength. 
 
 On March 26th, three weeks after admission, she complained of pain in 
 the left iliac fossa, and a firm tumor about the size of a hen's egg could be 
 felt deeply in that part. There was no tenderness in the spine, no"numbness 
 in the legs, nor other symptoms of disease of the spine, nor was there any 
 evidence of disease of the ovary. The bowels were easily acted on, but this 
 action did not affect the size of the tumor nor alleviate the symptoms. The 
 urine was normal, and there was no indication of renal disease. 
 
 May 10 The pain had returned with much severity, and hectic came on. 
 The tumor increased -in size ; it could be felt extending to the quadratus
 
 476 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 lumborum ; and it also reached to the anterior abdominal parieles, which, at 
 the left iliac fossa, were red, oedematous and exceeding tender. 
 
 19th. The bowels were acted upon three times freely, and a considerable 
 quantity of purulent mucus was discharged. The examination of this dis- 
 charge could detect no cancer cells. The pain and the hectic continued ; 
 the patient became pale and exhausted; the left thigh and leg, and after- 
 wards the right, became swollen and tender ; and there was excessive pain 
 in the course of the femoral veins. Nourishment and stimulants were ad- 
 ministered as the patient could take them. Quinine and opium, or morphia 
 were given. 
 
 On June 8th, the inflammatory oedema of the anterior abdominal parietes 
 had increased. My colleague, Mr. Callaway, made an incision at this part ; 
 and more than a pint of exceedingly offensive pus was evacuated. Every 
 means was used to sustain the patient ; but the discharge continued abundant, 
 and it had a feculent odor ; the appetite completely failed, and at length her 
 strength gave way. Bed sores formed on the sacrum ; and a few days before 
 her death cough came on, which aggravated her distress. She gradually 
 sank and died June 24th. 
 
 Inspection was made twenty-four hours after death. The body was 
 blanched, and the lower extremities were redematous ; the posterior lobes of 
 the lungs were in a state of red hepatization . Abdomen The peritoneum 
 was healthy, except in the left iliac region, where the omentum and several 
 coils of intestine were adherent. In this region was an abscess, situated be- 
 hind the peritoneum and fascia, and containing offensive, feculent pus ; it 
 extended to the anterior abdominal parietes in front, above to the diaphragm 
 and kidney, and posteriorly nearly to the spine. Very careful examination 
 could detect no disease of the ilium, nor vertebrae, nor of the pelvic cellular 
 tissue. The abscess communicated with the sigmoid flexure by three small 
 openings, in close contact the one with the other ; their edges were not thick- 
 ened, but valvular. The small and large intestines were otherwise healthy, 
 and the opening into the intestine was evidently secondary. The uterus, 
 ovaries, and kidneys were normal. The stomach was of normal size ; its 
 mucous membrane was pale, and it had undergone degeneration. The liver 
 was more than 5 Ibs. in weight, and extremely fatty. The lower portions of 
 the vena cava, and of the common iliac and external iliac veins, were filled 
 with very firm, white, adherent fibrin ; and the coats of the veins were much 
 thickened. 
 
 The review of this case showed that the pain in the course of the 
 ilio-hypogastric nerve arose from direct pressure upon that nerve by 
 inflammatory effusion ; that the tumor felt in the iliac fossa consisted 
 of this effusion pushing forward the peritoneum and sigmoid flexure; 
 that the subsequent symptoms arose from suppuration, and its ex- 
 tension in various directions ; inwards into the colon, leading to some 
 extravasation of feces into the abscess and of pus into the alimentary 
 canal ; forwards, so as to reach the anterior parietes, where it was 
 opened ; upwards, to the diaphragm ; and inwards, to the cava and 
 iliac vessels, which became involved and obstructed by fibrinous 
 material. That it did not arise from diseased bone was proved by 
 careful examination ; and it is probable that some accidental blow 
 had led to this suppuration, with its fatal results ; or, that irritation 
 in the intestine had led to inflammation external to it, and subse- 
 quently to suppuration.
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 477 
 
 After the tumor had been felt, evidence of suppuration soon arose- 
 and the discharge of purulent mucus showed that it had formed a 
 communication with the intestine, or that there was ulceration of 
 the coats of the intestine itself. Keual, ovarian, spinal, or parietal 
 suppuration, or cancerous disease of the sigmoid flexure, might give 
 rise to many of these symptoms. The absence of all indication of 
 diseased kidney was shown in the condition of the urine. Disease 
 of the spine was exceedingly doubtful, from the absence of tender- 
 ness and numbness, and from the course of the suppuration. The 
 position which the tumor assumed and vaginal examination showed 
 that the ovary was not involved. The tumor appeared to arise from 
 disease near to the sigmoid flexure, either commencing in that, viscus 
 and extending outwards, or beginning in the parietes and makin<r 
 its way into the intestine. It was in deciding as to which of these 
 might be correct that the principal difficulty consisted. The dis- 
 charge of purulent mucus from the intestine, and the feculent char- 
 acter of the pus, indicated a connection between the abscess and the 
 intestine. Before death, I was led to believe that the disease com- 
 menced in the sigmoid flexure, and that the suppuration external to 
 the intestine was secondary; the inspection after death showed that 
 the reverse was the case. This instance resembled cases of suppu- 
 ration external to the rectum, but so deeply was the mischief situ- 
 ated, that any exploratory incision would have been unjustifiable 
 till there was more certain evidence of suppuration than was pre- 
 sented at the commencement of the disease. 
 
 CASE CLXXIV. Abscess in the Loins. Feculent-smelling Discharge. 
 
 Pleuro-pneumonia with Feculent-smelling Septum. Recovery T. H , 
 
 aet. 34, was admitted into the Clinical Ward, under my care, June, 1855. 
 He was a man of steady and industrious habits. His health had been good 
 till an attack of rheumatic fever two years before; and at Christmas, 1854, 
 six months before admission, he had a very severe injury whilst at work; he 
 fell upon his head, and it was believed that the skull was fractured. He 
 remained for some time in the hospital, under the care of Mr. Birkett, but 
 left well, and continued so till three weeks before admission, when, in the 
 middle of the night, he awoke with great difficulty of breathing, the respira- 
 tion being accompanied with considerable distress and pain. These symptoms 
 increased greatly in severity, and presented the signs of pleuro-pneumonia 
 on the right side. 
 
 On admission he was exceedingly ill; his countenance was pale; his eyes 
 were glistening; the lips and nostrils were contracted; the teeth were covered 
 with sordes; the tongue was brown at the base and edges ; and the skin was 
 hot and clammy. In the chest there was found to be increased roundness of 
 the right side at the base, with imperfect mobility, increased dulness on per- 
 cussion, and loss of tactile vibration; and in front, below the nipple, there 
 was a pleuritic rub. On the left side the respiration was peurile; and at the 
 apices the expiratory murmur was prolonged and coarse. The position of 
 the heart was normal; its sounds were healthy, but the precordial dulness 
 was somewhat increased; the respiration was 26 per minute; the pulse 95, 
 feeble and compressible; the urine was high colored, acid, sp. gr. 1025. He 
 reclined on his back towards the right side, with his knees drawn up, and 
 the head thrown forward.
 
 478 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 The prostration increased till June 14th, when deep-seated fluctuation 
 below the ribs on the right side could be detected beneath the lumbar fascia 
 about the quadratus lurnborum muscle. An exploring net-die was passed, 
 and afterwards a director, and the wound enlarged; about a pint of pus, 
 having a strong fecal odor, was discharged, and the abscess continued to dis- 
 charge freely. After the opening of the abscess the respiration became more 
 free, and he coughed up a considerable quantity of frothy mucus, having the 
 same odor as the pus. His strength was sustained by nourishing food and 
 stimulants; by quinine and opium; diarrhoea was occasionally troublesome, 
 and the offensive expectoration became exceedingly distressing. 
 
 On July 2d, he had so much improved as to be carried out into the open 
 air for half an hour. The offensive character of the breath and respiration 
 gradually subsided ; healthy respiration became audible nearly to the base of 
 the lung, and he continued to gain flesh. 
 
 In October he returned to his work, and then appeared a stout hale man ; 
 but a flstulous opening remained up to that time, which occasionally dis- 
 charged freely. The sinus healed in about six months, and he then appeared 
 in good health, May, 1857. 
 
 In this case deep-seated suppuration took place near the quadratus 
 luraborum muscle; acute pleuro-pneumonia on the right side, and 
 the most severe constitutional symptoms followed. The pus, which 
 was evacuated, and the mucus expectorated, were of a most offensive 
 and feculent odor; but microscopical examination of the pus could 
 not detect decided fecal elements. Diarrhoea came on; the feculent 
 character of the discharges slowly subsided, but the offensive char- 
 acter of the expectorated matter tried the patient much. Several 
 facts render it probable, that the abscess was in close contact with 
 the ascending colon; mere contact with the intestine would be suffi- 
 cient to explain the fecal odor; and it may be, that the contents of 
 the abscess were partially discharged into the colon. 
 
 In the investigation of the case, several modes of explanation 
 were suggested: 1, an abscess, the result of the blow; 2, caries of 
 the vertebrae or their processes; 3, abscess of the liver; 4, empyema; 
 5, suppuration external to the kidney, from disease of that organ. 
 Although there was evidence of acute disease of the chest, the 
 abscess was evidently below the diaphragm, and probably in con- 
 tact with it. -The character of the pus, and the absence of the 
 elements of bile, indicated freedom from hepatic disease. It is pro- 
 bable that disease of a vertebra or of one of its processes had been 
 set up by the blow. 
 
 The treatment in both the cases just detailed appears sufficiently 
 clear; namely, as soon as a tolerably certain evidence of suppuration 
 is obtained, to make a free outlet for the pus, and to support the 
 patient by every means in our power. 
 
 To deter the opening of the abscess tends to increase fecal ex- 
 travasation where there is communication with the colon; and in 
 other cases the pus readily extends among the cellular tissue which 
 connects the layers of fascia and muscle. 
 
 CASE CLXXV. Abscess in the Loins. Pleuro-pneumonia. Recovery. 
 A Greek sailor was admitted into Guy's Hospital under my care in 1877,
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 479 
 
 with pain in the left loin, between the ribs and the crest of the ilium The 
 ^verity of the febrile disturbance led to some doubt whether the patient was 
 suffering from enteric fever or from tuberculosis ; still the especial complaint 
 was o tenderness in the lorn. One of my surgical colleagues kindly exam. 
 medium, but at first did not think that the "symptoms warranted^ ex- 
 ploratory operation. After a few days, when the pain was still more decided 
 and accompanied with tenderness, pleuro-pneumonia on that side came on 
 Ihe operation was again delayed, but soon the symptoms of local disease 
 became more evident. Mr. Jacobson opened the abscess, and the patient 
 lowly recovered ; the pneumonia soon subsided. There was no proof of 
 communication between the abscess and the lung, but the close proximity of 
 hsease below the diaphragm led apparently to the thoracic mischief. 
 
 /, Mi f carria 9^ Pyamia. Abscess between the Uterus 
 
 and Bladder. Abscess m the Loins, opening into the Ascending Colon, and 
 into the Iliac Vein For the following case I am indebted to my friend 
 Dr. Hardwicke, of Leeds. 3 
 
 Ann D , at. 37, was admitted into the Leeds Infirmary, December 12th 
 
 hhe was a married woman, the mother of four children, the youngest bein- 
 
 two years old; she had enjoyed tolerable health; but had suffered severely 
 
 a rheumatism four years previously, and from scarlet fever in her child- 
 
 hood. She had not menstruated since her last confinement. 
 
 When admitted, the uterus was enlarged nearly to the umbilicus. Her 
 present illness had commenced three weeks before admission. She had not 
 been suffering previously from any pain, nor from disorder of the bowels. 
 .ring the day of the attack she had been working hard, and awoke in the 
 night with violent pain in the lower part of the abdomen, of a bearing-down 
 character. She thought that relief would be obtained by an action of the 
 bowels, but found that she could not pass anything, and that the sensation of 
 forcing and pain continued. On the following day she got up, but fainted 
 and had a severe rigor ; on the third day, she noticed that her abdomen 
 was enlarged, chiefly on the right side ; this was the seat of all the pain, and 
 became s6 tender that she could not bear the weight of the clothes upon the 
 part. Her left side had been free from pain throughout. The bowels re- 
 mained confined for four or five days after the commencement of her illness, 
 and were only moved by a second dose of purgative medicine. The consti- 
 pation continued till the time of admission. Miscarriage then took place. 
 On December 17th, she appeared anxious, and had a slightly yellow tin<*e 
 There were a few bronchial rales in the chest. The heart's action 
 was irregular and intermittent, but unattended with any bruit. Her abdo- 
 men was large, the superficial veins being distended. On the right side 
 above the ilium there was an elastic tender swelling, with apparent^ uctua- 
 tion in it ; in front it was ill defined, but above was separated from the liver 
 by a resonant space. There were no symptoms to connect it with the kid- 
 ney, and it did not extend into the, right groin. The tongue was furred and 
 The bowels were purged by medicine. The urine contained no 
 albumen, but at times the coloring matter of bile was in abundance. The 
 pulse was irregular, and generally intermitted every -fifth beat. 
 
 December 30th. The tumor had been gradually disappearing, and for the 
 last two days could not be detected ; there was also resonance at the part ; 
 she complained much of " rheumatic" pain in both her shoulders and elbows, 
 but less of pain in her side ; the bowels had been regular till this day, when 
 she passed three or four large evacuations, consisting chiefly of dark coagulated 
 blood. This continued till the following day, when she sank.
 
 480 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 Inspection was made seven hours after death. The body was slightly 
 wasted. The lungs were healtliy in structure ; on the right side there were 
 firm adhesions at the base. The pericardium contained about Jiij of serum. 
 The heart was a little enlarged, but there was no valvular change. There 
 was redness with effused lymph over the peritoneum on the right side; and 
 the caecum was pushed a little upward and glued by recent adhesion to the 
 posterior wall of the abdomen, and to the transverse colon. The liver was 
 large and fatty ; the gall-bladder contained two calculi, each about the size of 
 a marble. The spleen was rather enlarged. The kidneys were large, soft, 
 and of loose texture, and showed but little distinction between the cortical 
 and medullary structures. Numerous small cysts were found in their sub- 
 stance; and the capsule separated readily. On detaching the ascending colon 
 from its adhesions, which was done very easily, a quantity of dark clotted 
 blood escaped, and the bowel was found to form the anterior wall of a large 
 cavity, filled with coagulated blood. It occupied the position of a psoas 
 abscess, and extended behind the psoas muscle, and even for a short distance 
 below Poupart's ligament. The blood was confined by the fascia, and occu- 
 pied the whole of the right iliac fossa. There was a small portion of fibrin 
 in it, but no pus could be detected; several nerves were found passing from 
 the spinal column through the middle of the cavity ; and the iliac vessels lay 
 on the inner side and slightly in front of it. The artery was healthy through- 
 out ; the vein was roughened posteriorly, and formed a portion of the boundary 
 of the cavity described. At the termination of the common iliac vein on the 
 right side was a large irregular opening posteriorly, forming a communication 
 between the vein and the cavity in the muscle. Above this point the vessel 
 was healthy; below, and throughout the external and internal iliac veins, the 
 coats appeared thickaned, and the vessels were closed by firm adherent clot. 
 Around the opening on the inner side there were small excrescences of lymph, 
 almost similar to those sometimes found on the valves of the heart. The 
 lumbar portion of the spine was removed, and carefully examined, but no 
 caries nor other disease could be found. The sacro-iliac synchondrosis was 
 sound, and no diseased bone could be detected at any part. The small intes- 
 tine was slightly injected at one or two points. The large intestines were 
 healthy, except the ascending colon ; there was some vascularity, and an in- 
 jected appearance in small isolated spaces. On its posterior wall were four 
 or five large ragged openings, varying from the size of a sixpence to a shilling. 
 There was a brown discoloration of the bowel for some distance around the 
 openings, and their edges were thin, having the mucous membrane entire as 
 far as the border of the opening. The peritoneal covering was roughened 
 and uneven, being generally wanting round the edges of the openings, so as 
 to give them a bevelled appearance on their outer aspect. The colon contained 
 a small quantity of blood. There was thickening of the cellular tissue about the 
 uterus on the right side ; and a circumscribed abscess, the size of a small orange, 
 was found between it and the bladder; but this was entirely distinct from the 
 cavity in the psoas. The uterus was contracted to the size of an orange, and 
 felt soft. The os was dark and discolored. The ovaries were small and flabby, and 
 did not present any corpus luteum. The uterus was covered internally by a thin 
 layer of dark clot, and to its posterior wall was firmly attached a fibrous mass 
 of the same color and appearance. The structure of the walls was healthy. 
 
 Many of the earlier symptoms in this case arose from threatening 
 miscarriage after a day of hard work ; and it appeared probable that 
 a state of pyaemia was afterwards produced, and would have pro- 
 bably terminated fatally, if the hemorrhage from the divided cava 
 had not led to comparatively sudden death. The cause of the abscess
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 481 
 
 behind the colon, which extended into the cava, and afterwards into 
 the large intestine, was not apparent; it arose either from some 
 laceration of muscular fibre of the psoas and subsequent suppuration; 
 or it occurred as one of the secondary deposits in pyaemia. It is 
 exceedingly improbable that the vein was primarily lacerated ; we 
 are rather disposed to believe that ulceration perforated its coats. 
 The extension into the colon was evidently from without, the larger 
 size of the ulcer on the external aspect, and the sudden discharge of 
 blood by stool, showed this to have been the case. 
 
 CASE CLXXVII. Abscess in the Hypogastric region of the Abdominal 
 JParietes, simulating Ovarian Disease. Recovery. Emma N , aged about 
 25, a cook, was admitted under my care into Guy's Hospital, October 13th, 
 1856. She was a single woman, and had enjoyed good health till twelve 
 months previously, when she had violent pain in the left side, which was said 
 to arise from inflammation of the uterus, and she was leeched, poulticed, and 
 blistered. Three weeks before admission a swelling was perceived in the left 
 iliac region, which was exceedingly tender on pressure. 
 
 On admission, at the lower part of the abdomen, between the hypogastric 
 and left iliac regions, a hard, unyielding tumor was detected, which was 
 slightly tender and painful on pressure ; it extended obliquely towards the 
 median line of the abdomen, and appeared to be beneath the muscles ; there 
 was no redness of the skin, and the pain was only manifested on pressure. 
 It appeared closely to resemble an ovarian tumor. There was no febrile 
 disturbance and the skin was moist; rest was enjoined, and the infusion of 
 roses with magnesia was prescribed. 
 
 Ten days after admission the tumor became more painful, and on the 27th 
 the skin slightly inflamed ; leeches were applied, and cataplasms, &c. 
 
 November 2d. The character of the tumor was now manifest, fluctuation 
 was distinct, the pain superficial, but severe. On the 4th, the abscess was 
 opened by my colleague, Mr. Forster, and a pint of pus was evacuated. The 
 abscess slowly healed, and on the 23d she left the hospital convalescent. 
 
 CASE CLXXVIII. Suppuration external to the Right Kidney. Fibroid 
 Thickening of the Tunic of the Kidney. Chronic Pyelitis. Obliteration of 
 the Vena Cava. Adhesion, thinning, and doubtful Perforation of the 
 Ascending Colon Hugh M , set. 36, was admitted September 12th, 1855. 
 Six months previously he had received a blow on his back, and suffered 
 directly afterwards from hrematuria ; this discharge of blood continued for 
 three weeks, and severe pain in the back came on. The pain continued, 
 and gradually a swelling formed in the loins to the right of the spine. After 
 the blow he had several rigors, and some febrile excitement. The abscess in 
 the loins was opened on November 26th, and from that date continued to 
 discharge freely. He was a man of middle stature, with long thin hair, and 
 had a haggard and cachectic appearance. The urine contained much mucus. 
 Stimulus and steel were prescribed. 
 
 November 22d. He had gradually emaciated, but enjoyed his food ; his 
 bowels were regular, his tongue very clean ; he had had swelling and ] ain 
 in his right leg for two weeks. On December 19th, the abdomen and lower 
 extremities were much swelled ; the vessels on the surface were pronnnent. 
 and the larger capillaries of the skin intensely injected, as if new vessels 
 had been formed ; the skin was shining, white, and tense. He was in con- 
 
 TT 1 J 
 
 siderable distress, and very prostrate, though not in severe pain. He had a 
 rather troublesome cougk. His strength gradually failed, and he sank. 
 31
 
 482 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 On inspection, January 7th, the abdomen only was examined. The 
 oedema of the lower extremities, and the congestion of the vessels had disap- 
 peared. The peritoneum contained about four quarts of clear serum ; it was 
 smooth and shining, except on the peritoneal surface of the bladder, and in 
 the right iliac fossa, where it was opaque and covered by numerous granules, 
 from about the size of a pin's head to a pea. 
 
 The stomach and ileum were healthy ; but the lower part of the latter was 
 of a gray color. The^vhole of the caecum and ascending colon were of a deep 
 iron-gray, and contained much irregular pigment in the substance of the 
 mucous membrane. The caecum and ascending colon were so firmly adhe- 
 rent, and their walls so thinned posteriorly, that they gave way on removing 
 them, even if they were not already in communication with the abscess 
 behind them, which was probably the case. The whole of the peritoneum 
 and sub-peritoneal tissue around the right kidney to the aorta was much 
 thickened, semi-cartilaginous, and, formed the boundaries of a sinus filled with 
 pus ; this communicated with the opening made in the loins, and extended 
 down as low as the pelvis. The aorta was normal ; the vena cava, about two 
 inches from the liver, was completely occluded by the thickened, and by the 
 fibrinous external deposit; its walls were irregular, puckered, and it con- 
 tained a firm clot. The right renal vein was obliterated, but the artery was 
 normal. The left kidney was hypertrophied, the right kidney and the ureter 
 contained opaque concrete pus, distending the calyces ; the secreting struc- 
 ture was destroyed, and surrounded by a dense fibrous envelope. The blad- 
 der was small, thickened, and its mucous membrane irregularly granular. 
 The dense tissue about the right kidney involved the right semilunar gan- 
 glion ; it could with difficulty be dissected ; the cells contained a considerable 
 quantity of pigment, and their nuclei were indistinct. 
 
 The blow on the loins produced in this instance hsematuria; and 
 led to abscess, and to chronic disease of the kidney. The new tissue 
 had become fibrous, and exceedingly dense ; the ascending colon was 
 adherent, and apparently perforated, so as to communicate with the 
 abscess ; but no fecal discharge took place from the back, nor was 
 there any evidence of purulent evacuation from the bowels. The 
 superficial abdominal veins were intensely congested, evidently from 
 obstruction of the cava. 
 
 CASE CLXXIX. Fecal Abscess in the Pelvis, communicating with the 
 Ovary and Bladder, opening twice into the Rectum, and in the Groin. Sarah 
 Y , aet. 24, residing in Lambeth Road, was admitted August. 22d. Till 
 nine weeks before admission she enjoyed good health, and at that time, on 
 going to breakfast, was seized with sickness, and with great pain in the abdo- 
 men ; after a few days she had rigors for three or four hours, and the pain, 
 vomiting, and purging continued for seven or eight days more ; she then 
 became more comfortable, and improved in health ; one week before admis- 
 sion she was again attacked with vomiting, pain, and purging ; and these 
 symptoms continued for three or four days. On admission her countenance 
 was Hushed, there was great pain in the abdomen, and intolerance of pres- 
 sure ; the countenance was anxious, and there was general tremor. The 
 pain continued very severe till her death, and the diarrhoea was persistent ; 
 for some days the motions appeared to be of a purulent character. A few 
 days before death a feculent abscess opened in the right groin below Poupart's 
 ligament.
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 483 
 
 On inspection, the thoracic viscera were healthy; there were some pleuritic 
 adhesions, but no tubercle. 
 
 Abdomen The general cavity of the peritoneum, except in the pelvis, 
 appeared healthy ; the viscera were collapsed ; the small intestine was adhe- 
 rent to the brim of the pelvis, and to the caecum. 
 
 The stomach was pale, but on microscopical examination it was found to 
 be healthy. The small intestines were healthy ; the colon, as far as the sig- 
 moid flexure, was much contracted, and contained small scybalous grains, 
 firmly attached to the mucous membrane of the intestine. The viscera of the 
 pelvis were found to be firmly united by adhesions. On taking out the uterus 
 some superficial ulceration was found at the os uteri ; the left ovary and tube 
 were normal ; but on the right side, at the position of the Fallopian tube and 
 ovary, was a sac capable of holding about ij of fluid, filled with purulent and 
 feculent secretions ; the abscess communicated by an irregular opening with 
 the first part of the rectum, and extended into an irregular abscess, containing 
 feces, situated between the ovary and rectum. This abscess passed down- 
 wards towards the bottom of the pelvis, and opened again into the rectum by 
 a small circular opening about three inches above the anus : its boundaries 
 were exceedingly irregular, burrowing beneath the pelvic fascia ; it extended 
 to the bladder, and had perforated its fundus by a circular opening ; it also 
 passed upwards to the psoas muscle, and reached the crest of the ilium ; below 
 it passed beneath Poupart's ligament, and at Scarpa's triangle formed a large 
 ulcerated opening, about two inches in diameter. The mucous membrane of 
 the rectum was congested and gray ; its calibre at the part between the two 
 openings was diminished. The bladder was small, and its mucous membrane 
 was red, but the cavity did not contain any feces, nor did it appear that any 
 had passed by the urethra. The kidneys and spleen were healthy ; the liver 
 was tatty, moderate in size ; its weight 2 Ibs. 7 oz. 
 
 In this case, inflammation appeared to have commenced in the 
 right ovary ; suppuration and local peritonitis followed ; communi- 
 cation then took place with the rectum; fecal abscess was the result; 
 this burrowed beneath the pelvic fascia, and formed a second opening 
 into the rectum, one into the bladder, and along the psoas muscle it 
 reached the skin upon the thigh. 
 
 The diarrhoea proved to be tenesmus with purulent discharge, 
 and is an indication of one of the fallacies in the diagnosis of dysen- 
 tery. There was some ulceration at, the os uteri. The severe pain 
 arose partly, I doubt not, from pressure on the nerves in the psoas 
 muscle, namely, the ilio-hypogastric, ilio-lumbar, and last dorsal 
 nerve, and from the attacks of local peritonitis. 
 
 CASE CLXXX Abscess external to the Rectum leading to Perforation. 
 
 Considerable Fibrous Thickening, and Simulation of Cancerous Disease 
 Ann C , aet. 55, a needlewoman, living at Bermondsey, was admitted into 
 Guy's Hospital, March, 1857. She had been married eighteen years, and 
 had" had one child. Till ten years before admission she had enjoyed good 
 health, when she fell and struck the sacrum ; she suffered much, and was con- 
 fined to her bed : from that time there had been a constant discharge from 
 the rectum, with pain in defecation, and she had been unable to stand or 
 walk on account of the pain. Three years later she was supposed to have 
 inflammation of the uterus ; but the catameriia had continued regularly till 
 thirteen months before admission. For three or four months the left leg had 
 been swollen, and for two months the abdomen had been tense and painful.
 
 484 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 She was a small delicate woman ; the abdomen was tense and tympanitic. 
 The chest was normal, and the heart feeble. There was a constant discharge 
 of mucus and slimy secretion from the rectum ; and its calibre was much con- 
 tracted. The urine was albuminous. Her strength gradually became ex- 
 hausted, and she died in a few weeks. 
 
 The walls of the rectum were exceedingly rigid, dense, and fibrous, and 
 communicated with an abscess, or rather sinus, on the concavity of the sacrum. 
 This chronic inflammatory action had extended to the neighboring parts, and 
 led to stricture. 
 
 During life this was supposed to have been a case of cancerous 
 disease, but the post-mortem inspection did not confirm this sup- 
 position ; it showed that inflammation commenced after the fall in 
 the cellular tissue external to the bowel, and led to the dense fibrous 
 constriction. This condition of rectum leads to abundant discharge 
 of mucus, simulating diarrhoea or dysentery. A similar state of 
 rectum was observed in a case under my own care, associated with 
 albuminuria ; there, however, limited to the walls of the rectum, 
 and not as here produced by external inflammation. This case is 
 another evidence of the severity of pain when the inferior portion of 
 the rectum is diseased, as compared with the immunity from it, in 
 disease of the sigmoid flexure. The nerves are more easily com- 
 pressed, and the outlet is also freely supplied with nerves of sensation. 
 In this instance colotomy might have been attended with considerable 
 benefit. 
 
 CASE CLXXXI. Multilocular Ovarian Tumor. Perforation of the 
 Ccecum. Fecal Abscess. Pneumonia. Pus in the Ovarian Veins Martha 
 L , set, 33, was admitted into Guy's Hospital, December 12th, 1855. She 
 was a married woman, who had resided at Poplar. She had had five chil- 
 dren, and the youngest was fourteen months old at the period of her admis- 
 sion ; but before the birth of her child, she had had pain occasionally, of a 
 severe character, in the left iliac region. After parturition, swelling of the 
 abdomen increased, but with scarcely any pain for a time, till the exertion of 
 walking produced it severely ; she stated that the tumor fell from side to side. 
 Four months before admission great pain came on in the left iliac region, 
 extending to the hypochondrium of the same side. The abdomen afterwards 
 increased much in size, and the catamenia ceased. She had also suffered 
 from diarrhoea. 
 
 On admission she was pale, her countenance was expressive of anxiety; 
 the mind was active. The abdomen was swollen and tense, and the skin 
 about the umbilicus was red and inflamed ; there was dulness on percussion 
 in each iliac region, but especially on the left side, and on that side a tumor 
 could be felt extending towards the loins. The abdomen was tympanitic at 
 the umbilicus, and for a short distance on either side. The urine was high 
 colored, and contained lithates. The bowels were relaxed ; there was nausea 
 with loss of appetite. She was ordered Dover's powder three times a day, a 
 blister to be applied to the abdomen, and milk diet. The diarrhoea became 
 persistent, and was with difficulty checked. On December 20th, paroxysmal 
 pain in the back came on, and the abscess at the umbilicus had broken and 
 discharged feculent, with relief to the patient; opium and chloroform were 
 given. The fecal discharge through the parietes continued till death, which 
 was preceded by an aphthous condition of the mouth, by violent retching and
 
 PERFORATION OF THE INTESTINE FROM WITHOUT. 485-, 
 
 vomiting, and by aggravation of pain in the abdomen. She lingered till 
 February 5th. 
 
 On inspection, acute pleuro-pneumonia was found at the base of the right 
 lung. In the abdomen, the stomach and transverse colon were found mode- 
 rately distended ; and reaching from the umbilicus to the pelvis was a tumor, 
 composed of ovarian cysts ; it was connected with the left ovary, and filled 
 the left iliac fossa in front of the sigmoid flexure. On cutting down the 
 median line, an abscess was opened extending to the right, into the caecum, 
 the anterior surface of which was destroyed. The abscess was formed in 
 front by the anterior abdominal parietes, which had become perforated ; to 
 the left by the ovarian tumor ; to the right by the caecum and kidney ; below, 
 by the fundus of the uterus, and by the rectum. The walls of the abscess 
 were covered with lymph, and the cavity contained feces. The ovarian 
 growth was six to eight inches in diameter, composed of cysts, some capable 
 of holding several ounces of fluid, others almost microscopic ; the fluid was 
 tenaceous and gelatinous ; and the walls of the cyst were vascular ; near the 
 caecum one of these cysts appeared to be connected with the abscess. The 
 large ovarian veins extending into the tumor were filled with thin pus. The 
 right ovary was small and atrophied. The uterus was healthy. The mucous 
 membrane of the caecum and ileum were much congested. The stomach was 
 pale, and presented gastric solution at its greater curvature. The liver, kid- 
 neys, spleen, and mesenteric glands were healthy. 
 
 The ovarian disease was the commencement of the fatal affection ; 
 one of its cysts had become adherent to the caecum, and had led to 
 perforation; local peritonitis and fecal abscess followed. As to the 
 ovarian disease, it was of the ordinary multilocular character. The 
 diagnosis of ovarian disease was not certain ; movable carcinomatous 
 tumors become developed in the omentum; and the position of the 
 growth was at first that presented by diseased glands about the kid- 
 ney; it extended less into the loins, however, than is usual in the 
 latter disease. The local peritonitis and perforation of the intestine 
 were evident; and the treatment most likely to afford partial relief 
 was that adopted, namely, the administration of opiates and of nour- 
 ishment to sustain the patient. 
 
 CASE CLXXXII. Ovarian Tumor filled with Feces and opening into the 
 Ileum. Pneumonic Phthisis Catherine S , set. 47, was admitted into 
 Guy's Hospital, December 14th, 1853, and died March 23d, 1854. She had 
 been a washerwoman, and had resided at Clapham. For sixteen years the 
 abdomen had gradually enlarged, but she had followed her occupation till five 
 months before her death, when, during menstruation, she took cold, and suf- 
 fered from pain in the abdomen. On admission there was severe pain in the 
 wholo of the abdomen, with loss of appetite, thirst, and want of sleep. The 
 countenance was pale and anxious; the tongue was brown ; the skin was hot 
 and dry. Ovarian disease could not be detected by vaginal examination. 
 Symptoms of pneumonic phthisis and pleurisy came on, and she died about 
 three months after admission. 
 
 On inspection, the left pleura was found full of pus; the right lung con- 
 tained a vomica, and presented indurated lung tissue around it. Peyer's 
 glands were ulcerated. In the caecum was a small ulcer, and another was 
 found in the appendix, which contained feces. The right ovary was diseased, 
 and constituted a cyst, five inches in diameter, with thickened walls. The 
 cyst was firmly adherent to the lower part of the ileum, and communicated
 
 486 PERFORATION OF THE INTESTINE FROM WITHOUT. 
 
 with the intestine. It was filled with feces, and was adherent to the uterus 
 at the lower part. The left ovary was atrophied ; the cervix of the uterus 
 was enlarged and thickened ; the kidneys were pale ; and the liver was fatty. 
 
 The commencement of the affection strongly indicated ovarian dis- 
 ease ; suppuration took place around the ovary, and led to symptoms 
 resembling peritonitis ; pus was probably discharged by the bowel. 
 Inflammatory disease was afterwards developed in the lung, and led 
 to a fatal termination. 
 
 CASE CLXXXIII. The following is one of a very unusual char- 
 acter, and the preparation is in the Guy's Museum, Nos. 2516 and 
 2517. 
 
 Extra-Uterine Fcetation opening into the Si ff moid Flexure. Elizabeth 
 H , aged about 20, had led an irregular life, and had had a child eighteen 
 months previous to admission ; she was not aware that she was pregnant ; 
 she had been ill for six months, but had only been confined to her bed for 
 three or four weeks. She was in a state of extreme prostration, and had 
 obstinate diarrhoea ; the evacuations consisted of blood and pus ; there was 
 slight tenderness of the abdomen, some fulness, but no defined tumor. She 
 died in sixteen days. 
 
 Inspection Abdomen In the pubic region there were firm adhesions, 
 and there was a cavity bounded by the ascending colon, and by the lower 
 part of the sigmoid flexure ; posteriorly, by the rectum and sacrum ; ante- 
 riorly, by the parietes, by the pubes and bladder ; and laterally by the pelvis. 
 This cavity was filled with pus, and contained a decomposing foetus about 
 three months old. There were traces of placenta ; and extending into the 
 sigmoid flexure was an opening two to three inches in length and one in 
 breadth. The uterus was small, and no decidua was present it. 
 
 In the 'Guy's Reports' of 1838, Dr. Bright records a remarkable 
 case of abscess of the spleen, which perforated the colon; the diagno- 
 sis was exceedingly obscure. 
 
 The patient was a young woman, aged twenty-five, much emaci- 
 ated, of peculiarly sallow complexion and anxious countenance; she 
 had great uneasiness and pain in the abdomen, particularly at the 
 scrobiculus cordis and right hypochondrium; food increased the pain; 
 the vomiting was constant, sometimes directly after food had been 
 taken ; there was also occasional bilious vomiting ; the tongue was 
 dry and glossy, and she gradually sank. On inspection, the lungs 
 and heart were found to be healthy; the liver was hard and granular; 
 the lower part of the spleen was occupied by an abscess, which was 
 firmly adherent to the transverse colon, and had opened into it. 
 There was also an abscess in the left ovary.
 
 487 
 
 CHAPTER XYIII. 
 
 INTESTINAL WORMS. 
 
 THE observations of late years have brought to light many facts 
 connected with intestinal worms, especially as to their developmental 
 changes. Since the translation of Kitchen meister's work by Dr. Lan- 
 kester for the Sydenham Society, and of Von Siebold's treatise by 
 Professor Hnxley, the knowledge of entozoa has been advanced by 
 various observers, but especially by the elaborate treatise of Dr. 
 Cobbold in 1864 ; and to this latter work and to the excellent con- 
 tribution of Heller in Ziemssen's 'Encyclopaedia,' 1 must refer for the 
 full description of the several forms of intestinal worms. These en- 
 tozoa are of different kinds, but those which, from their resemblance 
 to portions of white tape, have been designated tapeworms are the 
 most numerous. The order Cestoda comprises numerous varieties 
 of tapeworm or tsenia, and several of them have only been found in 
 the human subject. 
 
 Teenia soliurn. 
 
 Toenia medio-canellata (T. saginata.) 
 
 Toenia nana. 
 
 Tasnia flavo-punctata. 
 
 Taenia elliptica (T. cucumerina.) 
 
 Bothriocephalus latus. 
 
 Bothriocephalus cordatus. 
 
 Each tapeivorm is a chain of living segments forming, as they have 
 been designated, a colony of animals; they do not possess any mouth 
 or true vascular system, but the nutrition is by imbibition. The head 
 of the animal, scolex, is small, and it has two to four suckers, in 
 most varieties with a coronet of booklets, and connected with it are 
 the segments of the body (strobiles), of a tape-like form, which grad- 
 ually attain their full sexual development. The head is small, about 
 half the size of a pin's head ; this is joined to the rest of the body by 
 a neck, which soon becomes divided into segments, which vary in 
 size, at first small, one eighth of an inch in breadth and a quarter to 
 half an inch in length, but they gradually increase in breadth as they 
 pass downwards till they become about a quarter of an inch in length 
 and nearly half an inch in breadth. The lower border of each seg- 
 ment is larger than the upper, and in this way the segments are ap- 
 plied, the lower one fitting against, and, as it were, into the upper, 
 thus forming an irregularly jointed band. Each fully developed seg- 
 ment contains both male and female sexual organs, the genital open- 
 ing being a slightly raised projection at the side or upon the central 
 surface of the animal. These structures are seen as branching ves- 
 sels in the segments. The development takes place by the budding
 
 488 INTESTINAL WORMS. 
 
 of these segments, the number of segments increase, and each has 
 independent germs of new life. The ova are very numerous, and 
 globular or elliptical in form. The embryos have three pairs of 
 booklets, but do not at once form the tsenia, but having entered into 
 the stomach of another animal with the food, they begin to develop, 
 passing into the blood or into the vessels and attaining a cystiform 
 state, are known as hydatids. The hydatid reaches its further state 
 of complete development only after subsequent admission into a dif- 
 ferent animal. Thus, the ova of the tasnia coenurus in a dog become 
 in sheep the hydatid known as ccenurus cerebralis, whilst these hyda- 
 tids, if eaten again by a dog, become the taenia coenurus. The hyda- 
 tids, or ecchmococci, that are so frequently seen in human subjects, 
 are not from the taenia solium, the common tapeworm, but the im- 
 perfect developmental stage of the taenia ecchinococcus which is 
 found in dogs, and has been found in those animals as a small taenia 
 with four joints, and about a quarter of an inch in size. The taenia 
 solium has its early stage in the cysticercus of the pig measly pork 
 the cysticercus of the cow becomes the tsenia medio-canellata. 
 The larval or hydatid stage presents a head, as in the adult form, 
 but is a mere cyst, and the head may be retracted into it. The head 
 presents a projection or rostellum with four suckers, and with coro- 
 net of booklets in the sexually mature tsenia. 
 
 The Tsenia solium is the most common form of tapeworm in 
 England ; it is found in the small intestine, and is generally single 
 and attains to seven or even ten feet in length. The head can easily 
 be recognized on careful examination, and is about the size of an 
 ordinary small pin's head; about six inches from the head the seg- 
 ments become distinct, and soon attain their full development. The 
 head has four circular suckers, and placed on a projection or rostel- 
 lum is a double circle of booklets. The segments, proglottides, are, 
 as we have before said, hermaphrodite; there are openings of the 
 sexual organs on alternate sides, the oviducts forming the greater 
 part of the animal. The ova are produced in immense numbers, 
 they are globular in form, and are about ^^th of an inch in dia- 
 meter. It is these ova which become the cysticercus cellulosa in 
 the pig. Kiichenmeister produced in man the tsenia solium directly 
 from the cysticercus cellulosa of a pig; he administered the embryos 
 to a man three days before his execution, and afterwards found 
 several taeniae in the intestine. Ziemssen, quoting Leuckart, men- 
 tions a case in which a young man swallowed of his own accord four 
 embryos of cysticercus cellulosa, and four months afterwards passed 
 segments of the tapeworm, and after medicine had been given two 
 perfect specimens of the taenia soliurn. This tapeworm occasionally 
 presents irregularities in form from the union of segments or of two 
 worms. 
 
 The Tsenia medio-canellata or sayinata is a larger worm, and less 
 transparent than the taenia solium; the segments are also broader; 
 the head has no rostellum nor booklets, but in the centre of the 
 head are four suckers which are firmer and of a deeper color than 
 in the taenia solium. The uterus is more finely divided; there are
 
 INTESTINAL WORMS. 489 
 
 from fifteen to twenty dichotomous branches. The ova are oval, 
 and rather larger than those of the taenia solium, and the embryos 
 possess three pairs of booklets. The ova cannot be distinguished 
 from those of the tsenia solium; in the cysticercus state they have 
 been found in the cow and in the giraffe, and also in the sheep, goat, 
 and calf, when segments of the worm have been given with their 
 food. 1 
 
 This form of taenia is most common in Africa, but is also found in 
 Northern and Southern Germany. 
 
 The Taenia nana is a small worm, about one inch in length, and 
 one fiftieth in breadth ; the head is round, and it has four disks and 
 a single row of small booklets. The segments are about 150 in num- 
 ber, and the lateral openings are all on the same side. The author 
 just quoted states, that this worm was found by Bilharz in Egypt in 
 great numbers in the intestine of a boy who died from meningitis. 
 
 The Tvenia elliptica has a more chain-like appearance, and the 
 head possesses three or four rows of booklets. It has been found in 
 man, but especially in children, and also in dogs and cats. 
 
 The Tivnia flavo-punctata has never been fully described, and is of 
 rare occurrence. 
 
 The Bothriocephalus latus is the largest worm which is known to 
 infest human beings, and it attains the length of fifteen to twenty-five 
 feet, sometimes even, it is said, as much as sixty feet. The head of 
 this entozoon is very different from those previously described, as it 
 does not possess any booklets, but the head, which is club-shaped, 
 is deeply grooved on each side. The segments are broader than 
 they are long, and when fully developed are nearly square. The 
 genital pores resemble a small rosette and are situated about the 
 centre of the segment, and they are all placed on the same side of 
 the worm. The eggs are brown in color and oval in form, and are 
 provided with a lid which separates from the rest of the egg. The 
 eggs are at first ciliated and enable the young to float in water ; they 
 are in this state also possessed of six booklets. The worm is gene- 
 rally single, but there may be several of the same kind, and other 
 forms of taenia are said to have been present with it. The bothrio- 
 cephalus latus has been found in Sweden, in Northwestern Eussia 
 and Eastern Prussia, in Switzerland, and in Belgium and Holland. 
 
 The Bothriocephalus cordatus differs from the last described worm 
 in the form of its head, which is broad, short, and the grooves are 
 on the flat surfaces rather than on its margins. The body com- 
 mences directly from the head, and the segments rapidly increase in 
 breadth. It has been found in Greenland. 
 
 The symptoms that arc produced by the presence of tsenia may be 
 divided into those which are directly connected with disturbance of 
 the functions of the alimentary canal, and those which are reflex in 
 their character ; the patient is generally pale ; the appetite is found 
 to be unnatural, being variable in character, and sometimes craving. 
 
 1 Heller in 'Ziemssen's Encyclopaedia of the Practice of Med.,' Eng. tr., vol. vii, 
 p. 717.
 
 490 INTESTINAL WORMS. 
 
 The condition of the bowels is also irregular ; there may be diarrhoea 
 or constipation ; pain resembling colic is often complained of, with 
 a sense of exhaustion at the stomach, and often with nausea and a 
 sense of malaise, but the only pathognomonic symptom is the recog- 
 nition of segments of the taenia, which are present in the evacuations. 
 These segments may be single, or pieces several inches in length 
 may be passed ; but we have no security that the patient is really 
 freed from his tenant unless the head of the animal is discharged. 
 Other symptoms are due to reflex action, as itching of the nose and 
 anus, headache, disturbance of sight, the sensation as of ringing 
 noises in the ear, sometimes convulsion, or epilepsy ; at other times 
 pain in the lirnbs and in the region of the heart may be produced, 
 so also palpitation of the heart. 
 
 The manner in which human beings become infested with these 
 pests is by the introduction of the ova with the food. If meat be 
 imperfectly cooked the ova are not destroyed ; thus, imperfectly 
 cooked meat, pork, or sausages, raw meat or salads, may be the 
 agents by which the ova are introduced. 
 
 The treatment of tapeworm is in most instances one that leads to 
 a satisfactory result in the expulsion of the worm ; but, unless the 
 head of the animal be detected, we can have no certainty that the 
 pest is removed. Numerous remedies have been used, but the Male 
 fern is, I believe, the best ; the observations made many years ago 
 by Sir William Gull testified to the efficacy of this remedy. The 
 powder of the rhizome of the Filix mas may be given in doses of 
 one to three drachms, but a better preparation is the liquid extract 
 or the oil of male fern, in doses of 3j mixed with mucilage mixture 
 and aromatic water. The remedy should be given after the patient 
 has been fasting for five or six hours, and should be followed by a 
 dose of castor oil. Kousso is another of these remedies ; it is the 
 dried blossom of the Bray era anlhelmintica, and it should be admin 
 istered when the patient is fasting. An infusion should be made, a 
 quarter of an ounce in four ounces of boiling water, and when cool 
 the whole quantity should be swallowed. The remedy is an effec- 
 tive one, but very nauseous, on account of its smell. 
 
 The oil of turpentine in Jj or ij doses is also very efficacious. It 
 also should be given on an empty stomach, and at bedtime, for the 
 turpentine often produces temporary headache and giddiness. 
 Kamtela or Kameela is also recommended, 1 in doses of 3j or ij, mixed 
 with mucilage and followed by a purgative. The bark of the pome- 
 granate root (Granati radicis cortex) is given in the form of decoction, 
 and often proves efficacious; it also should be given several hours 
 after food and be followed by a purgative. Other remedies have 
 been used, but those we have mentioned are the most important. 
 Questions sometimes arise in the treatment of tapeworm as to the 
 propriety of postponing our remedies ; thus the entozoon is some- 
 times found during an attack of enteric fever, or during pregnancy, 
 and the question arises whether injury will accrue from the remedies 
 
 1 Dr. Gordon, ' Report on Diseases of the Stomach and Bowels in India.'
 
 INTESTINAL WORMS. 491 
 
 used. In an instance of a patient recovering from enteric fever in 
 Guy's, under the care of the late Dr. Babington, full doses of oil of 
 turpentine were given without producing any injurious effect, and 
 the patient was freed from the taenia ; again, in pregnancy with ex- 
 cessive irritability of stomach it is better to make the attempt of 
 cure than to allow the patient to go on unrelieved. Sometimes one 
 remedy after another is tried without success, but the fault will 
 generally be found to be in the mode of administration. 
 
 The Round worms the Nematoda are more highly organized, 
 and there are several species which infest the intestinal canal. One 
 of the best known is the Ascaris lumbricoides, the round worm, as it 
 is termed, varying in size from four to six inches in the male to ten 
 or fifteen inches in the female ; it is cylindrical in form, and has 
 three lips surrounding the mouth of the animal. The male is much 
 smaller than the female, and the spermatic duct opens at the same 
 opening as the intestine, and two curved spicula are seen projecting 
 from the part. The female contains two long coils of ovary and 
 oviduct, which open into a vagina. The ova are oval, and are pro- 
 duced in immense numbers, and are expelled with the feces. They 
 are about ^\^ to ^\^ of an inch in diameter. It is not ascertained 
 in what way they obtain entrance into man, but they locate them- 
 selves in the small intestine, and often are very numerous in the 
 same individual ; sometimes clusters of them, two or three, may 
 exist together in different portions of the whole canal, in the duode- 
 num, jejunum, ileum, and stomach ; I have seen them in the oesopha- 
 gus, and cases have been described where they have produced fatal 
 results by getting into the larynx ; they are found also in the colon. 
 It has been stated that they afe able to destroy the coats of the in- 
 testine and thus reach the peritoneal cavity ; but it is now generally 
 believed that ulceration and perforation had taken place, and the 
 lurnbricus had used the opening thus made; the irritation they pro- 
 duce may, however, aggravate ulceration in a marked degree ; still, 
 some instances appear to confirm the idea that lurnbrici may them- 
 selves induce ulceration and consequent perforation ; such, for in- 
 stance, is one recorded in the 'British Medical Journal' of 1861, by 
 Dr. Sandwith, in which a small perforation in the middle of the 
 duodenum led to fatal perforation. Dr. Young, in a paper in the 
 'Medical Gazette,' records several cases where lumbrici were evacu- 
 ated through the abdominal parietes ; one instance was in a child, 
 aged seven ; several worms had been discharged from the bowels, an 
 abscess afterwards formed in the right lumbar region, and living 
 lumbrici were evacuated ; after two years the abscess healed. 
 
 In another case, a child aged fifteen had severe pain in the abdo- 
 men, and lumbrici were found in the stools ; an abscess formed on 
 the right side of the abdomen, and lumbrici were passed through it; 
 on inspection it was found that a fecal abscess had been formed at 
 the commencement of the colon, into which also the jejunum opened. 
 It is probable that in both these cases either caecal or strumous dis- 
 ease or direct injury had led to abscess, through which some of the 
 lumbrici were discharged. The same paper mentions a recorded
 
 492 INTESTINAL WORMS. 
 
 case of an infant, in whom a lumbricus was discharged from the 
 navel ; and another of a woman, in whom an artificial anus existed 
 in the right groin, through which a lumbricus was passed. A worm 
 crawled from the mouth of a young patient of mine during the night, 
 who had passed numerous lumbrici, after the administration of 
 santonine ; the worm was observed on the child's pillow. It is, 
 however, probable, that the passage into the trachea and bronchi 
 only takes place after the death of the patient. The symptoms found 
 with this worm are a tumid, full, and doughy state of the abdomen, 
 indicating that the secretions and muscular coat are not in their 
 normal condition ; the body is often feebly nourished ; the cheerful- 
 ness is lost ; the appetite is Variable, sometimes craving, but un- 
 certain ; there is frequently severe colic; the breath is offensive, and 
 there is irritation of the nose and anus. Other signs are frequently 
 found, but they are in many instances sympathetic from the irrita- 
 tion of the intestine, especially when the subject is strurnous, and 
 predisposed to disease in other viscera; thus the brain often sympa- 
 thizes, so that the patient may be seized with convulsions, or have 
 attacks of chorea, or epileptic fits, conditions which are entirely 
 removed by the evacuation of the entozoa. 
 
 These worms occur more frequently in young children, but are 
 not limited to them, for we observe them in young adults of both 
 sexes, but especially in delicate and in strumous subjects. 
 
 The best remedy by which to get rid of the round worm is santo- 
 nine, in doses of 3 to 5 grains given every or every other night on 
 an empty stomach. The santonine is obtained from an undetermined 
 species of Artemisia. The general health should be improved by 
 proper diet and by tonics, and the 'bowels acted upon by gentle 
 aperients. Stronger purgatives are often given, as jalap and scam- 
 mony; but, although they remove a large quantity of mucus, they 
 do not generally effect a cure. 
 
 The Oxyuris vennicularis is well known as the threadworm, and 
 in its appearance it closely resembles a minute portion of ordinary 
 thread. The male is smaller than the female, and is about one-sixth 
 of an inch in length. The female is about one-third to half an inch. 
 The animal has a mouth closed by three lips, from which extends 
 the oesophagus and intestinal canal. The eggs are oval and about 
 ssflth to y&nth of an inch in size. They pass all the stages of de- 
 velopment in the intestinal tract. 
 
 The threadworm is found in both small and large intestine ; the 
 mature females are said to be especially found in the caecum. The 
 threadworms are present in the rectum, and pass from it to the 
 perineum and even reach the vagina ; but it is erroneous to state that 
 they only exist in the rectum. The eggs are swallowed with the 
 food, and development begins in the stomach when the egg is acted 
 upon by the gastric juice. As long as the threadworm exists only 
 in the small or in the upper part of the large intestine no symptom 
 is produced, but in the rectum its presence causes intolerable itching. 
 Itching of the nose, impairment of appetite, general restlessness, 
 and distress, may be produced by threadworms; we have seen urti-
 
 INTESTINAL WORMS. 493 
 
 caria present in children thus affected, but whether as the effect of 
 threadworms is doubtful. They are more common in young child- 
 ren, but are also observed in adults. 
 
 In the treatment they may be destroyed and washed away from 
 the rectum by means of enemata; the best is composed of one-third 
 or half a pint of lukewarm infusion of quassia, or of salt and water; 
 decoction of oak bark, dilute solution of alum, may be also used ; at 
 the same time gentle aperients should be given, but such as will 
 thoroughly empty the bowel, as rhubarb and magnesia, if sufficiently 
 active; jalap with rhubarb, syrup of senna, confection of sulphur, or 
 a few grains of gray powder; afterwards rnild chalybeate medicines 
 may be administered. The oil of male fern and santonine have less 
 effect upon the threadworm, than in the cases in which we have 
 recommended them. It is important to be very careful both as to 
 the food taken, and as to the perfect cleanliness that should be ob- 
 served in every respect. 
 
 The Tricocephalus dispar, the whipworm, is a small worm about 
 two inches in length, with a thread like head, the smallest part of the 
 animal constituting about two-thirds of its length ; it is generally 
 found in the caecum. On the abdominal surface is a longitudinal band, 
 and the intestinal tract passes throughout the length of the animal 
 from the oesophagus and the stomach. The male is rather smaller 
 than the female, and the male genital organ presents a spiculum which 
 projects from the cloacal opening ; it is set with numerous sharp 
 points, and is surrounded by a sheath. The eggs are oval, they are 
 very numerous, and have, at either extremity, a minute projection. 
 
 We are not acquainted with any symptom produced by the pre- 
 sence of these worms; they have generally only been recognized 
 after the death of the patient on post-mortem examination. I have 
 in this way found them, whilst I had the charge of the post-mortem 
 examinations at Guy's Hospital. 
 
 The DochmiiiSj or Strongylus duodenalis, or the Anchylostomum 
 duodenal^ was discovered by Dubini in 1838 in the north of Italy. 
 It is a small cylindrical worm, the male nearly half an inch and the 
 female three-quarters of an inch in length. At the bell-shaped 
 mouth are several strong hooks ; the male terminates in a lobate 
 enlargement, but the female is pointed. The animal fixes itself in 
 the duodenum and jejunum; it is very common in Egypt, according 
 to Bilharz. Its presence produces anaemia, and its attendant symp- 
 toms of weakness, palpitation, disturbance of the senses; there is 
 craving or depraved appetite and dyspnoea. These symptoms arise 
 from the loss of blood. 
 
 No medicine is known directly to dislodge the animal, but the 
 treatment must be carried out on general principles to remove the 
 worm and to relieve the bloodless condition by chalybeates. Tur- 
 pentine, followed by chalybeates, would be apparently the best plan 
 of treatment. These cases are not seen in England, and I am depen- 
 dent on the description and statement of other observers. 
 
 Several minute kinds of Trematoid worms have been recognized.
 
 494 INTESTINAL WORMS. 
 
 The Distomum crassum was found by Busk in the duodenum of a 
 Lascar, and the Distoma heterophyes has been discovered by Dr. 
 Bilharz in Egypt in the intestine of a boy. The Bilharzia haBma- 
 tobia, also prevalent in Egypt, has been the cause of diarrhoea and 
 hsematuria; but for many particulars of these and other varieties 
 which have been noted by observers we must refer to the treatises 
 already mentioned.
 
 CHAPTER XIX. 
 
 ON PERITONITIS. 
 
 REFERENCE has frequently been made in the preceding chapters 
 to disease of the serous investment of the intestines, the peritoneum : 
 and we propose now to review the general forms of peritonitis, to 
 notice the pathological appearances they present, the symptoms by 
 which they are indicated, the causes which produce them, and then 
 the treatment best calculated for their removal. 
 
 Peritonitis is presented under the form of acute or plastic inflam- 
 mation, chronic inflammation, purulent inflammation, septic inflam- 
 mation. 
 
 Acute peritonitis. The earliest pathological appearance which the 
 peritoneum presents, when acutely inflamed, is congestion of the 
 capillary vessels, with a loss of the smooth and shining appearance 
 of the serous membrane; dry ness then takes place, from the dimin- 
 ished secretion, and slight opacity follows. This congestion is espe- 
 cially manifest at the angles of contact of the coils of the intestine, 
 thus producing vascular lines, which pass along the long axis of 
 bowel ; in very acute disease, however, the whole surface is reddened. 
 The inflammatory oedema which gives opacity to the serous mem- 
 brane is an indication that the sub-peritoneal coat is involved; it 
 arises from interstitial cell-growth. The muscular coat next partici- 
 pates in the disease; its contractile power is diminished, and the 
 intestine distends, producing the tympanitis -of which we shall have 
 to speak; the coats of the intestine may be readily separated from 
 each other; effusion of lymph then takes place, and it is often found 
 to cover over the intestine in large flakes, mixed with serum in the 
 more dependent situations; if the disease be at a very early stage, 
 or slight in degree, this lymph is represented by a mere stickiness 
 and very slight adhesion between the intestines. The serum is 
 sometimes present in considerable quantities, and in chronic perito- 
 nitis fills and distends the serous sac; but the conditions of the fluid 
 effusion vary according to the character and the intensity of the 
 disease; sometimes it consists of clear serum containing portions of 
 semi-coagulated fibrin; at other times the serum may be almost of 
 the character of pus, and between these extremes every gradation 
 is observed. In proportion as the effusion is less organized it is 
 corpuscular in character, and approaches proportionately to the 
 appearance of pus. As the peritonitis subsides, these effusions may 
 gradually become absorbed; but more generally they leave traces 
 of their presence, the lymph becomes organized, fibres are produced, 
 and vessels become developed in them ; adhesions between portions 
 of intestine are thus formed, either uniting them closely together, or
 
 496 ON PEHITONITIS. 
 
 constituting bands, which may be the cause of subsequent internal 
 strangulation; 1 the lymph which covers the viscera, as the liver and 
 spleen, often forms a thick investment, which gradually becomes 
 firm, fibrous, and cartilaginous in density, and calcareous particles 
 are occasionally developed in it, especially in the splenic adhesions; 
 at an early stage these investments may be stripped off' from the 
 proper tunic of the viscus, but afterwards they become inseparably 
 united. Again, sometimes the lymph is spread generally upon the 
 viscera, or it forms rounded patches, or it has a cribriform appear- 
 ance, as if rounded portions had been removed or absorbed. Lymph 
 deposited upon and between the layers of the mesentery and omen- 
 turn leads to gradual contraction, to shortening, and fibroid thicken- 
 ing. In some cases the serous membrane has a granular appearance; 
 these granules must not be mistaken for an appearance sometimes 
 found several days after death, when the serous membrane appears 
 sprinkled with grains of sand; these possess the crystalline character 
 of triple phosphate, and are probably formed after death. Lastly, 
 acute peritonitis may lead to a general thickening of the serous 
 membrane without adhesions; the membrane becomes dense, whitish, 
 thickened, arid fibrous, and this arises from the fibrinous effusion 
 taking place in the substance of the membrane rather than on its 
 surface. In chronic peritonitis the same general changes are pro- 
 duced; lymph may be effused, become organized, and form adhesions 
 or produce thickening of the serous membrane; or effusion of serum 
 takes place, so as to distend the serous membrane, even without 
 previous acute symptoms. The thickening of portions of peritoneum 
 covering the liver which is frequently found after the pressure from 
 stays and belts, consists in part of a fibroid degeneration of the serous 
 membrane itself. 
 
 Peritonitis is either general or local ; the former is often rapidly 
 fatal; the latter is in many instances conservative in its action ; and 
 in perforation of the intestine from numerous causes, it limits or pre- 
 vents extravasation. If extravasation have occurred, it may be so 
 localized by peritoneal adhesions, that life is prolonged for weeks, or 
 even for many months. When acute inflammation in the abdominal 
 glands or viscera takes place, local disease of the peritoneum in the 
 neighborhood is set up; thus the peritoneum covering the liver be- 
 comes involved in hepatic disease, and that in the pelvis in acute 
 disease of the ovary. 
 
 Tubercular peritonitis has already been described. 
 
 Cancerous disease of the peritoneum frequently leads to inflamma- 
 tory change of an acute or chronic form, but these changes will be 
 subsequently referred to; it occurs either as a primary disease of a 
 scirrhous, medullary, or colloid form, or as a secondary one, from the 
 extension of -the disease to the peritoneum from the intestine. Thus, 
 in cancerous disease of the stomach, or of the caecum and colon, tuber- 
 cles with inflammatory lymph are often found upon the peritoneum; 
 
 1 Bands leading to strangulation do not always have an inflammatory origin. See 
 an interesting pamphlet on this subject, by Mr. Gay.
 
 ON PERITONITIS. 497 
 
 so also with cancerous disease of the ovaries and of the mesenteric 
 and lumbar glands; but in advanced life especially, primary cancer- 
 ous disease of the peritoneum is not unfrequent ; an immense number 
 of tubercles, some semi-transparent, others red and congested, from 
 the size of grains of sand to split peas, are found everywhere stud- 
 ding the serous surface, mixed more or less with ordinary fibrin and 
 lymph; sometimes the deposition of pigment in these tubercles gives 
 them a black color, and a form of rnelanosis is produced; this appear- 
 ance, however, is to be distinguished from the blackness arising from 
 effused blood. This form of cancerous disease is generally associated 
 with considerable serous effusion, and it is more common in women 
 than in men. Again, sometimes cancerous disease especially in- 
 volves the ornentum or the mesentery; and it is generally, when 
 so situated, either of a medullary character, constituting large masses, 
 composed of nuclei and nucleated cells, or of a scirrhoid character, 
 when the affected parts become thickened by a fibro-cancerous growth ; 
 sometimes the disease consists of colloid growth. The omentum 
 in these cases, often forms a dense, hard mass, extending across 
 the abdomen at the umbilical region ; it is then several lines in 
 breadth, and semi-cartilaginous, but still more or less transparent; 
 and serous or fibrinous effusions may have taken place in con- 
 siderable quantity into the serous sac. In some cases, both of minute 
 cancerous tubercles on the peritoneum, and of the more general 
 thickening to which we have just referred, it is very difficult to 
 draw an exact line of demarcation between the simple products of 
 ordinary inflammation and those of true cancerous disease. If a 
 large quantity of pigment be deposited in the cells of the growth, 
 as we sometimes find in medullary cancer of the omentum, &c., the 
 term melanotic cancer is applied. Colloid cancer affects the perito- 
 neum either in part, as when the ornentum only is affected, or gene- 
 rally, when it envelops almost the whole of the abdominal viscera; 
 it presents the semi-gelatinous appearance of colloid with intersect- 
 ing bands, constituting alveoli, which contain large nucleated cells 
 and colloid matter. This colloid disease of the peritoneum is either 
 primary or it follows from colloid affection of the stomach, the 
 caecum, &c. 
 
 The symptoms of acute peritonitis are generally very characteristic, 
 as when, for instance, the stomach and appendix caeci are perforated 
 by ulceration, sudden intense pain comes on, the patient is "doubled 
 up," unable to move, and lies with the legs flexed; the countenance 
 expresses the intensity of the suffering, as well as the serious nature 
 of the disease ; the distress and pain are evident in the features, the 
 eyes are sunken, the face is pallid, the abdomen very shortly becomes 
 distended, tender and tympanitic; no pressure can be borne, and 
 even the weight of the bedclothes becomes insufferable ; the pulse is 
 small, compressible ; and, if reaction take place from the first sudden 
 collapse, it becomes more hard, frequent and wiry; the bowels are 
 generally confined, especially at the early stage of the acute disease, 
 but sometimes towards the close of the malady diarrhoea may super- 
 vene. The urine is scanty, and if the vesical peritoneum be in- 
 32
 
 498 ON PERITONITIS. 
 
 volved, retention often takes place. If the peritoneal surface of the 
 stomach be implicated, vomiting is a frequent and distressing symp- 
 tom, and green bilious fluid is ejected. The mind may be conscious 
 and strong throughout, even when the powers of life are fast failing, 
 and the pulse is scarcely perceptible at the wrist. 
 
 In many cases of perforation the patient scarcely rallies from the 
 first sudden collapse, and death takes place in five to ten hours 
 after the onset of the disease ; in other instances, however, the signs 
 of febrile excitement, which are never well marked in acute perito- 
 nitis, are more evident, as shown by heat of skin, especially of the 
 abdomen, by thirst, and by a frequent and hard pulse. If the dis- 
 ease tend to an unfavorable termination, the prostration increases, 
 the patient is restless, the tongue dry and brown, the pulse compres- 
 sible, failing and irregular; the extremities become cold, a clammy 
 sweat breaks out, hiccough comes on, and then death follows, the 
 patient often remaining sensible till the close, and the subsidence of 
 pain, as life is ceasing, occasionally gives to the superficial observer 
 a false hope of recovery. On the contrary, when the vomiting sub- 
 sides, the pain and distension lessen, the countenance becomes less 
 haggard and dejected, the pulse soft and less frequent, but tolerably 
 firm, and especially, when the patient has refreshing sleep, we may 
 regard the immediate danger as less imminent. Gradually all the 
 symptoms may disappear, and the patient completely recover, with 
 perhaps some peritoneal adhesions and thickening. It may be that 
 effusions take place, which are more gradually absorbed, or become 
 very persistent ; again, if fecal extravasation have occurred, repeated 
 attacks of local peritonitis, with hectic fever, follow, or renewed 
 general inflammation destroys the life of the patient. 
 
 It must be remembered, however, that pain is not an invariable 
 symptom of peritonitis ; sometimes the patient presents an exhausted 
 appearance, the tongue is dry and brown, the pulse is very compres- 
 sible, the abdomen is distended, but no complaint is made, and the 
 patient dies from asthenia or exhaustion, and on the post-mortem 
 table the coils of intestine are found to be covered with lymph, and 
 the whole serous membrane acutely inflamed. Such cases we have 
 often seen after paracentesis in chronic disease of the liver. Again, 
 in cases of pyaemia, and of septic poisoning, acute inflammation, 
 leading to purulent effusion into the serous cavity, takes place with- 
 out any pain in many instances. Other symptoms are present, 
 distension of the abdomen, tympanitis, sometimes but not invariably, 
 constipation, and dryness of the tongue. There may be vomiting 
 and hiccough, and failing pulse ; the mind may be clear, or there 
 may be delirium and unconsciousness before a fatal termination 
 ensues. 
 
 Chronic Peritonitis may commence with the symptoms of acute 
 disease, and subsequently produce recurrent pain, distension and 
 effusion. This recurrence of symptoms is more especially the case 
 in the course of tubercular and cancerous disease. In these instances 
 the symptoms are less severe, although of the same general char- 
 acter; pain, with distension and tympanitis, and with a peculiar
 
 ON PERITONTTIS. 
 
 haggard expression, which is very characteristic of abdominal affec- 
 tion; the abdomen is at the same time hot, and tender on pressure. 
 
 In strumous peritonitis, the pain is paroxysmal, and often resembles 
 severe colic; the bowels are irregular, the stomach sometimes irrita- 
 ble, the tongue red and injected, the patient fretful, and as the 
 intestines become matted together by adhesions, the viscera move 
 en masse, and a doughy sensation is communicated on manipulation ; 
 or these strumous and inflammatory adhesions may be local, simulat- 
 ing abdominal tumors. The indications of disease are also associated 
 with general strumous cachexia. and are often complicated with 
 pulmonary disease. Too frequently hectic supervenes, and this is 
 especially the case when fecal abscess has been produced, and the 
 hope of ultimate recovery is then almost taken away. In strumous 
 peritonitis also the pain may be very slight, whilst effusion gradually 
 takes place to a considerable extent, as we sometimes find in children 
 after measles, &c., or excessive tympanitis may be produced without 
 any acute pain. 
 
 In cancerous peritonitis there is the same expression of distress on 
 the countenance, with pain and heat of the abdomen, with gradual 
 distension, and often with serous effusion; if the disease consist in 
 cancerous growth in the omentum and mesentery, a tumor may 
 generally be felt; if it extend to the peritoneum from the stomach, 
 liver, intestine, ovary, &c., the earlier symptoms will be indicative 
 of the primary malady. It must, however, be remembered, that in 
 both strumous and cancerous disease the symptoms of acute perito- 
 nitis may be suddenly developed in the course of the chronic disease, 
 from perforation of the intestine or otherwise, and lead to a speedily 
 fatal termination. This acute mischief is sometimes set up by per- 
 foration from degeneration of cancerous deposit, or by paracentesis, 
 the persistent irritation and congestion of the serous membrane 
 passing very readily into general and acute inflammation. In colloid 
 disease of the peritoneum, the symptoms are often obscure, they are 
 pain, with heat and more or less distension of the abdomen, and 
 sometimes diarrhoea; but if the intestine become involved, other 
 diagnostic symptoms arise. 
 
 Diagnosis. The pain of peritonitis may not only be absent, on ac- 
 count of some peculiarity in the character of the disease, but the 
 patient may be rendered unconscious of it from cerebral oppression, 
 or from the dyspnosa and distress of pulmonary and cardiac disease 
 fully engrossing the sensibilities of the sufferer. 
 
 Still there are painful conditions of the abdomen for which perito- 
 nitis may be mistaken. 1st. Flatulent colic. The pain and distension 
 are in this disease sometimes very severe, the countenance may be 
 haggard and distressed, and collapse sometimes results ; but there is 
 not the tenderness of peritoneal inflammation, the symptoms are less 
 persistent, the pulse less affected, the collapse rarely so profound. 
 2d. In hysterical affections of the abdomen, the pain is very super- 
 ficial, and firm pressure can frquently be borne, notwithstanding 
 that the patient almost shrieks before the hand has reached the
 
 500 ON PERITONITIS. 
 
 surface; the countenance does not express the distress of serious 
 organic disease, the pulse may be almost unaffected; still, in this 
 disease, we have seen a patient bled from the arm to syncope, 
 with the idea that acute disease existed. 3d. The vomiting and 
 sudden pain of perforated intestine are sometimes mistaken for gall- 
 stone ; but the latter disease is free from the acute tenderness and 
 distension of peritonitis. 4th. Neuralgic pain from disease of the 
 spine, of a functional or organic character, often simulates peritonitis; 
 but here, also, there is an absence of tenderness on pressure of the 
 abdomen, of distension and tympanitis, as well as of the general ex- 
 pression of peritoneal disease ; the pain is situated in the course of 
 the spinal nerves, and often extends over the crest of the ilium in 
 the course of the last dorsal nerve, or into the groin and testicle in 
 the course of the genito-crural nerve ; there are also, generally, some 
 indications of spinal disease in local pain of the vertebrae, with modi- 
 fied motion and sensibility of the lower extremities, and loss of power 
 of the sphincter muscles. 5th. Suppuration of the abdominal parie- 
 tes is at an early stage very difficult to distinguish from peritonitis. 
 6th. The pain from the distension consequent on the enlargement of 
 abdominal tumors and effusions may easily be mistaken for perito- 
 nitis, as, for instance, in aneurism, in ovarian and cancerous tumors, 
 and in dropsies ; but in these cases, as we have before said, peritoneal 
 disease is often set up in the progress of the malady. 7th. During 
 the course of peritonitis, the muscular fibres of the bladder sometimes 
 fail to contract, apparently from loss of power, and the urine is 
 retained, thus closely simulating simple retention of urine; on the 
 contrary we have also witnessed distension of the urinary bladder 
 from enlarged prostate or other cause, producing pain which re- 
 sembled peritonitis, and which had been sent to the hospital as a 
 case of abdominal tumor. 
 
 In reference to the prognosis of peritonitis, instances of intestinal 
 perforation are generally quickly fatal, in from five to ten hours; 
 but in some cases this issue might be prevented if perfect rest were 
 maintained, stimulants and purgatives avoided, and opium given ; 
 for by movements of the body extravasation is increased, and we 
 have seen castor-oil floating in the peritoneum after perforation had 
 taken place. In other cases, we must be guided in the prognosis by 
 the cause of the peritonitis, whether it be of a remedial character or 
 not. As to those symptoms which immediately indicate a favorable 
 or unfavorable termination, we have already alluded to them in de- 
 scribing the general characteristics of the disease. 
 
 Caiisfs. Although peritonitis is spoken of and treated as an 
 idiopathic disease, we do not find that it is so ; it is excited by injury 
 to the serous membrane, or by the direct propagation of disease ; 
 and to elucidate this part of our subject we have referred to the in- 
 spections made at Guy's Hospital during a period of twenty-five 
 years ; out of 3752 inspections 501 were instances of peritonitis ; but 
 we cannot find a single case thoroughly recorded in Avhich disease 
 could be correctly regarded as existing solely in the serous mem- 
 brane.
 
 ON PERITONITIS. 501 
 
 In relation to its causes, cases of peritonitis may be divided into 
 three classes. 1. Peritonitis produced by the extension of disease 
 from adjoining viscera, or excited by direct injury, including cases 
 of perforation of viscera, extravasation, violence, &c. 2. Peritonitis 
 connected with blood changes, as when inflammation of the serous 
 membrane occurs in the course of alburninuria, pyaemia, puerperal 
 fever, erysipelas, &c. 3. Peritonitis caused by general nutritive 
 changes of the system, which have been followed by acute or chronic 
 disease of the peritoneum, such as struma, cancer, &c. ; and corn- 
 prising also those cases in which the circulation of the peritoneum 
 has been so altered by continued hypenemia (modifying its state of 
 growth), that very slight exciting causes suffice to induce acute mis- 
 chief, as occurs in peritonitis with cirrhosis, diseases of the heart, 
 &c. In reference to the instances found amongst the large number 
 of inspections just referred to, we find 
 
 1. Peritonitis from direct extension . . 261 
 
 2. Peritonitis connected with blood changes . 94 
 
 3. Peritonitis connected with general or local 
 
 perverted nutrition .... 146 
 
 501 
 
 It will be evident that the first class might be regarded as disease 
 of a local kind, and the second and third as of a general character. 
 The first division includes 261 instances of peritonitis, and of these 
 102 were produced by hernia, internal and external, intussusception, 
 bands of adhesion, and cancerous obstruction. In 19 cases the ob- 
 struction was of an internal kind, and in not a few of these death 
 followed from rupture of the intestinal coats ; 35 cases were caused 
 by injuries or operations directly affecting the serous membrane. 
 In some instances of severe abdominal injury, death resulted before 
 any sign of inflammation had taken place, the injury being of such 
 a character that no treatment could be more than palliative in the 
 most trifling degree, as when the jejunum was completely divided 
 by a vehicle passing over the body. 
 
 Among the operations referred to, one was for the removal of an 
 ovarian cyst ; one a case of gastrotomy ; fourteen were cases of 
 paracentesis abdominis, which was performed in five patients to re- . 
 lieve ascites accompanying cirrhosis, in two for ascites with heart 
 disease, and in seven to empty large ovarian cysts. In instances of 
 ascites from heart disease, chronic bronchitis, and cirrhosis, the 
 whole of the peritoneal capillaries are in a state of continued hyperae- 
 mia; the serous membrane becomes opaque and thickened, and a 
 very slight fresh exciting cause is sufficient to produce acute disease. 
 If a large number of instances of paracentesis abdominis had been 
 taken, it would have been found that in ovarian disease, especially 
 of persons advanced in life, paracentesis is much less frequently 
 followed by a severe and fatal result than in ascites following cir- 
 rhosis. 
 
 Perforation of the intestine into the peritoneal sac constitutes a
 
 502 ON PERITONITIS. 
 
 most important cause of peritonitis, and we shall briefly notice the 
 several varieties. Out of the 501 cases of peritonitis perforation 
 occurred 56 times, namely : 
 
 10 from hernia; 
 
 9 from disease of the stomach ; 
 15 from ulceration of the ileum in enteric fever ; 
 4 from tubercular disease; 
 
 11 from disease of the cascum and appendix; 
 
 1 from cancer of the vagina; 
 4 from cancer of the colon ; 
 
 2 from ovarian adhesions. 
 
 56 
 
 This lesion, so often fatal in enteric fever, generally supervenes 
 about the twenty-first or twenty-second day, and many instances are 
 no. doubt accelerated by muscular movements ; the period, however, 
 of perforation, is subject to considerable variation, occurring some- 
 times as early as the tenth day ; in others, being postponed till the 
 fifth or sixth week, when the patient may seem convalescent. We 
 have before referred to the fact, that in fever, peritonitis is set up 
 by ulceration, although the peritoneum may be entire, transudation 
 having taken place in a sufficient degree to produce acute mischief. 
 
 In tubercular disease the sudden and intense peritonitis from 
 perforation is generally prevented by adhesions ; occasionally, how- 
 ever, these limitations of the mischief are incomplete; in the ulcera- 
 tion of phthisis, as well as in tubercular disease of the peritoneum, 
 this sudden termination is found to occur. 
 
 Diseases of the caecum and of the appendix are still more frequent 
 causes of peritonitis, and in these affections perforation often takes 
 place unexpectedly. In perforations, however, of every kind, the 
 extravasation may be circumscribed, and local peritonitis and fecal 
 abscess be the result ; numerous instances of this kind are detailed 
 in preceding chapters. 
 
 Another frequent source of peritonitis consists in the extension of 
 disease from the bladder, uterus, and other pelvic viscera ; and in 
 less severe degrees local peritonitis is often observed from ovarian 
 irritation. The enumeration of the pelvic origin of forty-two cases 
 from amongst the numbers we have before referred to will best 
 illustrate the nature of this cause : 
 
 6 from ovarian disease; 
 1 from ulcerated vagina and uterus; 
 1 from strumous disease of the testicle and castration; 
 1 from diseased prostate; 
 1 from strumous pyelitis; 
 1 from fistula in ano ; 
 1 from cancerous disease of the bladder ; 
 1 from polypus in the bladder ; 
 l-l from cystitis, calculus in the bladder, stricture, &c.;
 
 ON PERITONITIS. 503 
 
 1 from extravasation of urine ; 
 
 2 from sloughing perineum ; 
 
 1 from sloughing of the nates ; 
 10 from lithotomy ; 
 1 from diseased hip and pelvis. 
 
 4.2 
 
 This number does not include peritonitis from stricture and chrome 
 ulceration of the rectum ; diseases which not unfrequently extend to 
 the serous membrane. The introduction of bougies, and the incau- 
 tious digital examination of the bowel, may sometimes lead to acute 
 peritonitis. 
 
 Peritonitis is also caused by diseases of the liver and gall-bladder, 
 and some of these are instances of extreme interest ; thus, abscess in 
 the liver, hydatid disease, gall-stone, primary disease of the gall-blad- 
 der may each induce disease of the general serous membrane. In 
 many cases of chronic congestion and enlargement of the liver, and 
 in cirrhosis, especially of an acute kind, the peritoneum becomes im- 
 plicated ; and the serous membrane is found, when a fatal issue has 
 taken place, to be thickened and chronically inflamed; acute peri- 
 tonitis is in these conditions very easily induced ; but we have in- 
 cluded these chronic forms of hepatic disease amongst the third class 
 of causes of peritonitis. 
 
 Peritonitis is sometimes the result of acute disease of the mucous 
 membrane of the intestine, extending to the deeper coats, and to the 
 peritoneum itself, leading to inflammation, or to perforation and fecal 
 abscess. Ulceration of the colon was the cause of fecal abscess in 
 three of the instances we have previously mentioned, and a case of 
 simple perforation was from this cause. In three other instances, 
 acute dysentery, with sloughing of the coats of the intestine, also pro- 
 duced peritonitis. 
 
 In reference to the etiology of peritonitis, the following table shows 
 not only the large proportion of cases due to simple extension of dis- 
 ease to the serous membrane, but the forms of disease by which 
 peritonitis is induced ; 261 instances from 501 are thus referable to 
 direct extension : 
 
 From hernia, of which 19 were cases of internal obstruction . .102 
 
 " injuries or operations . . . . . .35 
 
 " perforation of the stomach, ileum, caecum and appendix, colon, 
 
 &c. (other 13 mentioned with hernia or with caecal disease) . 43 
 " perforation leading to fecal abscess (2 cases mentioned else- 
 where) . . . . . . .17 
 
 " typhoid ulceration without perforation . . . /) 
 
 " disease or operations on the bladder and pelvic viscera, &c. . 42 
 " disease of liver and gall-bladder, &c. . . . .11 
 
 " acute disease of the colon (3 others enumerated with perforations) 3 
 " diseases of caecum or appendix (9 others previously mentioned) 3 
 
 261
 
 504 ON PERITONITIS. 
 
 "We now turn to the second division, namely peritonitis connected 
 with a changed condition of blood, such as exists in albuminuria, in 
 pyaemia, in puerperal peritonitis, and in erysipelas, &c. 
 
 In albuminuria, where the renal disease is of an acute kind, lymph 
 may be effused, and the symptoms of peritonitis are often well marked ; 
 but in some cases, in which there is small granular kidney, with con- 
 tracted liver, the peritoneum is thickened, and more chronic disease 
 is found to exist. Albuminuria is a frequent cause of serous inflam- 
 mation affecting the pleura, the pericardium, the arachnoid, sometimes 
 the joints, and, as these cases show, the peritoneum also. It rarely, 
 however, happens that the peritoneum only is affected, although such 
 is sometimes the case. The symptoms also are often masked by the 
 distress arising from the general anasarca, and the dyspnoea from 
 cedernatous lungs. 
 
 Puerperal peritonitis is often associated with suppuration either 
 in the uterine veins, or in the pelvic cellular tissue, or in the broad 
 ligaments. But there are sometimes instances in which the peritoni- 
 tis arises from a general cause, and these may perhaps be considered 
 as pyaemic or even of a rheumatic character, or connected, as we have 
 before said, with renal disease. Thus, peritonitis is found with peri- 
 carditis and with pleurisy; with pneumonia and dysentery, or with 
 these conditions renal disease may be also combined. The two fol- 
 lowing cases are worthy of record in their causative relation. 
 
 CASE CLXXXIV. Hypertrophy of the Heart. Adherent Pericardium. 
 Acute Pericarditis. Pleurisy and Peritonitis -- James M , set 9, was a 
 delicate boy, who had suffered from cough, but there was no history of 
 rheumatism ; he had been in the hospital for disease of the bones of the foot, 
 and left nearly well ; in one week he returned very ill, and was found to be 
 suffering from pericarditis ; there was slight pain in the shoulder, but no 
 swelling of the joints generally. He died in three days. There was a ciea- 
 trix on the foot, showing the part from which the fourth metatarsal bone had 
 been removed ; but there was no suppuration. There was general pleurisy 
 on both sides, recent lymph in small quantities being found ; the lungs were 
 congested, and the bronchi full of tenacious mucus. There was acute and 
 chronic pericarditis, as shown by adhesions of recent lymph, and in some 
 parts by very firm fibrinous bands. Minute depositions were found on the 
 cardiac valves. In the abdomen, although the serous membrane had not lost 
 its transparency, there were some flakes of recent lymph and a small quantity 
 of serum. 
 
 Was this general disease of the character of rheumatism ? 
 must regard it as arising from some general cause, and in that re- 
 spect very different from so-called idiopathic peritonitis. 
 
 CASE CLXXXV. Acute Peritonitis. Pericarditis. Plenro-pneumonia. 
 Small Granular Kidneys William B , aet. 42, was admitted into Guy's 
 Hospital, June 13th, 1855; he had been a laborer, and had resided in the 
 Borough. A year previously he had had jaundice, and three days before 
 admission had had rigors, but on the following day, although feeling ill, lie 
 went to his employment; the next day he gave up work. On admission, he 
 was very ill, presenting the signs of pneumonia of the right lung; the dulness 
 rapidly increased, with bronchophony ; much blood was expectorated, and he
 
 ON PERITONITIS. 505 
 
 became delirious, but whilst sensible did riot complain of pain. The urine 
 was not albuminous. He died on the 20th. There was recent consolidation 
 of the whole of the right lung ; the pericardium was covered with a layer of 
 fresh lymph ; there was also acute peritonitis, the intestines being adherent 
 by recent lymph. There was a hydatid cyst in the liver, surrounded by a 
 dense white envelope, one-eighth of an inch in thickness, and containing dis- 
 integrated membrane with opaque fluid ; the gland itself was fatty. 
 
 The kidneys were granular and coarse, the tunic adherent, the secreting 
 tubes filled with inflammatory products. 
 
 The third and last class comprises peritonitis of a general char- 
 acter, arising from tubercles and cancer, in which the peritoneal 
 disease is often very insidious. We include in this division those 
 cases in which, after a prolonged state of hyperaemia, the serous 
 membrane becomes thickened, and a very slight cause suffices to 
 produce acute disease. 
 
 The only remaining causes are those in connection with chronic 
 disease of the liver and the thoracic viscera, producing prolonged 
 hyperaemia of the peritoneal vessels and ascites, and readily termi- 
 nating in acute peritonitis ; hence the danger of tapping in these 
 instances ; but acute peritonitis often occurs in cirrhosis from other 
 very slight exciting causes. 
 
 In cirrhosis the peritoneal covering of the liver is very generally 
 thickened. We do not, however, refer to this merely partial affec- 
 tion, but to those in which the whole serous membrane is affected. 
 
 In 'the second and third divisions of cases of peritonitis, the causes 
 were as follows : 
 
 From Bright's disease . . . .63 
 " pyaemia, 13 ; erysipelas, 5 ; puerperal 
 
 fever, 10 ; with pneumonia, 3 . 31 
 " tubercular disease . . . .70 
 " cancerous disease . . . .40 
 " hepatic disease . . . .27 
 " heart disease ..... 9 
 
 240 out of 501 instances. 
 
 Treatment. The consideration of the origin of peritonitis, either 
 in its local or general source, is the best guide to proper treatment, 
 whether it arise 1st, from extension of disease from adjoining 
 viscera, or from perforation and injuries; 2d, from blood changes, 
 such as occur in albuminuria, pyaemia, and erysipelas, &c. ; 3d, from 
 almost imperceptible changes or deficiencies in general nutrition 
 modifying the state of the general health, as in struma, cancer, and 
 climacteric changes ; or from the hyperaemia of the peritoneum, con- 
 sequent on cirrhosis and chronic disease of the heart and lungs, when 
 upon very slight exciting causes, acute mischief follows. In the 
 first forin^ if perforation have taken place, perfect rest is exceedingly 
 important, in diminishing extravasation, and in localizing the perito- 
 neal mischief; purgative medicines of all kinds should be avoided, 
 and also stimulants, which are often unfortunately given at once, 
 before a medical practitioner sees the patient. This injudicious
 
 506 ON PERITONITIS. 
 
 attempt to 'relieve pain by purgatives, carminatives, and stimulants, 
 may deprive the patient of the hope of recovery ; for, as we have 
 before said, we have seen castor oil floating in the peritoneal cavity. 
 Food, also, should be abstained from, or only a few spoonfuls ad- 
 ministered to relieve thirst ; in more chronic forms, not arising from 
 perforation, food of a fluid and bland kind only is admissible ; and 
 even when the more active symptoms have subsided, the return to 
 solid forms of aliment must be very cautiously made. When there 
 are symptoms of failing power, stimulants in small quantities may 
 be given, but they are best combined with demulcent food, as brandy 
 with arrow-root, &c. 
 
 As regards medicinal treatment, we believe the plan recommended 
 by Dr. Stokes and Dr. Graves to be of the greatest value, not only 
 in cases of perforation of the intestine, but where the peritoneum is 
 acutely inflamed from the direct extension of disease. It consists in 
 the administration of opium in full and repeated doses ; and its bene- 
 ficial result arises from its favoring rest of the intestines and the 
 localization of the mischief, from the mitigation of suffering which it 
 affords, whilst at the same time it alleviates nervous prostration and 
 collapse, and facilitates reparative action. The opiate plan may be 
 combined with the external application of anodyne remedies, such as 
 chloroform liniment with belladonna liniment, warm linseed poultices, 
 cotton wool sprinkled with laudanum. Turpentine may be also ap- 
 plied on a flannel wrung out of hot water. Local peritonitis is also 
 greatly relieved by the same remedies and external applications, as 
 when produced by ovarian and csecal disease; but blisters are of value 
 in more chronic cases, and especially in those instances in which re- 
 peated attacks of peritonitis occur. Mercury, either in the form of 
 gray powder, calomel, blue pill, or as mercurial inunction, is, we be- 
 lieve, injurious in all these cases of acute direct peritonitis. It tends 
 to prevent adhesion, it excites peristaltic action, it promotes ulcera- 
 tion, it increases the depression consequent on the disease, which is 
 often the immediate cause of death, and lastly, it renders the intes- 
 tinal contents more fluid, thereby increasing extravasation. We are 
 well aware that many instances of acute peritonitis from diseased 
 caecum, from enteritis, and from ovarian disease, recover after mer- 
 cury has been given; but as far as the causes we have enumerated 
 can be any guide, and from extensive experience in these cases, we 
 strongly deprecate its use. 
 
 Effervescent medicines generally increase the painful distension of 
 the abdomen, but diaphoretics and salines are sometimes of value 
 when combined with opium. 
 
 In the subsequent treatment we must not be too desirous of induc- 
 ing action from the bowels, and, when necessarv, gentle enemata are 
 better than purgatives administered by the mouth; many days may 
 elapse without any action, and aperients frequently produce a renewal 
 of pain. 
 
 When the more active symptoms have subsided, opium may be 
 continued with vegetable tonics or with quinine. If fluid effusions 
 have formed, iodide of potassium and diuretics may be advisable, 
 and the abdominal glands may then be beneficially stimulated by an
 
 ON PERITONITIS. 507 
 
 occasional dose of gray powder or calomel. Preparations of iron are 
 not generally well borne in the convalescence from acute peritonitis 
 t will often be found that as the health becomes established the 
 fluid effusion rapidly disappears ; in other cases the repeated applica- 
 tion of counter irritants may be required, and sometimes it is well to 
 remove the serum by paracentesis. 
 
 In the peritonitis of albuminuria the best treatment consists in the 
 relief of the general disease by diaphoretic medicines, counter irrita- 
 tion and cupping on the loins, also bv free evacuation of the bowels ; 
 but mercurial preparations very readily affect the system, producing 
 severe salivation, without corresponding benefit. When effusion 
 becomes extreme, it is better to attempt its removal by puncturing 
 the thighs and by purgatives rather than by directly emptying the 
 serous cavity. I have sometimes used with benefit the minute drain- 
 age-tubes recommended by Dr. Southey. Hot-air baths are some- 
 times of great service. 
 
 In the treatment of the peritonitis of pyaemia and erysipelas the 
 local disease is to be less regarded than the general one, nor should 
 we attempt to cure the peritonitis of this kind by depletion and mer- 
 curial preparations. Opium and salines, with the free use of stimu- 
 lants, are apparently the best remedial agents we can employ. Ty- 
 phoid symptoms too frequently come on, and precede a fatal result. 
 
 In puerperal peritonitis the same plan of treatment may be adopted. 
 In some cases the blood becomes affected by the absorption of septic 
 material ; or pelvic phlebitis and cellulitis are followed by the peri- 
 toneal disease ; and, from the beneficial effect following the internal 
 administration of tincture of the sesquichloride of ironin erysipelas 
 and diphtheritic disease of the throat, Dr. Heslop has recommended 
 the same remedy in puerperal peritonitis, as being a disease closely 
 allied in character. Those cases which we have seen recover have 
 apparently been benefited by thoroughly washing away uterine dis- 
 charges, by the free use of opium, and\y stimulants; but we are 
 quite prepared to hear further reports of the good results of the 
 tincture of the sesquichloride. In puerperal peritonitis the use of 
 turpentine internally has been recommended, and has been followed 
 sometimes by a beneficial result. 
 
 In the treatment of acute peritonitis in struma, the same rules 
 ought to be borne in mind as in the treatment of strumous pneu- 
 monia. Opium is of value not only in relieving the pain and the 
 great nervous prostration so constant in disease of the abdomen, but 
 it also facilitates the recovery of the injured structure. Warmth 
 and anodyne applications may be used ; purgatives should be avoided, 
 and rest strictly maintained ; but mercurial preparations, given so as 
 to affect the mouth, are as injurious in this form of strumous com- 
 plication as in any other, and it is not necessary to recur to mercury 
 for an aperient remedy, nor to prevent the opiates from checking 
 secretion. 
 
 In the more chronic forms the means best calculated to remove 
 the local malady are those suited for the removal of that general 
 state of the system which has predisposed to the complaint; such as
 
 508 ON PERITONITIS. 
 
 nourishment as far as it can be borne, cod-liver oil, steel as in the 
 form of iodide steel wine, the iodide of potassium, alkalies, &c. Oc- 
 rasionally counter irritants may be used, and moderate pressure on 
 the abdomen employed to promote the absorption of serous effusions; 
 an elastic bandage, strips of plaster, as the adhesive or the belladonna 
 plaster, may be thus applied; in some instances in which I have 
 used the arnmoniacum plaster with mercury, the intolerable itching 
 which was produced compelled the removal of the application. 
 Residence at the seaside greatly facilitates- recovery in these cases. 
 In slow strumous effusion, especially in young persons, after perito- 
 nitis, it is often extremely difficult to produce absorption, and para- 
 centesis is sometimes advisable. 
 
 Peritonitis with cancerous disease is always associated with enfeebled 
 power and diminished functional activity. Remedies such as diuretics 
 have very little effect in promoting the absorption of fluid, and any 
 measures which still further diminish strength appear to increase 
 dropsical effusion. To sustain the powers of life by every available 
 means is the best preventive against this result. If acute symptoms 
 supervene, the opiate plan of treatment must be followed, with rest 
 and bland nutritious diet. If paracentesis be performed, temporary 
 relief may be obtained ; but more frequently the patient very rapidly 
 declines, and we then h'nd that the whole of the diseased peritoneal 
 surface has increased in vascularity and lymph is poured out. 
 
 Peritonitis with cirrhosis is generally found in persons who have 
 been of intemperate habits; the arteries are often diseased, and the 
 kidneys may be granular and atrophied. At an early stage of the 
 disease, when the diet can be regulated, and the excretory functions 
 of the liver, the kidneys and the skin stimulated to increased action, 
 the symptoms may, in a great degree, be alleviated; and when acute 
 peritonitis is set up with cirrhosis, no class of cases are more bene- 
 fited by the judicious use of the ordinary remedies for peritonitis, 
 namely, local depletion, and mercurials with opium, on account of 
 the stimulant effect which mercurials have on the excretory glands; 
 but all the good effect of mercury may be attained without that 
 remedy being used so as to produce salivation. 
 
 If the peritonitis be of a chronic form, and associated with ad- 
 venced cirrhosis, our measures will, at best, be only palliative. Some 
 have recommended mild mercurial salivation before tapping, to 
 prevent the supervention of acute symptoms; but we have no ex- 
 perience of such a treatment, and we believe that if tapping be 
 really necessary mercurial salivation would be detrimental, and 
 would increase the exhaustion which often follows the operation, or 
 that the mercurial cachexia would lead to the speedy reaccumulation 
 of the fluid. Mercurial frictions are less objectionable when used 
 with moderation ; and minute doses of blue pill, with tonics, as qui- 
 nine, or with aperients, are, in many instances of chronic peritonitis 
 from hepatic disease, of great service. Other remedies may also be 
 tried, as diuretics, iodide of potassium, riitro-hydrochloric acid, &c., 
 but the persistent congestion of the vena portae interferes with their 
 absorption and with their beneficial action. Nearly the same re-
 
 ON PERITONITIS. 509 
 
 marks apply to the treatment of peritonitis coming on in the course 
 of chronic disease of the heart and of the lungs. In these cases I 
 never recommend paracentesis, unless compelled by the urgent 
 distress from enormous distension. 
 
 We believe that the benefit generally ascribed to mercury in the 
 treatment of acute peritonitis is not an established fact, and the 
 good results which apparently follow its Tise may, perhaps, be more 
 correctly attributed to the opium with which it is usually combined. 
 
 M. Beau has employed large doses of quinine in the treatment 
 of acute peritonitis, but we have no experience of this mode of treat- 
 ment. 
 
 Numerous instances might be adduced to illustrate the symptoms, 
 the pathological appearances, and the treatment of acute as well as 
 chronic peritonitis ; the fearful suddenness, and oftentimes fatal re- 
 sult of the former, and the insidious character of the latter, might 
 be abundantly demonstrated ; each chapter has contained some 
 illustrations of peritoneal disease, but a few cases in which some 
 peculiarities were observed, are all that we shall mention. 
 
 CASE CLXXXVI. Peritonitis. Local Suppuration. Perforation of 
 the Diaphragm Robert P , aet. 26, was admitted into Guy's Hospital, 
 January 6th, 1858 ; he had been a laboring man, residing in Bermondsey ; 
 and stated that he had been well till seven weeks previously, when one night 
 he was suddenly seized with violent pain in the abdomen, accompanied by 
 vomiting and purging ; he was, however, able to walk to an apothecary's 
 house the next day, but the symptoms remained, and afterwards increased in 
 severity. When admitted he was exceedingly ill, and there was much ob- 
 scurity as to the precise character of the disease ; he had the appearance of a 
 patient in the later stage of typhoid fever ; the diagnosis was peritoneal dis- 
 ease. He died on the 9th. 
 
 The body was wasted, the abdomen tumid. The brain was not examined. 
 The left lung was pushed up, and its base was adherent to the diaphragm ; 
 when the lung was removed its lower surface was found to form part of an 
 abscess situated in the abdomen, and which had perforated the diaphragm. 
 The abscess was in the left hypochondriac region ; and the surface of the 
 spleen, the left lobe of the liver, and the diaphragm formed its walls ; the 
 surface of the lung opposed to the opening of the diaphragm was also involved. 
 The fluid in the abscess was well-formed pus, without odor. The neighbor- 
 ing organs were carefully examined, to see if any disease in them had pro- 
 duced the abscess, but nothing could be satisfactorily found. The stomach 
 and its mucous membrane were healthy. The duodenum and colon were 
 firmly united, and gave way on attempting to separate them. All the in- 
 testines were more or less united, but there was no ulceration. The kidneys 
 were coarse ; the heart and bronchial glands were healthy. 
 
 We believe that the local peritoneal disease in this instance arose 
 from some blow which the patient had received, for there was no 
 evidence of perforation of any of the viscera, 
 
 CASE CLXXXVI I. Chronic Painless Peritonitis. Tubercle. Great 
 
 Tympanitis William F , aet. 46, was admitted into Guy's, February 13th, 
 
 1857, and died March 26th, 1857. 
 
 He had been for several years a policeman in the Borough, and was of
 
 510 ON PERITONITIS. 
 
 temperate, steady habits. He had not received any blow on the abdomen, 
 nor was he aware of any exciting cause of the disease ; lie had had diarrhoea, 
 however, some months previously. Two weeks before admission the abdo- 
 men became enlarged and tense, but without any pain ; this increase of size 
 went on till admission, when the abdomen was distended and tympanitic, but 
 still free from pain. 
 
 He was a tall man, spare, and emaciated, the eyes glazy and sunken, the 
 pupils contracted, and the conjunctiva injected, the pulse very small, quick, 
 and compressible, the tongue clean, the bowels open regularly, the urine 
 scanty. In the abdomen slight fulness could be detected in the region of the 
 liver ; fluctuation was indistinct. The abdomen was neither hot nor tender 
 on pressure. He was prostrate and sunken in the bed ; but he could take food 
 well, and was quite sensible. At the apices of the chest the respiration was 
 very coarse, almost bronchial ; the heart sounds were normal. The tympani- 
 tis in great measure subsided about, a fortnight before death, but he became 
 gradually more prostrate ; still, he did not suffer from any pain. Three days 
 before death his mind wandered considerably. Only eight or ten weeks 
 intervened between the commencement of the symptoms and the fatal issue. 
 
 Inspection about twelve hours after death. Abdomen. The intestines 
 were moderately distended ; the peritoneum contained about two quarts of 
 bloody serum ; the intestines were everywhere covered over with lymph in 
 grains somewhat resembling tubercles ; there were some tolerably strong bands 
 of adhesion, and the small intestines were united together, but not firmly. 
 The investment of the spleen was more than a quarter of an inch in thick- 
 ness, and of a whitish color from lymph, and contained yellow opaque grains 
 or cheesy masses from degenerating tissue. The appendix was coiled like the 
 letter S, on the right side of the cascum, and was adherent. The liver was 
 fatty; the spleen semi-diffluent ; the kidneys somewhat granular and atrophied. 
 The mesenteric glands were healthy. The stomach was contracted and small, 
 and presented scarcely any post-mortem solution. In the ileum were several 
 small passive ulcers, extending through the mucous membrane, but without 
 any injection around them. The caecum and colon were healthy. The ap- 
 pendix contained feces surrounded by thickened mucus. Chest The pleura 
 was adherent at both apices, but especially on the left side; the left apex was 
 puckered, and was of an iron-gray color, consolidated, and it contained some 
 calcareous masses ; some small granular masses resembling tubercles were 
 observed. At the base of the right lobe were several lobules consolidated, 
 and some were in a state of softening, or gray hepatization ; they were situated 
 beneath the pleura as in pyaemia. The heart was healthy, except slight 
 atheroma of the valves. The tubercles in the peritoneum consisted of elon- 
 gated fibre-cells, with a nucleus rendered very distinct by acetic acid ; in 
 some parts more rounded nucleated cells were closely aggregated, in others 
 fibres were formed ; some portions showed degenerating tissue. The structure 
 was more highly organized than in struma, but it could not be considered 
 cancerous. 
 
 Many facts of great interest were presented in this case. 1st. The 
 insidious character of the peritonitis, unaccompanied by pain, but 
 marked by tympanitis, with gradually increasing prostration. 2d. 
 The blood effused into the serous membrane, which apparently arose 
 from the rupture of newly-formed capillaries. 3d. The apparent 
 tendency to struma, as shown by the condition of the lungs, which 
 presented a retrocedent state of chronic pneumonia. 4th. The condi- 
 tion of the blood, as indicated by the pysemic lobular pneumonia,
 
 ON PERITONITIS. 5J_|_ 
 
 the diffluent state of the spleen, and the effusion of blood into the 
 peritoneum As to the exciting or predisposing causes of disease 
 nothing could be found ; it was not a case apparently of enteric fever 
 he had not been more exposed than policemen generally are to cold 
 r wet ; he had been a man of temperate habits, and there was no 
 isease of the liver beyond fatty degeneration. The probable pre- 
 .isposing cause was the strumous diathesis. We have already re- 
 ferred to this case as one which might easily have been mistaken at 
 an early stage for one of functional dyspepsia; and other cases of a 
 similar kind have come under our notice. 
 
 CASE CLXXX YIN Ulceration of the Intestine. Strumous Peritonitis, 
 fecal Abscess. Umbilical Discharge. Mary Ann E , jet. 38, by occupa- 
 tion a servant, was admitted, under Dr. Hughes' care, into Guy's Hospital, 
 Hh, 1857, and died on August 4th. She had resided at Brixton and 
 [ two months previous was quite well, when she began to suffer from pain 
 in the abdomen ; this gradually increased with vomiting and distension ; and 
 at last several tumors appeared. On admission she was very ill, with symp- 
 toms of general peritonitis, tenderness, distension, &c. Three or more denned 
 tumors could be felt ; one at the umbilicus, a second in the ri^ht hypochon- 
 dnum, and a third on the left side. They could be reduced by pressure^ and 
 fluctuation was believed to be felt. On July 30th the tumor near the um- 
 nhcus burst at that part, and pus having a fecal odor was discharged She 
 d,ed on August 4th. The body was wasted. The thoracic viscera were 
 Ihere was a large fecal abscess below the umbilicus circumscribed 
 by the liver and the colon, and extending into the transverse colon ; upon 
 attempting to separate the intestine, further openings were made. Numerous 
 ulcers were found in the ileum, cascum, and colon ; and most of these ulcers 
 had perforated the coats of the intestine ; extravasation had, however, been 
 prevented by adhesions. Between the coils of intestine close to the mesen- 
 tery were several loose earthy bodies, and similar ones were found in the 
 mesenteric glands. The liver was fatty. 
 
 Although there was no evidence of tubercular disease in the lungs 
 of this patient, we regarded the case as one of strumous disease of 
 the abdomen, from the condition of the mesenteric glands, and the 
 general character of the disease. It is probable that ulceration of 
 the mucous membrane of the ileum first took place, possibly from 
 enteric fever, and afterwards chronic peritonitis supervened; the 
 latter was marked by severe attacks of pain and vomiting ; adhe- 
 sions between the coils of the intestine then formed, and limited the 
 extravasation which subsequently took place from the perforated 
 intestine. 
 
 In strumous peritonitis suppuration sometimes arises from the de- 
 generation of the low organized peritoneal product, and the pus 
 forms an opening into the intestine, namely, from the peritoneal to 
 the mucous surfaces. In other cases, the perforation is from within; 
 the extensive ulceration of the small and large intestine in this case 
 rendered it probable that the latter was the course of the disease. 
 The external opening at the umbilicus is a rare event in these cases, 
 and if a fecal abscess thus opening had been the only one, great relief 
 to the pain and distress might have followed; but these collections of
 
 512 OX PERITONITIS. 
 
 fecal matter were numerous. The calcareous condition of some of 
 the mesenteric glands, and loose calcareous bodies of similar kind in 
 their neighborhood, are interesting facts connected with the expla- 
 nation of loose bodies sometimes found in the serous sac. 
 
 CASE CLXXXIX. Ascites. Cancer of the Ovaries and Peritoneum. 
 Paracentesis. Peritonitis. Ann II , aet. 45, was admitted under my care 
 September 20th, 1858. She was a single woman, and had ceased to men- 
 struate in December, 1857. Since that time the abdomen had begun to 
 swell, and ascites came on ; she was tapped, and dark colored fluid was drawn 
 off; vomiting with severe pain in the abdomen supervened, and continued 
 till her admission. There was then great emaciation, and irritability of the 
 stomach was still very troublesome. The abdomen became very large, and 
 fluctuation very distinct. Severe pain, with tympanitis, subsequently came 
 on, and she gradually sank. 
 
 On inspection, the peritoneum was found studded with cancerous tubercles; 
 the omentum was contracted, and contained much deposit; the stomach was 
 irregularly contracted into two pouches; the pylorus was healthy; but an 
 inch from the pylorus its coats were invaded by cancerous disease ; the mucous 
 membrane in several parts was intensely congested. The intestines were 
 distended with flatus, and there were indications of peritonitis at the lines of 
 contact of the coils of the intestine; some serous effusion was observed. The 
 deposit on the peritoneum consisted of abundant nuclei. There was a medul- 
 lary tubercle in the kidney; the glands were otherwise healthy, but there 
 were no tubercles in the liver. The pleura presented numerous tubercles ; 
 and there was a considerable quantity of serous effusion in botli serous cavi- 
 ties. The heart was normal. The spleen was enlarged. Both ovaries witli 
 the uterus were united into one mass by deposit of a fibro-medullary char- 
 acter; and numerous cysts were observed containing secondary cysts. The 
 os uteri was healthy. 
 
 The acute peritoneal mischief was set up by the paracentesis; 
 constant pain, and almost daily vomiting, with gradually increasing 
 exhaustion followed, till death ensued. The onset of the disease 
 was insidious, and probably arose in the ovaries; cancerous tuber- 
 cles were then developed on the peritoneum, and effusion took place. 
 This effusion may be without pain, excepting that arising from dis- 
 tension; at length the large size of the abdomen, the painful disten- 
 sion, the inability to take food from the pressure on the stomach, 
 the impeded respiration, the sleepless nights, and the general distress, 
 cause the patient to long for relief; but there is always the danger 
 of more acute inflammatory disease being set up, as was the case in 
 this patient before she applied for admission into Guy's Hospital. 
 
 CASE CXC. Carcinoma of the Peritoneum, with Effusion. Paracen- 
 tesis Mary T , ret. 57, admitted into Guy's Hospital April 25th, 1857, 
 and died on August 28th. 
 
 She stated that about two months before admission the abdomen began to 
 swell, and gradually increased. On June 13th, paracentesis abdominis was 
 performed, and again on July Uth; at each operation more than five gallons 
 of fluid being drawn off. No signs of peritonitis followed, but she gradually 
 sank. 
 
 On inspection, the lungs and pleura were found to be healthy ; there was 
 recent lymph effused on the anterior aspect of the pericardium, upon the
 
 ON PERITONITIS. 
 
 ventricles; and a small quantity posteriorly. In the abdomen there were 
 several pints of fluid; numerous white cancerous nodules were scattered over 
 the serous membrane, especially on the intestines. The membrane also was 
 thickened by chronic action, in a more marked degree on the anterior parie- 
 The peritoneum covering the liver was opaque, and in some places 
 tubercular. The omentum was drawn up and formed a solid mass (cancerous) 
 The lymphatic glands were only slightly affected, but there were some large 
 masses between the diaphragm and the liver. The surface of the diaphrao-m 
 itself was affected; the tunic of the spleen was opaque; the liver, spleen 
 suprarenal capsules and kidney were healthy. The right ovary consisted of 
 a mass of new growths and cysts, about the size of the fist; the former were 
 made up of a spongy-looking fungus, composed of fibre-cellular structure, and 
 the latter were filled with fluid. There were some smooth cavities containing 
 a soft sebaceous matter, and amongst this were numerous hairs. 
 
 In this case the disease also probably commenced in the ovaries- 
 there was absence of pain, but gradual effusion; the ascites was,' 
 however, greatly relieved by paracentesis, no acute peritonitis fol- 
 lowed, but, as too frequently happens, the fluid soon re-collected 
 and again required to be drawn off; but at each time the patient 
 was less able to rally from the effect of the operation. 
 
 CASE CXCI. Chronic Peritonitis. Renal Disease. Spurious Cysts in 
 the Peritoneum Elizabeth S , set. 44, a stout married woman, was admitted 
 December 7, 1859, under Dr. Barlow's care, and died February 11, 1860. 
 She had been confined eight months before admission; and swelling of the 
 legs was followed by effusion into the abdomen. There was general anasarca, 
 and the urine was albuminous. The abdomen became distended ; there was 
 distressing cough ; prostration supervened, and she gradually sank. 
 
 Inspection There was effusion into the left pleura, and the bronchial tubes 
 were much congested. Heart The muscular fibre was pale ; the right and 
 left ventricles were both much dilated. Abdomen The intestines were dis- 
 tended ; on opening the serous membrane an appearance very closely resem- 
 bling ovarian dropsy presented itself. The supposed cyst on the right side 
 consisted of peritoneal effusion, shut off by fibrinous adhesions. This serous 
 collection extended from the right iliac region as high as the liver, and be- 
 tween the liver and diaphragm ; the fibrous cyst could in great measure be 
 separated from the peritoneum, and contained many pints of slightly milky 
 serum. Another cyst was found between the colon and the stomach. The 
 mesentery was slightly contracted, and all the intestines were matted together. 
 The kidneys contained cysts and some inflammatory deposit. The liver was 
 soft and congested. The ovaries were atrophied. 
 
 Effusion into the peritoneum with serous inflammation is of fre- 
 quent occurrence in renal disease, and such was the cause of the as- 
 cites in this case. It is, however, especially recorded on account of 
 the very peculiar appearance that was presented on opening the ab- 
 domen ; there was the precise resemblance of a patient affected with 
 ovarian dropsy, for the lymph effused upon the peritoneum had 
 formed a cyst, and shut off the serous exudation. The lymph with 
 its contained serum could be separated from the liver and intestine, 
 but the ovaries themselves were healthy. 
 
 OO
 
 514 ON PERITONITIS. 
 
 CASE CXCII. Colloid Cancer of the Peritoneum and Ascending Colon 
 Harriet K , aet. 32, a hawker residing in Kent Street, was admitted into 
 Guy's Hospital March 27th, 1861, under the care of Dr. Rees. Her general 
 health was good, and her habits of life temperate ; but she had an aniumic 
 appearance. Her employment exposed her to wet, cold, and fatigue, and 
 she had evidently suffered from causes of depression, having had improper 
 food, and the care of a family of five children. There was no history of 
 hereditary disease. 
 
 Six months previous to her admission she was seized with a sharp pain at 
 the lower part of the abdomen, and the pain was increased on pressure. From 
 that time the bowels became relaxed, but the diarrhoea had been more severe 
 for three months, ten to twelve motions being passed ; the motions were of a 
 dark color, and sometimes were of a white glairy matter, like white of egg. 
 Small masses of indurated feces were also sometimes passed. She complained 
 of a sense as of great weight at the lower part of the abdomen when standing. 
 For a short time she suffered from dyspnoea, but the cough was slight ; the 
 expectoration was greenish and tenacious. There had been no catamenial 
 discharge for eighteen months. She suffered from vomiting; the pulse, 120, 
 was small and soft ; the tongue was dry in the centre, but the tip and edges 
 were clean and moist. The diarrhoea continued to the close, but it was par- 
 tially checked by treatment ; she sank a week after admission. 
 
 Inspection was made twenty-four hours after death. The thoracic viscera 
 were natural. The whole of the peritoneum was covered with colloid cancer, 
 which extended from the diaphragm to the pelvis : no viscera, however, were 
 involved except the ascending colon, and it was doubtful whether this was 
 primary or secondary disease. On opening the abdomen the omentum was 
 seen spread over the surface of the intestine, and reached nearly to the pubes. 
 The mesentery was converted into a solid mass of colloid, an inch in thick- 
 ness, and of considerable density. It formed a tolerably uniform mass, except 
 at the edges, where the disease existed in the form of distinct nodules ; the 
 omentum was slightly adherent. On raising the omentum adhesions existed 
 with the ascending colon, and on opening this portion of the intestine the 
 walls were found to be involved, and in part destroyed by the disease. The 
 cascum itself was free, but above it the walls of the colon were converted into 
 a solid tumor for about five inches. In other parts the disease was confined 
 to the peritoneum, but in the ascending colon it had penetrated the coats and 
 had partially destroyed them ; thus, on section, the muscular coat could be 
 seen traversing the centre of the colloid growth. The mesentery and its 
 glands and the lumbar glands were free from disease ; but the whole of the 
 diaphragmatic peritoneum was covered, so also the peritoneal surface of the 
 bladder, liver, and spleen. The substance of the liver and spleen were 
 healthy, so also the kidneys, uterus, and ovaries. The left iliac vein was 
 distended with an ante-mortem clot. The microscope showed colloid struc- 
 ture in the peritoneal growth. 
 
 This was a well-marked instance of colloid disease of the perito- 
 neum originating in similar disease of the colon. A glairy discharge 
 from the bowels was present, but I have not observed this symptom 
 in other instances of colloid disease which have come under my 
 notice. Pain in the region of the colon was the first indication of 
 disease, and was followed by diarrhoea of a very persistent character, 
 by vomiting, and gradual prostration. There was nothing, however, 
 during the course of the complaint to enable us to diagnose its pre-
 
 ON PERITONITIS. 515 
 
 cise character. The patient was only thirty-two years of age, but 
 she had had five children. 
 
 LOOSE BODIES are occasionally found in the peritoneal cavity, oval 
 in form, and in size varying from that of a bean to that of a pigeon's 
 egg. They do not appear to produce any symptom, but they have 
 been known to pass into hernial sacs. They are variously constituted. 
 1st. Some arise from growths connected with the intestine, and whilst 
 some may be quite free, others are found pendant by long thread- 
 like bands. 2d. The separation of appendices epiploicse apparently 
 constitutes others, as in a case recorded by Mr. Shaw, and as shown 
 by the arrangement of its layers. 3d. The separation of calcareous 
 and degenerate glands may also give rise to these loose bodies. This 
 mode of formation appeared probable in Case CLXXXVIII. 4th. 
 The coagulation of fibrinous masses or of blood may lead to their 
 .formation ; but this source is of very doubtful occurrence, although 
 in spurious melanosis dark portions of effused blood may seem to be 
 in an almost separated condition. 5th. Other occasional but rare 
 conditions are proliferous cysts, simple and dermoid cysts.
 
 516 
 
 CHAPTER XX. 
 
 ASCITES. DROPSY. 
 
 THE term dropsy is often limited in its application to the effusion 
 of fluid into the peritoneal cavity; this, however, is more correctly 
 designated ascites, or peritoneal dropsy. The peritoneum is the lin- 
 ing membrane of the cavity in which the intestines and numerous 
 other viscera are placed, it is a serous membrane like the pleura, and 
 covered over by a cellular investment, formerly regarded as epithelial: 
 modern histologists have shown that this is not strictly true, for the 
 peritoneal cells are part of the connective tissue, and therefore endo- 
 thelial. The serous membrane is richly supplied with vessels, and 
 it is from these when in a state of active or passive congestion that 
 the effusion takes place ; these vessels participate in the more acute 
 changes of peritonitis, in which lymph and fibro-albumiuous pro- 
 ducts, and the various manifestations of cellular growth are found. 
 The membrane has also abundant lymphatic vessels. It is, however, 
 especially with fluid effusions into the serous membrane that we have 
 now to do. These fluids are variously composed, according to the 
 nature of the process which has led to them; the quantity of albumen 
 varies, and sometimes leucocytes and cells are found answering to true 
 pus cells; blood is sometimes present, and if the fibrinous material be 
 abundant it may be recognized after death in a coagulated form ; some- 
 times urea is present, and generally some saline constituents. The 
 quantity of the fluid is equally variable ; it may be only a few ounces 
 which gravitate into the pelvis, or it may amount to several gallons. 
 The fluid is usually transparent, of a greenish-yellow color, and slightly 
 alkaline in reaction. If there be disease of the lymphatic vessels, 
 the fluid becomes milky and opalescent, so also it is turbid, if inflam- 
 matory action have place, and proportionately so, as the fluid is more 
 or less purulent. "We have already referred to the occasional pres- 
 ence of blood; this may arise from a transudation of has ma tine in 
 consequence of a changed character of the blood, as in purpura, or 
 it may be due to rupture of congested vessels, as in heart disease, or 
 even to the rupture of newly formed capillaries. Sometimes the 
 fluid is more thick and viscid. For the convenience of description 
 as well as of diagnosis and of treatment, it may be well to divide as- 
 cites into several varieties. 
 
 1. From weakness, asthenic dropsy, such as we find in old age and 
 in states of exhaustion. 
 
 2. From congestion of a passive character, mechanical or secondary 
 dro/tsy, such as we have in chronic bronchitis, in emphysema, in heart 
 disease, in pressure on the vena cava, and to some extent in chronic
 
 ASCITES. DROPSY. 517 
 
 disease of the liver, cirrhosis. In all these states the vena portse 
 and its tributary branches are over-distended. 
 
 3. From peritoneal inflammation and congestion of an active kind 
 inflammatory dropsy. 
 
 4. From disease of the liver, the kidneys, the spleen, and the lym- 
 phatic glands, glandular dropsy. 
 
 5. From strumous or tubercular disease. 
 
 6. From cancerous disease of the peritoneum in its several forms 
 whether primary or secondary. 
 
 7. Ovarian dropsy. This, however, is not ascites, although ascites 
 may be associated with it. The disease is limited to the ovaries, 
 and the effusion is cystiform. 
 
 The first symptom of the presence of fluid in the peritoneum is 
 the increase in size of the abdomen; the quantity generally, however, 
 attains to a considerable proportion before it is noticed by the patient. 
 Then, unless the patient is stout, and there is a large quantity of fat 
 in the parietes or in the omentum, the fluid may be detected by the 
 sense of fluctuation which is communicated when one hand is placed 
 on one side of the abdomen and a gentle tap is given on the opposite 
 side ; or if the fluid is small in quantity and the loin is bulging, one 
 hand may be placed towards the back, and a gentle blow given on 
 the same side in front ; the readiness with which fluctuation can be 
 felt is greater if the parietes of the abdomen be thin. The fluid in 
 the abdomen, unless it be limited by adhesion, will flow from side to 
 side and gravitate according to the position of the patient. It will 
 fill the pelvis, and if the patient lie upon the back it will pass into 
 the loins; the form of the abdomen is altered, therefore, by the bulg- 
 ing of the loins and the apparent flaccid condition of those parts. 
 If, however, there be irritation of the peritoneum, as from inflamma- 
 tory action, or from the presence of cancerous tubera upon the serous 
 membrane, there is greater tension of the muscular walls of the abdo- 
 men and less projection of the loins. The quantity of fluid may be 
 estimated by the extent of the dulness when a patient is in a standing 
 position as compared with that on lying down; where fluid is present 
 immediately beneath the parietes there is dulness, and where there 
 is intestine there is resonance on percussion; hence we find in ordi- 
 nary cases, if the effusion be moderate in quantity, that the intestines 
 float on the fluid, and the abdomen is resonant in front, whilst there 
 is dulness on the side, from the gravitation towards the loins; if, 
 however, the patient turn on one or other side, the line of dulness is 
 altered, for the fluid passes from one side to the other. If the fluid 
 is in very large quantity and the abdomen is so distended, that the 
 intestine being held back by the mesentery cannot reach its anterior 
 wall, the dulness is general. Again, in some cases of chronic inflam- 
 mation, the mesentery becomes thickened and contracted and the 
 same restraining effect is produced, because the intestines are tied 
 down; still further, adhesions may limit the fluid, so that it cannot 
 gravitate to the dependent parts.' 
 
 Other symptoms are produced by ascitic distension ; the skin be- 
 comes stretched, the coriurn gives way, and transverse markings are
 
 518 ASCITES. DROPSY. 
 
 produced, they may be of a reddish color, but frequently when the 
 distension is lessened they assume a white appearance, as seen after 
 pregnancy ; in very great distension, the umbilicus sometimes yields, 
 it bulges out in a globular form; the skin is thin, and the vessels are 
 evident; sometimes rupture takes place, and the fluid escapes, a 
 result to be avoided if possible, as it often leads to acute peritoneal 
 inflammation and the exhaustion of the patient. If the inguinal 
 canal is open, fluid may pass into the scrotum ; but the distension of 
 the tunica vaginalis must not be mistaken for swelling of the scrotum 
 produced by oedema or by pressure on the veins. When the ascites 
 is great, there is also pressure on the large vein of the abdomen, the 
 vena cava; then the blood is prevented from returning from the 
 lower extremities and oedema is the result; and therefore, in ordinary 
 ascites, the enlargement of the abdomen always precedes the swelling 
 of the feet and legs. The interference with the venous circulation 
 also alters the state of the kidneys; the renal veins are distended, 
 the glands act feebly from the passive congestion, urine is often 
 scanty and is not increased by diuretic medicines; but as soon as the 
 pressure is removed by paracentesis then the kidneys act freely. 
 The fluid also presses upon the upper part of the abdomen and the 
 diaphragm ; the liver is pushed up on the right side, and the spleen 
 on the left; and the fluid may pass over the edge of the liver, be- 
 tween it and the parietes. Digestion is also interfered with, for the 
 stomach is compressed; sometimes severe vomiting is induced or 
 there is loss of appetite, pain after food, and sense of great distension. 
 It is very remarkable how these gastric symptoms may suddenly 
 cease when the pressure is taken off. We have already referred to 
 the fluid passing into the pelvis, the bladder and rectum may both 
 be compressed, and in women the fluid may be felt in the recto-vesi- 
 cal pouch. The general symptoms as to the pulse, the tongue, the 
 temperature and the respiration, vary according to the state of the 
 patient. The fluid in the peritoneum may, however, be associated 
 with a solid tumor, whether in the ovary, in the glands or in other 
 parts; again a hydatid cyst in any of the abdominal viscera may 
 complicate the diagnosis. A large ovarian cyst may be present and 
 be recognized by its fixed position, the non-gravitation of the fluid 
 &c., but it may be associated with ascites; there may be fluid outside 
 the cyst in the peritoneum ; lastly, pregnancy may be present with 
 ascites. Pregnancy is sometimes attempted to be hidden under the 
 name of dropsy, and a medical man ought never to be thrown off his 
 guard in this respect. 
 
 1. Ascites from weakness, asthenia or exhaustion is sometimes 
 observed after loss of blood, or in chronic disease, as in the latter 
 stages of phthisis; and we may in advanced life, when the circulation 
 has become very feeble, observe the same condition. The fluid in 
 these cases slowly collects, there is neither pain nor inflammatory 
 action ; the ankles, and even the whole leg, become cedematous. 
 The effusion is of a passive character, and is due to the feeble con- 
 dition of the circulation, and it may be, to obstruction of the vessels 
 from thrombosis; there is no febrile disturbance, and the patient is
 
 ASCITES. DROPSY. 519 
 
 often unconscious of the ascitic enlargement. In these instances the 
 ascites is purely symptomatic of a state of general exhaustion no 
 treatment is required, beyond what is necessary to sustain the feeble 
 circulation; to attempt to remove^ the fluid by purgatives and 
 diuretics would lead to increased weakness and would also augment 
 the ascites. 
 
 2 Ascites produced by congestion of the portal circulation. This 
 is also of a passive character and is secondary to other disease, and 
 may be regarded as mechanical as to the manner in which it is' pro- 
 duced. The hepatic dropsy to which we have presently to refer, is, 
 in many instances, of the same secondary character. The minute 
 branches of the portal vein are distributed everywhere upon the 
 abdominal viscera, the stomach, the small and large intestine as well 
 as upon the peritoneum ; congestion of these vessels, which is often 
 of an extreme character, leads to the discharge of serous fluid into 
 the general cavity of the peritoneum. It commences in the abdomen 
 f the liver only is affected, but in the cases to which we now refer, 
 the obstruction extends to the cava and the legs, and the legs and feet 
 also become oedematous. These cases are especially those of obstruc- 
 tive disease of the valves of the heart, and obstruction in the lungs, as 
 we find m chronic bronchitis and emphysema. In the former class of 
 maladies, cardiac affection, we may instance stenosis or contraction of 
 the mitral valve ; the blood is unable to pass onwards freely ; the left 
 auricle is first overstretched, next the pulmonary veins, and thus the 
 whole lungs necessarily become surcharged ; hence also the chronic 
 congestion of the lungs, the attacks of pulmonary apoplexy and of 
 pleuritic effusion. Since, however, the blood is retarded in the lungs, 
 the right side of the heart is next distended, and the power of the 
 right ventricle is overtaxed to propel the blood onward ; the muscle 
 becomes hypertrophied and the cavity dilated ; next the right auricle 
 is similarly distended, and the blood is retarded in the superior cava, 
 and also in the inferior cava; the large hepatic veins opening into 
 the cava immediately before it passes the diaphragm, to reach the 
 auricle of the heart, necessarily become distended, hence the con- 
 gestion of the liver, its increase in size, and the nutmeg appearance 
 it presents. Not only are the veins of the liver overstretched, but 
 also those which form the inferior cava, the renal veins and the iliac 
 veins from the pelvis and lower extremities ; it is in this way that 
 oedema of the feet is produced as well as ascites, the latter being due 
 to the state of the portal circulation. The congestion of the liver 
 interferes with its secretions, and distension of the portal ramifi- 
 cations in the stomach and intestine induces disturbance of their 
 functional integrity; saHowness or even jaundice is produced and 
 the severe gastric ^symptpms i which we have previously described. 
 These symptomr are 'often regarded as the primary disease, and the 
 dropsy of the abdomen is diagnosed as primary instead of being 
 secondary in character. The enlargement of the liver, the jaundice, 
 the severe flatulence, disordered appetite, the furred tongue, pain at 
 the stomach, all tend to confirm the opinion that the abdomen is the 
 primary source of the disease. As a rule in every case of ascites the
 
 520 ASCITES. DROPSY. 
 
 heart and lungs should be carefully examined. The same remark 
 may be made in reference to the kidney; the chronic congestion leads 
 to an albuminous condition of the urine, and this may be regarded 
 as the primary malady. Care will, however, prevent this mistake. 
 The urine is generally scanty, of a deep color and of a high specific 
 gravitv. It is well, to remember that chronic congestion may give 
 rise not only to inflammation of the surface of the liver, and peri- 
 hepatitis, but also to a state of general subacute peritonitis. 
 
 The treatment of these cases is often attended with marked relief; 
 it is important to try and remove the cause as far as possible, 
 whether it be due to disease of the heart or lungs, and thus to lessen, 
 if possible, the secondary affection and remove the ascites. The 
 relief of the latter is often attended with marked diminution in the 
 symptoms of the primary disease ; if the congestion of the portal 
 system is lessened, that of the liver is also lessened and so also the 
 distension of the right side of the heart. Having lessened the cardiac 
 oppression, the lungs are also relieved, the heart's action becomes 
 more regular; the breathing is more free, and the patient's distress 
 proportionately relieved. The treatment of the secondary affection 
 is often more important than that of the primary disease; thus it 
 may be well to use expectorants to lessen the bronchitis, and stimu- 
 lants such as ether, ammonia, and ardent spirits to help the action 
 of the heart, so also digitalis may be of the greatest service; but if 
 we act upon the abdominal glands so as to increase their activity we 
 shall more effectually lessen the primary, whilst we remove the 
 secondary, trouble. 
 
 / Purgatives and diuretics should be used; I prefer a combination 
 of blue pill, or calomel, or the black suboxide of mercury, with squill 
 and digitalis. At the same time other diuretics should be given, as 
 the acetate, nitrate, citrate, or iodide, or acid tartrate of potassium, 
 with nitric ether, broorn, &c. If the bowels are confined a mercurial 
 purgative or jalap, or scammony, should be prescribed; podophyllin 
 or elaterium may also be used, or the saline purgatives, as magnesia 
 or aperient mineral waters. If the bowels act freely, and the patient 
 is enabled to pass three or four pints of urine, the ascites is lessened, 
 and the chest affection is relieved. The gray suboxide of mercury 
 is often a good remedy in these cases in one-grain doses, so also the 
 copaiba resin in ten or fifteen grains dissolved in spirit, and given in 
 mucilage mixture. The gum resins and turpentine are also some- 
 times of service. In this form of dropsy tapping is less necessary 
 than in hepatic ascites; relief is afforded by the means we have 
 mentioned, or if absolutely necessary the legs may be punctured, 
 and serum allowed to drain from them. There is a greater disposi- 
 tion to the supervention of peritonitis if tapping be performed. 
 
 The third form of ascites is that which follows inflammation of 
 the peritoneum, inflammatory or peritoneal ascites. In strumous sub- 
 jects, and in tubercular disease, serous effusion takes place, but we 
 are now referring to those cases in which there is no such cachexia. 
 The serous membrane becomes inflamed, and pain and other symp-
 
 ASCITES. DROPSY. 521 
 
 toms of peritoneal disease, with serous effusion follow. The abdo- 
 men is rounded and tense, and there may be general uneasiness. 
 
 The diagnosis of these cases is difficult, for the disease may be 
 confounded with strumous peritonitis, and also with that form of 
 peritoneal mischief in which the serous membrane is studded with 
 cancerous tubera. It is rather by negative reasoning than by direct 
 symptoms that we are led to the diagnosis; the occurrence of an 
 acute attack, with the absence of other exciting causes of disease, 
 either in the thoracic viscera or in disease of glands, as the liver or 
 kidney. In the treatment, diuretics may be used, but purgatives 
 only with caution. The abdomen is sometimes with advantage 
 strapped over with the "Emplastrum Ammoniaci cum Hydrargyro," 
 which tends to promote absorption ; the disadvantage of this appli- 
 cation is the intolerable itching of the skin that it often induces. It 
 is very important in these cases to improve the general health. 
 
 The fourth variety of ascites is that which is due to disease of the 
 (/lands, the liver, the kidneys, the spleen, or the lymphatic glands. 
 We have already referred to that form of ascites which is due to 
 secondary congestion of the liver, and it is not our intention to de- 
 scribe all the S3'mptoms of hepatic disease. Many forms of hepatic 
 disorder of an organic kind exist without any dropsy or chronic 
 enlargement, enlargement from fatty degeneration, from chronic 
 obstruction of the bile ducts, from cancerous disease, hydatids, &c., 
 but it is in those forms of disease in which the portal circulation is 
 obstructed that effusion takes place. We have mentioned chronic 
 disease of the heart, chronic bronchitis, and emphysema; the same 
 kind of obstruction may be due to thrombus or to the pressure of a 
 cancerous growth, but the disease may be primarily one of the liver. 
 In chronic inflammation of the liver, cirrhosis, the fibroid tissue of 
 Glisson's capsule becomes thickened; the liver is enlarged and con- 
 gested, the congestion at first affecting the margin of the lobules, the 
 portal circulation, rather than the centre of the lobule, the hepatic 
 venous circulation, as in secondary congestion. As the effused in- 
 flammatory product contracts, the circulation through the vena portae 
 becomes more obstructed, clusters of lobules are cut off from other 
 parts and give the gland a granular appearance; if the contraction 
 be seen on the surface of the liver the organ has an irregular aspect, 
 and when the contractions are more decided the surface has been 
 compared to one studded with hob-nails, hence the term hob-nail 
 liver. When contraction thus takes place the venous circulation is 
 more interfered with than the arterial, and as the result of that con- 
 gestion asc^tes is produced, and the abdomen swells. As the ob- 
 struction increases the veins communicating with the general venous 
 circulation become enlarged, and the superficial epigastric vein of 
 the abdomen returns some of the blood from the lower part of the 
 abdomen to the mammary and intercostal veins, and in this way 
 the blood reaches the vena azygos and the right side of the heart. 
 The haernorrhoidal veins also communicate with the branches of the 
 iliac, and thus relieve the vena portae. These enlarged veins in cir- 
 rhosis are seen on the surface of the abdomen; and from the congeg-
 
 522 ASCITES. DROPSY. 
 
 tion of the hsemorrhoidal veins just referred to there is a tendency 
 to hemorrhage from the rectum. As the liver contracts there is 
 diminished dulness, which may not reach the margin of the ribs; 
 and with this condition the symptoms gradually increase in severity ; 
 bilious attacks, irritability of stomach, disordered appetite, irregular 
 bowels, flatulence, and gradual diminution of strength are produced; 
 the body wastes, but the abdomen is enlarged; the legs are thin, 
 the face haggard, the capillary veins of the face are distinct, the 
 tongue may be at first but little furred, but afterwards it becomes 
 injected; the pulse is weak and irritable: the skin is sallow or semi- 
 jaundiced; the patient complains of weakness, and the nights are 
 often disturbed; the blood becomes changed in character, it coagu- 
 lates feebly, and there is a tendency to hemorrhage; the urine is 
 high colored, and loaded with phosphates. If the surface of the 
 liver be also inflamed (peri hepatitis) there is pain in the right side, 
 and often still more decided contraction; it becomes rounded at its 
 margin, and is often peculiarly shrunken as wasting increases. This 
 form of ascites is recognized not only by the presence of the symp- 
 toms just described, but by the absence of other indications of dis- 
 ease; there is no evidence of pulmonary nor of cardiac disease, no 
 sign of renal disease, nor of tumor pressing upon the vena portae, 
 nor of enlargement of the spleen or lymphatic glands. The swelling 
 begins in the abdomen, there is no general anasarca as in acute renal 
 disease, nor do the legs swell as in cardiac and thoracic disease. 
 
 In hepatic dropsy there is a tendency to hemorrhage, and we find 
 that bleeding takes place from the nose, sometimes from the bowels; 
 coffee-ground vomit from the stomach indicates slight oozing of blood 
 into the stomach from distended capillaries ; sometimes bleeding takes 
 place from the gums; and it is always advisable to avoid any sur- 
 gical operation if possible, for even the puncture of paracentesis may 
 lead to troublesome hemorrhage ; the clinical history enables us to 
 distinguish the disease from purpura haemorrhagica. If renal disease 
 be also present there is more general anasarca, and the urine gives 
 some decided evidence of the presence of albumen. It is sometimes 
 difficult to distinguish hepatic dropsy from carcinomatous disease of 
 the peritoneum; the pain may be mistaken for peri-hepatitis; there 
 is absence of cardiac, pulmonary, and renal disease, the abdomen is 
 the only part affected, and the cancerous cachexia may be imper- 
 fectly developed; the history of the case, however, indicates more 
 acute disease, the abdomen is more tense, there is less bulging in the 
 loins, and there is less evidence of venous obstruction. 
 
 In the treatment of hepatic dropsy, we must remember that we 
 have to do with disease in an advanced stage; for the period for treat- 
 ment of chronic inflammatory disease of Grlisson's capsule is before 
 the development of dropsy; when, however, ascites has taken place, 
 we may endeavor to produce absorption by the use of diuretics, as 
 the acetate, nitrate, or iodide of potassium, with broom, nitric ether, 
 squill, and mercurials in alterative doses; purgatives may be given, 
 and iodine applied externally ; in every case the diet should be care- 
 fully regulated, and stimulants, if possible, avoided ; but it will be
 
 ASCITES. DROPSY. 523 
 
 found that diuretics have often very little effect, for they are not ab- 
 sorbed on account of the distension of the portal veins; copaiba resin 
 I have seen of service in increasing the quantity of urine; and some 
 the saline purgative mineral waters are also of great value If 
 purgatives are administered freely when the strength is exhausted 
 the effusion will often be found to increase: jalap, cream of tartar and 
 scammony may be used; the podophyllin resin may be administered 
 m doses of one-third of a grain to a grain, or as a tincture, one grain 
 being dissolved in 3,j of rectified spirit, and HU Y to ] x given di f uted 
 with water or added to the tincture of jalap; it is a good plan to com- 
 bine a laxative with a tonic, as the taraxacum with bark or the in- 
 fusion of senna with that of gentian, or the sulphate of magnesia in 
 small doses with quinine. If, however, these remedies have failed 
 and the patient has become prostrate, the tongue red, the pulse fail- 
 ing, the stomach irritable, the urine scanty, and the mind distressed 
 it is often very desirable to resort to paracentesis. If there are com- 
 plications of renal or splenic disease, and if the peritoneum has be- 
 come inflamed, as shown by the pain of perihepatitis, there is greater 
 danger of peritonitis; but these complications need not necessarily 
 preclude the operation. In those instances in which peritonitis fol- 
 lows paracentesis abdominis, we must not expect that the pain of 
 peritonitis will always be present; the patient may merely seem to 
 be prostrate, his tongue dry and brown, the pulse failing, and death 
 may take place apparently from exhaustion, whilst on examination 
 we may find the whole of the serous membrane covered with lymph 
 and acutely inflamed. Where the umbilicus has become distended, 
 and at length yields, the sudden discharge of the ascites is generally 
 followed by peritonitis. 
 
 In ascites connected with renal disease, the serous membrane is 
 often changed in structure, so that it becomes pale, and there is sub- 
 acute peritonitis; the countenance is pallid, the urine is albuminous; 
 there is general anasarca, and an absence of svmptoms of hepatic! 
 cardiac, and pulmonary disease. The liver and" the spleen may also 
 be affected, as in lardaceous disease; there is no difficulty in the rec- 
 ognition of such cases, but greater difficulty is found in the diagnosis 
 of chronic cardiac and pulmonary disease in which the kidney has 
 become affected by secondary congestion; the urine in such cases of 
 thoracic disease is scanty, it is high colored, of high specific gravity, 
 and when the congestion of the right side of the heart is relieved, 
 the albumen disappears. It would be foreign to our purpose to enter 
 upon a description of all the forms of renal disease and their treat- 
 ment; it will suffice to remark that the ascites rarely requires separate 
 treatment; sometimes, however, the distension of the peritoneum is 
 so great, and there is so much pressure upon the stomach, that there 
 is excessive vomiting, and scarcely any food can be taken. There 
 may be violent vomiting simply from renal disease, but it is more 
 trying when the stomach is compressed by ascitic fluid. In the 
 treatment of renal ascites, if the malady be acute, benefit is derived 
 from diaphoretics, as acetate of ammonia, with antimony; from hy- 
 dragogue cathartics, as compound jalap powder and elaterium; from
 
 624 ASCITES. DROPSY. 
 
 Turkish and hot-air baths, &c., but when the disease is chronic, these 
 remedies too much exhaust the patient, and saline medicines, with 
 iron or quinine, are more beneficial. If the legs are very oedematou? 
 it is better to puncture them, and in this way to relieve the ascites 
 rather than to perform paracentesis abdominis. Care is required lest 
 erysipelatous or gangrenous inflammation supervene. 
 
 Disease of the spleen, with enlargement, may be found in con- 
 nection with disease of the liver and the kidney, as in lardaceous 
 disease, but in the enlargement with ague the latter glands are 
 unaffected, and there may be no ascites ; in leukaemia or leucocy the- 
 mia, the spleen especially is enlarged and the blood is altered in 
 character, there being an excess of white corpuscles or leucocytes. 
 In the latter stages of this disease ascites comes on, as much, how- 
 ever, from the altered condition of the blood as from any primary 
 affection of the serous membrane ; the patient is anasmic and the 
 strength gradually fails; the heart becomes irritable, and there is 
 disturbance of digestion ; sometimes the bowels become disordered 
 and diarrhoea supervenes, or hemorrhage, as epistaxis, may come 
 on ; these latter symptoms increase the exhaustion, and may be the 
 immediate precursor of a fatal termination. The cerebral condition 
 is altered, the brain is irritable, and convulsions may follow. The 
 spleen in this disease attains enormous proportions, and as it in- 
 creases in size passes downwards and extends towards the median 
 line ; it becomes tilted forward as it enlarges ; the notch at the ante- 
 rior border becomes very distinct, and is one means whereby we 
 may recognize the enlarged gland. This anterior notch may, how- 
 ever, be simulated by a mass of enlarged glands, and great enlarge- 
 ment of the supra-renal capsule may also be mistaken for enlarge- 
 ment of the spleen. Since attention was drawn to this form of 
 disease by Dr. Hughes Bennett and Professor Virchow, numerous 
 instances have been recorded, and the pathological changes have 
 been noted, but the treatment has not been attended with any satis- 
 factory result ; the malady has, in most cases, steadily progressed, 
 and has terminated fatally. Iodide and bromide of potassium have 
 been used, and by some strongly recommended; but the steady use 
 of quinine and of steel, with good nourishment, has been attended 
 with a better result, although the benefit has only been temporary. 
 Several instances have been recorded 1 in which phosphorus has been 
 used by Wilson Fox, Broadbent, and others, but without results 
 which warrant us in advocating its use. The anaemia has not been 
 checked by its administration, nor is life prolonged. Neither has 
 the heroic treatment of removing the gland given encouragement to 
 repeat the operation. Mr. Bryant has twice removed an enormous 
 spleen in cases at Guy's Hospital, but each patient sank in a few 
 hours. 
 
 In general enlargement of the lymphatic glands, as in Hodgkin's 
 disease, there is less affection of the spleen, in fact it is often un- 
 affected, whilst the glands in the neck and in the axilla, in the groin 
 
 1 Clinical Society's Trans.
 
 ASCITES. DROPSY. 525 
 
 and in the abdomen, become enormously hjpertrophied ; there is 
 
 Jess tendency to ascites, but in some cases of enlargement of the 
 
 abdominal lymphatic glands there is an effusion of serum which 
 
 from the chylous vessels becoming implicated, and from obstruction 
 
 e mesenteric lymphatics, becomes of a milky white color These 
 
 instances are rare, and sometimes the milky character of the serous 
 
 ion may be regarded as an accidental condition from obstruction 
 
 of some of the mesenteric vessels, the disease being only of a partial 
 
 character; m other instances there is general disease of the mesen- 
 
 snc glands, the lymphatics are observed as whitish cords in the 
 
 mesentery and on the coats of the intestine. Disease of the recepta- 
 
 culura chyli or pressure upon it by morbid growths, may induce 
 
 the same condition of chylous dropsy. 
 
 The next form of ascites that we have to notice is that which is 
 Found m connection with tubercular disease of the peritoneum and 
 with strumous disease. This disease has already been described and 
 we need not fully remark upon it. It will be sufficient to state that 
 the malady is not always attended by the same symptoms: in some 
 stances the deposition of tubercle is associated with considerable 
 ittammatory effusion, the intestines become adherent and matted 
 together ; ulceration, perforation, and fecal abscess may be produced 
 the abdomen becomiDg large, not so much from serous effusion, as 
 from distension of the intestine. In other cases the serous effusion 
 the prominent sign, and we have true ascites. In a third class of 
 the abdomen becomes very large, but not from serous effusion 
 or from inflammatory disease, as in the first class, but without pain 
 sorile excitement, the intestine becomes weak, its muscular wall 
 yields, the mesenteric glands may be enlarged, and we have the 
 appearance of ascites, but without the reality; the abdomen is 
 resonant everywhere. It is therefore only in the second class that 
 ropsy of the peritoneum really exists. The symptoms of the first 
 class we have already described ; in strumous ascites, the symptoms 
 are very insidious ; there is the history of tubercular disease ; there 
 5 impairment of general health, it may be with some disease of the 
 apices of the lungs ; the abdomen gradually enlarges without pain ; 
 the digestion is interfered with, and the bowels are inactive. When 
 this condition comes on in young women, it may be mistaken for 
 ovarian dropsy. As to the treatment of these cases it is well to 
 improve the general health, to act freely on the bowels, and to use 
 iodine, internally, in the form of iodide of potassium or iodide of 
 iron, externally, as the tincture or the solution of iodine. Cod-liver 
 oil should be given. In an instance of this kind that came under 
 my notice in a delicate young lady, gentle means were of little avail, 
 but the effusion disappeared under the violent but dangerous use of 
 drastic purgatives by an unqualified practitioner. 
 
 Cancerous disease of the peritoneum is another cause of ascites ; 
 we do not, however, refer to those cases of cancerous disease in 
 which malignant tumors variously located interfere with the venous 
 circulation, and thus cause dropsy. This is sometimes the case in 
 cancerous disease of the liver and" of the glands at the portal fissure,
 
 526 ASCITES. DROPSY. 
 
 the growth may invade and obstruct the vena cava and thus check 
 the return of blood. There is an interesting class of cases in which 
 the peritoneum is especially diseased ; the serous membrane is 
 studded with tubercles varying in size from a millet seed to that of 
 a pigeon's egg; the tubera are soft, sometimes very vascular and 
 composed of cancerous cells; the mesenteric glands may also be 
 involved, and sometimes the omentum is infiltrated with inflamma- 
 tory and cancerous product, so that it is thickened, contracted, and 
 forms a dense horizontal band immediately beneath the stomach 
 and transverse colon. The amount of inflammatory product varies 
 exceedingly, sometimes a layer of lymph is observed on the serous 
 membrane ; there is, however, in nearly all cases a large amount of 
 serous effusion constituting ascites, and it is often discolored by 
 admixture with blood. The disease probably originates in the sub- 
 serous lymphatic vessels, and extends till the whole serous mem- 
 brane is involved, but it is also spread, it is believed, by direct con- 
 tact of one part with another, or by the dislodgment of cells, which 
 become attached and increase at the point of their fresh adhesion. 
 Sometimes there is considerable amount of dark colored pigment in 
 the deposit, and the growth is regarded as melanotic in character ; 
 this, however, is uncommon. 
 
 We refer in this description to those instances in which the peri- 
 toneum is especially diseased, for in many cases of disease of the 
 uterus and ovaries the serous membrane is secondarily involved, so 
 also in disease of the stomach. Dr. Fagge in a paper in the 'Guy's 
 Hospital Reports' for 1875 gives the following statistics. In 45 cases 
 of disease of the peritoneum the viscera were only free 6 times;, in 
 19 cases the ovaries were affected, and 17 the stomach. Of these 17 
 cases 7 were without disease of the ovary, but in 10 disease of the 
 ovaries also existed. In 3 the disease appeared to commence in the 
 uterus, 3 in the pancreas, and 2 in the rectum. In the 45 only 11 
 were males. 
 
 The malady is one affecting persons in middle and advanced life, 
 and the subjects of it are generally beyond fifty years of age : it is 
 not limited to women, although more common amongst them, as we 
 have just remarked. The general health of the patient fails, there 
 is weakness, emaciation, a cachectic appearance, and the abdomen 
 becomes enlarged ; the rapidity of the effusion varies, generally it 
 is slow, but I have known the attainment of a considerable size in 
 three or four weeks; the severity of pain differs considerably, some- 
 times it is slight, at other times very distressing. The form of the 
 disease is unlike that of slow and passive ascites ; there is irritation 
 of the serous membrane, the recti become consequently rigid, and 
 there is less flaccidity of the abdomen ; the loins are less distended, 
 and the abdomen is more prominent anteriorly ; the abdominal walls 
 are thin, and if there be venous obstruction, the veins are enlarged. 
 As prostration increases the pulse becomes more compressible, the 
 tongue red and glazy, and diarrhoea may supervene ; these patients 
 sink from exhaustion, or by the occurrence of more severe inflam- 
 mation.
 
 ASCITES. DROPSY. 52J 
 
 The disease is sometimes mistaken for cirrhosis in consequence of 
 the absence of disease of the chest, and of oedema of the le's the 
 urine also being free from albumen. The instances most difficult of 
 diagnosis are those in which the cancerous disease is acute, and the 
 pain m the right hepatic region resembles perihepatitis. in a case 
 
 this kind under my care m the clinical wards of Guy's Hospital 
 
 Ihe* nZ t'T U ti ^^ SiXtj J ! arS f a 6 ' the dlsease was a ^te,' 
 the pain in the right side pointed to hepatic disease, the fluid had 
 
 collected in about three weeks, and he sank within a month after 
 admission; the cachectic pallor and general distress were different 
 from cirrhosis, and there was no history of intemperate habits In 
 women the disease may be mistaken for ovarian disease, or for those 
 cases where ascites is a complication of the ovarian malady 
 
 reatment of these cases is unsatisfactory, and it is of little 
 avail to try and promote the absorption of the fluid by diuretics or 
 by purgative medicines. More will be effected by soothino- any 
 irritable condition by mild doses of morphia, by the use of tonics as 
 quimne, or by iodide of potassium. If the fluid is sufficient greatly 
 to distend the abdomen and to press on the stomach, it may be well 
 to draw it off, but there is great fear that exhaustion may rapidly 
 supervene, or that a low form of peritonitis may be induced 
 
 Ovarian dropsy is the last form that we have to notice, and we do 
 o partly because ascites is sometimes associated with it and because 
 is often mistaken for peritoneal dropsy. It would be foreign to 
 r purpose to enter into the pathology of ovarian disease/we would 
 >nly remark that the disease may be a single cyst or it may be raulti- 
 locular with varying degrees of solid deposit in the walls; sometimes 
 T? P ls dense and fi brous, and non-malignant, at other times it 
 has all the characteristics of cancerous disease ; it may be free from 
 adhesions, or the cyst may be firmly fixed to adjoining structures 
 I be ovarian tumor begins from below, and is generally felt in one or 
 other iliac region; it is dull, and if full of fluid, the fluid does not 
 gravitate as in ascites. There is dulness in front, and the sides are 
 esonant the reverse being the case in ordinary ascites; portions of 
 the solid walls of the cyst may be felt in some cases immediately 
 low the liver or the spleen, but the hardness can be more easily 
 moved than if those viscera were involved, and the tumor is not 
 affected by respiratory movements. It is in cases in which, with the 
 ovarian cyst, we have ascitic fluid, extending to the loins, that diao-. 
 s sometimes becomes difficult. The fluid in the cyst may be 
 serous, or sero-sanguinolent; the albumen contained in the fluid is 
 different from that found in peritoneal effusion, in that after beino- 
 coagulated by heat, it is redissolved by acetic acid when boiled again. 
 The admirable lectures recently given by Mr. Spencer Wells at the 
 Eoyal College of Surgeons, and published in the 'British Medical 
 Journal,' refer to the vatiety of cell structures found in these ovarian 
 fluids; he speaks of "the ovarian granule-cell" described by Dr. 
 Hughes Bennett, and by Dr. Drysdale, in Dr. Atlee's work, as being 
 rather larger than the red blood-corpuscles, and he refers to others^ 
 which show the more or less malignant character of the disease.
 
 528 ASCITES. DROPSY. 
 
 We have already referred to the close sympathy which exists 
 between the stomach and the ovary, and the severity of the vomit- 
 ing and other gastric symptoms which sometimes occur at the com- 
 mencement of ovarian disease. In the treatment of ovarian dropsy 
 it is useless to attempt to secure the absorption of the fluid by diu- 
 retics or by the use of iodine or of mercurials ; if there be inflamma- 
 tion or ascites, much may be done to relieve these conditions, but 
 the ovarian disease will not be lessened. Small doses of morphia 
 will sometimes lessen nervous irritability and may retard the pro- 
 gress of the case, but if the disease be slight it is better not to dis- 
 tress the patient by treatment which will do more harm than good. 
 If the cyst become very large paracentesis may be performed, but it 
 is only a palliative measure. The fluid will re-collect, and the only 
 really effectual measure is to remove the cyst. Although a most 
 formidable operation it is one which by the skill of modern surgery 
 is attended with a large amount of success. 
 
 In the remarks that we have made upon the several forms of 
 ascites we have adverted to many points connected with diaynosis, 
 and it is not necessary again to dwell upon them. So also as to 
 prognosis ; the ascites is so generally a symptom of some other dis- 
 ease, that the result depends in great measure upon the original 
 malady. 
 
 The treatment must also be according to the cause of the effusion. 
 Diuretics are of greater service in the ascites from chest disease, 
 than in that from cirrhosis of the liver; but in the latter disease, it 
 is well to try them, for in some cases they are certainly beneficial ; 
 the acetate and nitrate of potash are the most effective, the iodide 
 may be used, and may be given with broom juice. The copaiba 
 resin in doses of ten to fifteen grains rubbed down with a little recti- 
 fied spirit, and given in a mucilaginous mixture, is a valuable 
 diuretic, and is often taken by patients without dislike. The mode- 
 rate use of mercurials is sometimes beneficial in the early stage of 
 dropsy from cirrhosis, and still more in those instances of obstructed 
 hepatic circulation from disease of the heart and chronic disease of 
 the chest, chronic bronchitis, and emphysema. Purgatives are of 
 value, and sometimes suffice to remove the fluid from the serous 
 cavity; these may be given in the form of saline aperients, as sul- 
 phate of magnesia, or, the more irritating medicines jalap and scam- 
 mony, and sometimes the aperient mineral waters. If there be 
 peritoneal irritation and inflammation these remedies are unsuitable. 
 Blisters, and the application of iodine, may serve a double purpose, 
 not only may they relieve severe pain, but they may promote the 
 absorption of the fluid. 
 
 It will, however, be frequently found, when the patient is ex- 
 hausted from chronic disease of the liver, as cirrhosis, that diure- 
 tics and purgatives are of no avail, but greater benefit is derived 
 from the use of tonics with gentle aperients, as taraxacum with bark, 
 or quinine with sulphate of magnesia. A time will, however, come 
 when the question of drawing off' the fluid must be entertained, and
 
 ASCITES. DROPSY. 529 
 
 the operation is frequently followed by the greatest amount of relief 
 Sometimes the fluid only re-collects very slowly; after the pressure 
 on the abdominal viscera has been removed the kidneys will fre 
 quently act freely, and that without any diuretic. The operation 
 of paracentesis should, however, be postponed if there be evidence 
 of peritonitis or of inflammation on the surface of the liver peri- 
 hepatitis ; m these cases there is greater danger of peritonitis When 
 the operation is decided upon, it is well to act gently on the bowels 
 and to ascertain that the bladder is empty, the fluid mav then be 
 drawn off by trocar and canula, the patient being raised up, and a 
 flannel bandage placed round the abdomen to give support as the 
 pressure from the fluid is lessened. After the operation the patient 
 should be perfectly quiet, solid food should be avoided, and, if neces- 
 sary, an opiate given to insure repose. 
 
 34
 
 530 
 
 CHAPTEK XXI. 
 
 ABDOMINAL TUMORS. 
 
 BEFORE proceeding to the consideration of true abdominal tumors, 
 it may be well to notice those which are of a delusive character, and 
 have been called by Dr. Addison and Sir Wm. Gull " phantom 
 tumors." It is a common thing for patients to suppose that there is 
 something seriously wrong because one portion of the abdominal 
 walls projects more prominently than another ; sometimes the left 
 hypochondrium is found to be enlarged from a flatulent stomach, or 
 the caecum or sigmoid flexure from similar gaseous distension, or the 
 abdominal wall yields so as to form a direct protrusion ; these con- 
 ditions are easily recognized, the part is found to be flatulent on per- 
 cussion, and manipulation fails to detect any solid growth ; but in 
 the " phantom tumor," a solid mass is felt, but it is in the parietes, 
 and it is due to muscular contraction ; the part is hard and dense, 
 and may be readily mistaken ; it is, however, fairly resonant on percus- 
 sion, and by gentle and continued manipulation the muscle relaxes; 
 if the hand be gently placed on the hard mass, and the attention of 
 the patient diverted by conversation of an absorbing character, at 
 the same time that the fingers are gently moved about the mass, 
 the hardness disappears. This contraction of the muscular walls 
 may be found at any part, sometimes it is on the right side, and the 
 patient seems to have enlargement of the liver ; frequently it is one 
 of the transverse muscular bands of the rectus, sometimes it is the 
 quadratus lumborum, or the transversalis muscle of the abdomen. 
 
 It is scarcely correct to speak of a loose kidney as a " phantom 
 tumor," it is a movable one, but it does not entirely disappear by 
 pressure, although it may pass beyond the reach of the hand. 
 
 It is important in the study of abdominal tumors to have a defi- 
 nite acquaintance with the exact position of the abdominal viscera. 
 For the convenience of description, the abdomen is divided into 
 several region marked out by lines from fixed points. A line drawn 
 round the upper part of the abdomen at the most prominent part of 
 the costal cartilages, and a second at the crest of the ileum, divide 
 the surface into three zones, and these again by two perpendicular 
 lines are subdivided each into three other spaces, the lines passing 
 downwards from the cartilage of the eighth rib to the middle of 
 Poupart's ligament. In the upper zones we have the right and left 
 hypochondriac regions, on either side of the epigastric space or scro- 
 biculus cordis; in the central zone, the right and left lumbar regions 
 are on either side of the umbilical, and below, in the third zone, the 
 right and left iliac are situated on either side of the hypogastric re- 
 gion. During health these regions are occupied by their respective
 
 ABDOMINAL TUMORS. 531 
 
 viscera, and it is useless to try and ascertain abnormal states, unless 
 there be a thorough knowledge of that which is normal. We would 
 further add, that in every case of abdominal tumor it is important 
 to inquire, 1st, into the general history of the symptoms of the 
 patient ; 2d, to ascertain the exact position of tumor, and the physical 
 signs ; and 3d, to learn whether there is any functional disturbance 
 pi the abdominal organs. It is not likely that any viscus is involved 
 ma morbid growth, if it perform its functions in a healthy manner. 
 It may be well to consider these regions as regards their normal 
 and abnormal contents. The right hypochondrium contains especially 
 the liver and gall-bladder, but the gland passes into the epigastric 
 region, and reaches the left hypochoudrium ; when enlarged it ex- 
 tends into the umbilical and right. lumbar regions. The liver is 
 attached to the diaphragm, and to a certain extent moves with it. 
 It reaches upwards as high as the fifth rib, where the dulness com- 
 mences and is partial, at the sixth rib the dulness is complete ; when 
 the patient is recumbent the liver is behind the ribs, unless, as is 
 generally the case in women, it has been pushed down by compres- 
 sion, but in the erect and sitting postures the liver may be felt an 
 inch below the ribs. Beside the liver and gall-bladder the right 
 hypochondrium contains the angle of the ascending colon, par? of 
 the duodenum, the right supra-renal capsule, and the upper part of 
 the right kidney. It must be remembered in reference to .enlarge- 
 ment of the liver that the gland may be pushed down by pleuritic 
 effusion. In large effusions into the right pleura the liver is always 
 displaced. 
 
 2. The liver may be pushed down by effusion between the upper 
 lobe and the diaphragm, the effusion being either serous or puru- 
 lent; in these cases the symptoms may closely resemble pleuritic 
 effusion. Many years ago a woman was admitted under my care 
 into Guy's Hospital with severe peritoneal symptoms after a fall 
 from a cart upon the abdomen. The pain was great, and the strength 
 gradually gave way. On examination of the lower part of the right 
 lung before death, dulness on percussion, with bronchial breathing 
 and modified voice sound was heard, and some who had not known 
 the previous history believed the disease to be above the diaphragm. 
 On the post-mortem table a trocar was introduced between the ribs 
 posteriorly and pus exuded, apparently confirming the idea that 
 empyema existed, but on fuller examination it was found that the 
 pus was situated between the liver and the diaphragm ; there had 
 been peritonitis, and the pus was circumscribed by adhesions. 
 
 3. The liver may be pushed down by the development of tumors, 
 or by a hydatid cyst in the right lobe of the liver. This cyst o>r 
 tumor may be so situated behind the ribs as to be quite beyond the 
 
 Breach of the hand. A woman in middle life was admitted under 
 / my care into Guy's with the liver extending into the umbilical 
 region, the surface was smooth, the gland passed lower into the 
 abdomen, and the strength of the patient at length gave way and 
 she sank. On examination, when the abdomen was opened, the 
 liver seemed to fill the greater part of the abdomen on the right
 
 532 ABDOMINAL TUMORS. 
 
 side; the surface was smooth, and it was only when the gland was 
 drawn down from the diaphragm that the true nature of the enlarge- 
 ment was recognized. An enormous hydatid cyst occupied the right 
 lobe and pressed in every direction, but did not reach the free sur- 
 face of the liver. In the examination of an enlarged liver the patient 
 should be placed on the back, the knees drawn up, and the head 
 comfortably supported, and the patient's attention should be absorbed 
 by conversation, if possible. Sudden pressure will often detect an 
 enlarged gland, which could not be recognized by gradual pressure; 
 if the ringers be passed upwards from below, the edge may be caught, 
 and they should then be gently passed over the gland to ascertain 
 whether there are any irregularities; the surface is dull on percus- 
 sion; at the upper part where the liver is overlapped by lung there 
 is partial resonance, and we sometimes find that the lower edge may 
 be covered by the colon, and resonance is thus produced. 
 
 4. Enlargement of the gall-bladder is found generally opposite the 
 tenth rib, it is pyriform and when filled with bile will yield some- 
 what to pressure. Sometimes I have found it filled with a great 
 number of gall-stones, so that it resembled a solid mass; a very dif- 
 ferent condition was found some years ago in a case under the late 
 Dr. Babington, the specimen of which is in Guy's Museum ; the gall- 
 bladder communicated with the intestine and was filled with gas, so 
 that there was resonance on percussion. 
 
 5. Enlargement of the liver, if general, arises from congestion, 
 from inflammation, from fatty deposit, from lardaceous disease, from 
 obstruction of the bile-ducts; if local, from hydatid tumor, from 
 syphilitic deposit, from cancerous growths, from abscess in the liver, 
 or from suppuration in connection with the bile-ducts. 
 
 6. An enlargement of the right kidney can sometimes be felt 
 immediately below the right lobe of the liver; it will be found to 
 extend into the loin. 
 
 7. Malignant disease of the right supra-renal capsule may also 
 reach the lower part of the liver. I have found a tumor of the left 
 supra-renal capsule simulating enlargement of the spleen. 
 
 8. Malignant disease of the pancreas and first part of the duode- 
 num are recognized by their clinical history ; the hardness may be 
 felt closely in contact with the liver. 
 
 9. Cancerous disease of the angle of the ascending colon is also 
 felt in this region; in this disease pain comes on several hours after 
 food, and there is likely to be discharge of blood or of mucus from 
 the bowels. 
 
 In the epigastric region we find the stomach and its lesser curva- 
 ture, and the left lobe of the liver ; the gall-bladder and the pyloric 
 extremity of the stomach are situated at its union with the right 
 hypochondriac region ; posteriorly we have the pancreas, the aorta, 
 the vena cava, the coeliac axis and the commencement of its large 
 branches; at the lower part of this region we have the transverse 
 colon, varying, however, in position according to the distension of 
 the stomach. We would remark that yielding of the parietes, with
 
 ABDOMINAL TUMORS. 533 
 
 flatulent distension of the stomach, often gives rise to the idea of 
 tumor. 
 
 2. Abscess sometimes forms in the parietes in this part not only 
 m the muscular parietes, but in the loose cellular tissue about the 
 end of the sternum. In a case of that kind in the clinical ward of 
 Gruy s some years ago, there was a projection at the scrobiculus cordis 
 which was afterwards found to be an abscess which extended to the 
 under surface of the diaphragm. 
 
 3. Abnormal pulsation is often felt at the epigastric region ; this 
 may arise from an aneurismal tumor in connection with the aorta 
 or with the cceliac axis; in aneurism of the aorta close to the dia- 
 phragm it is, however, very difficult to feel the aneurismal tumor 
 unless it be of large size. In the majority of cases a pulsating tumor 
 at the scrobiculus cordis is found to arise from disease of the left 
 lobe of the liver pressing upon the abdominal aorta; in other cases 
 the pulsating mass may consist of a vascular and pulsating medullary 
 growth in the stomach. 
 
 4. Tumors of different kinds in the left lobe of the liver are found 
 in this region. 
 
 5. Disease at the lesser curvature of the stomach may not only be 
 felt in this region, but may have pulsation communicated to it from 
 the aorta. 
 
 6. Chronic ulcer with thickened walls may constitute the tumor 
 felt at the epigastric region ; but 
 
 7. A hard mass felt in the epigastrium is more frequently found 
 to be malignant disease. 
 
 On a level with the umbilical line and situated posteriorly we have 
 the pancreas, but so deeply is the gland placed that it is difficult to 
 recognize enlargement by digital examination. 
 
 Malignant disease of the pancreas where there is much enlarge- 
 ment may be sometimes recognized, but in such cases we principally 
 depend upon the clinical history and the general symptoms, in form- 
 ing a correct diagnosis. In a case of inflammation of the cellular 
 tissue about the pancreas which I saw in consultation some years 
 ago, there was a hard swelling felt at the upper part of this region ; 
 there was severe pain, with febrile excitement, and I supposed the 
 case was one of gastric disease ; post-mortem examination showed 
 that the stomach was healthy, but that the swelling was an abscess 
 connected with the pancreas. 
 
 In chronic disease of the omentum, often of a malignant character, 
 the serous membrane is puckered and drawn upwards, so that it 
 forms a firm band passing across the abdomen, at the lower part of 
 the epigastric or at the upper part of the umbilical region. It may 
 be associated with malignant disease of the peritoneum, as we have 
 mentioned. 
 
 In the left hypochondrinm we have the cardiac extremity of the 
 stomach, the spleen, the left supra-renal capsule, and a portion of the 
 kidney. The left angle of the colon may also extend to this space. 
 The most common tumor found in this region is the spleen, which 
 as it increases in size not only passes upward and raises the level of
 
 534 ABDOMINAL TUMORS. 
 
 dulness on that side, but it passes downwards and is also directed 
 forwards. This forward direction may be due to the band of perito- 
 neum immediately beneath the gland, but there is no doubt of the 
 fact that the spleen, as it increases, and it attains sometimes an 
 enormous size, passes not only into the lumbar but also into the 
 umbilical region. The fissure at the anterior edge assists us in the 
 recognition of the spleen, but this is not a certain sign, for the fissure 
 between two enormously enlarged lymphatic glands may communi- 
 cate to the touch the same impression. The spleen enlarges after a 
 full meal ; it may increase from temporary portal congestion ; it is 
 felt below its normal position in enteric and other fevers, but these 
 conditions would not be designated as tumors. It is in the enlarge- 
 ment after ague, in leucocythemia, in lardaceous disease, that we 
 find the spleen to attain to very large proportions, and in these cases 
 the increase is general. In abscess, in hydatids, and in malignant 
 disease, the enlargement is partial. 
 
 2. Another turnor in the left hypochondrium arises from enlarge- 
 ment of the left kidney or from hydatid at that part, but in this case 
 the growth extends more into the loin, and there is more likelihood 
 of distension of the lower ribs on that side. 
 
 3. Malignant disease of the supra-renal capsule on the left side 
 sometimes presses forward to the anterior part, and is felt immedi- 
 ately below the spleen. I have known it mistaken for an enlarge- 
 ment of the spleen itself, for the growth was large, and i$ appeared 
 to pass from beneath the ribs. 
 
 4. Aneurismal disease at the commencement of the descending aorta 
 sometimes pushes forward the spleen, and the diagnosis is difficult. 
 In the case to which I refer, the lower ribs were prominent, but pul- 
 sation was very indistinct. The patient died from rupture of the 
 aneurismal sac behind the peritoneum. 
 
 5. The solid walls of an ovarian cyst sometimes reach into the left 
 hypochondrium, form a tumor, and simulate disease of the spleen. 
 The tapping of the cyst would be one means of diagnosis of a case 
 of this kind, for the solid portion of the cyst would then pass towards 
 the pelvis. 
 
 6. It is scarcely necessary to mention the manner in which the 
 spleen may be pushed down by effusions both into the pleura and 
 into the pericardium. 
 
 7. Local suppuration may occur in this region and produce a swell- 
 ing resembling a tumor. 
 
 The next zone of the abdomen is divided into the central, the um- 
 bilical, and into the right and left lumbar spaces. In the ln.mbar 
 regions the kidneys and the ascending and descending colon may be 
 causes of tumors. The kidneys extend to the loin, and as they pass 
 forward can be felt anteriorly to the inner side of the colon. The 
 condition of the urine, in the discharge of blood, of pus, or of cancer- 
 ous cells, affords to us an important guide in diagnosis. A tumor 
 from distended pelvis of the kidney is most uncertain as to its size. 
 Sometimes a calculus may block up the ureter, and the pelvis of the 
 kidney gradually attains large dimensions, till at length the ureter
 
 ABDOMINAL TUMORS. 535 
 
 is distended beyond the size of the obstructing calculus, and a sudden 
 discharge of several pints of urine at once diminishes the size of the 
 tumor. The same may be the case in suppuration of the kidney. 
 In a patient under my care in Guy's, a large tumor extended from 
 the right lumbar into the iliac region, and would suddenly subside on 
 the discharge of several pints of urine. This condition came on 
 when the patient was about sixteen; he was a shoemaker, and al- 
 though he had several severe attacks, he continued his work till he 
 was nearly sixty-four years of age, when he died in Guy's Hospital 
 from a large cancerous growth which affected the kidney on the same 
 side. After death it was found that a calculus was the cause of the 
 obstruction of the ureter. 
 
 2. The glands in connection with the kidney, the lumbar glands, 
 sometimes form a large tumor in this region; the urine is then unaf- 
 fected, the growth is more irregular, and there are generally other 
 indications of malignant disease. In hydatid disease of the kidney 
 the tumor is rounded and elastic. 
 
 3. Accumulations in the ascending or descending colon form masses 
 in these regions, but the clinical history, the absence of severe symp- 
 toms, and the relief by purgative medicine, characterize these cases. 
 
 4. In intussusception a doughy, elongated mass may be felt in the 
 ascending or even in the descending colon. The severe and spasmo- 
 dic pain, the vomiting which is often present, the obstruction of the 
 bowels, and the discharge of blood and of mucus, indicate the charac- 
 ter of the affection. 
 
 5. In diseases of the spine leading to suppuration there is a bulging 
 in the loin, and it may be a projection anteriorly, which can be felt 
 on digital examination. 
 
 6. Abscess in the loin and in the quadratus lumborum muscle may 
 lead to enlargement, and may extend into the bowel. Thus, we have 
 known an abscess pass into the caecum, and have seen suppuration 
 primarily connected with the bowel reach the loin. 
 
 7. Ovarian tumors may pass from the iliac fossa into the loin, but 
 more frequently they extend into the umbilical region. 
 
 In the umbilical region we have the transverse colon and the 
 ornentum attached to it, the small intestine, with the mesentery and 
 mesenteric glands, and posteriorly the aorta and vena cava. On 
 either side are the right and left renal vessels. The position of the 
 transverse colon varies greatly ; sometimes its curve is greatly in- 
 creased, and it may reach nearly to the hypogastric region. The 
 curve may be increased as the consequence of distension, or by the 
 dragging of an omental hernia. Tumor in the walls of the intestine 
 also changes its position. 
 
 2. Intussusception of the small intestine is often found in the um- 
 bilical region. 
 
 3. Tumors in the omentum and in the mesentery. In the former, 
 the mass is movable, and there is no functional disturbance of the 
 intestine. 
 
 4. In strumous disease of the intestine the bowels are often matted 
 together by inflammatory adhesion, and the mass resembles a tumor.
 
 536 ABDOMINAL TUMORS. 
 
 Sometimes there is suppuration or fecal abscess, or it may be the 
 discharge takes place from the umbilicus. 
 
 5. Ovarian tumors are often found to extend into the umbilical 
 region. 
 
 6. Aneurismal disease of the aorta and the branches of the abdo- 
 minal aorta may be felt in this space, but frequently enlarged glands, 
 pressing upon the aorta or upon the renal arteries, simulate true 
 aneurismal disease. Sometimes we can remove the gland from the 
 pulsating vessel beneath, by manipulation or by changing the posi- 
 tion of the patient, but this is not invariably the case. 
 
 In studying enlargement in the loins it is important to remember 
 that both the ascending and descending colon closely sympathize 
 with diseased structures before or behind them, the intestine becomes 
 inactive, the passage of the contents impeded, and the fulness may 
 resemble primary tumor of the bowel. 
 
 The remaining regions are the hypoyastric and the right and left 
 iliac. 
 
 In the hypogastric region whenever a tumor is felt we must always 
 render ourselves sure that the bladder is not distended. Urine may 
 pass constantly, in fact, there may be a constant dribbling from over- 
 distension of the bladder, and thus the disease be unsuspected. In 
 this way I have known the bladder reach above the umbilicus and 
 contain many pints of urine. 
 
 2. Enlargements of the uterus, whether from pregnancy or turner, 
 extend into the hypogastric region. 
 
 3. Fibroid tumors of the uterus and of the ovaries, and cystiform 
 disease of the ovaries, extend into right or left iliac region, and also 
 into the central space. 
 
 4. Hydatid disease of the cellular tissue in connection with the 
 bladder forms a rounded tumor in this space, in touch very closely 
 resembling a distended bladder. 
 
 5. Aneurismal disease of the iliac vessels must also be borne in 
 rnind as a cause of tumor in the lateral portions of the hypogastric 
 region. 
 
 In the riyht iliac region we have the caecum and its appendix, and 
 diseases of these structures constitute many of the morbid enlarge- 
 ments at this part. The mischief may, however, be external to the 
 caecum, peri- typhlitis; in these diseases we have local pain and 
 tenderness, febrile excitement, generally a disordered condition of 
 the bowels, constipation, sickness, and it may be peritonitis. In 
 tumor from enlarged glands, there is less interference with the action 
 of the bowels. In pelvic abscess the bowel is free, the mischief is 
 found to extend from above, and it passes onwards in the direction 
 of the psoas and iliacus muscles. A tumor from renal disease may 
 reach the iliac fossa, but it can be traced upwards, and the urine will 
 be found to be diseased in most cases, if carefully examined, except 
 in instances in which one kidney does the entire work and the other 
 is completely shut off. 
 
 An aneurismal tumor from disease of the iliac vessels is recognized
 
 ABDOMINAL TUMORS. 537 
 
 by its pulsatile and expansive character, and by the condition of the 
 circulation of the limb. 
 
 Ovarian tumors reach to the right or left loin; sometimes they 
 become adherent to the bowel, and I have known an ovarian cyst 
 become adherent to the caecum, and having discharged its contents 
 into the bowel, the cyst has become filled with fecal matter. Acute 
 disease of the right ovary sometimes closely resembles typhlitis, but 
 the pain is lower, it extends into the pelvis; the tenderness, the con- 
 stipation, the febrile excitement, may be equally marked in the acute 
 disease of the ovary, as in cascal disease. 
 
 In the left iliac region many morbid growths correspond to those 
 on the right side, but here the sigrnoid flexure takes the place of 
 the caecum. The curvature of this part of the bowel varies greatly ; 
 sometimes the sigrnoid flexure extends to the right side, and there 
 may be adhesion to the caecum. In other cases of distension it 
 bends upon itself, it falls into the pelvis, and the acute bending at 
 a right angle leads to obstruction. The termination of the sigmoid 
 flexure in the rectum at the brim of the pelvis is the partoften 
 affected by disease, and a tumor can in most cases be made out by 
 careful manipulation. Sometimes there is a rounded growth in 
 connection with the mucous membrane of the bowel, at other times 
 all the coats are thickened and contracted, as if a piece of string had 
 been tied round the bowel ; all these states lead to gradually increas- 
 ing obstruction, which may become complete. 
 
 Inflammatory adhesion sometimes takes place between the sigmoid 
 flexure and the bladder; an external tumor is felt on deep but gentle 
 manipulation. The diagnosis and the prognosis of these cases are 
 often very obscure, and in several we have known direct communica- 
 tion take place with the bladder, and fecal discharge with the urine 
 supervene. Colotomy is of the greatest service in these cases. 
 
 We have thus briefly sketched the site and the character of abdo- 
 minal tumors; each case has a clinical history of its own, and it is 
 by the careful study of that history, in connection with the position 
 of the tumor and the disturbances of the functional activity that are 
 associated with it, that we can make out the true nature of the dis- 
 ease. Many most interesting cases of abdominal tumor might have 
 been added to this chapter; the difficulties in the diagnosis might 
 thereby have been more fully indicated, and the various modes of 
 relief discussed ; but, we have refrained on account of the length to 
 which this work has already extended, and we have only given the 
 general facts which these instances of disease have brought out. 
 
 We have sought to show the leading characteristics of diseased 
 conditions as manifested in the various portions of the alimentary 
 canal ; and to do this have recorded the cases themselves, as facts 
 upon which each one may form his own opinion, rather than depend 
 entirely upon the deductions we have drawn from them. Such gene- 
 ral conclusions in most chapters have preceded the cases upon which 
 they are founded; and we leave them before our readers with the 
 hope that they will serve further to elucidate the general symptoms, 
 pathology, and treatment of diseases of the alimentary canal.
 
 ILLUSTRATIVE CASES. 
 
 CASE 
 
 I Diffused Inflammation of the Throat. 
 II Diffused Inflammation of the Throat. Ulceration of the 
 
 Pharynx. 
 
 Ill Carcinoma of the Throat. Tubercular Pneumonia. 
 IV Diseased Cartilages of the Trachea. Ulceration of the 
 
 (Esophagus. 
 
 V Ulceration of the (Esophagus. Perforation of the Trachea. 
 VI Dysphagia. Mania. 
 VII Spasmodic Affection of the (Esophagus. 
 VIII Stricture of the (Esophagus. 
 IX Stricture of the (Esophagus. 
 X Cancerous Disease of the Lower Third of the (Esophagus. 
 
 Division of the Canal. Death from Bronchitis. 
 XI Cancer of the (Esophagus. Sloughing Pneumonia. The 
 
 Pneumogastric Nerve involved. 
 XII Cancer of the (Esophagus, of the Cervical Glands, and of 
 
 the Thyroid Body. Gangrene of the Lung. 
 
 XIII Epithelial Cancer of the (Esophagus, Pancreas, Liver, and 
 Kidneys. The Pneumogastric Nerves involved. Granu- 
 lar Kidneys. Chronic Pleuro-pneumonia with Cancer. 
 Fibrous Tumor in the Uterus. Cancer of Supra-renal 
 Capsules and Semilunar Ganglion. 
 
 XIV Epithelial Cancerous Tumor in the Pharynx, closing the 
 entrance into the (Esophagus. Effusion of False Mem- 
 brane in the Larynx and Trachea. Acute Bronchitis. 
 XV Carcinoma of the (Esophagus, communicating with the 
 
 Trachea. Cancer of the Lung and of the Kidney. 
 XVI Cancer of the (Esophagus. Extension into the Lung. 
 
 Gangrene. 
 
 XVII Cancer of the (Esophagus. Pneumonia. The Pneumo- 
 gastric Nerve involved. 
 
 XVIII Cancer of the (Esophagus. The left Pneumogastric in- 
 volved. Pneumonia. 
 
 XIX Cancer of the (Esophagus. Communication with the Left 
 Bronchus. The Pneumogastric involved. Old Vomica 
 in the Lung. Extension of Disease through the Dia- 
 phragm. 
 
 XX Cancer of the (Esophagus. Pneumogastric Nerves trun- 
 cated. Sloughing extending through the Lung and 
 through the Diaphragm. 
 
 XXI Medullary Cancer of the (Esophagus. Chronic Pneumonia. 
 Vomica. Acute Pneumonia.
 
 540 ILLUSTRATIVE CASES. 
 
 CASK 
 
 XXII Cancer of the (Esophagus. Artificial opening made into 
 
 the Stomach. 
 
 XXIII Cancer of the (Esophagus. Sloughing. Perforation of 
 
 the Aorta. Sudden and Fatal Hemorrhage. 
 
 XXIV Aneurism of the Aorta and Sloughing (Esophagus. 
 
 XXV. Aneurism of the Ascending Aorta rupturing into the Peri- 
 cardium. Communication of the (Esophagus with the 
 left Bronchus. 
 
 XXVI Aneurism. Pressure on the (Esophagus and on the left 
 
 Bronchus. Difficulty in Deglutition. Sudden Death. 
 XXVII Dissecting Aneurism of the Aorta bursting into the (Eso- 
 phagus. 
 
 XXVIII Poisoning by Sulphuric Acid. 
 
 XXIX Poisoning by Soap Lees. 
 XXX Poisoning by Sulphuric Acid. 
 XXXI Poisoning by Nitric Acid. 
 XXXII Poisoning by Nitric Acid. Recovery from the Primary 
 
 Effects. 
 
 XXXIII Poisoning by Strong Solution of Ammonia. 
 XXXI V Rupture of the (Esophagus. 
 
 XXXV Syphilis. Diphtheritic Inflammation of the Stomach. Dis- 
 eased Kidneys. Necrosis of the Bones of the Nose. 
 XXXVI Suppuration in the Coats of the Stomach. 
 XXXVII Superficial Ulceration of Stomach. Diseased Supra-renal 
 
 Capsules. 
 XXXVIII Chorea. Endocarditis of the Mitral. Ulceration of the 
 
 Stomach. 
 XXXIX Catarrh and Superficial Ulceration of the Stomach. Cystic 
 
 Disease of the Ovary. 
 XL Follicular Ulceration of the Mucous Membrane of the 
 
 Stomach, with Renal Anasarca and Diseased Heart. 
 XLI Follicular Inflammation of the Stomach. Burn on the Leg. 
 
 Amputation. Abscess in the Lung and Spleen. 
 XLII Chronic Ulcer of the Stomach. Phthisis. Branches of 
 
 the Pneumogastric Nerves involved. 
 
 XLIII. Chronic Ulceration of the Stomach, involving the Pneumo- 
 gastric Nerve. Atrophy of the Left Lobe of the Liver. 
 Death from Exhaustion. 
 XLIV Chronic Ulceration of the Stomach, with Painter's Colic. 
 
 Perforation. 
 XLV Perforation. Ulcer of the Stomach, with a second small 
 
 Chronic Ulcer in the same organ. 
 
 XLVI Chronic Ulceration. Death from Perforation. 
 XLVII Chronic Ulcer of the Stomach. Perforation. 
 XLVIII Perforating Ulcer of the Stomach. 
 XLIX Ulcer of the Stomach. Perforation. 
 
 L Chronic Ulcer of the Stomach. Perforation of all the coats 
 
 except the Peritoneal. Fatal Peritonitis. 
 LI. Perforation of the Stomach. Local Suppuration in the 
 
 Peritoneum. Pleuro-pneumonia. 
 
 LII Chronic Ulceration of the Stomach, extending to the Dia- 
 phragm, and simulating Pneumothorax. 
 
 LIII Fecal Abscess, connected with the Stomach, the Lung, the 
 Spleen, and the Transverse Colon.
 
 ILLUSTRATIVE CASES. 541 
 
 CASE 
 
 LIV Chronic Ulcer of the Stomach. Peritoneal Abscess. Per- 
 foration of the Diaphragm. Empyema. 
 
 LV Chronic Ulceration of the Stomach. Perforation. A sinus 
 extending into the Left Lung. Gangrene. Empyema. 
 Second Chronic Ulcer. 
 
 LVI Chronic Ulceration of the Stomach. Fatal Hemorrhage. 
 Perforation of the Splenic and of the Pancreatic Arteries. 
 LVII Ulceration of the Stomach. Fatal hemorrhage. 
 LVIII Chronic Ulceration, with Villous Growth. Stomach ex- 
 ceedingly contracted simulating Cancer. 
 LIX Chronic Ulcer of the Stomach. 
 LX Chronic Ulcer of the Stomach. Relieved. 
 LXI Ulceration (cancerous) of the Stomach. Relieved. 
 LXII Ulceration of the Stomach. Sloughing. Paraplegia. Soft- 
 ening of the Spinal Cord. Disease of the Vertebra. 
 LXIII Mottled Kidney. Anasarca, Pneumonia. Sloughing mu- 
 cous membrane of the Stomach. 
 
 LXIV Thickened Pylorus. Cicatrix of the mucous membrane, 
 with hypertrophy. Ulceration of the Caecum and Colon. 
 Fatty Degeneration of the Heart. 
 LXV Diseased Pylorus. Phthisis. 
 LXVI Scirrhous Pylorus. Carcinomatous tubercles in the Liver, 
 
 Spleen, and Kidney, and on the Diaphragm. 
 
 LXVII Medullary Cancer of the Stomach, having a villous char- 
 acter. 
 
 LXVIII Cancerous disease of the Stomach. Exhaustion. Epileptic 
 Fit. Coma. Serous subarachnoid effusion. Some thick- 
 ening of the Arachnoid. 
 
 LXIX Villous Cancer of the Stomach. Perforation. Extension 
 into the Left Lobe of the Liver. Secondary opening into 
 the Duodenum. Death from sudden Hemorrhage into 
 the Stomach. 
 
 LXX Villous Growth of the Stomach. Cirrhosis. Ascites. 
 LXXI Colloid Cancer of the Stomach and of the Colon. 
 LXXII Colloid Cancer of the Stomach, the Omentum, the Perito- 
 neum, and of the Rectum. 
 
 LXXIII Chronic Ulceration of the Stomach. Cancer. 
 LXXIV. Cancer of the Stomach. Communication with the Colon. 
 Ulceration of the Caecum and Ileum. Chronic Phthisis. 
 LXXV Struma. Cancer of the Stomach. 
 
 LXXVI Cancer of the Stomach. Disease of the Supra-renal Cap- 
 sule. 
 
 LXXVII Cancer of the Pylorus, simulating Disease of the (Eso- 
 phagus. Communication with the Colon. 
 LXXVIII Cancer of the Pylorus. Hydatid Disease of the Cellular 
 
 Tissue of the Bladder. 
 
 LXXIX Haematemesis from Cancer of the Liver. 
 LXXX Haematemesis from Portal Congestion. 
 LXXXI Hsematemesis after great Intemperance. 
 LXXXII Haematemesis. Vicarious Menstruation. Aggravated Hys- 
 teria, simulating Fever. 
 
 LXXXIII Vicarious Menstruation from the Stomach. 
 LXXXIV. Typhus Fever. Haematemesis.
 
 ILLUSTRATIVE CASES. 
 CASE 
 
 LXXXV Inflammation of the Bronchi, of the Bile-Ducts, or Biliary 
 Hepatitis, &c. Acute Congestion of the Duodenum. 
 
 LXXXVI Ulceration of the Duodenum. Perforation. 
 
 LXXXVII. Chronic Ulcer in the Duodenum. Carcinoma of the Liver. 
 Jaundice. Granular Kidneys. Obliteration of the Bile- 
 Duct. 
 LXXXVIII Strumous Disease of the Abdomen. Perforating Ulcer of 
 
 the Duodenum and Caecum. 
 
 LXXXIX. Gall-Stone. Ulceration of the Gall-Bladder and Duodenum. 
 Large Gall-Stone impacted in the Jejunum. Death from 
 Hemorrhage. 
 
 XC Cancer of the Duodenum. 
 
 XCI. Chronic Peritonitis. Acute Peritonitis. Tubercular de- 
 position on the Serous Membranes and in the Glands. 
 Constriction of the Duodenum, and great Dilatation of 
 its first portion. Small Ulcer in the Duodenum. Large 
 Chronic Ulcer in the Colon. 
 XCII. Obstruction from Biliary Calculus in the upper part of the 
 
 Jejunum, thirty inches from the Pylorus. 
 XCIII Disease of the Pancreas. Suppuration and Gangrene. 
 
 Pressure on the Duodenum. 
 XCIV. Perforation of Duodenum after Death from Solution by 
 
 Gastric Juice. 
 XCV Acute Enteritis. 
 
 XCVI Enteritis simulating Mechanical Obstruction. 
 XCVII Sloughing Ileum. Thrombosis of the Mesenteric Veins. 
 Peritonitis. Chronic Tubal Nephritis. Lobular Pneu- 
 monia. 
 
 XCVIII Slight Strumous Disease of the Mesenteric Glands. Diar- 
 rhoea. Pneumonia. 
 
 XCIX Strumous Peritonitis. Fecal Abscess. Artificial Anus. 
 C Strumous Disease of the Mesenteric Glands. Obstruction 
 of the Lacteals. Ulceration of the Small and Large 
 Intestine. Dysentery. Phthisis. 
 CI Ulcerated Colon. Phthisis. No cough. 
 CII Phthisis. Ulceration of the Rectum and Sigmoid Flexure. 
 CIII Unusually free Caecum. 
 CIV Unusually free Caecum. 
 CV Caecum inverted. 
 
 CVI Intestinal Obstruction of the Ascending Colon. The Caecum 
 twisted to the left side into the Left Iliac and Hypochon- 
 driac Regions. Death on the 20th day. 
 CVII Twisted Caacum. Obstruction. Peritonitis. 
 CVIII. Cascal Distension and Inflammation. Typhlitis. 
 CIX Caecitis or Typhlitis. 
 CX Typhlitis. 
 
 CXI Caecal Inflammation simulating Hip-joint Disease. 
 CXII Caecal Disease. Typhlitis. Recovery. 
 CXIII Strumous Inflammation of the Caecum. 
 CXI V Perforation of the Caecum. Abscess extending to the Groin. 
 
 Phthisis. 
 
 CXV Tuberculosis. Ulceration of the Intestine. Ulceration of 
 the Caecum. Perforation. Abscess behind the ascend- 
 ing Colon. Old Hydatid in the Liver.
 
 ILLUSTRATIVE CASES. 543 
 
 CXVI Inflammation of the Colon from Plum Stones. Ulceration. 
 Perforation. Peritoneal Abscess. Thickening and Con- 
 traction of the Bowel. 
 CXVII Phthisis. Ulceration of the Larynx and of the Ileum. 
 
 Concretion in the Appendix. 
 CXVIII Pyagmia. Necrosed Humerus. Csecal Disease. . 
 
 CXIX Disease of the Caecum following a Blow. Perforation of the 
 Appendix. Suppuration. General Peritonitis. Almost 
 complete secondary Perforation of the Caecum. 
 CXX Local Peritonitis. Perforation of the Appendix Cseci. 
 
 Strangulation of the Ileum by the Appendix. 
 
 CXXI Perforation of the Appendix Caeci. Abscess behind the 
 Ascending Colon, opening into the Colon. Clot in the 
 Vena Portae and Mesenteric Vein. Pyaamia. 
 CXXII Cancer of the Caecum. Abscess in the Groin. 
 C XXIII Colloid Cancer of the Caecum. Jaundice. 
 CXXIV Appendix Caeci in the Inguinal Canal. 
 
 CXXV Inanition. Diarrhoea. 
 CXXVI Chronic Diarrhoea. Hysteria. Great relief from Tincture 
 
 of Iron. 
 
 CXX VII Inflammation of the Colon. Diphtheria of the Pharynx. 
 CXXVIII Diphtherite of the Colon. Dysentery. Chorea. 
 CXXIX Inflammation of the Colon. Hernia. 
 CXXX Dysentery. Ulceration of the Small Intestine. Fecal 
 
 Abscess. Peritonitis. 
 
 CXXXI Ulceration of the Large Intestine. Perforation. Sub- 
 mucous Suppuration. Pus in the Portal Vein, and In- 
 flammatory Patches in the Liver. 
 CXX XI I Dysentery. Perforation of the Colon. 
 
 CXXXIII Chronic Bronchitic Phthisis. Cirrhosed and Lardaceous 
 Liver. Contracted Abscess of the Liver. Chronic 
 Dysentery, and Chronic Peritonitis. 
 C XXXIV Chronic Dysentery. Hepatic Abscess. Pyaemia. Abscess 
 
 in the Brain and Lung. 
 CXXXV Dysentery. Abscess of the Liver. Perforation of the 
 
 Diaphragm. Empyema. 
 
 CXXXVI Chronic Ulceration of the Intestine. Dysentery. Cicatri- 
 zation. Contraction. Perforation. Abscess near the 
 Crest of the Ileum. 
 
 CXXXVII Dysentery. Pneumonia. Hydrencephaloid Disease. 
 CXXXVIII Diphtherite of the Caacum and Colon. Bronchitis. Pneu- 
 monia. Cirrhosis. 
 
 CXXXIX Inflammation of the Colon and Rectum with False Mem- 
 brane and superficial Ulceration, &c. Pneumonia. Ente- 
 ric Fever ? 
 
 CXL Fever. Peritonitis. 
 
 CXLI Fever. Perforation of Intestine in the seventh week. 
 CXLII Perforation of the Ileum. Typhoid Fever. 
 CXLIII Internal Strangulation of the Ileum. Band of Adhesion. 
 CXLIV. Internal Strangulation. A Loop of Small Intestine passed 
 
 into a hole in the great Omentum. 
 
 CXLV Internal Strangulation of the last eighteen inches of the 
 Small Intestine by means of a Diverticulum from the 
 ileum. Fatal after thirty-eight hours.
 
 r 
 
 544 ILLUSTRATIVE CASES. 
 
 CASK 
 
 CXLVI Internal Strangulation of a large part of the Small Intes- 
 tine. Death on the fifth day. 
 
 CXLVII Internal Strangulation. Old Peritoneal adhesions. Peri- 
 tonitis. Suppuration. 
 
 CXLVIII Lead Colic. Internal Strangulation of the Intestine from 
 old disease of a Mesenteric Gland, and subsequent Fibroid 
 Contraction. 
 
 CXLIX. Mechanical Obstruction terminating favorably after seventy- 
 eight hours. 
 CL. Internal Strangulation and Constipation. Subsidence of 
 
 Symptoms. Death from Phthisis. 
 CLI. Colic. Simulation of Internal Strangulation. Recovery. 
 
 CLII Colic. Lumbrici. Diarrhoea. Intussusception of the 
 
 Ileum and Ascending Colon into the Descending Colon. 
 
 CLI II Intussusception. Recovery. Caecum and whole of the 
 
 Ascending Colon passed per Rectum. 
 
 CLIV Constipation. Subsequent perforation. Peritonitis. In- 
 tussusception restored ? 
 
 CLV Phthisis. Intussusception of the Ileum. Peritonitis. 
 CLVI Intussusception of Ileum. Perforation. Peritonitis. 
 CLVII Intussusception of Sigmoid Flexure. External Protrusion. 
 
 Symptoms of Strangulation. Peritonitis. Death. 
 CLVIII Columnar Epithelioma of the Sigmoid Flexure, with Can- 
 cerous Infiltration of Glands near the Gall-Bladder. 
 CLIX Cancer of the Sigmoid Flexure. Perforation. 
 CLX. Cancerous Disease of the Sigmoid Flexure. Ecchymosis 
 of Stomach. Ulceration of the Ileum. Contracted 
 Mitral Valve. 
 CLXI Cancer of the Liver, of the Lumbar Glands, and of the 
 
 Sigmoid Flexure. 
 CLXII Cancerous Ulceration of the Sigmoid Flexure of the Colon. 
 
 Constipation. 
 CLXIII Cancer of the Sigmoid Flexure. Obstruction Relieved. 
 
 Gradual Exhaustion. 
 CLXIV Colloid Cancer of the Sigmoid Flexure. Artificial Anus 
 
 in the Groin. Pleuro-pneumonia. 
 CLXV Cancerous Disease of the Sigmoid Flexure. Diarrhoea. 
 
 Perforation. Fecal Abscess. 
 
 CLX VI Cancerous Disease of the Rectum. Old Hernia. 
 CLXVII Cancerous Disease of the Transverse Colon. Fecal 
 
 Abscess. 
 
 CLXVIII Carcinoma of the Rectum, of the Ovaries, and of the Peri- 
 toneum. Acute Peritonitis. Scirrhus. 
 
 CLXIX Epithelioma of Rectum. Contraction and Obstruction. 
 Artificial Anus in the Loins. Diseased Appendix Caeci. 
 Fecal Abscess. 
 
 CLXX Cancer of Jejunum, and of the Mesenteric Glands. Soften- 
 ing of the Spinal Cord. Paraplegia. 
 CLXXI. Cancerous Ulcer of the Colon opening into the Duodenum. 
 
 Diarrhoea. Vomiting. 
 
 CLXXII Ulceration of the Colon. Intestinal Obstruction from Con- i 
 traction of the Transverse Colon. Cancer. Dysentery. 
 Constipation. Diarrhoea.
 
 ILLUSTRATIVE CASES. 545 
 
 CASE 
 
 CLXXIII.Suppuration external to the Sigtnoid Flexure of the Colon 
 opening on the Anterior Abdominal Parietes, and 
 communicating with the Intestine. 
 
 Abscess in the Loins. Feculent smelling discharge 
 Pleuro-pneumonia with Feculent smelling Sputum! 
 Kecovery. 
 
 *'-- Bceea in the Loins - Pleuro-pneumonia, Recovery. 
 LMiscarnage. Pyaemia. Abscess between the Uterus and 
 Bladder Abscess in the Loins, opening into the As- 
 cendmg Colon and into the Iliac Vein. 
 I. Abscess in the Hypogastric Abdominal Parietes simulating 
 
 Ovarian Disease. 
 
 CLXXVIILSuppuration external to the Right Kidney. Fibroid 
 Ihickenmg of the Tunic of the Kidney. Chronic Pye- 
 htis. Obliteration of the Vena Cava. Adhesion, 
 thinning and doubtful perforation of the Ascending 
 Colon. 
 
 CLXXIX Fecal Abscess in the pelvis, communicating with the 
 Ovary and Bladder, opening twice into the Rectum and 
 on the Groin. 
 
 CLXXX Abscess external to the Rectum leading to perforation. 
 Considerable fibrous thickening, and Simulation of Can- 
 cerous Disease. 
 
 CLXXXI Multilocular Ovarian Tumor. Perforation of the Caacum. 
 Fecal Abscess. Pneumonia. Pus in the Ovarian 
 Veins. 
 CLXXXII Ovarian Tumor filled with Feces and opening into the 
 
 Ileum. Pneumonic Phthisis. 
 
 [II Extra-uterine Fetation opening into the Sigmoid Flexure. 
 CLXXXI V Hypertrophy of the Heart. Adherent Pericardium. Acute 
 
 Pericarditis. Pleurisy and Peritonitis. 
 .vLXXXV Acute Peritonitis. Pericarditis. Pleuro-pneumonia. 
 
 Small Granular Kidneys. 
 
 CLXXXVI Peritonitis. Local Suppuration. Perforation of the Dia- 
 phragm. 
 
 CLXXXVII Chronic painless Peritonitis. Tubercle. Great Tym- 
 panitis. 
 CLXXX VIII Ulceration of the Intestine. Strumous Peritonitis. Fecal 
 
 Abscess. Umbilical Discharge. 
 CLXXXIX Peritoneal Ascites. Cancer of the Ovaries and Peritoneum. 
 
 Paracentesis. Peritonitis. 
 
 CXC Carcinoma of the Peritoneum with Effusion. Paracen- 
 tesis. 
 CXCI Chronic Peritonitis. Renal Disease. Spurious Cysts in 
 
 the Peritoneum. 
 CXCII Colloid Cancer of the Peritoneum and Ascending Colon. 
 
 35
 
 INDEX. 
 
 4 BERCROMBIE, disease of stomach, 18 
 A O3sophageal stricture, 64 
 muco-enteritis, 276 
 diarrhoea, 360 
 ileus, 425 
 
 Abdominal spaces, 530 
 Abscess in parotid gland, 37 
 pharynx, 50 
 tongue, 34 
 tonsil, 42 
 
 abdominal parietes, 473-533 
 in the iliac fossa, 322 
 Addison, Dr., phantom tumors, 530 
 
 disease of supra-renal capsule, 137 
 \Adhesions causing strangulation, 421^423 
 Albuniinuria, dyspepsia in, 218 
 
 peritonitis in, 504 
 Alcohol, use of, 212-297 
 cause of disease, 220 
 poisoning by, 126 
 Alderson, Sir J., on cancer, 73 
 Amyloid disease of stomach, 125 
 Anaemia, disease of spleen, 524 
 Aneurism, cause of dysphagia, 101 
 
 hemorrhage from stomach, 233 
 vomiting, 247 
 diagnosis of, 187 
 causing epigastric pain, 244 
 Aneurismal tumor, 534, 536 
 Angina Ludovici, 48 
 scrofulous, 50 
 ulcerative, 50 
 
 Annular stricture of oesophagus, 68 
 Annesley on dysentery, 360 
 Anstie, Dr., use of alcohol, 297 
 Aphthae, 29 
 
 Appendix caeci, atrophy, 318 
 concretion, 318-319 
 diseases of, 312-315 
 dilatation, 318 
 increase in length, 318 
 perforation of, 320 
 strangulation by, 422 
 tubercle in, 290 
 Ascaris lumbricoides, 491 
 
 vermicularis or oxyuris vennicularis, 
 
 492 
 Ascites, 516 
 
 varieties of, 516 
 symptoms of, 517 
 treatment, 528 
 Asthenia causing dropsy, 518 
 
 Atrophy of caecum, 315 
 
 tongue, 26 
 
 intestine, 278 
 
 stomach, 115 
 
 Auscultation of oesophagus, 72 
 A very, Mr., obstruction from displacement 
 of caecum, 325 
 
 BAKER, Sir G., on lead colic, 404 
 Ballard, Dr., on pepsin, 214 
 Ballingall on dysentery, 360 
 Baly on dysentery, 360, 361, 362, 366 
 Bamberger on dilatation of stomach, 120 
 croupous gastritis, 132 
 phlegmonous gastritis, 133 
 Bands causing strangulation, 421, 425 
 Barlow, Dr., case of duodenal disease, 271 
 internal strangulation, 421, 427, 
 
 428 
 
 Barker, Dr., dilatation of oesophagus, 67 
 Barthey on enteritis, 280 
 Batters by, Dr., diagnosis of caecal disease, 
 
 322 
 
 Bazin, ichthyosis of the tongue, 28 
 Bean, M., quinine in peritonitis, 509 
 Beaumont, Dr., observations by, 18 
 ! Bell, Sir C., oesophageal pouch, 67 
 ! Bennett, Dr. Hughes, leucocythemia, 524 
 Billing, Dr., 412 
 
 Bird, Dr. Golding, caecal concretion, 319 
 Birkett, Mr., cancer of intestine, 432 
 Bladder, distension of, 536 
 
 perforation by disease of the sigmoid 
 
 flexure, 432-537 
 
 Boudon on ipecacuanha injection, 287-356 
 I Bougies in stricture of oesophagus, 64 
 : Brain disease, vomiting in, 250 
 
 diagnosis of enteritis, 285 
 Brinton on cancer, 186 
 
 follicular gastritis, 138 
 ulcer of stomach, 147 
 ileo-colic valve, 314 
 intestinal obstruction, 430 
 Broadbent, Dr., phosphorus in enlarged 
 
 spleen, 524 
 
 Broussais on enteritis, 276-279 
 Brown, Dr. Blakeley, case of duodenal 
 
 obstruction. 274 
 Bryant, Mr., colotomy, 438 
 
 on opening small intestine, 438 
 removal of spleen, 524
 
 548 
 
 INDEX. 
 
 Bucoal psoriasis, 28 
 
 Budd, Dr., on gastric solution, 114-115 
 
 dyspepsia, 217 
 
 dysentery, 364 
 
 gastric fermentation, 231 
 Bulbar paralysis, 43 _ 
 Bulimia, 229 ,* 
 Burns, ulceration of duodenum, 255, 256 
 
 pALCULI in appendix caeci, 318 
 \J Cancrum oris, 3133 
 Cancer of the cjecum, 317, 322, 323 
 duodenum, 265 
 tonsil, 43 
 pharynx, 51 
 oesophagus, 72-73 
 intestine, 423-431 
 varieties of, 432 
 symptoms, 433 
 diagnosis, 435 
 treatment, 436 
 (Jases of, 455 
 stomach, 182 
 
 table of cases, 189 
 treatment, 192 
 diagnosis, 185-207 
 cause of hemorrhage, 233 
 Cancer of peritoneum, 496, 499, 505, 508, 
 
 525 
 Catarrh al inflammation of intestine, 
 
 277-349 
 
 colon, 276, 360-389 
 stomach, 129 
 
 Caustic treatment of tonsillitis, 41 
 Chambers, Dr. King, pyrosis, 218 
 Charcot, vomiting, 255 
 Children, diarrhoea in, 290 
 Chouppe, ipecacuanha injection, 287-356 
 Cicatrices in oesophagus, 71 
 the intestine, 363, 423 
 Clark, Dr. Andrew, catarrh of colon, 392 
 Clarke, Dr. Fairlie, on buccal psoriasis, 
 
 28 
 
 Clinical Society, case by Dr. Gray, 271 
 Cobbold, Dr., on entozoa, 487 
 Caecum, atrophy, 315 
 
 cancer of, 317, 322, 342 
 changes of position, 325, 391 
 congestion, 315 
 cases of disease, 325 
 diseases of, 391 
 
 disease of, causing peritonitis, 502 
 diagnosis of disease, 322 
 distension of, 315, 320, 321 
 discoloration, 316 
 
 inflammation of, typhlitis, 316, 321 
 oedema, 315 
 
 prognosis in disease, 323 
 symptoms of disease, 320 
 treatment, 324 
 
 trichocephalus dispar in, 318 
 tubercle in appendix, 290 
 nlceration, 316 
 Colic, flatulent, 398 
 
 Colic 
 
 from lead, painters', 405 
 
 morbid secretion, 402 
 
 improper food, 401 
 
 spasmodic, 398 
 
 causes of, 399, 403 
 
 diagnosis, 283, 399, 402 
 
 treatment, 400, 402, 405 
 Colon, accumulation in, 585 
 
 diagnosis of disease, 188 
 
 catarrh, 360, 389 
 
 communication with stomach, 433 
 
 distension of, 408 
 
 pouches of, 408 
 
 tumor in, 532 
 
 sigmoid flexure, ulceration, 537 
 Colotoiny, 437 
 Concretions in appendix, 318 
 
 intestine, 419 
 
 Congenital defects of oesophagus, 69 
 Constipation, effects of, 407 
 
 causes, 409 
 
 treatment, 415 
 
 Contraction, hour-glass, of stomach, 124 
 Copland, Dr., enteritis, 276 
 
 oedema of legs in caecal disease, 315 
 
 on colic, 398 
 Corrosives, stricture of oesophagus from, 
 
 106 
 Corvisart, pepsin, 214 
 
 pancreatic fluid, 253 
 
 duodenal dyspepsia, 253 
 Crupous gastritis, 132 
 Cru'veilhier, softening of stomach, 114 
 Cunningham, Dr., on cholera, 350 
 Curling, Mr. T. B., ulceration of duode- 
 num in burns, 255 
 
 on colotomy, 438 
 Cynanche parotidea, 37 
 Cysts in pharynx, 51 
 
 in oesophagus, 59 
 
 DAVIES-COLLEY, Mr., colotomy, 438 
 deafness from tonsillitis, 41 
 Diaphragm, extension of oesophageal can- 
 cer to, 74 
 Diarrhoea, bilious, 347 
 
 catarrhal, 348 
 
 choleraic, 350 
 
 cases of, 358 
 
 causes, 353 
 
 diagnosis of, 355 
 
 dysenteric, 349 
 
 inflammatory, 276 
 
 prognosis of, 354 
 
 serous, 350 
 
 in strumous disease, 289, 290 
 
 varieties of, 346 
 Dickinson, Dr., on lardaceous disea-.'. 
 
 309 
 Dilatation of oesophagus, 66 
 
 of stomach, 120 
 
 in cases of, 122 
 Diphtheria, 46
 
 INDEX. 
 
 Diphtheritic paralysis, 47 
 
 statistics of, 48 
 Diphtheritic membrane in oesophagus, 5 
 
 inflammation of stomach, 131 
 Distension of caecum, 315 
 Diverticula in duodenum, 253 
 causing strangulation, 422 
 Dix, Mr. J., case of disease of liver, 267 
 Dropsy, varieties of ascites, 516 
 
 ovarian, 527 
 
 Durham, Mr., on gastrotomy, 100, 101 
 Duodenum, anatomy of, 252 
 cancer of, 265 
 cases of disease, 259 
 congenital malformation, 253 
 congestion, 254 
 congestion, chronic, 256 
 diseases of, 252 
 distension of, 253 
 diverticuli, 253 
 inflammation of, 258 
 obstruction of, 268 
 secretion of, 253 
 solution of, 274 
 table of cases, 265 
 ulceration, 255, 258 
 vomiting in diseases of, 247 
 Dysentery, 361 
 
 morbid anatomy, 361 
 sequelae, 362, 363 
 symptoms, 364 
 causes, 366 
 prognosis, 368 
 pus in vena portae, 380 
 hepatic abscess, 364 
 contraction of colon, 385 
 diagnosis, 368 
 treatment, 369 
 cases of, 373 
 
 with pneumonia, 361, 386 
 causing perforation, 363, 379 
 fecal abscess, 363, 379 
 cancer of colon, 363 
 Dyspepsia, varieties of, 211 
 atonic, 211 
 climacteric, 214 
 in chronic diseases, 214 
 excessive secretion of gastric juice, 
 
 216 
 
 from fermentation, 231 
 from impeded movements, 229 
 from nervous system, 222 
 from vascular supply altered, 220 
 duodenal, 257 
 in phthisis, 21 
 Dysphagia, causes of, 60 
 from diphtheria, 47, 55 
 paralysis of soft palate, 47 
 suppuration in the pharynx, 50 
 spasmodic stricture, 62, 65 
 foreign bodies, 110 
 laryngeal disease, 60 
 paralysis of pharynx, 65 
 in mania, 62 
 from action of poisons, 106 
 
 Dysphagia 
 
 disease of oesophagus, 56 
 ulceration of oesophagus, 56 
 syphilitic disease, 69 
 from cicatrices, 71 
 
 cancer, 72 
 
 polypus, 101 
 
 aneurism, 101 
 
 tumors, 104 
 in pericarditis, 105 
 
 ECCHYMOSIS of oesophagus, 110 
 Embolism of gastric vessels, 150 
 
 as a cause of gastric ulcer, 150 
 Emphysema of the mucous membrane of 
 
 the stomach, 117 
 
 Empyema from ulcer of the stomach, 164 
 165 
 
 abscess of the liver, 384 
 Enteric fever, 393 
 Enteritis, 276 
 
 pathological changes in, 276 
 
 symptoms, 279, 281 
 
 diagnosis, 283 
 
 cases of, 281 
 
 causes of, 285 
 
 prognosis, 286 
 
 treatment, 286 
 
 causing intestinal obstruction, 424 
 Epithelioma of oesophagus, 74 
 Eustachian tube in parotitis, 37 
 
 tonsillitis, 40 
 Evanson, diseases of children, 287 
 
 FAGGE, Dr. Hilton, on dilatation of 
 stomach, 123 
 suppurative gastritis, 134 
 on lardaceous disease, 310 
 old intussusception, 452 
 peritoneal diseases, 526 
 gums in poisoning by lead, 32 
 i'eces, character of, 352 
 ^"ecal abscess, with perforation of stomach, 
 . 163 
 
 dysentery, 379 
 
 disease of caecum, 333, 334, 335 
 cancer of caecum, 342 
 "ecal abscess with cancer of colon, 463, 
 
 464, 466 
 with suppuration in the parietes 
 
 of the abdomen, 475, 479 
 from ovarian disease, 482, 484, 
 
 485 
 
 with umbilical discharge, 302 
 'enwick, Dr., on the stomach in scarla- 
 tina, 27, 133 
 
 'ermentation, cause of, in dyspepsia, 231 
 'ever, hemorrhage, 235, 395 
 
 typhoid disease of the intestine, 393 
 symptoms, 394 
 treatment, 395 
 cases of, 396 
 ibroid disease of pylorus, 178 
 
 35*
 
 550 
 
 INDEX. 
 
 Fistula, gastric, 94 
 
 Fletcher, Mr., on cesophageal bougies, 80 
 
 Follicular gastritis, 138 
 
 Foreign bodies in oesophagus, 110 
 
 stomach, 208 
 
 duodenum, 268 
 
 appendix cseci, 318 
 
 intestine, 424 
 
 Forster, Mr., gastrotomy, 94 
 Fox, Dr. Wilson, on furred tongue, 27 
 
 gastric catarrh, 130 
 
 phosphorus in diseased spleen, 
 
 524 
 Fraser, Dr., on green vomit, character of, 
 
 233 
 Furred tongue, 27 
 
 pAIRDENER, Dr., communication of 
 \J stomach and colon, 433 
 (rail-bladder, enlargement of, 532 
 Gall-stone, impaction of, 262, 268, 424 
 Gangrenous stomatitis, 33 
 Garrod, Dr., blood in gout, 218 
 Gastralgia, 224' 
 Gastritis, acute, 127, 241 
 
 chronic, 129 
 
 diphtheritic, 131 
 
 with scarlatina, 27 
 
 phlegmonous, 133 
 Gastric ulcer, 139 
 
 table of, 144 
 
 juice, composition of, 210 
 disordered states, 211 
 
 solution, 111, 113 
 
 of duodenum, 274 
 Gastrotomy, 76, 191 
 
 table of cases, 100 
 Gay, Mr., constipation, 415 
 Glands, mesenteric, disease of, 293 
 
 causing obstruction, 423 
 Glandular ascites, 521 
 
 disease in Hodgkin's disease, 524 
 Glossitis, 33, 36 
 
 acute, 34 
 
 subacute, 34 
 
 Gmelin, Dr., secretion of caecum, 314 
 Goodhart, Dr., on lardaceous disease, 310 
 Goodsir on sarcina, 231 
 Gorham, Mr., discharges in intussuscep- 
 tion, 284, 428 
 Gordon, report on diseases in India, 490 
 
 treatment of tapeworm, 490 
 Gout, dyspepsia in, 218 
 Graves, Dr., treatment of peritonitis, 506 
 
 cerebral vomiting, 249 
 Gray, Dr. T. 6., case of impacted gall 
 
 stone, 271 
 
 Gall, Sir Wm., on dilatation of the sto- 
 mach, 123 
 
 ulceration of duodenum, 255 
 
 case of caecal disease, 328 
 fever, 394 
 
 treatment of tapeworm, 490 
 
 phantom tumors, 530 
 
 Gums in stomatitis, 32 
 
 pigmented, in Addison's disease, 32 
 deposit of lead in, 32 
 in phthisis, 226 
 
 HALLIER, on cholera, 350 
 Hamburger, on cosophageal auscul- 
 tation, 72 
 Handfield Jones, on atrophy of stomach, 
 
 116 
 
 Harley, Dr., concretion in intestine, 419 
 Harty, Dr., on dysentery, 368 
 Headland, Dr., on the action of medicines, 
 
 21 
 
 Heart, dropsy in disease of, 519 
 Heidenheim, on the influence of bella- 
 donna upon the salivary gland, 33 
 Heller on intestinal worms, Ziemssen's 
 
 Encycl., 487 
 
 Hernia, diagnosis of, 283 
 Hesley, Dr., treatment of peritonitis. ">U7 
 Hilcon, Mr., on atrophy of the tongue, 26 
 operation in internal strangulation. 
 
 437 
 Hodgkin, Dr., on pathology of mucous 
 
 and serous membranes, 258, 300 
 disease of lymphatic glands, 524 
 Hsematemesis, 73, 233 
 symptoms of, 234 
 diagnosis, 236 
 treatment, 236 
 cases of, 237 
 
 from ulceration from gall-stone, 262 
 Hemorrhage in gastric ulcer, 141 
 
 in fever, 395 
 Hemorrhagic erosion, 134 
 Hemorrhoids, diagnosis of dysentery, 368 
 
 causing obstruction, 424 
 Hourglass contraction of stomach, 124 
 Howse, Mr., operation in intussusception, 
 
 439 
 Hulke on ichthyosis of the tongue, 28 
 
 on oesophagismus, 65 
 
 Hunter, Mr. John, on gastric solution, 114 
 Hutchinson, Mr. Jonathan, on the dys- 
 pepsia of phthisis, 21 
 operation in internal strangulation, 
 
 439 
 
 in intussusception, 453 
 case of, 439 
 Hydatid obstruction of duodenum, 268,274 
 
 tumors, 532, 534-536 
 Hydatids, 488 
 Hypertrophy of oesophagus, 66 
 
 of stomach, 119 
 Hysteria, diagnosis of enteritis, 284 
 
 TCHTHYOSIS of the tongue, 28 
 1 Ileo-colic valve, 314 
 Ileum, disease of, simulating caecal dis- 
 ease, 322 
 Ileus, 425 
 Inflammation of caecum, 316
 
 INDEX. 
 
 
 551 
 
 Inhalation in tonsillitis, 42 
 
 Internal strangulation, state of rectum 
 
 428 
 
 symptoms of, 429 
 cases of, 439 
 
 Intestine, disease of, in phthisis, 302 
 Intestinal obstruction, relative frequency 
 
 548 
 
 strangulation, 425 
 symptoms of, 425 
 worms, 487 
 
 symptoms of, tapeworm, 489 
 round worm, 492 
 thread worms, 492 
 treatment of tapeworm, 490 
 of round worm, 492 
 of thread worm, 493 
 varieties of, 487 
 tumors, 530, 532 
 
 Intestine, cancerous disease of, 431 
 perforation from without, 473 
 Intussusception, diagnosis of enteritis 
 
 284, 423, 429, 535 
 symptoms of, 431 
 causes of, and prognosis, 431 
 treatment of, 438 
 
 TENNER, Sir W., on use of hyposul 
 tl phites, 231 
 
 typhoid intestine, 393 
 Jones, Dr. Handfleld, pyrosis, 217 
 
 KENNEDY, Dr., hemorrhage without 
 ulceration, 235 
 Kidneys, disease of, cause of dropsy, 521, 
 
 523 
 
 diagnosis of enteritis, 285 
 tumors, 532, 534, 535 
 loose, 530 
 suppuration, diagnosis of, caecal dis- 
 ease, 322 
 
 King, Mr. Wilkinson, on gastric solution, 
 111 
 
 LABIO-GLOSSO-LARYNGEAL paralysis, 
 43 
 
 Lactic-acid fermentation, dyspepsia, 232 
 Lardaceous disease of stomach, 125, 289, 
 
 308 
 
 pathological changes, 309 
 symptoms, 310 
 prognosis, 310 
 table of relative frequency in viscera, 
 
 311 
 
 Laryngeal dysphagia, 60 
 Latham on dysentery, 360 
 Lead colic, 404 
 
 Lebert on ulceration of stomach, 148 
 Leudet, perforation of caecum, 317 
 Letzerich on diphtheria, 48 
 Lewis, Dr., on cholera spores, 350 
 
 J.i<mviUe,-hemorrhage into rectum, 2'!5 
 Liver, diagnosis of cancer of stomach, 
 187 
 
 disease of, causing dropsy, 519, 521 
 
 tumors of, 531 
 
 cirrhosis, 521, 527, 528 
 
 displacement of, 531 
 
 enlargement of, 532 
 Ludovici angina, 48 
 Lungs affected in tonsillitis, 41 
 
 affection in cancer of oesophagus, 78 
 Lyon, Dr., Crimean report, 361 
 
 VfAINGAULT on diphtheria, 47 
 ill Malformation of oesophagus, 69 
 Maramillation of stomach, 119 
 Marcet, Dr.,- foreign bodies in, 419 
 
 lardaceous disease, 309 
 Marsh, Sir Henry, irritability of stomach, 
 
 226, 250 
 Maunder, Mr., colotomy, 438 
 
 operation of opening small intestine, 
 
 438 
 
 Maunsell, on diseases of children, 287 
 Mayne, Dr., dysentery, 364 
 Mayo on cesophageal stricture, 64 
 Mediastinal tumors, 104 
 Medical Gazette, case of intussusception, 
 
 452, 453 
 Melsena, 351 
 
 Membranous pharyngitis, 46 
 Menstruation, vicarious, 233 
 Mercurial stomatitis, 32 
 Mesenteric disease of glands, 290, 293 
 symptoms, 294 
 diagnosis, 295 
 prognosis, 296 
 causes, 296 
 cases of, 306 
 Mesentery, contraction of, 517 
 
 tumors in, 535 
 Metastasis in parotitis, 37 
 McGrigor on dysentery, 360 
 Moore, Charles H., use of injection in diag- 
 nosis of strangulation, 428 
 tforehead on dysentery, 360, 362, 366 
 Morris, Mr. Henry, on ichthyosis of the 
 
 tongue, 28 
 Moxon, Dr., on phlegmonous gastritis, 134 
 
 lardaceous disease, 309 
 tfuguet, 30 
 Muco-enteritis, 276 
 cases of, 281 
 see Enteritis, 
 [ucous membranes, wasting of stomach, 
 
 115 
 
 wasting of intestine, 279 
 tubercle, 290 
 'urchison, Dr., hemorrhage in enteric- 
 fever, 395 
 on stomach, 146 
 
 communication of stomach and colon, 
 433
 
 552 
 
 so 
 
 INDEX. 
 
 1 YjBRYors rlyspli.-i-ia, 03 
 IN dvspopsia, 226 
 
 dinrrhoja, 350 
 Neuralgia of the tongue, 36 
 
 ABSTRACTION of duodenum, 268 
 \J organic, of intestine, 421 
 
 varieties, 421 
 
 symptoms, 425 
 
 Odling, Dr., csecal concretion, 319 
 (Edema of caecum, 315 
 (Esophagisinus, 65 
 (Esophagus, diseases of, 53 
 
 anatomy of, 53 
 
 acute inflammation, 54 
 
 ulceration of, 56 
 
 abscess, 59 
 
 cysts, 59 
 
 warts, 59 
 
 spasmodic stricture, 63 
 
 paralysis of, 65 
 
 hypertrophy of, 66 
 
 dilatation of, 66 
 
 pressure upon by tumors, 68 
 
 strictures, 69 
 
 congenital defects, 69 
 
 action of poisons, 105 
 
 cicatrices, 71 
 
 cancer of, 72 
 
 causes of death in cancer of, 75 
 
 tables of, 76 
 
 statistics of, 77 
 
 affections of the lung in, 78 
 
 polypi, 101 
 
 myoma of, 101 
 
 hemorrhage from, 233 
 
 obstruction in aneurism, 101 
 
 foreign bodies in, 110 
 
 ecchymosis of, 110 
 
 rupture of, 111 
 
 solution of, 111 
 Omentum, diagnosis of disease, 187 
 
 tumor in, 533-535 
 
 Oppolzer on phlegmonous gastritis, 134 
 Osborne, Dr., pain in gastric ulcer, 243 
 Ovary, disease of, producing dropsy, 517, 
 527 
 
 disease of with ascites, 518 
 
 tumors, 534, 535, 536, 537 
 
 diagnosis of caecal disease, 322 
 
 PAGET, Sir James, on atrophy of tongue, 
 26 
 
 psoriasis of the tongue, 28 
 
 ringworm, 36 
 Pain in disease of stomach, 224 
 
 as a symptom, causes of, 240 
 
 in internal strangulation, 426 
 Pancreas, diagnosis of disease, 187 
 
 causing obstruction, 268, 271, 272 
 
 tumor, 532, 533 
 
 Panum on circulation in the stomach, 149 
 Paralysis of the tongue, 26 
 
 Paralysis 
 
 soft palate, 43 
 
 stomach, 121 
 
 Parkes, Dr., on dysentery, 360 
 Parotitis, 37 
 
 Parietes, abdominal, suppuration in, 473, 
 474, 533 
 
 diagnosis of, treatment, 475 
 
 cases of, 475 
 Pathological transactions 
 
 caecum displaced, obstruction, Mr. 
 Abery, 325 
 
 cancer of intestine, Mr. Birkett, 432 
 
 case of intussusception, J. Hutchin- 
 son, 453 
 
 case of hsematemesis, 261 
 
 foreign bodies in appendix caeci, 318 
 
 case of constipation, Mr. Gay, 415 
 
 concretion in intestine, 419 
 Pavy, Dr., on gastric solution, 113, 149 
 Perforation of trachea in cancer of oeso- 
 phagus, 81 
 
 Pericarditis, dysphagia in, 105 
 Peristaltic movements, 426 
 Peritoneum, adhesions causing obstruc- 
 tion of duodenum, 268 
 
 tubercle of, 290, 296, 297 
 
 loose bodies in, 515 
 Peritonitis, pathology of, varieties, 495 
 
 symptoms, 497 
 
 diagnosis, 499 
 
 prognosis, 284, 500 
 
 causes, 529 
 
 treatment, 505 
 
 cases, 504, 509 
 
 causing obstruction, 424 
 
 chronic, 496, 507 
 
 tubercular, 496, 499, 504, 525 
 
 cancerous, 496, 499, 505, 508, 525, 
 527 
 
 in cirrhosis, 505, 508 
 
 in albuminuria, 504, 507 
 
 puerperal, 504, 507 
 
 strumous and tubercular, 297 
 
 cause of dropsy, 520 
 Pharynx, anatomy of, 45 
 
 spasm, 45 
 
 inflammation, 45 
 
 chronic, 46 
 
 follicular, 46 
 
 membranous, 46 
 
 phlegmonous, 48 
 
 syphilitic, 49 
 
 cancer, 50, 51 
 
 suppuration behind, 50 
 
 cysts in, 51 
 Philip, Dr. Wilson, experiments of, 21 
 
 distension of stomach, 230 
 Phillips, Mr. Benjamin, case of intussus- 
 ception, 452 
 
 Phlegmonous gastritis, 133 
 Phthisis, dyspepsia in, 21 
 
 disease of intestine, 302 
 
 stomatitis, 32 
 
 gums, 226
 
 INDEX. 
 
 553 
 
 Phthisis- 
 irritability of stomach, 251 
 Pleuritic effusion simulating enlargement 
 
 of liver, 531 
 
 Pneumogastric, influence on stomach, 21 
 Pneumonia in cesophageal cancer, 74 
 Poisons, effect of, 106 
 Poisoning, diagnosis of, 125 
 
 enteritis, 284 
 
 Poland, Mr., on cancer of tonsil, 43 
 Polypus in oesophagus, 101 
 
 intestine, 423 
 
 Polypi in stomach, 139, 181 
 Post-mortem solution of stomach, 113 
 Pouches, pharynx, 51 
 
 oesophagus, 67 
 
 Pringle, Sir J., use of ipecacuanha, 370 
 Prout, Dr., dyspepsia, 218 
 
 concretion in appendix, 319 
 Pulse, depression of, in abdominal disease 
 
 20 
 
 Pulsation, abdominal, 533 
 Pylorus, fibroid disease of, 178 
 cancer of, 182 
 
 QUININE in cancrum oris, 33 
 Quinsy, 38, 39 
 
 EECTUM, disease of, diagnosis of dysen- 
 tery, 368 
 
 polypus, 368 
 
 fibro-cellular ulceration, 368 
 
 state of sphincter, 369 
 
 impacted feces, 369 
 
 state of, in internal strangulation, 
 429 
 
 disease of, causing peritonitis, 503 
 Rheumatism, dyspepsia, 218 
 Rilliet on enteritis, 280 
 Rindfleisch on aphthae, 30 
 Ringworm of the tongue, 36 
 Rokitansky on gastric ulcer, 149 
 
 displacement of caecum, 312 
 
 dysentery, 361 
 
 typhoid intestine, 393 
 Roper, Dr., ileo-colic valve, 314 
 Rupture of oesophagus, 111 
 
 S ALTER, Dr. Hyde, on tracheal dys- 
 phagia, 61 
 Saiidvvith, Dr., perforation of intestine by 
 
 lumbrici, 491 
 Scarlatinal gastritis, 133 
 Schmidt, composition of gastric iuice, 
 
 216 
 
 hemorrhage from oesophagus, 233 
 Scrofulous angina, 50 
 Siebold, Von, treatise on entozoa, 487 
 Solution of oesophagus, 111 
 of stomach, 112-113 
 of duodenum, 274 
 South ey, Dr., drainage tubes, 507 
 
 Spasm of tongue, 36 
 
 of pharynx, 45 
 
 of oesophagus, 63 
 Spinal disease, 535 
 Spleen, disease of, causing ascites, 521, 
 
 removal of, by Mr. Bryant, 524 
 tumors of, 534 
 Staniland, constipation, 415 
 Steffen, on oesophageal disease in children 
 
 55 
 Stewart, Dr. Grainger, gastric crises in 
 
 locomotor ataxia, 225 
 
 Stewart, Dr. A. P., on typhoid fever, 393 
 btokes, Dr., treatment of peritonitis, 506 
 Stomach, solution of, 113 
 atrophy of, 115 
 hypertrophy of, 119 
 polypi in, 119, 219 
 mammillation of, 120 
 dilatation of, 120 
 hour-glass contraction, 124 
 lardaceous disease, 125 
 effects of poisons, 125 
 acute gastritis, 127 
 chronic, 129 
 diphtheritic, 131 
 suppurative, 133 
 suppuration in coats of, 133 
 ulceration of, 134 
 hemorrhagic erosion, 134 
 hemorrhage, 233 
 follicular ulceration, 138 
 perforating ulcer, 140 
 table of cases of ulcer, 144 
 causes of ulceration, 149 
 symptoms, 150 
 causes of death in ulcer, 153 
 treatment of ulceration, 171 
 sloughing of, 176 
 tumors of, 533 
 
 fibroid disease of pylorus, 1 78 
 cancer of, 182 
 diagnosis of cancer of, 185 
 statistics of cancer of, 186 
 treatment of cancer, 192 
 foreign bodies in, 253, 419 
 Stomatitis, 29 
 
 treatment of, 29 
 follicular affection in, 29 
 ulcerative, 31 
 phthisical, 32 
 scorbutic, 32 
 mercurial, 32 
 gangrenous, 33 
 syphilitic, 36 
 Strumous disease of alimentary canal, 
 
 289 
 
 peritoneum, 297, 496 
 symptoms, 300 
 causes, 301 
 treatment, 301 
 intestine, 535 
 
 Strangulation of intestine, 421, 425 
 from bands of adhesion, 431
 
 554 
 
 INDEX. 
 
 Suppuration behind pharynx, 50 
 
 in abdominal parietes, 473, 533, 534 
 diagnosis of caeca! disease, 322 
 
 Syphilitic ulceration of tongue, 36 
 pharyngitis, 49 
 stricture of oesophagus, 69 
 
 Supra-reiial capsule, tumor of, 532, 533, 
 534 
 
 TABLE of cases of cancer of ossophagus, 
 76 
 
 gastrotomy, 100 
 ulcer of stomach, 144 
 cancer of stomach, 189 
 dysentery, 373 
 Taylor, Dr., on poisons, 402 
 Teeth, carious, a cause of ulceration of the 
 
 tongue, 35 
 Thompson, Dr. T., on the gums in phthisis, 
 
 32, 226 
 
 on injections in phthisis, 306 
 Thrush, 30 
 Tiedemann on the secretion of the caecum, 
 
 314 
 
 Tongue wasting, and paralysis, 26, 27 
 anaemic, 27 
 livperaemic, 27 
 furred, 27 
 warty, 28 
 ichthyosis of, 28 
 in stomatitis, 29 
 inflammation of, 33, 35 
 abscess of, 35 
 
 treatment of acute inflammation, 34 
 chronic inflammation, 34 
 treatment of, 35 
 ulcerated, in phthisis, 35 
 
 from carious teeth, 35 
 syphilitic ulceration of, 36 
 neuralgia of, 36 
 spasm of, 36 
 ringworm of, 36 
 Tonsil, 38 
 
 structure of, 38 
 ulceration of, 38-40 
 acute catarrh of, 39 
 erysipelatous inflammation of, 40 
 cancer of, 43 
 suppuration of, 39 
 syphilitic ulceration of, 40 
 strumous disease of, 40 
 chronic hypertrophy of, 40 
 excision of, 42 
 
 Tracheotomy in acute tonsillitis, 42 
 Tracheal dysphagia, 60 
 Travers, case of perforation of duodenum, 
 
 260 
 
 Trichocephalus dispar, 492 
 in caecum, 318 
 
 Trousseau, injection of nitrate of silver, 
 
 358, 371 
 
 Tubercular disease of alimentary canal, 289 
 of peritoneum, 297 
 of intestine, 302, 394 
 Tumors, abdominal, 530 
 
 phantom, 530 
 
 varieties of, 531 
 
 causing obstruction, 423 
 Turnbull, Dr., on fermentation, 22 
 Turpentine in tonsillitis, 41 
 Twining, use of ipecacuanha, 370 
 Twist of caecum, 312 
 
 bowels, 423 
 
 Tympanitis in obstruction, 426 
 Typhlitis, 316 
 Typhus, parotitis in, 37 
 Typhoid disease of intestine, 393 
 
 TTLCERATION of stomach, 134 
 
 U follicular, 138 
 
 Ulcers of stomach, causes of, 149 
 symptoms of, 150 
 causes of death in, 153 
 treatment of, 171 
 of duodenum, 255, 258 
 of intestine in enteritis, 278 
 of colon in dysentery, 362, 363 
 in phthisis, 302 
 of caecum, 316 
 
 Urine, quantity of, in internal strangula- 
 tion, 427 
 
 Uterus, enlargements of, 536 
 
 Uvula, excision of, 42 
 
 TTERNEUIL'S case of gastrotomy, 101 
 Virchow on parotitis, 37 
 'Archiv', 32, 51 
 on amyloid disease, 309 
 Vomiting in gastric ulcer, 173 
 dyspepsia, 224 
 as a sign of disease, 240, 244 
 in internal obstruction, 427 
 
 WARD, Mr. N., foreign bodies in appen- 
 dix caeci, 319 
 
 Warty tumors of pharynx, 51 
 Weisse, Dr., use of raw meat, 291 
 West, Dr., on diarrhrea, 276 
 
 muco-enteritis, 280 
 
 Wilks, Dr., ulceration of duodenum, 255 
 cancer disease on dysenteric cicatrix, 
 363 
 
 YOUNG, Dr., lurnbrici passing through 
 abdominal parietes, 491
 
 WORKS BY AUSTIN FLINT, M.D., 
 
 Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. 
 
 A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE- 
 
 DESIGNED FOR THE USE OP STUDENTS AND PRACTITIONERS OF MEDICINE. 
 Fourth Edition, Revised and Enlarged. 
 
 In one large and clot ly printed octavo volume of nearly 1)00 pages : cloth, $6 : or strongly 
 bound in leather., with raised bands, $7. (Lately Issued.) 
 
 This excellent treatise on medicine has acquired 
 for itself in the United States a reputation similar to 
 that enjoyed in England by the admirable lectures of 
 Sir Thomas Watson. It may not possess the same 
 charm of style, but it has like solidity, the fruit of 
 long and patient observation, and presents kindred 
 moderation and eclecticism. We have referred to 
 many of the mostimportant chapters, and find there- 
 vision spoken of in the preface is a genuine one, and 
 that the author has very fairly brought up his matter 
 to the level ofthe knowledge of the present day. The 
 work hat. this great, recommendation, that it is in one 
 volume, and therefore will not be so terrifying to the 
 student as the bulky volumes which several of our 
 English text-books of medicine have developed into 
 British and For. Med.-Ghir. Rev., Jan. 1875. 
 
 It is of course unnecessary tointroduce or eulogize 
 this now standard treatise. All the colleges recom- 
 mend it as a text-book, and there are few libraries 
 in which one of its editions is not to be found. The 
 present edition has ben enlarged and revised to 
 bring it up to the author's present level of experience 
 and reading. His own clinical studies and the latest 
 contributions to medical literature both in this coun- 
 
 try and in Europe, have received careful attention 
 so that some portions have been entirely rewritten ' 
 and about seventy pages of new matter have been 
 added. Chicago Med. Jo'i-rn., June, 187.3 
 
 Has never been surpassed as a text-book for stu- 
 dent' and a book of ready reference for practitioners 
 The force of its logic, its simple and practical teach- 
 ings, have left it without a rival in the fleld ff Y 
 Med. Record, Sept. 15, 1874. 
 
 Prof. Flint, in the fourth edition of his great work, 
 has performed a labor reflecting much credit upon 
 himself, and conferring a lasting beneBt upon the 
 profession The whole work shows evidence of tho- 
 rough revision, so that it appears like a new hook 
 written expressly for the times. For the general 
 practitioner and student of medicine, we cannot re- 
 commend the book in too strong terms. 2f Y Med 
 Jmi.rn., Sept. 1873. 
 
 It is given to very few men to tread in the steps of 
 Austin Flint, whose single volume on medicine 
 though here and there defective, is a masterpiece of 
 lucid condensation and if general grasp of an enor- 
 mously wide subject. Land. Practitioner, Dec. '73. 
 
 PHTHISIS ITS MORBID ANATOMY, SYMPTOMATIC EVENTS AND 
 n?faMF^ TIONS ' FATAL ITY AND PROGNOSIS, TREATMENT AND PHYSICAL 
 DIAGNOSIS, IN A SERIES OP CLINICAL STUDIES. In one large and handsome octavo vol- 
 ume of 446 pages : cloth, $3 50. 
 
 III. 
 
 A PRACTICAL TREATISE ON THE PHYSICAL EXPLORATION OF THE 
 CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY 
 ORGANS. Second and Revised Edition. In one handsome octavo volume of 595 pages: 
 cloth, $4 50. 
 
 IV. 
 A PRACTICAL TREATISE ON THE DIAGNOSIS. PATHOLOGY AND 
 
 TREATMENT OF DISEASES OF THE HEART. Second Revised and Enlarged Edition 
 In one octavo volume of 550 pages, with a plate: cloth, $4. 
 
 V. 
 
 A MANUAL OP PERCUSSION AND AUSCULTATION- OP THE PHY- 
 SICAL DIAGNOSIS OF DISEASES OF THE LUNGS AND HEART, AND OF THO- 
 RACIC ANEURISM. In one handsome royal 12mo. volume of 255 pages: cloth, $1 75. 
 
 VI. 
 
 CLINICAL MEDICINE. A SYSTEMATIC TREATISE ON THE DTAG- 
 NOSIS AND TREATMENT OF DISEASES. DESIGNED FOR STUDENTS AND PRAC- 
 TITIQJSIERS OF MEDICINE. In one large and handsome octavo volume. (Shortly.) 
 
 HENRY C. LEA Philadelphia.
 
 WORKS ON PRACTICAL, MEDICINE. 
 
 BRISTOWE'S PRACTICE Just Issued. 
 A TREATISE ON THE THEORY AND PRACTICE OP MEDICINE. By 
 
 JOHN SYER BRISTOWE, M.D., F.R C.P., Physician and Joint Lecturer on Medicine, St. 
 Thomas's Hospital. Edited, with Additions, by JAMES H. HUTCHINSON, M.D.. Physician 
 to the Pennsylvania Hospital. In one large and handsome octavo volume of 1089 closely 
 printed pages,- cloth, $5 50; sheep, $6 50. 
 
 This portly volume is a marvel of condensation. 
 In a style at once clear, interesting, and concise, Dr. 
 Bristowe passes in review every conceivable subject 
 connected with the practice of medicine. Those 
 practitioners who purchase few books will find this 
 a most opportune publication, because so miny top- 
 ics not usually embraced in a work on practice are 
 adequately handled. The book is a thoroughly go >d 
 one, and its usefulness to American readers has been 
 increased by the judicious notes of the Editor. 
 Cincinnati Clinic, Jan. 7, 1877. 
 
 Upon the whole, we know of no work which we 
 could more confidently recommend to the student or 
 the practitioner, intending a review of the field of 
 theory and practice, than this book of Dr. Bris- 
 towe's. We thus commend it, because the vast ar- 
 ray of facts pertaining to the practice of medicine, as 
 it is to-day, are here presented ably, and with that 
 method, order, and perspicuity which, in all depart- 
 ments of education, distinguish the lessons of an ac- 
 ceptable and profitable teacher. Chicago Afed. 
 Journ. and Examiner, Aog. 1877. 
 
 FOTHERGILL'S HANDBOOK OF TREATMENT Just Issued. 
 
 TBE PRACTITIONER'S HANDBOOK OP TREATMENT: OR. THE PRIN- 
 CIPLES OP THERAPEUTICS By J. MILNER FOTHERGILL, M.D. Assistant Physician to the 
 Hospital for Diseases of the Chest, to the West London Hospital, etc. etc. In one very 
 neat octavo volume of about 575 pages : cloth, $4. 
 
 None can read it without being impressed with the | fundamental principles of medicine in such away 
 Immense amount of common sense which is possessed as to give them a practical application to treatment. 
 by the author, as well as natural tact in interpreting It is, in fact, one of the most interesting, entertaining, 
 the indications of treatment. His style is clear and and instructive works of its kind that we have ever 
 agreeable, and he has the faculty of expounding the i read. Med. Record, March 17, 1S77. 
 
 FOX ON DISEASES OF THE SKIN New Edition Just Ready. 
 
 EPITOME OP SKIN DISEASES, WITH FORMULAE. For Students and Prac- 
 titioners. By TILBURY Fox, M.D. , F.B.C.P., Physician to Department of Skin Diseases, 
 Univ. Hospital College, London, and T. C. Fox, B.A., M.R.C.S. Second edition. Tho 
 roughly revised and greatly enlarged. In one very handsome 12mo. volume of 216 pages. 
 Cloth, $1 38. 
 
 PREFACE. 
 
 "In preparing this edition of our 'EPITOME' for publication in the United States, we have 
 increased the matter to about three times its original amount. The kindly appreciation mani- 
 fested for the work by the American profession has stimulated us to spare no pains in rendering 
 it more worthy of their approbation, and in its enlarged form we believe that it will be found of 
 enhanced value. About two thirds of the work is newly written, and we may direct attention 
 particularly to the section regarding the Pathology of the Skin, which has been entirely recast, 
 and now contains a concise account of all the important changes taking place in the dermal 
 textures in disease. The clinical descriptions of diseases also have been amplified and occasion 
 ally remodelled. Lastly, we may say that, in adding material to the book we have selected 
 such as bears on the practical side of Dermatology, to the exclusion of that which is as yet 
 hypothetical or merely of interest to the curious student. 
 
 "The favorable reception accorded to the work on both sides of the Atlantic would seem to 
 show that it has realized the object with which it was prepared to afford assistance to the 
 student in his early study of dermatology, and to serve as a manual for ready reference by 
 the practitioner in his daily practice. For this latter purpose it has been specially adapted, by 
 means of the references made in the sections on treatment to the formulae at the end." 
 
 HAMILTON ON NERVOUS DISEASES Now Ready. 
 
 NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. By 
 
 ALLAN McLANE HAMILTON, M.D , Attending Physician to the Hospital for Epileptics and 
 Paralytics, Blackwell's Island, N. Y., and to the Out-Patients' Department of the New 
 York Hospital. In one handsome octavo volume of 512 pages, with 63 illustrations; 
 cloth, $3 50 
 
 This is unquestionably the best and most complete 
 text-book of nervous disease* that has yet appeared, 
 and were international jealousy in scientific affairs 
 at all pojsible, we might be excused for a feeling of 
 chagrin that it should be of American parentage. 
 This work, however, has been performed in New 
 York, and has been so well performed that no room 
 i-< left for anything but commendation. With great 
 skill, Dr. Hamilton has presented to his readers a suc- 
 
 cinct and lucid survey of all that is known of the 
 pathology of the nervous system, viewed in the light 
 of the most recent researches. From the preliminary 
 description ofthe methods of examination and study, 
 and of the instruments of precision employed in the 
 investigation of nervous diseases, up till the final 
 collection of formula, the book is eminently prac- 
 tical. Brain, London, Oct. 1878. 
 
 HENRY C. LEA Philadelphia.
 
 C. H,EA.'S 
 
 (LATE LEA & BLANCHAR&'s) 
 
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 MEDICAL AND SUEGICAL PUBLICATIONS, 
 
 In asking the attention of the profession to the works advertised in the following 
 pages, the publisher would state that no pains are spared to secure a continuance of 
 the confidence earned for the publications of the house by their careful selection and 
 accuracy and finish of execution. 
 
 The printed prices are those at which books can generally be supplied by booksellers 
 throughout the United States, who can readily procure for their customers any works 
 not kept in stock. AVhere access to bookstores is not convenient, books will be sent 
 by mail post-paid on receipt of the price, providing their weight does not exceed the 
 postal limit of four pounds (nee page 32); but no risks are assumed either on the 
 money or the books, and no publications but my own are supplied. Gentlemen will 
 therefore in most cases find it more convenient to deal with the nearest bookseller. 
 
 An ILLUSTRATED CATALOGUE, of 64 octavo pages, handsomely printed, will be for- 
 warded by mail, post-paid, on receipt of ten cents. 
 
 HENRY C. LEA. 
 
 Nos. 706 and 708 SANSOM ST., PHILADELPHIA, April, 1879. 
 
 ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO 
 
 THE AMERICAN JOURNAL_OT THE MEDICAL SCIENCES. 
 
 THEEE MEDICAL JOUEtf ALS, containing over 2000 LARGE PAGES, 
 Tree of Postage, for SIX DOLLAKS Per Annum, 
 
 TEEMS FOB, 1879. 
 
 The AMERICAN JOURNAL OF THK MKDICAL SCIENCES and 1 Five Dollars per annum, 
 The MEDICAL NEWS AND LIBRARY, both free of postage, ) in advance. 
 
 OR 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, published quar- 1 q. ,, ,, 
 
 terly (1150 pages per annum), with 
 
 The MEDICAL NEWS AND LIBRARY, monthly (384 pp. perannum), and [- per annum, 
 THE MONTHLY ABSTRACT OF MEDICAL SCIENCE (592 pages per j J Q advance 
 annum). 
 
 SEPARATE SUBSCRIPTIONS TO 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, when not paid for in advance. 
 
 Five Dollars. 
 
 THE MEDICAL NEWS AND LIBRARY, free of postage, in advance, One Dollar. 
 THE MONTHLY ABSTRACT OF MKDICAL SCIENCE, tree of postage, in advance, Two 
 
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 * # * Advance-paying subscribers can obtain at the close of the year cloth covers, 
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 (one annually), free by mail, by remitting ten cents for each cover. 
 
 In commencing the second year of the second half century in the career of the 
 "AMERICAN JOURNAL OF THE MEDICAL SCIENCES," the publisher has much pleasure in 
 assuring its wide circle of readers, that at no former period has it had the prospect of 
 a more extended sphere of usefulness. Sustained as it is by the profession of the whole 
 United States, and with a circulation extending to every country in which the English 
 language is read, the efforts of the editors will be directed, as heretofore, to render it in 
 every way worthy of its reputation, and of the universal favor with which it is received. 
 With its attendant periodicals, the " M KDICAL NEWS AND LIBRARY" and the " MONTHLY 
 A BSTRACT OF M EDiCALSciENCE," it combines the advantages of the elaborate preparation 
 which can be given to a quarterly, and the prompt conveyance of intelligence by the 
 monthly, while, the whole being under a single editorial supervision, the subscriber is 
 secured against the duplication of matter inevitable under other circumstances. These 
 efforts the publisher seeks to second by offering these periodicals at a price unprece- 
 dentedly low a price which places them within the reach of every practitioner, and gives 
 the equivalent of three or four large octavo volumes for the comparatively trifling 
 
 (For THE "OBSTETRICAL JOUUNAL," see p. 23.)
 
 2 HENRY C. LEA'S PUBLICATIONS (Am. Journ. Med. Sciences'). 
 
 cost of Six DOLLARS per annum. 
 
 The three periodicals thus offered are universally known for their high professional 
 standing in their several spheres. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 EDITED BY ISAAC HAYS, M.D., AND I. MINIS HAYS, M.D., 
 is published Quarterly, on the first of January, April, July, and October. Each num- 
 ber contains nearly three hundred large octavo pages, appropriately illustrated wher- 
 ever necessary. It has now been issued regularly for over FIFTY years, during the 
 whole of which time it has been under the control of the present senior editor. Through- 
 out this long period, it has maintained its position in the highest rank of medical peri- 
 odicals both at home and abroad, and has received the cordial support of the entire 
 profession in this country. Among its Collaborators will be found a large number of 
 the most distinguished names of4he profession in every section of the United States, 
 rendering its original department a truly national exponent of American medicine.* 
 
 Following this is the -'REVIEW DEPARTMENT," containing extended and impartial 
 reviews of important new works, together with numerous elaborate "ANALYTICAL AND 
 BIBLIOGRAPHICAL NOTICES" giving a complete survey of medical literature. 
 
 This is followed by the "QUARTERLY SUMMARY OF IMPROVEMENTS AND DISCOVERIES 
 ix THE MEDICAL SCIENCES," classified and arranged under different heads, presenting 
 a very complete digest of medical progress abroad as well as at home. 
 
 Thus, during the year 1878, the "JOURNAL" furnished to its subscribers 77 Original 
 Communications, 133 Reviews and Bibliographical Notices, and 255 articles in the 
 Quarterly Summaries, making a total of FOUR HUNDRED AND SIXTY-FIVE articles 
 illustrated with 48 maps and wood engravings, emanating from the best professional 
 minds in America and Europe. 
 
 That the efforts thus made to maintain the high reputation of the "JOURNAL" are 
 successful, is shown by the position accorded to it in both America and Europe as a 
 leading organ of medical progress: 
 
 This la universally acknowledged as the leading 
 American Journal, and has been conducted by Dr. 
 ll ys alone until 1869, when his son was associated 
 with him. We quite agree with the critic, that thi 
 journal is second to none in the language, and cheer- 
 fully accord to it the first place, for nowhere shall 
 we nnd more able and more impartial criticism, and 
 nowhere such a repertory of able original articles. 
 Indeed, now that the ''BrilUh and Foreign Medico- 
 Chirurgical Review" has terminated its career, the 
 American Journal stands without a rival. London 
 Med. Times and Gazette, Nov. '24, 1877. 
 
 The present number of the American Journal is an 
 exceedingly good one, and gives every promise of 
 maintaining the well-earned reputation f the review 
 Our venerable contemporary has our best wishes, 
 and we can only express the hope that it may con- 
 tinue Us work with as much vigor and excellence for 
 the next fifty years as it has exhibited in the past. 
 London Lancet, Nov. 24, 1877. 
 
 The Philadelphia Medical and Physical Journal 
 issued its first number in 1820, and after a brilliant 
 career, was succeeded in 1827 by the American 
 Journal of the Medical Sciences, a periodical of 
 world-wide reputation ; the ablest and one of the 
 oldest periodicals in the world a journal which has 
 an unsullied record. Gross's History of American 
 Med. Literature, 1S76. 
 
 It is universally acknowledged to be the leading 
 American medical journal, and, in our opinion, is 
 second to none in the language. Boston Med. and 
 Surg. Journal, Oct. 1S77. 
 
 This is the medical journal of our country to which 
 the American physician abroad will point with the 
 greatest satisfaction, as reflecting the state of medical 
 culture in his country. For a great many years it 
 has been the medium through which our ablest writ- 
 ers have made known their discoveries and observa- 
 tions Address of L. P. Ynndell, M.D., before Inter- 
 national Med. Congress, Sept. 1876. 
 
 And that it was specifically included in the award of a medal of merit to the Publisher 
 in the Vienna Exhibition in 1873. 
 
 The subscription price of the "AMERICAN JOURNAL OF THE MEDICAL SCIENCES" has 
 never been raised during its long career. It is still FIVE DOLLARS per annum ; and 
 when paid for in advance, the subscriber receives in addition the "MEDICAL NEWS AND 
 LIBRARY," making in all about 1500 large octavo pages per annum, free of postage. 
 
 II. 
 
 THE MEDICAL NEWS AND LIBRARY ' 
 
 is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
 annum. Its "LIBRARY DEPARTMENT" is devoted to publishing standard works on the 
 various branches of medical science, paged separately, so that they can be detached 
 for binding, when complete. In this manner subscribers have received, without ex- 
 pense, such works as '-WATSON'S PRACTICE," "WEST ON CHILDREN," "MALGAIGNE'S 
 SURGERY," "STOKES ON FEVER," GOSSELIN'S "CLINICAL LECTURES ON SURGERY," and 
 many other volumes of the highest reputation and usefulness. With July, 1878, was 
 commenced the publication of "LECTURES ON DISEASES OF THE NERVOUS SYSTEM," by 
 J. M. CHARCOT, Professor in the Faculty of Medicine of Paris, translated from the 
 French by GEORGE SIGERSON, M.D., Lecturer on Biology, etc., Catholic Univ. of 
 
 * Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted 
 by the Editor are paid for by the Publisher.
 
 HENRY C. LEA'S PUBLICATIONS (Am. Journ. Med. Sciences). 3 
 
 Ireland (see p. 17), which will be continued to completion during 1879. New sub- 
 scribers, commencing with January, 1879, can procure the previous portion by a 
 remittance of 50 cents, if promptly made. 
 
 The "NEWS DEPARTMENT" of the "MEDICAL NEWS AND LIBRARY" presents the 
 current information of the month, with Clinical Lectures and Hospital Gleanings. 
 A new and attractive feature of this will be found in an elaborate series of ORIGINAL 
 AMERICAN CLINICAL LECTURES, specially contributed to the News by gentlemen of 
 the highest reputation in the profession throughout the United States. During 1878 
 there have appeared Lectures by 
 
 S. D. GROSS, M.D., Prof, of Surgery, Jefferson Med. Coll., Philada. 
 
 T. GAILLARD THOMAS, M.D., Prof. Obstetrics. &c., Coll. Phys. and Surg., N. Y. 
 
 WILLIAM PEPPER, M.D., Prof. Clin. Medicine, Univ. of Penna. 
 
 LEWIS A. SAYRE, M.D.,Prof. Orthopaedic Surg..Bellevue Hosp.Med Coll., NY. 
 
 ROBERTS BARTHOLOW, M.D., Prof. Theory and Practice of Med., Med. Coll. of Ohio. 
 
 T. G. RICHARDSON, M.D., Prof. Genl. and Clin. Surg., Univ. of La., New Orleans. 
 
 S. W. GROSS, M.D., Surg. to Philada. Hospital. 
 
 P. PEYRE PORCHER, M.D., Prof, of Mat. Med. and Clin. Medicine, Med. Coll. of S. C. 
 
 WILLIAM GOODELL, M.D., Prof. Clin. Gynaecology, Univ. of Penna. 
 
 N. S. DAVIS, M.D.. Prof! Prin and Pra'c. of Med., Chicago Med. Coll. 
 
 W. H. VAN BUREN, M.D., Prof. Surgery, Bellevue Hosp. Med. Coll., N. Y. 
 To be followed by others of similar value from 
 
 AUSTIN FLINT, M.D.. Prof. Prin. and Prac. of Med. .Bellevue Hosp. Med. Coll., N.Y. 
 
 FORDYCE BARKER. M.I)., Prof. Clin. Midwifery, &c., Bellevue Hosp.Med. Coll., N.Y. 
 
 L. A. DUHRING. M.D., Clin. Prof, of Diseases of the Skin, Univ. of Penna. 
 
 THKOPHiLUsPARViN,M.D.,Prof. Obstetrics, <fcc.. Coll. Phys. and Surg., Indianapolis. 
 
 J. P. WHITE, M.D., Prof, of Obstetrics, &c., Univ. of Buffalo. 
 
 JOHN ASHHCRST, Jr., M.D., Prof, of Clin. Surg., Univ. of Penna. 
 
 D. WARREN BRICKELL, M.D., Prof. Obstetrics. &c.. Charity Hosp. Med Coll., N. O. 
 
 J. LEWIS SMITH, M.D., Clin. Lee. on Dis. of Chil., Bellevue Hosp. Med. Coll., N. Y. 
 
 WILLIAM F. NORRIS, M.D., Clin. Prof, of Diseases of the Eye, Univ. of Penna. 
 
 P. S. CONNER, M.D., Prof, of Anat. and Clin. Surgery, Med. Coll. of Ohio, Cin. 
 
 S. WEIR MITCHELL, M.D., Phys. to the Infirmary for Nervous Diseases. Philada. 
 
 J. M. DACOSTA, M.D., Prof. Prin. and Prac. of Med., Jeff. Med. Coll., Philada. 
 
 THOMAS G. MORTON, M.D., Surgeon to Penna. Hospital, Philada. 
 
 F. J. BUMSTEAD, M.D., late Prof, of Venereal Dis., Coll. Phys. and Surg., N. Y. 
 
 J. H. HUTCHINSON, M.D., Physician to Penna. Hospital. 
 
 CHRISTOPHER JOHNSON, M.D., Prof, of Surgery, Univ. of Md., Baltimore. 
 
 WILLIAM THOMSON, M.D., Lecturer on Ophthalmology, Jeff. Med. Coll., Philada. 
 
 With contributors such as these, representing every portion of the United States, 
 the publisher feels safe in promising to the subscriber a series of practical lectures 
 unsurpassed in variety, interest, and value. 
 
 As stated above, the subscription price of the " MEDICAL NEWS AND LIBRARY" is 
 ONE DOLLAR per annum in advance ; and it is furnished without charge to all advance- 
 paying subscribers to the "AMERICAN JOURNAL OF THE MEDICAL SCIENCES." 
 
 III. 
 
 THE MONTHLY ABSTRACT OF MEDICAL SCIENCE 
 
 is issued on the first of every month, each number containing forty-eight large octavo 
 pages, thus furnishing in the course of the year about six hundred pages. The aim 
 of the " ABSTRACT" is to present without duplicating the mutter in the "JOURNAL" 
 and "NEWS" a careful condensation of all that is new and important in the medical 
 journalism of the world, and all the prominent professional periodicals of both hemi- 
 spheres are at the disposal of the Editors. To show the manner in which this plan 
 has been carried out it is sufficient to slate that during the year 1878 it contained 
 
 3O Articles on Anntotny and J'lii/.\iolf/i/. 
 
 56 " " Mfiti-ria Medica and '1'lierapeutica. 
 
 23O " " JU<-(liciiie. 
 
 lot " " Siirfferj/. 
 
 79 ' " Midurifpry and fiifmecolofji/. 
 
 iy " " Mrdical Jurisprudence and Toxicology 
 
 making in all 558 articles in a single year. 
 
 The subscription to the "MONTHLY ABSTRACT," free of postage, is Two DOLLARS 
 AND A HALF a year, in advance. 
 
 As stated above, however, it will be supplied in conjunction with the "AMERICAN 
 JOURNAL OF THE MEDICAL SCIENCES" and the "MEDICAL NEWS AND LIBRARY," making 
 in all about TWENTY-ONE HUNDRED pages per annum, the whole free of postage, for 
 Six DOLLARS a year, in advance. 
 
 In this effort to bring so large an amount of practical information within the reach 
 of every member of the profession, the publisher confi iently anticipates the friendly
 
 HENIIY C. LEA'S PUBLICATIONS (Dictionaries). 
 
 aid of all who are interested in the dissemination of sound medical literature. He 
 trusts, especially, that the subscribers to the ''AMERICAN MEDICAL JOURNAL" will call 
 the attention of their acquaintances to the advantages thus offered, and that he will 
 be sustained in the endeavor to permanently establish medical periodical literature 
 on a footing: of cheapness never heretofore attempted. 
 
 PREMIUM FOR OBTAINING NEW SUBSCRIBERS TO THE "JOURNAL," 
 
 Any gentleman who will remit the amount for two subscriptions for 1879, one of 
 which must be for a new ntbscriber, will receive as a PREMIUM, free by mail, a copy of 
 " HOLOEN'S LANDMARKS. MKIHOAL AND SURGICAL" (for advertisement of which see p. 
 6), or of FOTHEKGILL'S " ANTAGONISM OF MEDICINES" (see p. lf>), or of "BROWNE ON 
 THE USE OF THE OPHTHALMOSCOPE" (see p. 29), or of " FLINT'S ESSAYS ON CONSERVATIVE 
 MEDICINE" (see p. 15), or of "STURGKS'S CLINICAL MKDICINE" (see p. 14), or of the 
 new edition of "SWAYNE'S OBSTETRIC APHORISMS" (see p. 21), or of "TANNER'S 
 CLINICAL MANUAL" (see p. 5), or of "CHAMBERS'S RESTORATIVE MEDICINE" (see p. 
 18), or of " WEST ON NERVOUS DISORDERS OF CHILDREN" (see p. 20). 
 
 *V* Gentlemen desiring to avail themselves of the advantages thus offered will do 
 well to forward their subscriptions at an early day, in order to insure the receipt of 
 complete sets for the year 1879. 
 
 Ig^ The safest mode of remittance is by bank check or postal money order, drawn 
 to the order of the undersigned. Where these are not accessible, remittances for the 
 "JOURNAL" may be made at the risk of the publisher, by forwarding in REGISTERKD 
 letters. Address, 
 
 HENRY C. LEA, Nos. 706 and 708 SANSOM ST., PHILADELPHIA, PA. 
 
 T\UNOLISON (ROBLEY), M.D., 
 
 Late Professor of Institutes of Medieinein Jefferson Medical College, Philadelphia. 
 
 MEDICAL LEXICON; A DICTIONARY OP MEDICAL SCIENCE: Con- 
 taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
 Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
 Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters ; Formulae for 
 Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of 
 the Terms, and the French and other Synonymes ; so as to constitute a French as well a? 
 English Medical Lexicon. A Ne,w Edition. Thoroughly Revised, and very greatly Mod- 
 ified and Augmented. By RICHARD J. DUNGLISON, M.D. In one very large and hand- 
 some royaloctavo volume of over 1100 pages. Cloth, $6 50; leather, raised bands, $7 50. 
 (Just Issued.) 
 
 The object of the author from the outset has not been to make the work a mere lexicon or 
 dictionary of terms, but to afford, undereach, a condensed view of its various medical relations, 
 and thus to render the work an epitome of the existing condition of medical science. Starting 
 with this view, the immense demand which has existed for the work has enabled him, in repeated 
 revisions, to augment its completeness and usefulness , until at length it has attained the position 
 of a recognized and standard authority wherever the language is spoken. 
 
 Special pains have been taken in the preparation of the present edition to maintain this en 
 viable reputation. Duringthe ten years which have elapsed since the last revision, the additions 
 to the nomenslature of the medical sciences have been greater than perhaps in any similar period 
 of the past, and up to the time of his death the author la bored assiduously to incorporate every- 
 thing requiring the attention of the student or practitioner. Since then, the editor hns been 
 equally industrious, so that the additions to the vocabulary are more numerous than in any pre- 
 vious revision. Especial attention has been bestowed on the accentuation, which will be found 
 marked on every word. The typographical arrangement has been much improved, rendering 
 reference much more easy, and every care has been taken with the mechanical execution. The 
 work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
 the additions have been incorporated with an increase of but little over a hundred pages, and 
 the volume now contains the matter of at least four ordinary octavos. 
 
 A book well known to our readers, and of which 
 every American ought to be proud. When the learned 
 author of the work passed away, probably all of us 
 feared lest the book should not maintain its place 
 in the advancing science whose terms it defines. For- 
 tunately, Dr. Kichard J. Dunglison, having assisted his 
 father in the revision of several editions of the work, 
 and having been, therefore, trained in the methods and 
 imbued with the spirit of the book, has been able to 
 edit it. not in the patchwork manner so dear to the 
 heart of book editors, so repulsive to the taste of intel- 
 ligent book readers, but to flit it as a work of the kind 
 should be edited to carry it on steadily, without jar 
 or interruption, along the grooves of thought it has 
 travelled during its lifetime. To show the magnitude 
 of the task which Dr Dunglison has assumed and car- 
 ried through, it is only necessary to stale that more 
 than six thousand new subjects have been added in the 
 presentedition. I'htla.Med. Times, Jan. 3, 1874. 
 
 About the first book purchased by the medical stu- 
 dent i* the Medical Dictionary. The lexicon explana- 
 tory of technical terms is simply a sine qua ncn. In a 
 
 science so extensive, and with such collaterals as medi- 
 cine, it is as much a necessity also to the practising 
 .ihysii-ian. To meet the wants of students and most 
 ;ihysii i:-.ns, the dictionary must be condensed while 
 jomprehensive, and practical while perspicacious. It 
 was because Dunglison's met these indication? that it 
 became at once the dictionary of general use wherever 
 medicine was studied in the English language. In no 
 former revision have the alterations and additions been 
 >o great. More than six thousand new subjects and terms 
 have been added. The chief terms have been set in black 
 letter, while the derivatives follow in small caps; an 
 arrangement which greatly facilitates reference. We 
 may safely confirm the hope ventured by the editor 
 " that the work, which possesses forhim a filial as well 
 *s an individual interest, will be found worthy a con- 
 tinuance of the position so long accorded to it as a 
 ftandard authority." Cincinnati Clinic. Jan. 10, 1874. 
 It has the rare merit that it certainly has no rival 
 
 references. London Medical Gazette.
 
 HENRY C. LEA'S PUBLICATIONS (Manuals^. 
 
 A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Doctors K. II. 
 " Clarke, H. J. Bigelow, S. D. Gross, T. G. Thom.-is, and J. S. Billings, "in one very hand- 
 some 12mo. volume of about 350 pages : cloth. $2 25. (Just Ready.) 
 
 This work appeared in the pages of the American Journal of the Medical Science? during the 
 year 1876. As a detailed account of the development of medical science in America, by gentle 
 men of the highest authority in their respective departments, the profession will no doubt wel- 
 come it in a form adapted for preservation and reference. 
 
 'OBLYN (RICHARD D.), M.D. 
 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AKD 
 
 THE COLLATERAL SCIENCES. Revised, with numerous additions, by ISAAC HAYS, 
 M. D., Editor of the "American Journal of the Medical Sciences." In one large royal 
 12mo. volume of over 500 double-columned pages ; .cloth, $1 50 ; leather, $2 00 
 It is the best book of definitions we have, and ought always to be upon the student's table. Southern 
 Xed. and Surg Journal. 
 
 T>OD WELL (G. F). F.R.A.S., c. 
 
 A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
 
 istry, Dynamics, Electricity. Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
 Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the 
 History of the Physical Sciences. In one handsome octavo volume of 694 pages, and 
 many illustrations : cloth, $5. 
 
 ffEILL (JOHN), M.D., and &MITH (FRANCIS G.), M.D., 
 
 Prof .of the Institutes of Medicine inthe Univ.of Pennc . 
 
 AN ANALYTICAL COMPENDIUM OF THE VARIOUS 
 
 BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
 new edition, revised and improved. In one very large and handsomely printed royal 12mi. 
 volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in 
 leather, with raised bands, $4 75. 
 
 HARTSHORN E (HENRY), M.D., 
 
 Professor of Hygiene in the University of Pennsylvania. 
 
 A CONSPECTUS OF THE MEDICAL SCIENCES; containing 
 
 Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
 Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large 
 royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations en 
 wood. Cloth, $4 25 ; leather, $5 00. (Lately Issued.) 
 
 We can say with the strictest truth that it is the j dents, but to many others whomay desire torefrefh 
 best work ofthekind with which we are acquainted j their memories with the smallest possible expends - 
 It embodies ina condensed form all recent contribn- ture of time. N. T. Med. Journal, Sept. 1874. 
 
 tions to practical medicine, and is therefore useful 
 to every busy practitioner throughout our country, 
 besides being admirably adapted to the use of stu- 
 dents of medicine. The book is faithfully and ably 
 executed. Charleston Med. Journ., April, 1875 
 
 The work is intended as an aid to the medical 
 stu lent, and as such appears to admirably fulfil its 
 object by itsexcellent arrangement, the full compi- 
 
 The student will find this the most convenient and 
 useful book of the kind on which he can lay his 
 hand. Pacific Med. and Surg. Journ., Aug. 1874. 
 
 This is the best book of its kind that we have ever 
 examined. It is an honest, accurate, and concue 
 compend of medical sciences, as fairly as possible 
 representing their present condition. The changes 
 and the additions have been so judicious and tho- 
 
 lation jf facts, the perspicuity aud terseness of Ian- j Toug ^ ag to render it. so far as> it goes, entirely trnst- 
 guage, and the clear and instructive illustrations worthy. If students must have a conspectus, they 
 
 will be wise to procure that of Dr. Hartshorne. 
 Detroit Rev. of Med and P/iarm., Aug. 1874. 
 
 in some parts of the work American Journ. of 
 Pharmacy, Philadelphia, July, 1874. 
 The volume will be found useful, not only to stn- 
 
 fUDLOW (J.L.), M.D. 
 
 A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 
 
 Surgery, Practice of Medicine, Obstetrics, Materia MeJica, Chemistry, Pharmacy, and 
 Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
 and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
 12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. 
 
 The arrangement of this volume in the form of question and answer renders it especially suit- 
 able for the office examination of students, and for those preparing for graduation. 
 
 /TANNER (THOMAS HA WKES), M.D., frc. 
 
 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAO- 
 
 NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
 TILBURY Fox, M. D., Physician to the Skin Department in University College Hospits , 
 Ac. In one neat volume small 12mo., of about 375 pages, cloth. $150. 
 
 *** On page 4, it will be seen tha 1 ; this work is offered as a premium for procuring new 
 subscribers to the "AMERICAN JOURNAL OF THE MEDICAL SCIENCES/'
 
 HENRY C. LEA'S PUBLICATIONS -(Anatomy^. 
 
 (HENRY), F.R.S., 
 
 Ltcturer on Anatomy at St. George's Hospital, London. 
 
 ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 
 
 H. V. CARTER, M.D., and Dr. WESTMACOTT. The Dissectionsjointly by the AUTHOR and 
 Dr. CARTER. With an Introduction on General Anatomy and Development by T. 
 HOLMES, M.A., Surgeon to St. George's Hospital. A new American, from the eighth 
 enlargec and improved London edition. To whicn is added " LANDMARKS, MEDICAL AND 
 SURGICAL," by LUTHER HOLDEN, F.R C.S., author of " Human Osteology," " A Manual 
 of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 
 522 large and elaborate engravings on wood. Cloth, $6 ; leather, raised bands, $7. 
 (Just Ready.) 
 
 The author has endeavored in this work to cover a more extended range of subjects than is cus- 
 tomary in the ordinary text-books, by giving not only the details necessary for the student, br,t 
 alaothe application of those details in'the practice of medicine and surgery, thus rendering it both 
 a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
 gravings form a special feature in the work, many of them being thesise of nature, nearly all 
 original, and having the names of the various parts printed on the body of the cut, in place of 
 figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
 wuich will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
 refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
 the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with 
 a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
 essential use to all physicians who receive students in their offices, relieving both preceptor and 
 pupil of much labor in laying the groundwork of a thorough medical education. 
 
 Since the appearance of the last American Edition, the work has received three revisions at the 
 hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever ha? seemed 
 requisite to maintain its reputation as acomplete and authoritative standard text-book and work 
 of reference. Still further to increase its usefulness, there has been appended to it the recent 
 work by the distinguished anatomist, Mr. Luther Holden "Landmarks, Medical and Surgical" 
 which gives in a clear, condensed, and systematic way, all the information by which the prac- 
 titioner can determine from the external surface of the body the position of internal parts. Thus 
 complete, the work, it is believed, will furnish all the assistance that can be rendered by type and 
 illustration in anatomical study. No pains have been spared in the typographical execution of 
 the volume, which will be found in all respects superior to former issues. Notwithstanding the 
 increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
 at a price rendering it one of the cheapest works ever offered to the American profession. 
 
 The recent work of Mr Holden, which was no- 
 ticed by u on p. 53 of this volume, has been added 
 a* an appendix, so that, altogether, this is the moit 
 practical and complete anatomical treatise available 
 to American students and physicians. The former 
 finds in it the necessary guide in makicg dissec- 
 tions; * very comprehensive chapter on minute 
 anatomy ; and about all that can be taught him on 
 general and special anatomy; while the latter, in 
 it* treatment of each region from a surgical point of 
 view, and in the valuable edition of Mr Holden, 
 will find all that will be essential to him in his 
 practice New Remtd'es, Aug 1S78. 
 
 This work is as near perfection as one could pos- 
 sibly or reasonably expect any book intended ax a 
 text-'book or a general reference book on anatomy 
 to be. The American publisher deserves the thanks 
 of th profession for appending the recent work of 
 Mr. Holden, "Landmarks, Medical and Surpical," 
 which has already been commended as a separate 
 
 to consult his books on anatomy. The work is 
 simply indispensable, especially this present Amer- 
 ican edition. Va. Med. Monthly, Sept. 187P. 
 
 The addition of the recent work of Mr. Holden, 
 as an appendix, renders this the most practical and 
 complete treatise available to American students, 
 who find in it a comprehenive chapter on minute 
 anatomy, about all that can be taught on general 
 and special anatomy, while its treatment of each 
 region, from a surgical point of vie T, in the valu- 
 able section by Mr Hoi den. is all that will be essen- 
 tial to them in practice. Ohio Mtdical Recorder, 
 Aug 1S7S. 
 
 It is difficult to speak in moderate terms of this 
 new edition of "Gray." It seems to be as nearly 
 perfect as it is possible to make a book devoted to 
 any branch of medical science. The labors of the 
 eminent wen who have successively revised the 
 eight editions through which it has passed, would 
 
 book. The latter work treating of topographical i seem. to leave nothing for future editor* to do. The 
 
 anatomy has become an essential to the library of 
 every intelligent practitioner. We know of no 
 book that can take its place, written as it is by a 
 most distinguished anatomist. It would be simply 
 a waste of words to say anything farther in praise 
 of Gray's Anatomy, the text-book in almost every 
 medical college in this country, and the daily refer- 
 ence book of every practitioner who has occasion 
 
 addition of Holden's " Landmarks" will make it as 
 indispensable to the practitioner of medicine and 
 surgery as it has been heretofjre to the student. As 
 regards completeness, ease of reference, utility, 
 beauty, and cheapness, it has no rival. No stu- 
 dent should enter a medical school without it ; no 
 physician can afford to have it absent from his 
 library St. Louis Clin. Rtcord, Sept. 1878. 
 
 ALSO FOR SALE SEPARATE 
 
 TTOLDEN (LUTHER), F.R.C.S., 
 
 Surgeon to St. Bartholomew's and the Foundling Hospitals. 
 
 LANDMARKS, MEDICAL AND SURGICAL. From the 2d London 
 
 Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. (Now Ready.) 
 The title of this book is very suggestive of its transparent before him, is incalculable. The map- 
 practical value, while the perusal of the work itself ping out of the human body is one which is most in- 
 Terifles the most extravagant expectations. The nructive to the practical man, and he is enabled, 
 object of the author has been to collect iu compact after considerable experience, to have landmark* 
 form thelandmarkn,ornnrface-markKoftbediflVrent of his own; but in the little work before ns this 
 partt of the body, aiid indicate tbeir relation to the knowledge is systematized in such an intelligible 
 deeper-seated parts. The valne of Ihissortof know- manner as to place it within ihe roach of all It is 
 I-dge to 'he pby-irian, but especially to the surgeon : one of the most intf restiEgliltle works we have neen 
 who. with anaiomical eye, con make the tissues for a long time. A. 1". Med. Record, May 11, 1878.
 
 HENRY C. LEA'S PUBLICATIONS (Anatomy'}. 
 
 A LLEN (HARRISON], M.D. 
 
 -*- Prnffs*or of Physiology in the. Univ. of Pa. 
 
 A SYSTEM OP HUMAN ANATOMY: INCLUDING ITS MEDICAL 
 
 and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an 
 Introductory Chapter on Histology. By E. 0. SHAKESPEARE, M D , Ophthalmologist to the 
 Phila. Hosp. In one large and handsome quarto volume, with 'several hundred original 
 illustrations on lithographic plates, and numerous wood-cuts in the text. (Preparing.) 
 In this elaborate work, which has been in active preparation for several years, the author has 
 sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
 the practical applications of the science to medicine and surgery. The work thus has claims upon 
 the attention of the general practitioner, as well as of the student, enabling him not only to re- 
 fresh his recollections of the dissecting room, but also to recognize thesignificance of all varia- 
 tions from normal conditions. The marked utility of the object thus sought by the author is 
 self-evident, and his long experience and assiduous devotion to its thorough development are a 
 sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
 spared with the illustrations. Those of normal anatomy are from original dissecti ..ns, drawn on 
 stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, 
 after the manner of " Holden" and " Gray," and in every typographical detail it will be the 
 effort of the publisher to render the volume worthy of the very distinguished position which is 
 anticipated for it. 
 
 J?LLIS (GEORGE V1\ER}~ 
 
 J-J Emeritus Professor rf Anatomy in University College., London. 
 
 DEMONSTRATIONS IN ANATOMY; Being a Guide to the Know- 
 ledge of the Human Body by Dissection. By GEORGE VIXER ELLIS, Emeritus Professor 
 of Anatomy in University College, London. From the Eighth and Revised London 
 Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
 (Nearly Ready.) 
 
 This work has long been known in England as the leading authority on practical anatomy, 
 aTid the favorite guide in the dissecting-room, ns is attested by the numerous editions through 
 which it has passed. In the last revision, which has just appeared in London, the accomplished 
 author has sought to bring it on a level with the most recent advances of science by making the 
 necessary changes in his account of the microscopic structure of the different organ?, as devel- 
 oped by the latest researches in textural anatomy. 
 
 'ILSON (ERASMUS), F.R.S. 
 
 A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 
 
 by W. H. GOBRECIIT, M.D , Professor of General and Surgical Anatomy in the Medical Col- 
 lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
 one large and handsome octavo volume, of over fiOO large pages ; cloth, $4 ; leather. $6. 
 
 fJEATH (CHRISTOPHER), F.R.C.S., 
 
 fJ- Teacher of Operative. Surgery in University College, London. 
 
 PRACTICAL ANATOMY: A Manual of Dissection?. From the 
 
 Second revised and improved London edition. Edited, with additions, by W. W. KEEN, 
 M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
 In one handsome royal 12ino. volume of 578 pages, with 247 illustrations. Cloth, $350; 
 leather, $4 00. 
 
 VMITH (HENRY H.), M.D., and CORNER ( WILLIAM E.), M.D., 
 
 Prof, of Surgery in the Univ. of Penna. , Ac. " Late Prof, of Anatomy in the Univ. of Per. na. 
 
 AN ANATOMICAL ATLAS, illustrative of the Structure of the 
 
 Human Body. In one volume, large imperial octavo, eloth, with about six hundred and 
 fifty beautitul figures. $4 50. 
 
 T>ELLAMY(E.),F.R.C.S. 
 ' 
 
 THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- 
 
 Book for Students preparing for their Pass Examination. With engravings on wood. In 
 one handsome royal 12mo. volume. Cloth. $2 25. (Lately Published.) 
 
 riLELAND (JOHX),N.D., 
 
 L/ professor of Anatomy and Physiology in Queen's College, Galway. 
 
 A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. 
 
 In one small volume, royal 12mo. of 182 pages: cloth, $1 25. (Just Issued.) 
 
 VCHAFER (EDWARD ALBERT), M.D., 
 
 O Asistan t Prof et tor of Physiology in University College, London. 
 
 A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 
 
 the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with 
 numerous illustrations: cloth, $2 00. (Jnst Issued.) 
 
 HORNER'S SPECIAL ANATOMY AND HISTOL- 1 SHARPEY AND CHAIN'S HUMAN ANATOMY. 
 OQY Eighth edition, extensively rpviaed aod Revised, by JOKPH LRIDT, MI)., Prof of Anal. 
 li'd Tn S vola Svo of over 1000 pages in U.,iv. of Penn. In two octavo voli. of abont 
 ' 1 1 lSOOpage. I wi,h511illu.tr.tlon.. Cloth,$60<.
 
 8 
 
 HENRY C. LEA'S PUBLICATIONS (Physiology}. 
 
 CARPENTER ( WILLIAM B.), M. D., F.R.S., F.G.S., F.L.S., 
 
 Registrar to University of London, etc. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HENRYPOWER, 
 
 M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
 American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
 tions, by FRANCIS G. SMITH, M.D., Professor of the Institutes cf Medicine in the Univer- 
 sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, 
 with two plates and 373 engravings on wood; cloth, $5 50 ; leather, $6 50. (Just Issued.) 
 The great work, the crown ing labor of the distinguished author, and through which so many 
 generations of students have acquired their knowledge of Physiology, has been almost meta- 
 morphosed in the effort to aCapt it thoroughly to the requirements of modern science. Since 
 the appearance of the last American edition, it has had several revisions at the experienced 
 hand of Mr. Power, who has modified and enlarged it so as to introduce all that is important 
 in the investigations and discoveries of England, France, and Germany, resulting in an enlarge- 
 ment of about one-fourth in the text. The series of illustrations has undergone a like revision , 
 a large proportion of the former ones having been rejected, and the total number increased 
 to nearly four hundred. The thorough revision which the work has so recently received in 
 England, has rendered unnecessary any elaborate additions inthis country, but the American 
 Editor, Professor Smith, has introduced such matters as his long experience has shown him to 
 be requisite for the student. Every care has been taken with the typographical execution , and 
 the work is presented, with its thousand closely, but clearly printed pages, as emphatically the 
 text-book for the student and practitioner of medicine the one in which, as heretofore, especial 
 care is directed to show the applications of physiology in the various practical branches of 
 medical science. Notwithstanding its very great enlargement, the price has not been in- 
 creased, rendering this. one of the cheapest works now before the profession. 
 
 We have been agreeably surprised tofiud the vol- 
 ume so complete in regard to the structure and func- 
 tions of the nervous system in all Its relations, a 
 subject that, in many respects, is one of the most diffi- 
 cult of all, in the whole range of physiology, upon 
 which to produce a full and satisfactory treatise of 
 the class to which the one before us belongs. The 
 additions by the American editor give to the work as 
 it is a considerable value beyond that of the last 
 English edition. In conclusion, we can give our cor- 
 dial recommendation to the work as it now appears. 
 The editors have, with their additions to the only 
 work on physiology in our language that, in the full- 
 est sense of the word, is the production of a philoso- 
 pher as well as a physiologist, brought it np as fully 
 as conld be expected, if not desired, to the standard 
 of our knowledge of its subject at the present day. 
 It will deservedly maintain the place it has always 
 had in the favor of the medical profession. Journ. 
 of Nervous and Mental Dltease, April, 1877. 
 
 "Good wine needs no bush" says the proverb, and 
 auold and faithful servant like the "big" Carpenter, as 
 carefully brought down as this edition has been by Mr. 
 Henry Power, needs little or no commendation by us. 
 Such enormous advances have recently been made in 
 our physiological knowledge, that what was perfectly 
 new a year or two ago, looks now as if it had been a 
 received and established fact for years. In this ency- 
 clopaedic way it is unrivalled. Here, as it seems to 
 us, is the great value of the book; one is safe in sending 
 a student to it for information on almost any given 
 
 subject, perfectly certain of the fulness of information 
 it will convey, and well satisfied of the accuracy with 
 which it will there be found stated. London Med. 
 Times and Gazette, Feb. 17, 1877. 
 
 Thus fully are treated the structure and functions ol 
 all the important organs of the body, while there are 
 chapters on sleep and somnambulism ; chapterson eth 
 nology, a full section on generalion. and abundant re- 
 ferences to the curiosiiies of physiology, as the evolu 
 tion of light, heat, electricity, etc. In short, this new 
 edition of Carpenter is, as we have said at the Ftnrt, 
 a very encyclopedia of modern physiology. The Glin- 
 ic, Feb. 24, 1877. 
 
 The merits of " Carpenter's Physiology" are so widely 
 known and appreciated that we need only allude briefly 
 to thefaot that in the latest edition will be found a com- 
 prehensive embodiment of the results of recent physio 
 lo<*ical investigation. Care has been taken to preserve 
 the practical character of the original work. In fact 
 the entire work has been brought up to date, and bears 
 evidence of the amount of labor that has been bestow nd 
 upon it by its distinguished editor, Mr. Henry Power. 
 The American editor has made the latest additions, in 
 order fully to cover the time that has elapsed since the 
 last English edition. N. Y. Me.d. Journal, Jan. 1877. 
 
 A more thorough work on physiology could not be 
 found. In this all the facts discovered by the late re- 
 searches are noticed, and neither student nor practi- 
 tioner should be without this exhaustive treatise on au 
 important elementary branch of medicine. Atlanta 
 Med. and Surg. Journal, Dec. 1876. 
 
 ( WILLIAM SENHOUSE), M.D. 
 A MANUAL OF PHYSIOLOGY. Edited by W. MORRANT BAKER, 
 
 M.D., F.R.C.S. A new American from the eighth and improved London edition. With 
 about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- 
 ume. Cloth, $3 25; leather, $3 75. (Lately Issued.) 
 
 Kirkes' Physiology has long been known as a concise and exceedingly convenienttext-book, 
 presenting within a narrow compass all that is important for the student. The rapidity with 
 which successive editions have followed each other in England has enabled the editor to keep 
 it thoroughly on a level with the changes and new discoveries made in the science, and the 
 eighth edition, of which the present is a reprint, has appeared so recently that it may be re- 
 garded as the latest accessible exposition of the subject. 
 
 On the whole, there is very little in the book 
 which either the student or practitioner will not find 
 of practical value and consistent with our present 
 knowledge of this rapidly changing science; and we 
 have no hesitation in expressing our opinion that 
 this eighth edition is one of the best handbooks on 
 physiology which wehaveinour language. N. Y. 
 Med Record, April 15, 1873. 
 
 The book is admirably adapted to be placed in 
 
 the hands of stndenis. Boston Med. and Surg. 
 Journ., April 10, 1873. 
 
 In its enlarged form it is, in ouropinion, stil! tie 
 beat book on physiology, most useful to thestudent. 
 Phila. Med. Times, Aug. 30, 1873. 
 
 This is undoubtedly the best work for students of 
 physiology extant. Cincinnati Med. Newt, Sept. 
 1ST3.
 
 HEXRY C. LEA'S PUBLICATIONS (Physiology}. 
 
 f}ALTON (J. C.), M.D., 
 
 X/ 
 
 Professor of Physiology in the College of Physicians and Surgeons, New York. <te. 
 
 A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 
 
 of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, 
 with three hundred und sixteen illustrations on wood. In one very beautiful octavo vol- 
 ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (.Just Issued.} 
 Daring the past few years several new works on phy- ( This popular text-book on physiology conies to us in 
 
 sinlogy, aud new editions of old works, have appeared, 
 competing for the favor of the medical student, but 
 none will rival this new edition of Dalton. As now en- 
 larged, it will be found also to be. in general, a satisfac- 
 tory work of reference for the practitioner. Chieayo 
 Mvl. Journ. and Examiner, Jan. 1 876. 
 
 Prof. Dalton has discussed conflicting theories and 
 conclusions regarding physiological questions with a 
 f;iirness, a fulness, and a conciseness which lend fresh- 
 ness and vigor to the entire book. But his discussions 
 have been so guarded by a refusal of admission to those 
 speculative and theoretical explanations, which at best 
 exist in the minds of observers themselves as only pro- 
 babilities, that none of his readers need be led into 
 grave errors while making them a study. The. Medical 
 Record, Feb. 19, 1876. 
 
 The revision of this great work has.brought it forward 
 with the physiological advances of theday. and renders 
 it, as it has ever been, the finest work for students ex- 
 tant. Nashville Journ. nf Mtd. and Surg.. Jan. 1876. 
 
 For clearness and perspicuity, Dalton's Physiology 
 commended itself to the student years ago. and was a 
 pleasant relief from the verbose productions which it 
 supplanted. Physiology has, however, made many ad- 
 vances since then and while the style has been pre- 
 served intact, the work in the present edition has been 
 brought up fully abreast of the times. Thenew chemical 
 notation and nomenclature have also been introduced 
 into the present edition. Notwithstanding the multi- 
 plicity of text-books on physiology, this will lose none 
 of its old time popularity. The mechanical execution 
 of the work is all that could be desired. Peninsular 
 Journal of Medicine, Dec. 1875. 
 
 its sixth edition with the addition of about fifty percent, 
 of new matter, chiefly in the departments of patho- 
 logical chemistry and the nervous system, where, the 
 principal advances have been realized. With so tho- 
 rough revision and additions, that keepthe work well 
 up to the times, its continued popularity may be confi- 
 dently predicted, notwithstanding the competition it 
 may encounter. The publisher's work is admirably 
 done. St. Louis Men. and Surg. Journ , Dec. 1875. 
 
 We heartily welcome this, the sixth edition of this 
 ad mirable text book . than which there are non e of equ 1 
 brevity more valuable. It iscordially recommended by 
 the Professorof Physiology in the University of Louisi- 
 ana, as by all competentteachersintheUnited State?, 
 and wherever the English language is read, this book 
 has been appreciated. The present edition, with its 31 6 
 admirably executed illustrations, has been carefully 
 revised and very much enlarged, although its bulk does 
 not seem perceptibly increased. New Orleans Medical 
 and Surgical Journal, March, 1876. 
 
 The present edition is very much superior to every 
 other, not only in that it brings the subject up to the 
 times, but that it dos.so more fully and satisfactorily 
 thananypreviousedition. Takeitaltogt-therit remains 
 in our humble opinion, thebest text book on physiology 
 in any land or language. The Clinic. Nov. 6, 1875. 
 
 As a whole, we cordially recommend the work as a 
 text-book for the student, and as one of the bpst. 
 The Journal oflfenmn and Mental Disease, Jan. 1876. 
 
 Still holds its position as a masterpiece of lucid writ- 
 in?, and is, we believe, on the whole, the best book to 
 place in the hands of the student. London Student? 
 Journal. 
 
 riUNGLISON (ROBLEY\ M.D., 
 
 *^ Professor of Institutes of Medicine in Jefferson Medical fyllege, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 
 
 extensively modified and enlarged, with five hundred and thirty-two illustrations. In two 
 large and handsomely printed octavo volumes of about 1500 pages, cloth, $7 00. 
 
 fJARTSHORNE (HENRY), M.D., 
 
 -*-* Professor of Hygiene, etc , in the Univ. ofPtnna 
 
 HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edi- 
 tion., revised. In one royal 12mo. vol., with 220 wood -cuts : cloth, $1 75. (Just Issued.) 
 
 [EHMANN(C. #.). 
 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- 
 tion by GEORGE E. DAT, M.D., F.R.S., <tc., edited by R. E. ROGERS, M D , Professor of 
 Chemistry in the Medical Department of the University of Pennsylvania, with illustratior s 
 selected from Funke's Atlas of Physiological Chemistry, and an Appendix of 
 plete in two large and handsome octavo volumes, containing 1200 pages, with nearly tv 
 hundred illustrations, cloth, $6 00. 
 
 TOT THE SAME AUTHOR. , , , - 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 
 
 German, with Notes and Additions, by J CHBSTON MORRTS, M.D., with an Introductory 
 Essay on Vital Force, by Professor SAKUEL JACKSON, M D.. of the University of Penn 
 gylvinia. With illustrations on wood. In one very handsome octavo volume < 
 p'ages. Cloth, $2 25. _ __ 
 
 ftEMSEN(lRA), M.D., PJi.D., 
 
 "** Professor of Vhemixtry in the Johns Hopkin* Unire^fity, Baltimore. 
 
 PRTNCIPLESOF THEORETICAL CHKMTSTRY. with special reference 
 
 to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
 232 pages: cloth, $1 50. (Just Issued.) 
 
 R AND FITTIG. 
 
 OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- 
 
 ditions from the Eighth German Ed. By IRA REMSEN, M D PhD Prof, of Cbe,n. 
 andPhysicsin Williams College, Mass. In one volume, royal 12mo.of 550 pp., cloth, *J.
 
 10 
 
 HENRY C. LEA'S PUBLICATIONS (Che mint 
 
 ffO WNES (GEORGE), Ph.D. 
 
 - A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 
 
 Practical. Revised and corrected by HENRY WATTS, B.A., F R.S., author of "A Diction- 
 ary of Chemistry," etc. With a colored plnte, and one hundred and seventy -seven illus 
 trationg. A new American, from tbi twelfth mid enlarged London edition. Edited by 
 ROBERT BRIDGES, M.D. In one large royal 12mo. volume, of over 1000 pages; 
 cloth, $2 75 ; leather, $3 25. (Just Ready) 
 
 Two careful revisions by Mr. Watts, since the appearance of the last American edition of 
 " Fownes," have so enlarged the work that in England it has been divided into two volumes. In 
 reprinting it, by the use of a stna'l and exceedingly clear type, cast for the purpose, it has been 
 found possible to comprise the whole, without omission, in one volume, not unhandy for study and 
 reference. The enlargement of the work has induced the American Editor to confine his additions 
 to the narrowest compass, and he has accordingly inserted only such discoveries as have been an - 
 nounced since the very recent appearance of the work in England, and has added the standards 
 in popular use to the Decimal and Centigrade systems employed in the original. 
 
 Among the additions to this edition will be found a very handsome colored plate, representing 
 a number of spectra in the spectroscope. Every care has been taken in the typographical execu- 
 tion to render the volume worthy in every respect of its high reputation and extended use, and 
 though it has been enlarged by more than one hundred and fifty pnges, its very moderate price 
 will still maintain it as one of the cheapest volumes accessible to the chemical student. 
 
 This work, inorganic and organic, is complete in 
 one convenient volume. In its earliest editions it 
 was fully up to the latest advancements and theo- 
 ries of that time. In its present form, it presents, 
 in a remarkably convenient and satisfactory man- 
 ner, the principles and leading facts of the chemistry 
 of to-day. Concerning the manner in which the 
 various subjects are treated, much deserves to be 
 Kaid.and mostly, too, in praise of the book. A re- 
 view of such a work ae Foumes's Chemistry within 
 the limits of a book-notice for a medical weekly is 
 simply out of the question. Cincinnati Lancet and 
 Clinic, Dec. 14, 1878. 
 
 When we state that, 5n our opinion, the present 
 e iition sustains in every respect the high reputation 
 which its predecessors have acquired and enjoyed, 
 we express therewith our fall belief in its intrinsic 
 value as a text-book and work of reference. Am. 
 Journ. of Pharm., Aug. 1878. 
 
 The conscientious care which has been bestowed 
 upon it by the American and English-editors renders 
 it still, perhaps, the best book for the student and the 
 practitioner who would keep alive the acquisitions 
 of his student days. It has, indeed, reached a some- 
 
 what formidable magnitude with its more than a 
 thousand pages, but with less than this no fair repre- 
 sentation of chemistry as it now is can be given. The 
 type is small but very clear, and the section* are very 
 lucidly arranged to facilitate study and reference. 
 MK& and Surg. Reporter, Aug 3,1878. 
 
 The work is too well known to American students 
 to need any extended notice; sullice it to say that 
 the revision by the English editor has been faithfully 
 done, and that Professor Bridges has added some 
 fresh and valuable matter, especially in the inor- 
 ganic chemistry. The book has always been a fa- 
 vorite in this country, and in its new shape bids 
 fair to retain all its former prestige. Boston Jour, 
 of Chemistry, Aug. 1878. 
 
 It will be entirely unnecessary for us to make any 
 remarks relating to the general characterof Fownes' 
 Manual. For over twenty yearn it has held the fore- 
 most place as a text-book, aud the elaborate and 
 thorough revisions which have been made from time 
 to time leave lit tie chance for any wide awake rival to 
 step before it. Canadian Pharm. Jour., Aug. 1878. 
 
 As a manual of chemistry it is without a superior 
 in the language. Md. Med. Jour., Aug. 1S78. 
 
 flLASSEN (ALEXANDER), 
 
 Professor in the Royal Polj/technio School, Aix la-Chapelle. 
 
 ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 
 
 notes and additions by EDGAR F. SMITH, Ph.D., Assistant Prof, of Chemistry in the 
 Towne Scientific School, Univ. of Penna. In one handsome royal 12tno. volume, of 324 
 pages, with illustrations; cloth, $2 00. (Just Ready.) 
 A smal', practical, comprehensive, and intelligible nature extant, insomuch as its methods are the best. 
 
 guide to practical elementary quantitative analysis, 
 and U particularly adapted to the wants of the be- 
 g'nner with laboratory work. If. Y. lied. Record 
 NJV. 12, 1878. 
 
 It ia probably the best manual of an elementary 
 
 It teaches by examples, commencing with single 
 determinations, followed by separations, and then 
 advancing to the analysis of minerals and such pro- 
 ducts as are met with in applied chemistry- It is 
 an indispensable book for students in chemistry. 
 Boston Journ. of Chemistry, Oct. 1878. 
 
 ftALLOWAY (ROBERT], F.C.S., 
 
 Prof of Applied Chemistry in the Royal Collrge f Science for Ireland, etc. 
 
 A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
 
 don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. (Lately 
 Issued.) 
 
 We regard this volume as a valuable addition to 
 
 the chemical text-books, and as particularly calcu 
 
 lated to instruct the student in analytical researches I Sapt. 1872. 
 
 of the inorganic compounds, the important vegetable 
 
 acid*, and of compounds and various secretions and 
 excretions of animal orig.n. Am. Jour, of Pharm., 
 
 DO WMAN (JOHN E.} , M.D. 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 
 
 ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- 
 ous illustrations. In one neat vol., royal 12mo., cloth, $2 25. 
 JJY THE SAME AUTHOR. 
 
 PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. In one 
 
 neat volume, royal 12mo., pp. 351, with numerous illustrations; cloth, $2 25.
 
 HENRY C. LEA'S PUBLICATIONS (Chemistry). 
 
 11 
 
 A TTFIELD (JOHN), Ph.D., 
 
 ^*- Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac. 
 
 CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICA1 ; 
 
 including the Chemistry of the U. 8. Pharmacopoeia. A Manual of the General Principles 
 of the Science, and their Application to Medicine and Pharmacy. Eighth edition revised 
 hy the author. In one handsome royal 12mo. volume of 700 pages, with illustration!?. 
 Clotb, $2 50 ; leather, $3 00. (Just Ready.) 
 
 EXTRACT FROM THE PREPACK. 
 
 The present, Eighth, edition contains such alterations and additions as seemed necessary f < r 
 the demonstration of the latest developments of chemiciil principles and the latest applications 
 of chemistry to Pharmacy. The Author has bestowed assiduous labor on the revision, and 
 the extent of the information thus introduced may be estimated from the fact that the Index 
 contains three hundred new references relating to the additional material. The work tow 
 includes the whol of" the chemistry of the United States Pharmacopoeia, of the British Pharma- 
 copoeia, and of the Pharmacopoeia of India. 
 
 Engravirgs, by G. Pearson, Esq., of most of the important pieces of apparatus employed in 
 studying chemistry experimentally, are reproduced in this Eighth Edition. The twenty micro- 
 scopic views are after drawings by Tufien West, Esq. 
 
 DLOXAM (C. L.), 
 
 -^-^ Professor of Chemistry in King's College, London. 
 
 CHEMISTRY, INORGANIC AND ORGANIC. From the Second Loi - 
 
 don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- 
 trations. Cloth, $4 00; leather, $5 00. (Lately Issued.) 
 
 We have in this work a eompleteand most excel- of that science as it now stands. We have spoken 
 lent text-book for the use of schools, and can heart- ; of the work as admirably adapted to the wants of 
 ily recommend it as such. Boston Med.and Surg. students ; it is quite as well suited to the require- 
 J'turn., May 28, 1874. i ments of practitioners who wig-h to review their 
 
 ' chemistry, or have occasion to refresh their memo- 
 
 The above is the title of a work which we can most rieg on any point re i at j ng to it. In a word, it is a 
 OJoscientionsly recommend to students of chemis- ! book to be - read by al] who wieh to knOW what ig 
 try. It is as easy-asa work on chemistry could be j the chemistry of the present day. American Prac- 
 made, at the same time that it presents a fall account j titioner, Nov. 1873. 
 
 (-1LO WES (FRANK). D.Sc., London. 
 
 Senior Science-Master at the High School , Kewcastle-underlyme, etc. 
 
 AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY 
 
 AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
 Laboratories of Schools and Colleges and by Beginners. From the Second and Revised 
 English Edition, with about fifty illustrations on wood. In one very handsome royal 
 12mo. volume of 372 pages: cloth, $2 50. (Now Ready.) 
 
 It is short, concise, and eminently practical. We 
 therefore heartily commend it to students, an<i e*pe- 
 eially to those who are obliged to dispense with 
 master. Of course, a teacher is in every way desi- 
 rable, but a good degree of technicil skill and prac- 
 tical knowledge can be attained with no other 
 instructor than the very valuable handbook now 
 under consideration. St Louis Clin. Record, Oct. 
 
 The work is so writ f enand arranged that it can be 
 comprehended by the student without a teacher, and 
 the descriptions and directions forthe various work 
 
 are so simple, and yet concise, as to be interesting 
 i and intelligible. The work is unincnmbered with 
 i theoretical deductions, dealing wholly with the 
 ' practical matter, which it is the a m of this compre- 
 j hensive text-book to impart. The accuracy of the 
 | analytical methods are vouched f>>r from the fact 
 that they have all been worked through by the 
 author and the members, of his c asv from the 
 printed text. We can heartily recommend the woik 
 to the student of chemistry as being a reliable at d 
 comprehensive one. Druggists' Advertiser, Oct. 
 15. 1877. 
 
 KNAPP'S TECHNOLOGY; or Chemistry Applied to 
 the Arts, and to Manufactures. With American 
 additions by Prof. WALTER R. JOHNSON. In two 
 
 very handsome octavo volumes, with 500 woe d 
 engravings, cloth, $6 00. 
 
 TjlARQUHARSON (ROBERT), M.D., 
 
 * Lecturer on Materia tfedica at St. Mary's Hospital Medical School. 
 
 A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Ed- 
 ited, with Additions, embracing the U. S. Pharmacopoeia. By FRAXK WOODBURIT, M.D. 
 In one neat rojal 12mo. volume of over 400 pages : cloth, $2. (Just Ifsned.) 
 Manv persons who learned therapeutics before ; it straight across the page, we at once perceive the 
 the pnv-ioloeical action of remedies was taught to \ relations of the one to the other. On this account, the 
 student find ,t difficult to discover the bearing of \ work is likely to be useful, not on y to students p. e- 
 phTsiolWieal action oa therapeutic employment ! paring for their examinations, bn to those ,medi 
 from ordinary text-books. Dr. Farqubarson has most men, also, who are well acquainted with larger 
 inwni.ms?y shown it by printing the two in parallel books on the same subject, but experience the diffl- 
 columns and corresponding p*,a,-ra .hs, so that, by culty, already mentioned of see.ng the relation, 
 running the eye down the left-hand side of a page we between the .ciionti and n,e of remedies. - Tht 
 get the physiological actions of a drug, and on the ! London Practitioner, January, 18/8. 
 right-hand the therapeutical uses, while, by running i
 
 12 HENRY C. LEA'S PUBLICATIONS (Mat. Med. and Therapeutics). 
 
 &ARR1SH (EDWARD), 
 
 Late Professor of Materia Medico, in the Philadelphia College of Pharmacy. 
 
 A TREATISE ON PHARMACY. Designed as a Text-Book for the 
 
 Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae an<l 
 Prescriptions. Fourth Edition, thoroughly revised, by THOMAS S. WIKGAND. In one 
 handsome octavo volume of 977 pages, with 280 illustrations; cloth, $5 50 ; leather, $6 50. 
 (Lately Issued.) 
 
 Of T)r. Parrish's great work on pharmacy it only 
 remains to be said that the editor has accomplished 
 his work so well as to maintain, in this fourth edi- 
 
 the work, not only to pharmacists, but also to the 
 multitude of medical practitioners who are obliged 
 to compound (heir own medicines. It will ever hold 
 
 tion, the high standard of excellence which it bad ! an honored place on our own bookshelves. Dublin 
 attained in previous editions, under the editorship of| Med. Press and Circular, Aug. 12, 1874. 
 its accomplished author. This has not been accom- | 
 pllshed without much labor, and many additions and 
 
 improvements, involving changes in the arrange- 
 
 We expressed our opinion of a former edition in 
 
 terms of unqualified praise, and we are in no mood 
 
 meutdf the several parts of the work, and the addi- to delr * c } fror " that op\ulo in reference to the pre- 
 tion of much new matter. With the modifications sent edition, the preparation of which has fallen into 
 
 thus effected it constitutes, as now presented, a com- 
 pendium of the science and art indispensable to the 
 pharmacist, and of the utmost value to every 
 practitioner of medicine desirous of familiarizing 
 himself with the pharmaceutical preparation of the 
 articles which he prescribes for his patients. Chi- 
 cago Med. Journ., July, 1874. 
 
 The work is eminently practical, and has the rare 
 merit of being readable and interest ing, while it pre- 
 
 cora pete nt bauds. It is a book with which no pharma- 
 cist can dispense, and from which no physician can 
 fail to derive much information of value to him in 
 practice. Pacific Med. and Surg. Journ., June, '74. 
 
 Perhaps one.ifnotthe most important book upon 
 pharmacy which has appeared in the English lan- 
 guage has emanated from the transatlantic press. 
 "Parrish's Pharmacy" is a well-known work on this 
 side of the water, and the fact shows ns that arealiy 
 
 serves a strictly scientific character. The whole work : useful work never becomes merely local in its fame, 
 reflects the greatest credit on author, editor and pub- i Thanks to the judicious editing of Mr. Wiegand, the 
 lisher. Itwillconveysomeideaoftheliberality which ' posthumous edition of "Parrish" has been saved to 
 has been bestowed upon its production when we men- the public with all the mature experience of its an- 
 tion that there are no less than 280 carefully executed thor. and perhaps none the worse for a dash of new 
 illustrations. In conclusion, we heartily recommend ' blood. Land. Pharm. Journal, Oct. 17, 1874. 
 
 J3TILLE (ALFRED], M.D., 
 
 Professor of Theory and Practice of Medicine in the University of Penna. 
 
 THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 
 
 on the Action and Uses of Medicinal Agents, including their Description and History. 
 Fourth edition, revised and enlarged. In two large and handsome 8vo. vols. of about 2000 
 pages. Cloth, $10; leather, $12. (Lately Issued.) 
 
 It is unnecessary to do much more than to an- 
 nounce the appearance of the fourth edition of this 
 well known and excellent work. Brit, and For. 
 Med.-Chir. Review, Oct Ib75. 
 
 For all who desire a complete work on therapeutics 
 and materia medica for reference, in cases involving 
 medico-legal questions, as well as for information 
 concerning remedial agents, Dr. Still^'s is "par ex- 
 cellence" the work. The work tveingout of print, by 
 the exhaustion of former editions, the author has laid 
 the profession under renewed obligations, by the 
 careful revision, importantadditions, and timely re 
 issuing a work not exactly supplemented by any 
 other in the English language, if in any language. 
 The mechanical execution handsomely sustains the 
 well-known skill and good taste of the publisher. 
 St. Louis Med. and Surg. Journal, Dec 1874. 
 
 From the publication of the first edition "Still6's 
 Therapeutics" has been one of the classics; its ab- 
 sence from our libraries would create a vacuum 
 which could be filled by no other work in the lan- 
 guage, and its presence supplies, in the two volumes 
 
 of the present edition, a whole cyclopaedia of thera- 
 peutics. Chicago Medical Journal, Veto. 1875. 
 
 The rapid exhaustion of three editions and the uni- 
 versal favor with which the work has been received 
 by the medical profestion, are sufficient proof of its 
 excellence as a repertory of practical and useful in- 
 formation for the physician. The edition before us 
 fully sustains this verdict, a s the work has been care- 
 fully revised and in some portions rewritten, bring- 
 ing it up to the present time by the admission of 
 chloral and croton-chloral. nitrite of amyl. bichlo- 
 ride of methylene, methylic ether, lithium com- 
 pounds, gelseminnm, and other remedies. Am. 
 Journ. of Pharmacy, Feb. 1S75. 
 
 We can hardly admit that it has a rival in the 
 multitude of its citations aiid the fulness of its re- 
 search into clinical histories, and we must assign it 
 a place in the physician's library; not, indeed, as 
 fully representing the present slate of knowledge in 
 pharmacodynamics, but asbyfarthe most complete 
 treatise upon the clinical and practical side of the 
 question. Boston Mtd. and. Surg. Journal, Nov.f, 
 
 /GRIFFITH (ROBERT E.), M.D. 
 
 A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
 ing and Administering Officinal and other Medicines. The whole adapted to Physiciars and 
 Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj JOUM M. 
 MA.ISCH, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large 
 and handsome octavo volume of about 800 pp., cl., $450 ; leather, $5 50. (Lately Issued.) 
 
 To the druggist a good formulary is simply indis 
 pensable, and perhaps no formulary has been more 
 extensively used than the well-known work before 
 us. Many physicians have to officiate, also, as drug- 
 gists. This is true especially of the country physi- 
 cian, and a work which shall teach him the means 
 by which to administer or combine his remedies in 
 the most efficacious and pleasant manner, will al- 
 ways hold Its place upon his shelf. A formulary of, 
 thin kind is of benefit also to the city physician in i 
 largest practice. Cincinnati dtinic, Feb. 21, 1874. 1 
 
 A more complete formulary than ills in its pres- 
 ent form the pharmacist or physician could hardly 
 desire. To the first some such work is indispensa- 
 ble, and it is hardly less essential to the practitioner 
 who compounds his own medicines. Much of what 
 is contained in the introduction ought to be com- 
 mitted to memory by every student of medicine. 
 As a help to physicians it will be found invaluable, 
 and doubtless will make its way into libraries not 
 already supplied with a standard work of the kind. 
 The American Practitioner, Louisville, July, '74.
 
 HENRY C. LEA'S PUBLICATIONS (Mat. Med.and Therapeutics). 13 
 UTILLE (ALFRED], M.f), LL.D., and JITAISCH (JOHN M.). Ph.D., 
 
 *J Pro/, of Theory and Practice of Medicine -L'-*- Pr.,f. of.Vut. 3fed. and S,,t in Phi/a, 
 
 and of Clinical Med. in Univ. of Pa. Coll. Pharmacy. S"cy to t he American 
 
 Pharmaceutical Association. 
 
 THE NATIONAL DISPENSATORY : Containing the Natural History, 
 
 Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
 the Pharmacopoeias of the United Stntes and Great Britain. In one very handsome 
 octavo volume of T628 pages, with over 200 illustrations. Extra cloth, $6 75 ; leather, 
 raised bands, $7 50. (Now Ready.) 
 
 . EXTRACT FROM THE PREFACE. 
 
 " In the rapid progress of modern research, few subjects have of late years received greater acces- 
 sions of facts than the group of sciences connected with materia niedica and therapeutics. The 
 new resources thus placed at the command of the pharmaceutist and physician have seemed to the 
 authors to justify an attempt to make, frum the advanced stand-point of the present day, a concise 
 but complete statement of all that is of practical importance to both professions a digest in which 
 that which is old and that which is new shall be so brought together as to give to the reader, within 
 the most moderate practicable compass, all the details in pharmacology, pharmacy, and thera 
 peuties, which he is likely to need in his daily avocations. In the almost infinite accumulation of 
 material, this has required a careful and conscientious sifting to discard that which is obsolete, 
 untrustworthy, or comparatively trivial, without impairing the practical completeness of the 
 work. That they have wholly accomplished their object the authors do not venture to claim ; but 
 they can say that years of constant labor have been devoted to the task of producing a work to 
 which the inquirer may refer with the certainty of finding everything which experience has stored 
 up as worthy of confidence in the subjects embraced within its scope." 
 
 From ACSTIX FLINT, M.D., Prof, of Principles and j the respect and attention due to authority. The 
 
 Practice of Med. in Bellevue Hosp. Med. Coll., "raison d'etre" of the book is modestly stated in 
 
 N. Y. the preface, and now that it has been published and 
 
 The Dispensatory fills a vacuum in medical lite- Peas to us its vast stores of information, we may 
 
 rature which has long existed Of its large and j add that il was almost a necessity ; and this we say 
 
 long circulation there can be no doubt. without meaning to impugn the great excellence of 
 
 | the works of similar character which have preceded 
 
 From ROBERT T. EDES, Prof, of Materia Medica In it. All of the descriptions, whether medical, botaii- 
 
 ical, or pharmaceutical, are clear, in good English, 
 
 Med. Dept. Harvard Univ. 
 
 It seems worthy of the high reputation of the au- 
 thors, and likely to fulfil the expectations with 
 which-we have anticipated its coming. The accu- 
 racy and value of its statements are of course as- 
 sured by the names of the authors, and I am very 
 favorably impressed with the method of arrange- 
 ment as likely to facilitate reference, a point of 
 great importance in a work of this class. I am par- 
 ticularly pleased with the brief and forcible but yet 
 careful and judicious statements of the therapeutic 
 value (and. what is quite as important, want of value) 
 of the various drugs treated of. 
 
 This is a most magnificent work, with its over six- 
 teen hundred closely printed pages and two hundred 
 illustrations. As should be in a Dispensatory, the 
 alphabetical order of arrangement has been adopted 
 throughout. But it would require several pages of 
 the Medical News for ns to give even briefly a de- 
 scription of the work. Prof. Stille's work on Mate;ia 
 Medica and Therapeutics has ever since its publica- 
 tion been a standard work on those subjects, and 
 this fact alone is certainly a guarautee of his quali- 
 fications for the important work of producing a Dis- 
 pensatory ; and as regards Professor Maisch, his 
 high standing as a chemist and pharmaceutist is 
 well known. We would probably make an impor- 
 tant omission in our brief notice of the work, if we 
 failed to draw attention to a feature quite novel in a 
 Dispensatory, namely, the possession of a Thera- 
 peutical Index. By reference to it the physician 
 can see at a glance the remedies usually employed 
 in any disease. The Index of Materia Medica covers 
 fifty-five triple columned pages, and contains about 
 10,400 references. The Therapeutical Index occupies 
 thirty-three double columned pages, and contains 
 about 3750 references. Cincinnati Med. Hews, 
 March, 1879. 
 
 The present Dispensatory is arranged in alpha- 
 betical order from the commencement, the recent 
 fcdvauces in chemistry are mentioned, and an effort 
 made to include the late novelties in the review of 
 the resources of the physician. This is carried out 
 with that sound conservative judgment which cha- 
 racterizes all Prof. Stille's work. The chemical 
 and pharmaceutical sections have, we may suppose, 
 received the especial care of Prof. Maisch; and as 
 
 and unencumbered with obsolete and unintelligible 
 terms. Those portions which have reference to 
 therapeutics form a convenient treatise on that sub- 
 ject, and are made the more valuable and available 
 by a complete therapeutical index. The purely 
 pharmacal part is as perfect as it is possible to make 
 it, and less could not have been expected when we 
 consider Prof. Maisch 's great qualifications for work 
 of that kind. A". C Med. Jou.ru., March, 1879. 
 
 The therapeutic part Is as rich as would be ex- 
 pected of the author of the most comprehensive work 
 on the subject in our language. The physiological 
 effects of drugs receive due attention, and their iu- 
 Sueuce over disease is stated succinctly. For the 
 task of winnowing the immense accumulation of 
 periodical literature, the experience and matured 
 judgment of Prof. Still6 were eminenlly fitted. No 
 pharmacist or doctor will repent the purchase of a 
 book which is at once a treasury of facts and the 
 digest of a decision of a high court. Louinville Med. 
 Ifews, March 29, 1879. 
 
 The pharmaceutical world has for a long time 
 been ou the qui vive, in expectation of the forthcom- 
 ing Dispensatory by Profs. Stille and Maisch, who 
 have acquired tuch a reputation in their respective 
 Departments that nothing but a satisfactory work 
 could be expected ; this expectation has been quite 
 realized. We have examined the work with some 
 care, and are very much pleased that we can pro- 
 nounce it to be reliable, comprehensive, and includ- 
 ing the latest re*earches available to its authors. 
 This is more particularly true as regards the portion 
 devoted to pharmaceutical subjects. We are fully 
 justified in stating that it is, taken altogether, one 
 of the most important and creditable publications 
 which have of late been issued by the American 
 press. It will be an indispensable reference book 
 both for the pharmacist and the physician. JVtia 
 Remedies, April, 1879. 
 
 A careful examination of the work calls forth un- 
 qualified praise for its excellent arrangement, fnll 
 yet concice information, its careful adherence to the 
 best authority on each particular topic, as well as 
 the entire elimination of all unnecessary and obso- 
 lete data and particulars. The arrangement of all 
 topics is purely alphabetical, and with surprising 
 
 he is futile princepgin that branch, nothing can be i fidelity to the wants both of the physician and phar- 
 
 said of them except in praise. Med. and Surg. Re- 
 porter April 5, 1879. 
 
 It has been prepared by two gentlemen whose 
 
 maceutist. New remedies which have come into 
 recent use are here found noticed, with such facts 
 as have been collated from careful investigation. 
 
 learning fully qualified them for the difficult task, j Druggist^ Circular and Chemical Gazette, Mareh, 
 and whose eminence entitles them to be heard with 1 1379.
 
 14 
 
 HENRY C. LEA'S PUBLICATIONS (Pathology, &c.). 
 
 (F.), AND T2ANVIER (,.), 
 
 v> ' Pro/, in A Faculty of Med , Paris. Prof in the College of Prance. 
 
 MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 
 
 Notes and Additions, by E. 0. SHAKESPEARE, M.D., Pathologist and Ophthalmic Surgeon 
 to Pbiluda. Hospital, Lecturer on Refrcction and Operative Ophthalmic Surgery in Univ. 
 of Penna. In one very handsome octavo volume of about 6CO pages, with over 300 illus- 
 trations. (Preparing.) 
 
 So much has been done of late years in the elucidation of pathology by means of the micro- 
 scope, and this subject now occupies so proininenta position ns one of the most important branches 
 of medical science, that the American profession cannot fail to welcome a truncation of the pre- 
 sent work, wnich, through its own merits find through the well-known reputation of its distin- 
 guished authors, is regarded in Europe as the standard text-book and work of reference in its 
 department. Such investigations and discoveries as have been made since its appenrance will be 
 introduced by the translator, nn<l the work is confidently expected to assume in this country the 
 game position which has been go universally accorded to it abroad. 
 
 (SAMUEL], M.D., 
 
 Aftittant Physician to the London ffogpital, 
 
 THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 
 
 Third Kevised and Enlarged English Edition. With eighty-four illustrations on wood. 
 
 In one very handsome volume, royal 12mo., cloth, $2 25. (Just Issued.) 
 
 are few books of thissizeon practical medicine that 
 containsomuchandconveyit so well as the volume 
 before us. It is a book we can sincerely recommend 
 to the student for direct instruction, and to the]prac- 
 titioner as a ready and useful aid to his memory. 
 Am. Journ. of Syphilography, Jan. 1874. 
 
 Of the many gnida-books on medical diagnosis, 
 cUimed to be written for the special instruction of 
 students, thie is the best. Theauthoris evidently a 
 well-read and accomplished physician. and he knows 
 how to teach practical medicine. The charm of sim- 
 plicity Is not the least interesting feature in the man- 
 nar in which Dr. Fen w ick conveys instruction. There 
 
 SCREEN (T. HENRY], M.D., 
 
 Lecturer on Pathology and Morbid Anatomy at Qharing-droiis Hospital Medical School, etc. 
 
 PATHOLOGY AND MORBID ANATOMY. Third American, from 
 
 the Fourth and Enlarged and Revised English Edition. In one very handsome octavo 
 volume of 332 pages, with 132 illustrations; cloth, $2 25. (Just Ready.) 
 
 This is unquestionably one of the best manuals on i ciently numerous, and usual y well made. In the 
 the subject of pathology and morbid anatomy that present edition, such new matter has been added as 
 can be placed in the student's hands, and we are was necessary to embrace the later results in patho- 
 glad to see it kept up to the times by new editions, logical research. No doubt it will continue to eujoy 
 Each edition is carefully revised by the author, with the favor it has received at the hands of the protes- 
 
 the view of making it include the most recent ad- 
 vances in pathology, and of omitting whatever may 
 have become obsolete. A". Y. Med. Jour., Feb. 1879. 
 
 sion. Med and tiurg. Reporter, Feb. 1, 1879. 
 
 For practical, ordinary daily n*e, this is undoubt- 
 edly the best treatise that is offered to fctndeUg of 
 
 The treatise of Dr. Green i compact, clearly ex- ; pathology and morbid anatomy. Cincinnati Lan- 
 pressf d, up to the times, and popular as a text-book, at and Clinic, Feb. 8, 1S79. 
 both in England and America. The cuts are suffl- ! 
 
 D 
 
 AVIS (NATHAN S.], 
 
 Prof, of Principles and Practice of Medicine, etc., in Chicago Med. College. 
 
 CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES; 
 
 being acollection of the Clinical Lectures delivered in the Medical Wards of Mercy Hos- 
 pital, Chicago. Edited by FRANK H. DAVIS, M.D. -Second edition, enlarged. In one 
 handsome royal 12mo. volume. Cloth, $175. (Lately Issued.) 
 
 WHAT TO OBSERVE AT THE BEDSIDE AND AFTER 
 DEATH IN MEDICAL CASES. From the second Lon- 
 don edition. 1 vol royal 12mo., cloth. $100. 
 
 CH RISTISON'S DISPENSATORY. With copious ad- 
 ditions, and 213 large wood-engravings, by K. 
 EILESPIBLI>GRIFFITH, M.D. One vol.Svo., pp. HOO. 
 cloth. $400. 
 
 CARPENTER'S PRIZE ESSAY ON THE USE CF 
 ALCOHOLIC LIQUORS IK HEALTH AMD DISEASE. Ne* 
 edition, with a Preface by D. F. COKDIB, M.D., atd 
 explanations of scientific wordr. In oneneatJ2mr. 
 volume, pp. 178. cloth. 60 cents. 
 
 OLUGE'S ATLAS op PATHOLOGICAL HISTOLOGY 
 Translated, with Notes and Additions, by JOSEPH 
 LKIDT, M. D. In one volume, very large imperial 
 qnarto, with 320 copper-plate figures, plain and 
 colored, cloth. t*00. 
 
 LA ROCHE ON TBLLOW FEVER. considered in Its 
 Historical, Pathological, Etiological, and Thera 
 peutical Relations. In two large and handsome 
 octavo volumes of nearly IflOO pp , cloth. $7 00. 
 
 HOLLAND'S MEDICAL NOTES AND REFLEC- 
 TIONS. 1 vol. 8vo., pp. 600, cloth. $3 50. 
 
 BARLOW'S MANUAL OF THK PRACTICE OF 
 MEDICINE. With Additions by D. F. COKDIF, 
 M D. 1 vol. 8vo., pp. 600, cloth. $2 50. 
 
 TODD'SCLINICAL LECTURES on CERTAIN ACUTE 
 DISEASES. In one neat octavo volume, of 320 pp , 
 loth. $2 50. 
 
 STURGES'S INTRODUCTION TO THE STUDY OF 
 CLINICAL MEDICINE. Being a Guide to the In- 
 vestigation of Disease. In one handsome 12mo. 
 volume, cloth, $1 2.5. (Lately Insued.) 
 
 STOKES' LECTURES ON FEVER. Edited by JOHH 
 WILLIAM MOORE, M.D. , Assistant Physician to the 
 Cork Street Fever Hospital. In one neat Sro. 
 volume, cloth, $2 00. (Just Issued.) 
 
 THE CYCLOPAEDIA OF PRACTICAL MEDICINE: 
 comprising Treatises on the Nature and Treatment 
 of Diseases, Materia Medica and Therapeutic*, Dis- 
 eases of Women and Children, Medical Jurispru- 
 dence, etc. etc. By DUNGLISOS, FORBTS, TWEEDIE, 
 and CONOLLY. In four large super royal octavo 
 volumes, of 3254 double columned p ige-s strongly 
 and handsomely bound in leather, $15; cloth, $11.
 
 HENRY C. LEA'S PUBLICATIONS (Practice of Medicine}. 
 
 15 
 
 ffLINT (A UST1N), M.D., 
 
 * Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. 7. 
 
 A TREATISE ON THE PRINCIPLES AND PRACTICE OF 
 
 MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth 
 edition, revised and enlarged. In one large and closely printed octavo volume of about 
 1 100 pp. ; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Lately 
 Issued. ) 
 
 By common consent of the English and American medical press, this work has been assigned 
 to the highest position as a complete and compendious text-book on the most advanced condi- 
 tion of medical science. At the very moderate price at which it is offered it will be found one 
 of the cheapest volumes now before the profession. 
 
 This excellent treatise on medicine lias acquired 
 for itself in the United States a reputation similar to 
 that enjoyed in England by the admirable lectures 
 of Sir Thomas Watson. It may not possess the same 
 charm of style, but it has like solidity, the fruit of 
 long and patient observation. and presents kindred 
 moderation and eclecticism. We have referred to 
 many of the most important chapters, and find there 
 vision spoken of in the preface is a genuine one, and 
 that the author has very fairly brought up hi f matter 
 to the level of the knowledge of the present day. The 
 work has this great recommendation, that it is in one 
 volume, and therefore will not be so terrifying to the 
 student as the bulky volumes which several of our 
 English text-books of medicine have developed in to. 
 British and Foreign Jled.-Chir. Rev., Jan. 187. 
 
 It is of course unnecessary to introduce or eulogize 
 this now standard treatise. All the colleges recom 
 
 in which one of its editions is not to be found. Tie 
 present edition has been enlarged and revised to 
 bring it up to the author's present level of experi- 
 ence and reading. His own clinical stndiesand the 
 latest contributions to medical literature both in 
 thic country and in Europe, have received careful 
 attention, to that some portions have been entirely 
 rewritten, and about seventy pages of new matter 
 
 havebeen added. Cnicngo 
 
 Jovr., June, 1873. 
 
 Has never been surpassed as a text-book for stu- 
 dents and a book of ready reference for practition- 
 ers TheforeB of its logic, its simple and practical 
 teachings, have left it without a rival in the field. 
 N. Y.Med Record,. Sept. 15, 1874. 
 
 It is given to very few men to tread in the steps of 
 Austin Flint, whose single volume on medicine, 
 though here and there defective, is a masterpiece of 
 lucid condensation and of general grasp of an enor- 
 
 mend it as a text-book, and there are few libraries monsly widesubject Land. Practitioner, Dec. '78. 
 
 C 
 
 C 
 
 THE SAME AUTHOR. 
 
 CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 
 
 and Treatment of Diseases. Designed for Students and Practitioners of Medicine. In 
 one large and handsome octavo volume. (In Prtss ) 
 
 THE SAME A UTHOR. 
 
 ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 
 
 TOPICS. In one very handsome rojal 12mo. volume. Cloth, $1 38. (Just Issued.) 
 
 WOODBVRT (FRANK), M.D , 
 
 Physician to the German Bvipitnl, Philadelphia, late Physician to the Out-patient Department 
 of t hi Jeff. College Hospital, etc. 
 
 A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF 
 
 Medicine ; for the use of Students and Practitioners. Based upon Husband's Handbook 
 of Practice. In one neat volume, rpyal 12mo. (In Frets.) 
 
 fJA R TSHORNE ( HENR Y), M. D., 
 
 *-* Professor of Hygiene in the University of Pennsylvania. 
 
 ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEI I- 
 
 CINE. A handy-book forStudents and Practitioners. Fourth edition, revised and im- 
 proved. With about one hundred illustrations. In one hand&ome royal 12mo volume, 
 of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Lately Issued.) 
 
 As ahandbook, which clearly sets forth the ESSEN- 
 TIALS Of the PRINCIPLES AND PRACTICE Of MEDICINE, 
 
 we do not know of its equal. Va. Mtd. Monthly. 
 As a brief, condensed, but comprehensive hand- 
 
 book, it cannot be improved upon. Chicago lied. 
 Examiner, Nov. 15, 1874 
 
 Without doubt the best book of the kind published 
 in the Enjzlixh language. St. Louis Med. and Surg. 
 Journ., Nov. 1874. 
 
 TXTATSON (THOMAS], M.D., frc. 
 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF 
 
 PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
 vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
 tions, by HENRY HARTSHORKE, M.D., Professor of Hygiene in the University of Penn- 
 sylvania. In two large and handsome Svo.vols. Cloth, $9 00; leather, $11 00. (Lately 
 Publisfied.) 
 
 ^It is a subject for congratulation and for thank- cate and important pathological and practical ques- 
 ful less that Sir Thomas Watson, during a period of | lions, the results of his clear insight and his calm 
 comparative leisure, after a long, laborious, and [judgment are now recorded for the benefit of man- 
 most honorableprofessional career, while retaining > kind, in language which, for precision, vigor, and 
 full possession of his high mental faculties, should j classical elegance, has rarely been equalled, and 
 have employed the opportunity to submit his Lee- | never surpassed The revision has evidently been 
 tures to a more thorough re vision than wa possible j most carefully done, and the results appear in al- 
 daring the earlier and busier period of his life, most every page. Brit. Med. Joum., Oct. 14, 1871. 
 Carefully passing in review some of the most intri- i
 
 16 
 
 HENRY C. LEA'S PUBLICATIONS (Practice of Medicine}. 
 
 JDRISTOWE (JOHN SYER], M.D., F.R.C.P., 
 
 J-) Phytician and Joint Lecturer on Medicine., St. Thomax'g FTntpital. 
 
 A MANUAL ON THE PRACTICE OP MEDICINE.. Edited, with 
 
 Additions, by JAMES II. Ilu- CHINSON, M.D., Physician to the Penna. Hospital. In one 
 handsome octavo volume of over 1100 pages : cloth, $5 50 ; leather, $6 50. (Jmt Issued.) 
 
 This portly volume Is a model of condensation. 
 In a stylo at once clear, interesting, and concise, Dr. 
 Bristowe passes in review every conceivable subject 
 connected with the practice of medicine. Those 
 practitioners who purchase few books will find this 
 a mof t opportune publication, because to many top- 
 ic* not usually embraced in a work on practice are 
 adequately handled. The book is a thoroughly g'od 
 one, and its usefulness to American readers has been 
 
 increased by the judicious notes of the Editor. 
 Cincinnati Clinic, Jan 7, 1877. 
 
 Anyone who wants a good, clear, condensed work 
 upon Practice, quite np with the most recent views in 
 pathology, will find this a most valuable work The 
 additions made by Dr. Hutchinson are appropifate 
 and useful, and so well done that we wir-h there were 
 more of them. Am. Practitioner, Feb. 1&77. 
 
 the Principles and Practice of Medicine at Guy's 
 
 fJABER'SHON (S. 0.). M.D. 
 
 -*--*- Senior Physician to and late Lecturer on 
 
 Hospital, etc. 
 
 ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 
 
 of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intes- 
 tines, and Peritoneum. Second American, from the third enlarged and revised Eng- 
 lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
 Cloth, $3 50. (Now Ready.) 
 
 This work has remained sime time out of print, owing to the careful and conscientious 
 revision which it has enjoyed at the hands of the author, and which has nearly doubled its 
 size since the appearance of the first edition. Yet there is no work accessible to the profession 
 to take its place, as a careful, practical guide on a class of diseases, which form so large and 
 important a portion of the duties of the physician, and for which the author's position has 
 given him almost unequalled opportunities for observation and experience. The very extensive 
 scope of the volume will be seen by the subjoined condensed 
 SUMMARY OF CONTENTS. 
 
 Chapter I. Introduction. II. On Diseases of the Tongue and Mouth. III. On Diseases of 
 the Pharynx. IV. On diseases of the (Esophagus. V. On Organic Diseases of the Stomach. 
 VI. On Functional Diseases of the Stomach. VII. On Diseases of the Duodenum VIII. 
 On Muco-Enteritis and Enteritis. IX. On Strutnous and Tubercular Disease of the Alimen- 
 tary Canal; Lardaceous Disease. X. On Diseases of the Caecum and Appendix Casci. XI. 
 On Diarrhoea. XII. On Dysentery and Catarrhal Inflammation of the Colon. XLII. On 
 Typhoid Disease of the Intestine. XIV. On Colic. XV. On Constipation. XVI. On Organic 
 Obstruction, Internal Strangulation, Intussusception, and Carcinoma of Intestine. XVII. 
 On Suppurntion of the Abdominal Parietes, Perforation of the Intestine from without, and 
 Abscess of the Abdominal Parietes extending into the Intestine; Fecal Abscess. XVIII. 
 On intestinal Worms. XIX. On Peritonitis. XX. On Aecites, Dropsy. XXI. On Abdomi- 
 nal Tumors. 
 
 amended by the author. Several new chapter* have 
 been added, bringing the work fully up to the times, 
 and making it a volume of interest to the practitioner 
 in every field of medicine and surgery. Perverted 
 nutrition is in some form associated with all diseases 
 we have to combat, and we need all' the light that 
 can be obtained on a subject so broad and general. 
 Dr Haberhon's work is one that every practili 'cer 
 should read and study for himself. JV. Y. Mtd. 
 Journ., April, 1879. 
 
 This valuable treatise on diseases of the stomach 
 and abdon.cn has been out of print for several years, 
 and is therefore not so well known to the profession 
 as it deserves to be. It will be found a cyclopaedia 
 of information, systematically arranged, on all dis- 
 eases of the alimentary tract, from the mouth to the 
 rectum. A fair proportion of each chapter Is devot- 
 ed to symptoms, pathology, and therapeutics. The 
 present edition is fuller man former ones in many 
 particulars, and has been thoroughly revised and 
 
 ffOTHERGILL (J. MILNER},M.D. Edin., M.R.C.P. Lond., 
 
 -*- Agst. Phys. to the West Lond. Hogp. ; Asst. Phys. to the City of Lond. Ho*p. , etc. 
 
 THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the 
 
 Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, 
 
 $4 00. (Now Ready.) 
 
 one of those books which both deserve and are likely to 
 survive. This book, although written ostensibly for the 
 young and inexperienced, may be very profitably studied 
 by those who have been practicing their profession 
 more or less empirically for thirty or forty years. We 
 content ourselves with again recommending the book 
 very cordially. Edin. Med. Journ., Jan. 1677. 
 
 We heartily commend bis bock to tbemedical student 
 as an honest and intelligent guide through the mazes of 
 therapeutics, and assure the practitioner who has grown 
 gray in the harness that he will derive pleasure and in- 
 struction from its perusal. Valuable suggestions and 
 material for thought abound throughout. BoslonMed. 
 and Surg Journal, Mar. 8, 1877. 
 
 Our friend* will find this a very readable book ; and 
 that it sheds light upon every theme it touches, causing 
 the practitioner to feel more certain of his diagnosis in 
 difficult cases. We confidently commend the work to 
 our readers as one worthy of careful perusal. It lighis 
 the way over obscure and difficult passes in medical 
 practice. The chapter on the circulation of the blood 
 is the most exhaustive and instructive to be found. It 
 la a book every practitioner nerds, and would have, if 
 he knew how suggestive and helpful it would be to 
 him. St. Louis MfJd. and Surg. Journ , April, 1877. 
 
 It is our honest conviction, after a careful perusal of 
 this goodly octavo, that it represents a great amount of 
 earnest thought and painstaking work, and is therefore 
 
 DT THE SAME AUTHOR. 
 
 THE ANTAGONISM OF THERAPEUTIC AGENTS, AND WHAT 
 
 IT TEACHES. Being the Fothergillinn Prize Essay for 1878. In one neat volume, royal 
 12mo. of 156 pages; cloth, $1 00. (Just Ready.) 
 
 It will be found a highly interesting study and I certain drugs. Medical and Surgical Reporter, 
 practical application of the antagonistic action of 1 Sept. 14, 187s.
 
 HENRY C. LEA'S PUBLICATIONS ^Practice of Medicine). 
 
 17 
 
 plXLA YSON (JAMES), M.D., 
 
 Physician and Lecturer on (Clinical Mefli"ine in fh Glasgow We.xtf.rn Infirmary, eta. 
 
 CLINICAL DIAGNOSIS; A Handbook for Students and Prnc- 
 
 titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
 tions. Cloth, $2 63. (Just Ready.) 
 
 The concurrence of gentlemen specially familiar with the several subjects being requisite to 
 the satisfactory development of a plan so extensive, Dr. Finlaygon has secured the co-operation 
 of Prof. Gairdner, who has contributed the chapter on the Physiognomy of Disease; Prof. \Vm. 
 Stephenson that on Disorders of the Female Organs ; Dr. Alex. Robertson that on Insanity ; 
 Prof. Samson Gemmell those on the Sphygmograph and Physical Diagnosis ; and Dr. Joseph 
 Coates those on the Fauces, Larynx, and Nares, and on the method of performing post-mortem 
 examinations. Other chapters have enjoyed the advantage of revision by gentlemen specially 
 versed in their several subjects ; and the volume is presented as thoroughly on a level with 
 the most advanced condition of knowledge in a department which has made such rapid strides 
 of advancement within the last few years. 
 
 The hook is an excellent one, clear, concise, con ve- This is one of the really useful books. It is attrac- 
 nient, practical. It is replete with the very know- j live from pr-face to the final page, and ought to be 
 ledge the student needs when he quits the lecture- ; given a place on every office table, because it contains 
 room and the laboratory for the ward and sick-room, , in a condensed form all that is valuable in semeiology 
 and does not lack in information that will meet the ; and diagnostics to be found in bulkier volumes, and 
 wants of experienced and older men. Phila. Med. '. because in its arrangement and complete index, it is 
 Times, Jan. 4, 1879. I unusually convenient for qnick reference in any 
 
 The aim of the author is to teach a student and ! emergency that may come upon the busy practitioner, 
 practitioner how to examine a case so as to n-e "all , ** " Med - Journ., Jan. 1879. 
 
 his knowledge'' in arriving at a diagnosis. All the i This is a most important work for students, and 
 various symptoms of the several systems are grouped one that is d> stined to become rapidly popular. It 
 together in such a manner as to mike their relations is composed of contributions from various eminent 
 to a final diagnosis clear and easy pf apprehension. , sources bearing upon this subject. The real secret 
 This work has been done by men of large experience of successful practice is the accurate diagnosis of 
 and trained observation, who have been long recog- , disease. This manual teaches the student to arrange 
 nized as authorities upon the subjects which they i his investigation in such system as to enable him, 
 treat. There is a profusion of illustrations to illns- ! with practice, to acquire this very desirable faculty, 
 trate subjects under discussion. The application of ( The division of the subject, as iu this work, among 
 electricity, and instruments of precision in diagnosis, i the highest authorities living, is a good idea, and 
 is fully discussed. This book is all good. We com- j gives us in one compact form a series of monographs 
 
 mend it to all students and practitioners of medicine 
 as a work worthy of a place in their libraries. Ohio 
 Med. Recorder, Dec. 1878. 
 
 written by masters. Nashville Journal of Med. 
 and Surg., Jan. 1879. 
 
 TJAM1LTOX (ALLAN McLANE), M.D., 
 
 Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. 7., 
 and at the Out- Tatients' Department, of the New York Hospital. 
 
 NERVOUSDISBASESjTHEIR DESCRIPTION AND TREATMENT. 
 
 In one handsome octavo volume of 512 pages, with 53 illus. ; cloth, $3 50. (Just Ready.) 
 
 This is unquestionably the best and most com- 
 plete text-book of nervous diseases that has yet ap- 
 peared, and were international jealousy in scientific 
 affairs at all possible, we might be excused for a 
 feeling of chagrin that it should be o'f American 
 parentage. This work, however, has been performed 
 in New York, and has been so well performed that 
 no room is left for anything but commendation. 
 With great skill, Dr. Hamilton has presented to his 
 readers a succinct and lucid survey of all that is 
 known of the pathology of the nervous system, 
 viewed in the light of the most recent researches. 
 From the preliminary description of the methods of 
 examination and study, and of the instruments of 
 precision employed in the investigation of nervous 
 diseases, up till the final collection of formulfe, the 
 book is eminently practical. .Brain, London, Oct. 
 1878. 
 
 The author tells ns in his preface that it has been 
 his object to produce a concise, practical book, and 
 we think he has been successful, considering the ex- 
 tent of the subject which he has undertaken. In 
 fact, it is more extensive than the title properly or 
 accurately indicates, embracing besides what are 
 usually regarded as nervous diseases inflammatory 
 affections, both acute and chronic, hemorrhages and 
 tumors of the cerebrum and cerebellum, medulla 
 oblongata, spinal cord and nerves, with thrombosis 
 and embolism of the arteries, sinuses, and reins. 
 The reader may therefore expect information, more 
 or less full and satisfactory, on almost every point 
 
 connected with the nervous system. We have no 
 hesitation in saying that reliance may be placed on 
 Dr. Hamilton's conscientious performance ot' his self- 
 assigned task, on his soundness of judgment, and 
 freedom from empiricism. Edinburgh Med. Journ., 
 Oct. 1878. 
 
 From a very careful examination of the whole 
 work, we can justly say that the author has not only 
 clearly and fully treated of diagnosis and treatment, 
 but, unlike most works of this class, it is very com- 
 prehensive in regard to etiology, and exposes the 
 pathology of nervous diseases in the light of the very 
 latest experiments and discoveries. The drawings 
 are excellent and well selected. After this careful 
 revision, we can heartily recommeud this work to 
 students and general practitioners in particular as 
 being a full exposition of diseases of the nervous sys- 
 tem, their pathology and treatment, to date. JV. Y. 
 Med. Record, Aug. 3, 1878. 
 
 As stated in the preface, the author's object has 
 been to write a concise and practical book, for 
 which there is certainly a place, and we think he 
 has succeeded admirably in fulfilling his object. 
 The usual plan is adopted in the classification of 
 the different diseases, the book not being greatly 
 unlike Hammond's in this respect, although it is 
 very noticeable throughout that the author's opin- 
 ions vary widely from those of Dr Hammond. Am. 
 Supp. Obstet. Sourn. Great Britain and Ireland, 
 July, 1878. 
 
 riHARCOT (J. M.), 
 
 Professor to the Faculty of Med. Paris, Phys. to La Salpetriere, etc. 
 
 LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- 
 lated from the Second Edition by GEORGE SIGERSO*. M.D., M.Ch., Lecturer OB Biology, 
 etc., Cnth. Univ. of Ireland. With illustrations. (Publishing in the Medical News and 
 Library, commencing with the July No. 1878 See page 2 )
 
 18 HKNRY C. LEA'S PUBLICATIONS {Diseases of the Chest, 
 
 'DROWN (LENNOX], F.R.C.S. Ed., 
 
 Senior Surgeon to the Central London Throat find Ear Hwpltal, etc., 
 
 THE THROAT AND ITS DISEASES. With one hundred Typical 
 
 Illustrations in colors, and fifty wood engraving?, designed nnd executed by the author. 
 In one very handsome imperial octavo volume of 351 pages; cloth, $5 00. (Now Ready.) 
 
 The author'* rare artistic skill hns been utilized 
 In the production of one hundred beautiful illustra- 
 tions iu colors, the very best of the kind we have 
 seen, and which have been distributed in ten plates. 
 Fifty wood engravings, designed and executed by 
 the author, appear in the body of the work these 
 
 are unusually accurate. In conclusion, we recom- 
 mend this beautiful volume an a.o acceptable addi- 
 tion to the library of those engaged ic the treatment 
 of diseases of the throat. N. Y. Med, Record. Nov. 
 9, 1S78. 
 
 &E1LKR (CAUL), M.D., 
 
 *~J Lecturer on LarynposC'py at the Univ. of Fenna , Chief of the Throat Dispeniary at the 
 
 Univ. Hospital, Phila , etc. 
 
 HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF 
 
 THE THROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume. 
 With illustrations. (In Press.) 
 
 PLINT (AUSTIN], M.D., 
 
 Professor of the Principles and Praottct of Medicine in Bellevue Hospital Jfed. College, N. Y. 
 
 PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
 ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT- 
 MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By AUSTIN 
 FLINT, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
 College, New York. In one handsome octavo volume : $3 50. (Lately Issued.) 
 
 This book contains an analysis, in the author's lucid 
 F/yle, of the notes whirh lie has made in several hun- 
 dred cases in hospital and private practice. We com- 
 
 mend the book to the perusal ot all interested in the 
 <tudy of :bN disease. Huston Med. and Surg. Journal, 
 Feb. 10, 18T6. 
 
 DY THE SAME AUTHOR. 
 
 A MANUAL OF PERCUSSION AND AUSCULTATION; of the 
 
 Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In 
 one handsome royal 12mo. volume: cloth, $1 75. (Just Issued.) 
 
 B 
 
 Y THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 
 
 AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 
 edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 
 Dr. Flint chose a difficult subject for his researches nd clearest practical treatise on those subjects, and 
 
 ind has shown remarkable powers of observation 
 in \ reflection, as well as great industry, in his treat- 
 ment of it. His book must be considered the fullest 
 
 should be in the hands of all practitioners and stu- 
 lents It is a credit to American medical literature. 
 Amer. Journ. of the Med. Sciences, July, 1860. 
 
 75 F THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON .THE PHYSICAL EXPLORA- 
 TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
 RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
 of 595 pages, cloth, $4 50. 
 
 WILLIAMS'S PULMONARY CONSUMPTION; its 
 Nature, Varieties, and Treatment. Wilh an An- 
 alysis of One Thousand Cases to exemplify its 
 duration. In one neat octavo volume of about 
 350 pages; cloth, $2 50. 
 
 DIPHTHERIA ; its Nature and Treatment, with an 
 account of the History of its Prevalence in vari- 
 ous Countries. By D. D. SI.ADE, M.D. Second and 
 revised edition. In one neatroyal 12mo. volume, 
 cloth, $1 25. 
 
 WALSHE ON THE DISEASES OF THE HEART AND 
 GREAT VESSELS. Third American Edition. In 
 1 vol. Svo., 420 pp., cloth, $3 00. 
 
 LECTURES ON THE DISEASES F THE STOMACH. 
 With an Introduction on its Anatomy and Physio- 
 logy. By WILLIAM BRJNTON, MD., F.R.S From 
 the second and enlarged London edition. With il- 
 lustrations on wood. In one handsome octavo 
 volume of about 300 pages: cloth, $3 24. 
 
 LA BOCHB OK PNEUMONIA. 1 vol. 8vo., cloth. 
 of 500 page*. Price, tS 00. 
 
 LINCOLN'S ELECTROTHERAPEUTICS; a Concise 
 Manual of Medical Electricity. In one very neat 
 royal 12mo. volume, cloth, with Illustrations, 
 ftl 50. 
 
 CLINICAL OBSERVATIONS ON FUNCTIONAL 
 NERVOUS DISORDERS By 0. H ANPFIEI.D JONK?, 
 M.D., Physician to St. Mary's Hospital, &c. Sec 
 oti'l American Edition. In one handsome octavo 
 Toluute of 348 pages, cloth, $3 25. 
 
 FULLER ON DISEASES OF THE LUNGS AND AIR- 
 PASSAGES. Their Pathology, Physical Diagnosis, 
 Symptoms, and Treatment. From the second and 
 revised English edition. In one handsome ocatvo 
 volume of about 500 pages : cloth, $3 50. 
 
 CHAMBERS'S MANUAL OF DIET AND REGIMEN 
 IN HEALTH AND SICKNEsS. la one handsjine 
 octavo volume. Cloth, ijS'2 7."> 
 
 CHAMBERS'S RESTORATIVE MEDICINE. An Har- 
 veian Annual Oration. With Two Sequels. In 
 one very handsome vol. small 12ino , cloth, $1 00. 
 
 PAVY'S TREATISE ON THE FUNCTION OF DI- 
 GESTION; its Disorders and their Treatment. 
 From the second London edition. In one hand- 
 some volume, small octavo, cloth, $2 00. 
 
 PAVY'S TREATISE ON FOOD AND DIETETICS. 
 Physiologically and Therapeutically Considered. 
 In one handsome octavo volume of nearly 600 
 pages, cloth, $4 75. 
 
 S vlITH ON CONSUMPTION ; ITS EARLY AND RE- 
 MSDIABLE STAGES. 1 vol. Svo. . pp. 254 *2 2-'. 
 
 BASHAM ON RENAL DISEASES: a Clinical Guide 
 to their Diagnosis and Treatment. With Illustra- 
 tions In one I2mo. vol. of 304 page?, cloth, $2 00. 
 
 LECTURES ON THE STUDY OF FEVER. By A. 
 HcDStix, M.D.. M.R.I. A., Physician to the ileath 
 Hospital. In one vol. 8vo., cloth, $2 50. 
 
 A TREATISE ON FEVER. By ROBKBT D. LYOHC, 
 KCC. Inoneoctavo volume of 362 pages, cloth, 
 $2 25.
 
 -~( VenerealDigeases, Ac.). 1 9 
 
 R 
 
 UMSTEAD (FREEMAN J.) MD 
 
 mTT^T 7 Venereal DietaSeS aithg 1 ' * ' Ph * nnd *'*- Tor*. AC 
 
 EASES T H ,J JO( J Y AND TR EATMENT OF VENEREAL DIB- 
 
 Cn " f - mi investi g ation " "P the subject. Third editicn, 
 
 1 one large and hand om octavo 
 
 ' the auth r has 8Ub J eoted " to * very 
 rewritten ' a d much new matter added, in order to 
 
 fu ompon oftK t . .'* ad n d condition of syphilography, but by care- 
 
 page /he labor thn, h f "T^" ^I*'? 11 ?' th W rk ha8 been increase * by only sixty-four 
 
 Son asa co m nlJ H 6S * t T* ^'^ '' h ped ' wilHn " for " continuance of its 
 complete and trustworthy guide for the practitioner. 
 
 le work on Venere 
 
 Widft f*i ron 1 a H * t v 
 
 been accep'ted as the staudard'but ap pears 'tThave 
 formed tl.e basis, to a large extent, of many of the 
 ^^^f*^ >!ve b^n wrUten y on the 
 England.- 
 
 n _ I ,VVrf e - m ^ t0 , 0mplelebookwith which weareae- 
 qnainted in the language. The latest views of the 
 
 ist authontiesareput forward, and the information 
 Is well arranged-a great point for the student and 
 
 HI more for the practitioner. The subjects of vix- 
 seral syphilis, syphilitic affections of theeyes, and 
 the treatment of syphilis by repeated inoculations, 
 are r e ry fully diseussed. Land. Lancet, Jan. 7, 71. 
 
 Dr. Bumstead's work is already go universally 
 Known as the best treatise in the English language on 
 
 ranereal diseases, that it may seem almost superflu- 
 ous to say more of it than that a new edition ha* been 
 issued. But the author's Industry has rendered thig 
 new edition virtually a new work, and so merits as 
 much special commendation as if its predecessors 
 hac not been published. As a thoroughly practical 
 book on a class of diseases which form a large 
 share of nearly every physician's practice, the vol- 
 ume beforf us is by far the best of which we have 
 knowledge .tf. T. Medical Gatetts, Jan. 28, 1871. 
 
 It Is rare in the history of medicine to find anyone 
 book which contains all that a practitioner needs t o 
 know; while the possessor of "Bnnmead on Vene- 
 real" has no occasion to look outside of Us covers for 
 anything practical connected with the diagnosis, his- 
 tory, or treatment of thse affections. N. T. Itedi- 
 "" Journal, March, 1871. 
 
 nULLERIEE (A.}, and 
 
 ^ Surgeon to the Hdvital du Midi. 
 
 J1DMSTEAD (FREEMAN J.), 
 
 - LJ Profesior of Venerea I IHttaseg in the College oj 
 Phyaitrianii and Surgeong. N. T 
 
 AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 
 
 FBKKMAN J. BUMSTBAD. In one large imperial 4to. volume of 328 pages, double-columns. 
 
 with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
 
 rongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
 
 Anticipating a very large sale for this work, it is offered at the very low price of THREBDOI,- 
 
 fcARS a Part, thus placing it within the reach of all who are interested in this department of 
 
 practice. Gentlemen desiring early impressions of the plates would do well to order it without 
 
 delay. A specimen of the plates and text sent free- by mail, on receipt of 25 cents. 
 
 We wish for once that onr province was not re- to its end, we do not know a single medical work, 
 
 strict d to methods of treatment, that we might say 
 some-hing of the exquisite colored plates In this 
 volume. -London Practitioner, May, 1869. . 
 
 As a whole, It teachea all that can be taught by 
 means of plates and print. London Lancet, March 
 IS, 1869. 
 
 Superior to anything of the kind ever before issued 
 on this continent. Canada Med. Journal, March, '69 
 
 The practitioner who desires to understand this 
 branch of medicine thoroughly should obtain this, 
 the most complete and best work ever published. 
 Dominion Med. Journal, May, 1869. 
 
 This ig a work of^master hands on both sides. M. 
 Gollerier is scarcely gecond to, we think we may truly 
 say ig a peer ofthe illustriousand venerable Ricord, 
 while in this country we do not hesitate to say that 
 Dr. Bumstead, as an authority, is without a rival 
 Assuring onr readers that these illustrations tell the 
 whole history of venereal disease, from its inception 
 
 which for its kind is more necesnary for them to 
 have. California 3fed. QanrMe, March, 1869. 
 
 The most splendidly illustrated work In the lan- 
 guage, and in our opinion far more useful than the 
 French original. Am. Jour. Med. Sciencet, Jan.'6b. 
 
 The fifth and concluding number of this magnificent 
 work has reached us, and we have no hesitation in 
 sayingthat its illustrations surpassthose of previous 
 cumbers. Boat Med. and Burg. J!., Jan. 14 1869. 
 
 Other writers besides M. Cullerier have given us a 
 good account of the diseases of which he treats, but 
 no one hag furnished us with such a complete series 
 of illustrations of the venereal diseases^ There is, 
 however, an additional interest and value possessed 
 by the volnmebefore UF; forit is an American reprint 
 and translation of M. Cullerier's work, with inci- 
 dental remarks by one ofthe most eminent Ameri- 
 can lyphilographers, Mr. Bumstead. Brit .andFoi . 
 Medioo-Ohir. Review, July, 1869. 
 
 ' ' EE (HENRY), 
 
 * Prof, of Surgery at the Rnyn I College of Snrgeon of England, etc. 
 
 LECTURES ON SYPHILIS AND ON SOME FORMS OF LOCAL 
 
 DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one 
 handsome octavo volume: cloth; $2 25. (Lately Published.) 
 
 The work is valuable, as it treats quite fully of sub- 
 jects which are not dwelt upon in the systematic work? 
 of other English authors of the present day. as the in- 
 oculability of syphilitic blood; the conditions under 
 which the secretions of primary and secondary syphi- 
 litic manifestations may be inoculated naturally or 
 artificially; the morbid processes produced bs such Inoc- 
 
 ulation; the moflifirations of these processes in patients 
 previous'y syphilitic: primary and secondary syphilitic 
 diseases ofthe mucous membranes and their liability 
 to communicate constitutional syphilis, etc. The book 
 is full of clinical material illustrating these topics, 
 original or quoted. Arc/lives of Dermatology, April, 
 1876. 
 
 TJ1LL (BERKELEY), 
 
 -*--* Surgeon to the Lock Hoxpital, London. 
 
 ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. 
 
 one handsome octavo volume ; cloth, $3 25. 
 
 In
 
 20 HENRY C. LEA'S PUBLICATIONS (Diseases of the Skin, (fee.). 
 'pl3X (TILBURY), M.D.,F.R.C.P.,and T. C. FOX, B.A., M.K.C.S., 
 
 Physician to the Department for Skin Diseases, University College Houjntnl. 
 
 EPITOME OF SKIN DISEASES. WITH FORMULAE. FOR STU- 
 
 DENTS AND PRACTITIONERS. Second edition, thoroughly revised and gre.'itly enlarged. In 
 one very handsome 12ino. volume of 216 pages. Cloth, $1 38. (Just Ready.) 
 
 PREFACE. 
 
 In preparing this edition of our "EPITOME" for publication in the United States, we have 
 increased the matter to about three times its original amount. The kindly appreciation mani- 
 fested for the work by the American profession hns stimulated us to spare no pains in rendering 
 it more worthy of their approbation, and in its enlarged form we believe that it will be found of 
 enhanced value. About two-thirds of the work is newly written, and we may direct attention 
 particularly to the section regarding the Pathology of the Skin, which has been entirely recast. 
 and now contains a concise account of all the important changes taking place in the dermal 
 textures in disease. The clinical descriptions of diseases also have been amplified and occasion- 
 ally remodelled. Lastly, we may say that in adding material to the book we have selected such 
 as bears on the practical side of Dermatology, to the exclusion of that which is as yet hypo- 
 thetical or merely of interest to the curious student. 
 
 The favorable reception accorded to the work on both sides of the Atlantic would seem to 
 show that it has realized the object with which it was prepared to afford assistance to the stu- 
 dent in his early study of dermatology, and to serve as a manual for ready reference by the 
 practitioner in his daily practice. For this latter purpose it has been specially adapted, by 
 means of the references made in the sections on treatment to the formulae at the end. 
 
 WILSON ( ERASM us), F. R. s. 
 
 THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 
 
 BASES OF THE- SKIN. In one very handsome royal 12ino. volume. $3 50. 
 
 (J.MOORE), M.D.,M.R.I.A. 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 
 
 volume, with exquisitely colored plates, <tc., presenting about one hundred varieties of 
 disease. Cloth, $5 50. 
 
 TJ1LLIER (THOMAS), M.D., 
 
 Physician to the Skin Department of University College Hospital, etc. 
 
 HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. 
 
 Second Am. Ed. In one royal 12mo. vol. of 358 pp. With Illustration:. Cloth, $2 25. 
 
 It is a concise, plain, practical treatise <ju the 
 var.ous diseases of the skin ; just such a work, 
 indeed as was much needed, both by medical stu- 
 dents ard practitioners. Chicago Medical Ex- 
 aminer, Maj 1865. 
 
 We can conscientiously recommend it to the stu- 
 dent ; the style is clear and pleasant to read, the 
 matter is good, andthe descriptions of disease, with 
 the modes of treatment recommended, are frequent- 
 ly Illustrated with well-recorded cases. London 
 Ifed. Cimes and Gazette, April 1, 1865. 
 
 WEST (CHARLES), M.D., 
 
 Physician to the Hospital for Sick Children, London, Sec. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILE- 
 
 HOOD. Fifth American from the sixth revised and enlarged English edition. In one large 
 and handsome octavo volumeof 678 pages. Cloth, $4 50 ; leather, $5 50. (Lately Issued ) 
 
 The continued demand for this work on both sides of the Atlantic, and its translation into 
 German, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want 
 extensively felt by the profession. There is probably no man living who can speak with the 
 authority derived from a more extended experience thnn Dr. West, and his work now presents 
 the results of nearly 2000 recorded cases, and 600 post-mortem examinations selected from 
 among nearly 40,000 sases which have passed under his care. In the preparation of the pre- 
 sent edition he has omitted much that appeared of minor importance, in order to find room for 
 the introduction of additional matter, and the volume, while thoroughly revised, is therefore 
 not increased materially in size. 
 
 or all the English writers on the diseases of chil- I highest living authorities in the difficult department 
 dran, there is no one so entirely satisfactory to u | of medical science in which he is most widely 
 a* Dr. West. For years we have held his opinion I known.- Boston Med. and Surg. Journal. 
 as judicial, and have regarded him as one of the I 
 
 1DY THE SAME AUTHOR. (Lately Issued.) 
 
 ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- 
 HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
 London, in March, 1871. In one volume small 12mo., cloth, $1 00. 
 
 JfY THE SAVE AUTHOR. 
 
 LECTURES ON THE DISEASES OF WOMEN. Third American, 
 
 from the Third London edition. In one neat octavo volume of about 550 pages, clotL, 
 $3 75; leather, $4 75.
 
 HENRY C. LEA'S PUBLICATIONS (Disease? of Children}. 21 
 
 &MITH (J. LE WIS), M.D., 
 
 Clinical Professor of Diseases of Children in the Bellevue Hospital Mtd. College, N Y. 
 
 A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 
 
 CHILDREN. Fourth Edition, revised and enlarged. In one handsome octavo volume 
 of about 750 pages, with illustrations. Cloth, $4 50 ; leather, $5 50. (Roiv Ready.) 
 The very marked favor with which this work has been received wherever the English lan- 
 guage is spoken, has stimulated the author, in the preparation of the Fourth Edition, to spare 
 no pains in the endeavor to render it worthy in every respect of a continuance of professional 
 confidence., Many portions of the volume have been rewritten, and much new matter intro- 
 duced, but by an earnest effort at condensation, the size of the work has not been materially 
 increased. 
 
 In the period which has elapsed since the third ' It is scarcely necessary for us to say th work be- 
 edition of the work, so extensive have been the ad- fore us is a standard work upon diseases of children, 
 vauces that whole chapters required to be rewritten, and that n o work has a higher standing than it upon 
 and hardly a page could pass without some material those affections. In consequence of its thorough re- 
 correction or addition. This labor has occupied the vision, the work has been made of more value than 
 writer closely, and he has performed it cun*cien- ever, and may be regarded as fully abreast of the 
 tionaly, so that the book may be considered a faith- times. We cordially commend it to students and 
 ful portraiture of an exceptionally wide clinical physicians There is no better work in the langnage 
 experience in infantile diseases, c rrected by a care- on diseases of children. Cincinnati Med. Ntios, 
 fol study of the recent literature of the subject. March, 1879. 
 Med. and Surg. Reporter, April 5, 1879. 
 
 riONDIE (D. FRANCIS), M.D. 
 ' A PRACTICAL TREATISE ON THE DISEASES OF CHIL- 
 
 dren. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 
 closely-printed pages, cloth, $5 25 : leather. $6 25. 
 
 gVITH (EUSTACE), M.D., 
 
 Physician to the Northwest London Free Dispensary for Siclt Children. 
 
 A PRACTICAL TREATISE ON THE WASTING DISEASES OF 
 
 INFANCY AND CHILDHOOD. Second American, from the second revised and en- 
 larged English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) 
 
 & WAYNE (JOSEPH GRIFFITHS), M.D., 
 
 Physician- Accoucheur to the British General Hospital. Ac. 
 
 OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
 MENCING MIDWIFERY PRACTICE Second American, from the Fifth and Revised 
 London Edition with Additions by E. R. HUTCHINS, M.D. With Illustrations. In one 
 neat 12mo. volume. Cloth. $1 25. (Lately Issued.) 
 
 # # * See p. 4 of this Catalogue for the terms on which this work is offered as a premium to 
 lubscribers to the " AMERICAN JOURNAL OF THE MEDICAL SCIENCES." 
 
 CHURCHILL ON THE PUERPERAL FEVER AND 
 OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 
 
 . 4.10, cloth %2 50 
 
 MEIGS ON THE NATURE, SIGNS. AND TREAT- 
 MENT OF CHILDBED FEVER. 1 vol. 8vo , pp. 
 365. cloth $2 00. 
 
 DEwWyS TREATISE ONTHE DISEASES OF FE- 1 ASHWELL's"pRACTICAL TREATISE ONTHE DH- 
 MALES. With illustrations. Eleventh Edition, j EASES PECULIAR TO WOMEN. Third American, 
 
 from the Third and revised London edition. Ivo!. 
 8vo., pp. 528, cloth. $3 50. 
 
 MALES. With illustrations. Eleventh Edition, j 
 with the Author's lastimprovementB and correc- 
 tions. In one octavo volume of 536 pages, with 
 plates, cloth. $3 00. 
 
 TJODGE (HUGH L.), M.D., 
 
 Emeritus Professor of Obstetrics, Ac., in the University of Pennsylvania. 
 
 ON DISEASES PECULIAR TO WOMEN ; including Displacements 
 
 of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
 one beautifully printed octavo volume of 531 pages, cloth, $4 50. 
 
 Professor Hodge's work Is truly an original one 
 from beginning to and, consequently no one can pe- 
 tase its pages without learning something new. At a 
 
 contribution tothe study ofwomen'Bdifeases.itisrf 
 great value, and is abundantly able to stand on its 
 own merits N. Y. Mtdical Record, Sept. 15, 166*. 
 
 SIHURCHILL (FLEETWOOD), M.D., M.R.I.A. 
 
 V ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 
 
 American from the fourth revised and enlarged London edition. With notes and add,t,or a 
 by D FRANCIS CONDIE, M.D., author of a "Practical Treatise on the Diseases of ( 
 dren " Ac. With one hundred and ninety four illustrations. In one very handsome octa 
 volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. 
 
 EXPOSITION OF THE SIGNS i RIGBY'B SYSTEM OF MIDWIFERY. With notes 
 
 In 1 vol. 8vo., of nearly 600 pp., cloth, $3 75.
 
 HENRY C. LEA'S PUBLICATIONS (Diseases of Women). 
 
 fTROMAS (T.GAILLARD),M.D., 
 
 i- Profetsor of Obstetrics, *c. , in the College o/ Physicians and Surgeons, N. T.,Ac. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth 
 
 edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 
 800 pages, with 191 illustrations. Cloth, $5 00; leather, $6 00. (Just Issued.) 
 The author has taken advantage of the opportunity afforded by the call for another edition of 
 this work to render it worthy a continuance of the very remarkable favor with which it has been 
 received. Every portion has been subjected to a conscientious revision, and no labor has been 
 spared to make it a complete treatise on the most advanced condition of its important subject. 
 A work which has reached a fourth edition, and j tsclasMcal without beingpedantic.full in the details 
 that, too. in the short space of five years, has achieved of anatomy and pathology, without ponderous 
 a reputation which places it almost beyond the reach I translation of pages of German literature, describe 
 of criticism, and the favorable opinions which we have j distinctly the details and difficulties of each opera- 
 a'roady expressed of the former editions seem to re- 1 tiou, without wearying and useless minutiae, and is 
 quire that we should do little more than announce , in all respects a work worthy of confidence, justify- 
 this new issue. We cannot refrain from saying that, ! ing the high regard In which its distinguished an- 
 as a practical work, this is second to none in the Eng- j thor is held by the profession. Am. Supplement, 
 
 Hsh, or, indeed, in any other language. The arrange 
 ment of the contents, the admirably clear manner in 
 which the subject of the differential diagnosis of 
 Several of the diseases is handled, leave nothing to be 
 desired by the practitioner who wants a thoroughly 
 clinical work, one to which he can re*er in difficult 
 eases of doubtful diagnosis with the certainty of gain- 
 ing light and instruction. Dr. Thomas is a man with a 
 very clear head and decided views, and there seems to 
 be nothing which he so much dislikes as hazy notions 
 of diagnosis and blind routine and unreasonable thera- 
 
 Obstet. Journ., Oct. 1874. 
 
 Professor Thomas fairly took the Profession of the 
 United States by storm when his book first made its 
 appearance early in 1S68. Its reception was simply 
 enthusiastic, notwithstanding a few adverse criti- 
 cisms from our transatlantic brethren, the first large 
 edition was rapidly exhausted, and in six months a 
 second one was isaned.and in two yearsathird one 
 was announced and published, and we are now pro- 
 mised the fourth. The popularity of this work was 
 
 f diagnosis anil bind routine ana unreasonable tnera- - - *"- . ."" . ,~At n 
 
 eutics. The student who will thoroughly study this * ephemeral, and itssuccess ^unprecedented 
 x* and test its principles by clinical observation, will the annaUof American medical literature. S 
 rtainly not be guilty of these faults.-iondon Zac<, ! ls a loB ? P 9rlod in medical scientific research but 
 eh n is- 1 ! 1 Thomas's work on " Diseases of Women" is still the 
 
 leading native production of the United States. The 
 
 leaaiug ua' i ve pruu uuuuu ui IUB uuneu omn3o. * w 
 Reluctantly we are obliged to close this unsatis- orderi the matter, the absence of theoretical dispni a- 
 
 factory notice of so excellent a work, and in cone lu 
 
 tiveness, the fairness of statement, and the elegarc 
 
 RARNES (ROBERT), M.D., F.R.O.P., 
 
 *-* Obstetric Physician to St. Thomas's Hotpital, itc. 
 
 A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
 CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
 English Edition. Inon handsome octavo volume, of 784 pages, with 181 illustrations. 
 Cloth, $4 50; leather, $5 50. (Just Ready.) 
 
 The call for a new edition of Dr. Barnes's work on the Diseases of Females has encouraged 
 the author to make it even more worthy of the favor of the profession than before. By a rear- 
 rangement and direful pruning space has been found for a new chapter on the Gynaecological 
 Relations of the Bladder and Bowel Disorders, without increasing the size of the book, while 
 many new illustrations have been introduced where experience has shown them to be needed. It 
 is therefore hoped that the volume will be found to reflect thoroughly and accurately the present 
 condition of gynaecological science. 
 
 Dr Barnes stands at the head of his profession in th work is a valuable one, and should be largely 
 the old country, and it requires but scant scrutiny consulted by the profession. Am. 8->pp Obstetrical 
 
 of his hook to show that it has been sketched by a 
 master. It is plain, practical common sense ; shows 
 very deep research without being pedantic ; is emi- 
 
 Journ. Gt. Britain and Ireland, Oct. 1S78. 
 
 No other gynaecological work holds a higher posi- 
 tion, having become an authority everywhere in 
 
 nently calculated to inspire enthusiasm without in- dlsease . s o f women. The work has been bronght 
 culcating rashness; points out the dangers to be j fully abreast of present knowledge. Every praeti- 
 a voided as well as the success to be achieved in the ! tion ' er of medloll je 8nould lliire it upon t he shelves 
 various operations connected with this branch of | of his lib rary and the gtu dent will find it a. superior 
 medicine; and will do much to smooth the rugged I t t-book.-n<*natt Med. News, Oct. 1S7S. 
 path of the young gynaecologist and relieve the per- 
 
 plexity of the man of mature year*. Canadian 
 Journ. of Med. Science, Nov. 1S78. 
 
 This second revised edition, of course, deserves all 
 the commendation given to its predecessor, with the 
 additional one that it appears to inclnde all or nearly 
 We pity the doctor who, having any consider- i all the additions to our knowledge of its subject that 
 able practice in diseases of women, has no copy of 1 have been made *ince the appearance of the first edi- 
 ' Barnes" for daily consultation and instruction. It ! tion The American references are, for an English 
 is at once a book of great learning, research, and j work, especially full and appreciative, and we can 
 Individual experience, and at the same time eml- cordially recommend the volume to American rpiid- 
 nently practical. That it has been appreciated by ] ers Joitrn. of Nervous and Mental Disiase, Oct. 
 
 the profession, both in Great Britain and in this 
 country, is shown by the second edition following 
 so soon upon the first. Am. Practitioner, Nov. 
 1873. 
 
 Dr Barnes'* work Is one of a practical character, 
 largely illustrated from cases in his own experience, 
 
 1878. 
 
 This second edition of Dr. Barnes's great work 
 comes to us containing many additions and improve- 
 ments which bring it up to date in every feature. 
 The excellences of the work are too well known to 
 require enumeration, and we hazard 'he prophecy 
 
 bat by no means confined to such, as will be learned i that they wi'l for many years maintain its high po- 
 from the f act that he quotes from no less than 62S siti.m as a standard text-book and guide book for 
 medical authors in numerous countries. Coming students and practitioners. N. 0. Mud. Journ., 
 from buch an author, it is not necessary to say that ; Oct. 1878.
 
 HENRY C. LEA'S PUBLICATIONS-^ Diseases of Women). 23 
 
 f]MMET (THOMAS ADDIS). M.D. 
 
 Snrge.on to the Woman's Hospital, N>w York, el'. 
 
 THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 
 
 use of Students and Practitioners of Medicine. In one large and very handsome octavo 
 volume of 806 pages, with 130 illustrations. Cl tb, $5; leather, $6. (Just Ready.) 
 Dr Emmet is so widely known as among the most eminent of those who have made gvnee- 
 oology a peculiarly American science that the profession cannot fail co welcome a work in which 
 he has condensed the results of his long and extensive experience. He has sought to consider 
 the whole subject of the diseases peculiar to females in a manner which will adapt the volume, 
 not only to the wants of the student as a text-book, but to those of the practitioner as an aid in 
 he emergencies of daily practice. A special feature of the work will be f-und in the numerous 
 condensed tables, which convey at a glance, and within the narrowest compass, the conclusions 
 to be drawn from the many thousand cases which have passed under the care of the author. 
 AVith trifling exceptions, the illustrations are all original, and the volume will be found in every 
 point of typographical execution worthy of the distinguished position which is confidently anti- 
 cipated for it. 
 
 (JHADWICK (JAMES R.), A.M., M.D. 
 
 A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one 
 
 neat volume, royal 12mo , with illustrations. (Preparing,) 
 
 America has contributed so largely to the advances which have made the treatment of Dis- 
 eases of Women a distinctive department of medical science, that the student will naturally 
 turn to American Books for the latest and most trustworthy instruction on the subject in its 
 most modern aspect. Yet there has thus far been no attempt in this country to produce a handy 
 manual, presenting in a condensed and convenient form the information requisite for the learner 
 or for the general practitioner. This want it h.-is been the effort of Dr. Chadwick to supply, and 
 the special attention which he has devoted to the subject is a guarantee of the value of his labors. 
 A distinguishing feature of the work will be a number of diagrammatic illustrations, facilitating 
 greatly the comprehension of the text. 
 
 TUJNCKEL (F.), 
 
 Professor and Director of the Gynecological Clinic in the University of Rostock. 
 
 A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- 
 MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent 
 of the author, from the Second German Edition, by JAMES READ CHADWICK, M.D. In 
 one octavo volume. Cloth, $4.00. (Lately Issued.) 
 
 This work wa< written, as the author tells us in 
 preface, to supp'y a want ariin^ from the very brief 
 
 on Obstetrics, in which respect it seems the profession 
 in his country is not different from our, and to fill a 
 blank left between the treatises upon the subject al- 
 
 ready in the field, and the present standpoint of sci- 
 ence. Tht work has reached a second edition, and 
 
 ution given to puerperal diseases by writers bears evidence throughout of careful study and prac 
 
 tical experience. As its title implies.it is a manual 
 rather than a treatise. American Journal o/JUfd. Sci- 
 ences, April, 1871. 
 
 fFHE OBSTETRICAL JOURNAL. (Free of postage for 1879.) 
 
 THE OBSTETRICAL JOURNAL of Great Britain and Ireland; 
 
 Including MIDWIFERY, and the DISEASESOF WOMEN AND INFANTS. With an American 
 Supplement, edited by J. V. INGHAM, M.D. A monthly -of about 9fi octavo pages, 
 very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 
 cents each. 
 
 Commencing with April, 1873, the Obstetrical Journal consists of Original Papertby Brit- 
 ish and Foreign Contributors; Transactions of the Obstetrical Societies in England and 
 abroad. Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and 
 Notes, Editorial, Historical, Forensic, and Miscellaneous; Selections from Journals; Cor 
 respondence, Ac Collecting together the vast amount of material daily accumulating in this 
 important and rapidly improving department of medical science, the value of the infor- 
 mation which it pre3ents to the subscriber may be estimated from the character of the gen- 
 tlemen who have already promised their support, including such names as those of Drs. AT- 
 THILL, AVELING, ROBERT BARNES, J. HENRY BENNET, NATHAN BOZEMAN, THOMAS CHAMBERS, 
 FLBBTWOOD CHURCHILL, CHARLES CLAY, JOHN CLAY, MATTHEWS DUNCAN, ARTHUR FARRE, 
 ROBERT GREENHALGH, GRAILY HEWITT, BRAXTON HICKS, ALFRED MEADOWS, W. LKISH- 
 MAN, ALEX. SIMPSON, HEYWOOD SMITH, TYLER SMITH, EDWARD J. TILT, LAWSON TAIT, 
 SPENCER WELLS, Ac. Ac. ; in short, the representative men of British Obstetrics and Gynse- 
 cology. 
 
 In order to render the OBSTETRICAL JOURNAL fully adequate to the wants of the Ameri- 
 can profession, each number contains a Supplement devoted to the advances made in Obstet- 
 rics and Gynaecology on this side of the Atlantic. This portion of the Journal is under 
 the editorial charge of Dr J. V. INGHAM ; to whom editorial communications, exchanges, 
 books for review, Ac., may be addressed, to the care of the publisher. 
 
 %* Complete sets from the beginning can no longer be furnished, but subscriptions can 
 oom-uence wuh January, 1879, or Vol VII., No 1, April, 1879.
 
 24 
 
 HENRY C. LEA'S PUBIICATIONS (Midwifery}. 
 
 pLAYFAIR ( W. S.}, M.D., F.R.C.P., 
 
 Professor of Obstetric Medicine in King's College, etc. etc. 
 
 A TREATISE ON TFIE SCIENCE AND PRACTICE OF MIDWIFERY. 
 
 Second American, from the Second and Revised English Edition. Edited, with Addi- 
 tions, by ROBERT P. HARRIS, M.D. In one handsome octavo volume of 639 pages, with 
 182 illustrations. Cloth, $4 00; Leather, $5.00. (Just Ready ) 
 
 In reprinting this work from the second London edition, the position which it has assumed 
 in this country ns an authoritative test-book seemed to call for such additions as would render 
 it more completely suited to the wants of the American student. A careful scrutiny on the part 
 of the editor has shown that but little was required for this purpose ; the work, though condensed, 
 being very complete and accurate. With the exception of numerous short foot-notes, therefore, 
 his additions have been confined to points in which the experience and practice of American 
 obstetricians differ from those of England, and to one or two matters of recent interest. These 
 ar chiefly the Csesarean Section ; the varieties of forceps, and their use in the dorsal decubitus; 
 dystocia from tetanoid uterine constriction; and the intra-venous injection of milk, as a substi- 
 tute for the transfusion of blood. 
 
 The position which this work has so qirckly taken 
 In thia country as an authoritative text-book rentiers 
 any extended consideration of its plan and scope 
 unnecessary. Its merits, which are many, have al- 
 ready found their way to the appreciation of students 
 and practitioners alike in the length and breadth of 
 the land. Am. Supp. Obatet. Journ. of Qt. Britain 
 and Ireland, Oct. 1878. 
 
 This excellent text-book has been submitted to a 
 thorough and careful revision, and will be found 
 fully np to the times in every department. The 
 cotes by the American editor enhance the value of 
 the work for the American student. Those on the 
 use of forceps are particnlirly good, and constitute 
 by themselves a valuable chapter. N. T. Med. 
 Journ., Nov. 1878. 
 
 The best work on the subject ever published in the 
 English language. It is written in a clear, pleasant 
 style, without that verbosity which characterizes 
 some modern and highly pretentious works. The au- 
 thor is quite up with the times, both in practice and 
 
 theory. It is the best text-book we have for students, 
 and sufficiently full of detail to supply all the wants 
 of the practitioner. We would gladly see it in the 
 hands of all who practise midwifery. Canadian 
 Journ. of Med. Soi., Nov. 1878. 
 
 Probably this is the very best and most useful 
 manual of midwifery now available to the profes- 
 sion. Itis written in lucid, scholarly English, which 
 some of our ois-Atlantic writers would do well to 
 imitate. There has been no attempt to swell the 
 magnitude of the work by fine writing, or by lengthy- 
 discussions ofobtcure points of which no trustworthy 
 solution has yet been reached ; on the contrary, the 
 tendency is throughout obviously towards simplic- 
 ity. The chapter upon the Mechanism of Labor 
 (which ought to be the crowning chapter in a trea- 
 tise on obstetrics) is remarkably clear and good, and 
 is divested of those features which in almost every 
 other work we know lets only darkness instead of 
 light in upon the subject. -V. C. Med. Journ., Oct. 
 1878. 
 
 H 
 
 'ODOE (HUGH L.), M.D., 
 
 Emeritus Professor of Midwifery, &c., in the University of Pennsylvania, Ac. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illns- 
 
 trated with large lithographic plates containing one hundred and fifty-nine figures from 
 original photographs, and with numerous wood-cuts. In one large and beautifully printed 
 quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 
 
 The work of Dr. Hodge is something more than i subject it is decidedly the best. Edinb. Med. Jour., 
 a simple presentation of his particular views in the Dec. 1864. 
 department of Obstetrics; it is something more 
 
 We have read Dr. Hodge's book with great 
 
 Am. Mf.d. Times, Sept. 3, 1864 
 
 arrived, point, we think, conclusively to the fact 
 
 Ills very large, profusely and elegantly illustrat- that, in Britain at least, the doctrines of Naegele 
 ed, and is fitted to take its place near the works of have been too blindly received. Glasgow Med. 
 great obstetricians. Of the American works on the i Journal, Oct. 1864. 
 
 **# Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
 on receipt of six cents in postage stamps. 
 
 WANNER (THOMAS H.), M.D. 
 ' ON THE SIGNS AND DISEASES OF PREGNANCY. First American 
 
 from the Second and Enlarged English Edition. With four colored plates and illustra- 
 tions on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. 
 
 f>A MSB TEA M ( FRA NCIS H.}, M.D. 
 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 
 CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
 edition, thoroughly revised by the author. With additions by W. V. KEATING, M. D., 
 Professor of Obstetrics, <fec., in the Jefferson Medical College, Philadelphia. In one Lirgre 
 and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
 bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
 all nearly 200 large and beautiful figures. $7 00.
 
 HENRY C. LEA'S PUBLICATIONS (Midwifery, Surgery}. 
 
 25 
 
 ^EISHMAN ( WILLIAM], H.D., 
 
 Regius Professor of Midwifery in the University of Glasgow, Ac. 
 
 A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 
 
 PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second 
 and Revised English Edition, with additions by JOHN S. PARRY, M.D., Obstetrician to the 
 Philadelphia Hospital, <tc. In one large and very handsome octavo volume of over 700 
 pages, with about two hundred illustrations : cloth, $5 ; leather, $6. (Just Issued.) 
 
 That this book is recommended as a text-book by 
 many of the leading scholars of medicine in tbis 
 country, is sufficient evidence of the favor in which 
 it is held. In a word, we know of no better book in 
 our language, both for the student and practitioner. 
 The value of the book is enhanced by this second 
 edition, which contains many notes by our late Dr. 
 Parry. Chicago Med. Journ. and Examiner, March. 
 1877. 
 
 But the most valuable additions to the volume are 
 those made by the American editor. One of the best tests 
 of a man's ability is for him to take a standard work in 
 our profession, like this of Dr. Leishman, and materially 
 improve it. Many a one, with more ambition than wis- 
 dom, has attempted it with other books and failed. But 
 Dr. Parry has succeeded most admirably. We know no 
 obstetrical work that has anything better on the use of 
 the forceps than that which Dr. Parry has given in this, 
 and no work that has the rational and intelligent views 
 upon lactation with which he has enriched this. Having 
 used " Lcishman" for two years as a text-book for stu- 
 dents,wecancordiallycommendit.andarequite satisfied 
 to continue such use now. Am. Practitioner, Mar. 1876. 
 
 Tbis new edition decidedly confirms the opinion which 
 we expressed of the first edition of tbe work, in the May, 
 1S74, number of this Journal, that this is "thebest 
 modern work on the subject in the English language." 
 The excellent practical notes contributed by Dr. Parry 
 refer pri ncipal ly to the use of the forceps, lactation , and 
 the puerperal diseases, and are intended to increase the 
 usefulness of the work in this country. An entirely new 
 chapter on diphtheria of puerperal wounds has been 
 
 added (Dr. P. has had unusual experience in this form 
 of puerperal fever), and also a number of illustrations 
 of the principal obstetrical instruments in usein Ame- 
 rica. We have no hesitation in saying thatthe work, in 
 its present shape, is a great improvement on its prede- 
 cessor, and in recommending it as tbe one obstetrical 
 text- book which we should advise every English f peak- 
 ing practitioner and student to buy. American Jour- 
 nal of Obstetrics, Feb. 1876. 
 
 Perhaps the most useful one the student can procure. 
 Some important additions have been made by the editor, 
 in order to adapt the work to the profession in this coun- 
 try, and some new illustrations have been introduced, 
 to represent the obstetrical instruments generally em- 
 ployed in American practice. In its present form, it is 
 an exceedingly valuable book for both the student and 
 practitioner. JV>u York JUed. Journal, Jan. 1876. 
 
 Since the publication of Tyler Smith's lectures on 
 midwifery, no text book which was in reality the 
 exponent of British practice has appeared in the 
 English language until Dr. Lei&hman supplied the 
 want by his system of midwifery, which was pub- 
 lished about three years ago. The chief feature in 
 this work is the exactness in description of the me- 
 chanism of labor ; it exhibits most accurate obser- 
 vation, and is a perfect analysis of the subject, it is 
 clear, precise and masterly. The work is in every 
 way a valuable addition to the works already be- 
 fore the profession on the science and practice of 
 obstetrics, and will, we doubt not, be the favorite 
 text-book used in our schools. Canada Med.and 
 Surg. Journal, Nov. 1S76. 
 
 P 
 
 ARRY (JOHN S.), M.D., 
 
 Obstetrician to th Philadelphia Hospital, Viee-Prest. of the Obstet. Society of Philadelphia. 
 
 EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 
 
 DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. 
 Cloth, $2 60. (Lately Issued.) 
 
 This work. being as near as possible a collection of the 
 
 In this work Dr. Parry has added a most valuable 
 contribution to obstetric literature, and one which 
 meets a want long felt by those of the profession who 
 have ever been called upon to deal with this class of 
 cases. Boston Med. and Surg. Journ.. March 9, 1876. 
 
 experiences of many persons, will afford a most useful 
 guide, beth in diagnosis and treatment, for this most 
 interesting and fatal malady. We think it should be in 
 the hands of all physicians practising midwifery. Cin- 
 cinnati Clinic, Feb. 5, 1876. 
 
 (LEWIS A.}, A.M., M.D., 
 
 Surgeon to the Presbyterian Hospital. 
 
 A MANUAL OF OPERATIVE SURGERY. In one very handsome 
 
 royal 12mo. volume of about 500 pages, with 332 illustrations ; cloth, $2 50. (Now Ready.) 
 The work before us is a well printed, profusely , performing them. The work is handsomely illus- 
 illnstrated manual of over four hundred and seventy ! trated, and the descriptions are clear and well drawn. 
 m^- : i,.. . ...,...,] ^t n,o TT.,,VV nriii it ia a flprpr and nsafnl volume: every student 
 
 pages. The novice, by a perusal of the work, will 
 gain a good idea of the general domain of operative 
 surgery, while the practical surgeon has presented 
 to him within a very concise and intelligible form 
 the latest and most approved selections of operative 
 procedure. The precision and conciseness with which 
 the different operations are described enable the 
 author to compress an immense amount of practical 
 Information in a very small compass. N. Y. Medical 
 Record, Aug. 3, 1878. 
 This volume is devoted entirely to operative snr- 
 
 s voume s evoe en , 
 
 gery, and is intended to familiarize the student with -Cincinnati Lancet an 
 the details of operations and the different modes of I 
 
 It is a clever and useful volume ; every student 
 should possess one. The preparation of this work 
 does away with the necessity of pondering over 
 larger works on surgery for descriptions of opera- 
 tions, as it presents in a nut-shell just what is wanted 
 by the surgeon without an elaborate search to find 
 it. Md. Med Journal, Aug. 1878. 
 
 The author's conciseness and the repleteness of 
 the work with valuable illustrations entitle it to be 
 classed with the text-books for students of operative 
 snreery, and as one of reference to the practitioner. 
 
 :? _ i f*t-..-t- T..I.. OT ic'rc 
 
 , ,, V? 
 c, July 27, 
 
 SKET'S OPERATIVE SURGERY. In 1 rol. 8vo. 
 el., of 650 pages'; withabout 100wood-uts. $3 26 
 
 COOPER'S LECTURES ON THE PRINCIPLES AND 
 PRACTICE OF SUROERY. In 1 vol. 8vo. cl'h, 750 p. $2. 
 
 GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
 OBKT. Eighth edit'n, improved and altered. With 
 thirty-four plates. In two handsome octavo vol- 
 umes, about 1000 pp.. leather, raised bandp. *6 50. 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. 
 By WILLIAM PiRKiB,F.R.S.E.,Profe*'rof Surgery 
 u the University of Aberdeen. Edited by Jons 
 
 NEILL, M.D., Professor of Surgery in the Petna. 
 Medical College, Surg'n to the Pennsylvania Hos- 
 pital, &c. In one very handsome octavo vol. of 
 780 pages, with 316 illustrations, cloth, $3 75. 
 
 MILLER'S PRINCIPLESOF SURGERY. Fourth Ame- 
 rican, from the Third Edinburgh Edition. In cue 
 large 8vo. vol. of 700 pages, with 340 illustrations, 
 cloth, $375. 
 
 MILLER'S PRACTICE OF SURGERY. Fourth Ame- 
 rican, from the last Edinburgh Kdition Revised by 
 the American editor. In onelargeSvo. vol. of nearly 
 700 pages, with 364 illustrations: cloth, $3 75.
 
 26 
 
 HE.N T RY C. LEA'S PUBLICATIONS (Surgery 
 
 S7ROSS (SAMUEL D.), M.D., 
 
 Prof ef/ior of Surgery in the Jf.ffi.rson Medical College of Philadelphia. 
 
 SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 
 
 and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth editioi. 
 carefully revised, and improved. In two large and beautifully printed imperial octavo vol- 
 umes of about 2300 pp., strongly bound in leather, with raised bands, $15. (Juft Issued.} 
 The continued favor, shown by the exhaustion of successive large editions of this great work, 
 proves that it has successfully supplied a want felt by American practitioners and students. In 
 tht present revision no pains have been spared by the author to bring it in every respect fully 
 up tc the day. To effect this a large part of the work has been rewritten, and the whole en- 
 arged bj nearly one-fourth, notwithstanding which the price has been kept at its former very 
 moderate rate. By the use of a close, though very legible type, an unusually large amount ol 
 matter is Jondensed in its pages, the two volumes containing as much as four or five ordinary 
 octavos. This, combined with the most careful mechanical execution, and its very durable bind 
 ing renderf , it one of the cheapest works accessible to the profession. Every subject properly 
 belonging to the lomain of surgery is treated in detail, so that the student who possesses this 
 work may be said to have in it a surgical library. 
 
 elition of Grog's " Surgery," will confirm his title of 
 
 We have now brought our tusk to a conclusion, and 
 have seldom read a work with the practical value of 
 which we have been more impressed. Every chapter is 
 so concisely put together, that the busy practitioner, 
 when in difficulty, can at once find the information he 
 requires. His work, on the contrary, is cosmopolitan, 
 the surgery of the world being fully represented in it. 
 The work, in fact, is so historically unprejudiced, and 
 so eminently practical, that it is almost a false compli- 
 ment to say that we believe it to be destined to occupy 
 a foremost place as a work of reference, while a system 
 of surzery like the present system of surgery is the 
 practice of surgeons. The printingand binding of the 
 work is unexceptionable; indeed.it contrasts, in the 
 latter reject, remarkably with English medical and 
 surgical cloth-bound publications, which are generally 
 so wretchedly stitched as to require re-binding before 
 they are any time in use. Dub. Journ. of Med. Sci.. 
 March, 1874. 
 
 Dr. Gross's Surgery, a great work, has become still 
 greater, both in size and merit, in its most recent form. 
 The difference in actual number of pages is not more 
 than [30, but. the size of the page having been in- 
 creased to what we believe is technically termed ele- 
 phant." there has been room for considerable additions. 
 which, together with the alterations, are improve- 
 ments. Land. Lancet, Nov. 16, 1872. 
 
 It combines, as perfectly as possible, the qualities of 
 a text-book and work of reference. We think this last 
 
 Primut intta- Part." It is learned, scholar-like, n e- 
 thodical, precise, and exhaustive. We scarr< iy think 
 any living man could write so complete and faultless a 
 treatise, or comprehend more solid, instructive matter 
 in the given number of pages. The labor must have 
 been immense, and the work gives evidence of i-rt-nt 
 powers of mind, and the highest order of intellect i;al 
 discipline and methodical disposition, and arrangement 
 of acquired knowledge and personal experience. A.I*. 
 Med. Journ., Feb. 1873. 
 
 As a whole, we regard the work as the representative 
 "System of Surgery" in the English language. Si- 
 Louis Medical and Surg. Journ., Oct. 1872. 
 
 The two magnificent volumes before us afford a veiy 
 complete view of the surgical knowledge of the day. 
 Some years ago we had the pleasure of presenting the 
 first edition of Gross's Surgery to the profession as a 
 work of unrivalled excellence; and now we have the 
 result of years of experience, labor.and study, all con- 
 densed upon the great work before us. And to students 
 or practitioners desirous^f enriching theirlilirary with 
 a treasure of reference, we can simply commend the 
 purchase of these two volumes of immense research 
 Cincinnati Lancetand Observer, Sept. 1&72. 
 
 A complete system of surgery not a mere text-book 
 of operations, but a scientific acconntof surgicul'thnorv 
 and practice in all its dnartments. Brit, and For. 
 Mod Chir. Rev., Jan. 1873. 
 
 B 
 
 7 THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON THE DISEASES, INJURIES, 
 
 and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third 
 Edition, thoroughly Revised and Condensed, by SAMUEL W. GROSS, M.D., Surgeon to 
 the Philadelphia Hospital. In one handsome octavo volume of 674 pages, with 170 illus- 
 trations: cloth, $4 50. (Just Issued.) 
 For reference and general information, the physician eases of the urinary organs. Atlanta Mtd Journ., Oc'. 
 
 orsurgeon can find nowork that meets their necessitiet 1876. 
 
 more thoroughly than this, a revised edition of an ex- u is with plea!!ure we DOW again take up tMs old 
 
 r.nllent treatise, and no medical library should be with- 
 out it. Replete with handsome illustrations and good 
 ideas, it has the unusual advantage of being easily 
 comprehended, by the reasonable and practical manner 
 in which the various subjects are syhtematized and 
 arranged We heartily recommend it to the profession 
 as a valuable addition to the important literature of dig- 
 
 worh in a decidedly new dress. Indeed, it must be re- 
 garded as a new book in very many of its parts. The 
 chapter? on -'Diseases of the Bladder," "Prostate 
 Body," and "Lithotomy," are splendid specimens of 
 descriptive writing; while the chapter on "Stricture'' 
 is one of the most concise and clear that we have ever 
 read. Aetr York Med. Journ., Nov. 1876. 
 
 T>r THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 
 
 AIR-PASSAGES. In 1 voi. 8vo., with illustrations, pp. 468, cloth, $ 75. 
 
 TjRUITT (ROBERT), M.R.C.S., frc. 
 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 
 
 A new and revised American, from the eighth enlarged and improved London edition. Illut- 
 trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
 volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 
 
 All that the surgical student or practitioner could 
 desire. Dublin Quarterly Journal. 
 
 It IB a moat admirable book. We do not know 
 when we have examined one with more pleasure. 
 Boston Med. and Surg. Journal. 
 
 In Mr. Drnitt'sbook, though contalningonly some 
 even hundred pages, both the principles and the 
 
 jractice of surgery are treated, and so clearly and 
 jerspicuonsly, as to elucidateeveryimportanltopic. 
 We nave examined thebook mostthoroughly, and 
 can say that this nuccese is well merited. Hit hook 
 moreover, possesses the inestimable advantages of 
 having the subjects perfectly well arranged atd 
 clan-ified and of being written in a style at once 
 clear tnd succinct. Am. Journal of Med. Scitncet.
 
 HENRY C. LEA'S PUBLICATIONS (Surgery}. 
 
 A SHHURST (JOHN, Jr.), M.D., 
 
 Prof, nf Clinical Surge.ry, Univ r,f Pa , Surgeon to the Episcopal Hospital, Philadelphia 
 
 THE PRINCIPLES AND PRACTICE OF SURGERY. Second 
 
 edition, enlarged and revised. In one very large and handsome octavo volume of over 
 1000 pages, with 542 illustrations. Cloth, $6; leather, $7. (Just Ready.) 
 
 Conscientiousness and thoroughness are two very j Ashhur it's Surgery is too well known ID this 
 marked trails of character in the author of this country to require special commendation from us 
 book. Out of these trails largely has grown the Thie, its second edition, enlarged and thoroughly 
 success of his mental fruit In the past, and the pre- revised, brings it nearer our idea of a model text- 
 sent offer seems in no wise an exception to what has bo tk than any recently published treatise Though 
 gone before. The general arrangement of the vol- : numerous additions have been made, the size of the 
 ume is the sameas in the first edition, but everypart work is not materially increased The main trouble 
 has been carefully revised, and much new matter of text books of modern times is that they are too 
 added. Phila. Med. Times, Feb. 1, 1S79. I cumbersome. The student needs a book which will 
 
 furnish him the most information in the shortest 
 
 ower of condensation, of accuracy and conciseness guarantee of the popularity of this edition, which is 
 f expression and thoroughly good English, Prof. frelsh from the editor s hands with many enlarge- 
 shhurst has no superior among the surgical writers "** and j improvements. The author of this work 
 
 Is deservedly popular as an editor and writer, and 
 his contributions to the literature of surgery hare 
 gained for him wide reputation. The volume now 
 
 jperior among the snrgi 
 in America. Am. Practitioner, Jan. 1879. 
 
 The attempt to embrace in a volume of 1000 pges 
 the whole field of surgery, general and special, 
 would be a hopeless ta-k unless through the most 
 tireless industry in collating and arranging, and 
 the wisest judgment in condensing and excluding. 
 These facilities have been abundantly employed by 
 the author, and he has given us a most excellent 
 treatise, brought up by the revision for the second 
 edition to the latest date. Of course this book is not 
 designed for specialists, but as a course of general 
 surgical knowledge and for general practitioners, 
 and as a text-book for students it is not surpassed 
 by any that has yet appeared, whether of home or 
 foreign authorship. N. Carolina Med. Journal, 
 Jaa. 1S79. 
 
 & . 
 
 offered the profession will add new laurels to those 
 already won by previous contributions. We cau 
 only add that the work is well arrang. d, filled with 
 practical matter, and contains in brief and clear 
 language all that is necessary U be learned by the 
 student of surgery whilst in attendance upon lec- 
 tures, or the general practitioner in hi* daily routine 
 practice. M<i. Med Journal, Jan. 1879. 
 
 The fact that this work has reached a second edi- 
 tion so very soon after the publication of the first 
 one, speak* more highly of its merits than anything 
 we might say in the way of commendation. It 
 seems to have immediately gained the favor of stu- 
 dent* and physicians. Cincin. Med. KKIBS, Jan. '79. 
 
 -DRY ANT (THOMAS], F.R.C.S., 
 
 *-* Surgeon to Quy'g Jfospital. 
 
 THE PRACTICE OF SURGERY. Second American, from the Sec- 
 
 ond and Revised English Edition. With Six Hundred and Seventy two Engravings on 
 Wood. In one large and very handsome imperial octavo volume of over 1000 large and 
 closely printed pages. Cloth, $6 ; leather, $7. (Just Ready.) 
 
 This work has enjoyed the advantage of two thorough revisions at the hand of the author since 
 the appearance of the first American edition, resulting in a very notable enlargement of size and 
 improvement of matter. In England this has led to the division of the work into two volumes, 
 which are here comprised in one, the size being increased to a large imperial octavo, printed on 
 a condensed but clear type. The series of illustrations has undergone a like revision, and will 
 be found correspondingly impro\ed. 
 
 The marked success of the work on both sides of the Atlantic shows that the author has suc- 
 ceeded in the effort to give to student and practitioner a sou ad and trustworthy guide in the 
 practice of Surgery; while the simultaneous appearance of the present edition in England and 
 in this country affords to the American reader the benefit of the most recent advances made 
 abroad in surgical science. t 
 
 There are so many text-books of surgery, so many 
 written by skilled and distinguished bauds, that to ob 
 tain the honor of a third edition in Euglaud is no light 
 praise. Mr. Bryant merits this, by clearness of style, 
 
 and good judgment in selecting the operations he re- 
 commends, in his new editions he goes carefully over 
 the i Id grounds, in light of later research. On these 
 
 Another edition of this manual having been called 
 for, the author has availed himself of the opportunity 
 to make no few alterations in the substance as well 
 as in the arrangement of the work, and, with a view 
 to its improvement, has recast the materials and re- 
 vised the whole. We onrselven are of the opinion 
 there is- no better work on surgery extant 
 
 , . 
 
 and many allied points, Mr. Bryant is a calm and un- | Cincinnati Med. News, March, 1879 
 
 partisan 'observer, and his book throughout has the 
 great merit of maintaining the true scientific, judicial 
 tone of mind. Mtd. and Surg. Reporter, March 22, 
 1879. 
 
 The work before us is the American reprint of the 
 
 Bryant's Surgery has been favorably received from 
 the first, and evidently grows in the esteem of the 
 profession With each succeeding edition. In glanc- 
 ing over the volume before us we find proof in almost 
 every chapter of the thorough revision which the 
 
 last London edition, and has the advantage over the work his undergone, rnmy parts having be*n cut 
 latter in being of more convenient size, and in being | out and replaced by matter entirely fresh. N. T. 
 compressed into one volume. The author has rewrit- Med. Journ., April, 1879. 
 
 ten the greater part of the work, and has succeeded, 
 in the amount of new matter added, in making it mark- 
 edly distinctive from previous ediiions. A few extra 
 pages have been added, and also a few new illustrations 
 introduced. The publishers have /presented the work 
 in a creditable style. As a conci.-e and practical manual 
 of British surgery it is perhaps without an equal, aud 
 will doubtless always be a favorite text-book with the 
 student and pracatiouer. -<Y. Y. iteU. Rteord, March 
 22, 1879. 
 
 Welcome as the new edition is, and as much as it 
 is entitled to commendation, yet its appearance at 
 this time is, in a certain seue, a matter of regre:, as 
 it will be in competition with another work, lately 
 issued from the s<me piess. But, the difficult ta-k 
 of forming a judgment as to the relative merits of 
 Bryant aud Ashuum we will not attempt, but pre- 
 dict that, considering the high excellence of both, 
 many others will likewise be turced to hesitate long 
 in uiitkiug choice between theiu Cincinnati Lan- 
 cet and Ctiniu, il^icu 22, ls<9.
 
 23 
 
 HENRY C. LEA'S PUBLICATIONS (Surgery). 
 
 JjJRICHSEN (JOHN E.), 
 
 Professor of Surgery in University College, London, etc. 
 
 THE SCIENCE AND ART OP SURGERY; being a Treatise on Bur- 
 
 gical Injuries, Diseases, and Operations. Carefully revised by the author from the 
 Seventh and enlarged English Edition. Illustrated by eight hundred and sixty two en- 
 gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages : 
 cloth, $8 50 ; leather, $10 50. (Now Ready.) 
 
 In revising this standard work the author has spared no pains to render it worthy of a continu- 
 ance of the very marked favor which it has so long enjoyed, by bringing it thoroughly on a 
 level with the advance in the science and art of surgery made since the appearance of the 
 last edition. To accomplish this has required the addition of about two hundred pages of text, 
 while the illustrations have undergone a marked intprovement. A hundred and fii'ty additional 
 wood-cuts have been inserted, while about fifty other new ones have been substituted for figures 
 which were not deemed satisfactory. In its enlarged and improved form it is therefore pre- 
 sented with, the confident anticipation that it will maintain its position in the front rank of 
 text-books for the student, and of works of reference for the practitioner, while its exceedingly 
 moderate price places it within the reach of all. 
 
 The seventh edition is before the world as the last 
 word or surgical science. There may be monographs 
 which excel it upon certain points, but as a con- 
 spectus upon surgical principles and practice it is 
 unrivalled. It will well reward practitioners to 
 read it, for it has been a peculiar province of Mr. 
 Erichsen to demonstrate the absolute interdepend- 
 ence of medical and surgical science We need 
 scarcely add, in conclusion, that we heartily com- 
 mend the work to students that they may be 
 grounded in a sound faith, and to practitioners as 
 an invaluable guide at the bednide. Am Practi- 
 tioner, April, 1878. 
 
 It is no idle compliment to say that this is the oest 
 edition Mr. Erichsen has ever produced of his well- 
 known book. Besides inheriting the virtues of i's 
 predecessors, it possesses excellences quite its own. 
 Having stated that Mr. Erichsen his incorporated 
 into this edition every recent improvement in the 1 
 science and art of surgery, it would be a supereroga- 
 tion to give a detailed criticism. In short, we un- 
 hesitatingly aver that we know of no other single 
 work where the student and practitioner can gain at 
 once so clear an insight in to the principles of surgery, 
 and so complete a knowledge of the exigencies of 
 surgical practice. London Lancet, Feb. 14, 1878 
 
 For the past twenty years Erichsen's Surgery has 
 maintained its place as the leading text-book, not only 
 in this country, but in Great Britain. That it is able 
 to hold its ground, is abundantly proven by the tho- 
 roughness with which the present edition has been 
 revised, and by the large amount of valuable mate- 
 rial that has been added. Aside from this, cne hun- 
 dred and fifty new illustrations have been inserted, 
 including quite a number of microscopical appear- 
 ances of pathological processes. So marked is this 
 change for the better, that the work almost appears 
 as an entirely new one. 3fed. Record, Feb. 23,1878. 
 
 Of the many treatises on Surgery which it has been 
 our task to study, or our pleasure to read, there is noue 
 which in all points has satisfied us so well as the classic 
 treatise of Erichsen. His polished, clear style, his free- 
 dom from prejudice and hobbies, his unsurpassed grasp 
 of his suhject, and vast clinieal experience, qualify him 
 admirably to write a model text-book. When we wish, 
 at the least cost of time, to learn the most of a topic in 
 surgery, we turn, by preference, to his work. It is a 
 pleasure, therefore, to see that the appreciation of it is 
 general, and has led to the appearance of anoiher edi- 
 tion. Alfd. and Surg. Reporter, i'eb. 2, 1878. 
 
 Notwithstanding the increase in size, we observe that 
 much old matter has been omitted. The entire work 
 has been thoroughly written up. and not merely amend- 
 ed by a few extra chapters A great improvement has 
 been made in the illustrations. One hundred and fifty 
 new ones have been added, and many of the old ones 
 have been redrawn The author highly appreciates the 
 favor wilh which his work has been received by Ameri- 
 can surgeons, and has endeavored to render bis latest 
 edition more than ever worthy of their approval. That 
 he has} succeeded admirably, must, we tiiiuk. be the 
 general opinion. We heartily recommend the book to 
 both student and practitioner. N. Y.Aled. Journal, 
 Feb. 1878. 
 
 Erichsen has stood so prominently forward for 
 years as a writer on Surgery, that his reputation is 
 world wide, and his name is as familiar to the med- 
 ical student as to the accomplished and experienced 
 surgeon. The work is not a reprint of former edi 
 lions, but has in many places been entirely rewrit- 
 ten. Recent improvements in surgery have not es- 
 caped his notice, various new operations have been 
 thoroughly analyzed, and their merits thoroughly 
 discussed. One hundred and fifty new wood-cuts 
 add to the value of this work. N. 0. Med. and Surg. 
 Journal, March, 1878. 
 
 H 
 
 OLMES (TIMOTHY), M.D., 
 
 Surgeon to St. George's Hospital, London. 
 
 SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
 
 some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather, $7. 
 (Just Issued.) 
 
 itsforceand distinctness. AM". Md. Record, April 
 14, 1876. 
 
 It will be found a most excellent epitome of sur- 
 gery by the geueral practitioner who ha* not the 
 time togiveattention to more minute and extended 
 works and to the medical student. In fact, we know 
 of no one we can more cordially recommend. The 
 author has succeeded well in giving a plain and 
 practical account of each surgical injury and dis- 
 ease, and of the treatment which is most com- 
 monly advisable. It will no doubt become a popu- 
 lar work in the profession, and,especially as a text- 
 book. Cincinnati Med. News, Aj>ril, 1S76. 
 
 sides ofthe Atlantic with much interest. Mr. Holmes 
 is a surgeon ot large and varied experience, and one 
 of the best known, and perhaps the most brilliant 
 writer npon surgical subjects in England. It is a 
 book for students and an admirable one and for 
 the busy general practitioner. It will give a student 
 all the knowledge needed to pass a rigid examina- 
 tion. The book fairly justifies the high expectations 
 that were formed of it. Its style is clear aud forcible, 
 even brilliant at times, and the conciseness needed 
 
 A8TITON ONTHE DISEASES, INJURIES. AKD MAL- 
 FORMATIONS OF THE RECTUM AND ANUS: 
 with remarks on Habitual Constipation. Second 
 A,mriean, from the fourth and enlarged London 
 Edition. With illustrations. In one 8vo vol.ol 
 28/ pages, eloth ,*3 25. 
 
 SARGENT ON BANDAGING AND OTHER OPERA- 
 TIONS OF MINOR SURGERY. New edition, with 
 an additional chapter on Military Surgery. One 
 12tno. vol. of SSSpagss, withlSi wood-cuts. Cloth, 
 $1 75.
 
 HENRY C. LEA'S PUBLICATIONS (Ophthalmology}. 29 
 
 IJAMILTON (FRANK H.), M.D., 
 
 ** Professor of Fractures and Dislocations, Ac., in Bellevue Hasp. 3fed. College, New Fork 
 
 A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
 TIONS. Fifth edition, revised and improved. In one large and handsome octavo volume 
 of nearly 800 pages, with 344 illustrations. Cloth, $5 75 : leather, $6 75. (Lately Issued.) 
 This work is well known, abroad as Well as at home, as the highest authority on its important 
 subject an authority recognized in the courts as well as in the schools and in practice and 
 again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- 
 gress for the speedy appearance of a translation in Germany. The repeated revisions which the 
 author has thus had the opportunity of making have enabled him to give the most careful consid- 
 eration to every portion of the volume, and he has sedulously endeavored in the present issue, 
 to perfect the work by the aid of his own enlarged experience, and to incorporate in it whatever 
 of value has been added in this department since the issue of the fourth edition. It will there- 
 fore be found considerably improved in matter, while the most careful attention has been paid 
 to the typographical execution, and the volume is presented to the profession in the confident 
 hope that it will more than maintain its very distinguished reputation. 
 
 There is no better work on the subject in existence 
 than that of Dr. Hamilton. It should be in the posses- 
 sion of every general practitioner and surgeon. The 
 Am. Journ. of Obstetrics. Feb. 1876. 
 
 The value of a work like this to the practical physi- 
 cian and surgeon can hardly be over-estimated, and the 
 necessity of having such a book revised to the latest 
 dates, notmeri'lyonaccountoftbepracticalimportance 
 
 of its teachings, but also by reason of the medico-legal 
 bearings of the cases of which it treats, and which have 
 recently been the subject of useful papers by Dr. Hamil- 
 ton and others, is sufficiently obvious to every one. The 
 present volume seems to amply fill all the requisites. 
 We can safely recommend it as the best of its kind in 
 the English language, and not excelled in any other 
 Journ. of Nervous and Menial Disease, Jan. 1876. 
 
 DROWNS (EDGAR A.), 
 
 Surgeon to the Liverpool Eye and Ear Infirmary, and tothe Dispensary for STcin Diseases. 
 
 HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 
 
 structionsin Ophthalmoscopy, arranged for the Use of Students. With thirty -five illustra- 
 tions. In one small volume royal 12mo. of 120 pages : cloth, $1. (Now Ready.) 
 This capital little work should be in the hands of i could scarcely fail of understanding them. Equally 
 ev^ry medical student, and we had almostsaid every | satisfactory are the directions for the use of the in- 
 general practitioner. Its explanation of the optic*! ; strnment and the suggestions to aid in interpreting 
 principles on which the ophthalmoscope is founded, what is seen. Detroit tfed. Journ., liov. 1S77. 
 is BO clear and simple that the most stupid reader j 
 
 flARTER (R. BRUDENELL), F.R.C.S., 
 
 Ophthalmic Surgeon to St. George's Hospital, etc. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 
 ed, with test-types and Additions, by JOHN GREEN, M.D. (of St. Louis, Mo.). In one 
 handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. (Just 
 Issued. ) 
 
 It would be difficult for Mr. Carter to write an unin- . manner, easy of comprehension, and hence the more 
 gtructive book, and impossible for him to write an un- j valuable. We would especially commend, however, as 
 
 interesting one. Even on subjects' with which he is not 
 bound to be familiar, hecan discourse with a rare degree 
 of clearness and effect. Our readers will therefore not 
 be surprised to learn that a work by him on the Diseases 
 
 of th 
 
 worthy of high praise, the manner iu which the thera 
 peutics of disease of the eve is elaborated, for here the 
 author is particularly clear and practical, where other 
 writers are unfortunately too often deficient. The final 
 
 alik 
 do, 
 
 the Kye makes a very valuable addition to ophthal- | chapter is devoted to a discussion of the usesand selec- 
 ic literature . . . The book will remain one useful tion of spectacles, and is admirably compact, plain, and 
 ike to the treneral and the special practitioner. Lon \ useful, especially the paragraphs on the treatment of 
 n fnnrrt Oct 30 1875 i presbyopia and myopia. In conclusion, our thanks are 
 
 nianctf,Oct.dU,18/a. j ^ t / autnor fo manyu8e f u i hintsin the greatsub- 
 
 It is with great pleasure that we can endorse the work 
 as a most valuable contribution to practical ophthal- 
 mology. Mr. Carter never deviates from the end he has 
 
 in view, and presents the s ubject in a clear and conci se | Q ct 23, 1875. 
 
 ject of ophthalmic surgery and therapeutics, afield 
 where of late years we glean but a few grains of sound 
 wheat from a massof chaff. New York Medical Recvrd, 
 
 (J.SOELBERG), 
 
 Professor of Ophthalmology in King's College Hospital, Ac. 
 
 A TREATISE ON DISEASES OF THE EYE. Third American, 
 
 from the Fourth and Revised London Edition, with additions ; illustrated with numerous 
 enzravings on wood, and six colored plates. Together with selections from the Test-types 
 of Jaeger and Snellen. In one large and very handsome octavo volume. (Preparing.) 
 
 T A URENCE (JOHN Z.), F.R.C.S., 
 
 *-* Editor of the Ophthalmic Review, *c 
 
 A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 
 
 Practitioners, Second Kdition, revised and enlarged. With numerous illustrations. In 
 one very handsome octavo volume, cloth, $2 7 
 
 TAWSON (GEORGE), F.R.C.S. EngL, 
 
 L* Assistant Surgeon to the. Royal London Ophthalmic Hospital, Meorfield*, Ac. 
 
 TNTTTRIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- 
 diate and Remote Effects. With about one handred illustrations. In cne very hand- 
 some octavo volume, clotb, $3 50.
 
 30 
 
 HENRY C. LEA'S PUBLICATIONS (Medical Jurisprudence). 
 
 TDURNETT (CHARLES H.), M.A ,M.D., 
 
 J-) Aurjtl Surg. to the Preb. Hotp., Surgeon-in-iharye ofthrlnjlr for Dig. of the Ear, Phila. 
 
 THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. 
 
 A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
 some octavo volume of 615 pages, with eighty-seven illustrations : cloth, $4 50 ; leather, 
 $5 50. (Just Ready.) 
 
 Recent progress in the investigation of the structures of the ear, and advances made in the 
 modes of treating its diseases, wouldseem to render desirable a new wovk in which all the re- 
 sources of the most advanced science should b> placed at the disposal of the practitioner. This 
 it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in 
 the special study of the subject are a guarantee that the result of his laboris will prove of service 
 to the profession at large, as well as to the specialist in this department. 
 
 On account of the great advances which have been 
 made of late years in otology, and of the increased 
 intf rest manifested in it, the medical profession will 
 welcome this new work, which presents clearly and 
 concisely its present aspect, whilst clearly indi- 
 cating the direction in which further researches can 
 be most profitably carried on. Dr. Barn- tt from hie 
 own matured experience, and availing himself of 
 the observations and discoveries of others, has pro- 
 duced a work, which as a text-book, stands facile 
 princtps in our language. We had marked several 
 pa-sages as well worohy of quotation and the atten- 
 tion of the general practitioner, but their number and 
 the space at onr command forbid. Perhaps it is bet- 
 ter, as the book ought to be in the hands of every 
 medical student, and its study will well repay the 
 busy practitioner in the pleasure he will derive from 
 the agreeable style in which many otherwise dry 
 
 As the title of the work indicates, this volume 
 treats of the anatomy and physiology of the ear, a 
 well an of its diseases, and the author has taken 
 special pains to make thisditlicult and complicated 
 matter thoroughly clear and intelligible The book 
 is desigued especially for the use of students and 
 general practitioners, and places at their disposal 
 much valuable material. Such a book as the pre- 
 sent one, we think, has long been needed, and we 
 may congratulate the author on his success in fill- 
 iug the gap. Both s-.udent and practitioner can 
 ttndy the work with a great deal of benefit. It is 
 profu-ely and beautifully illutrated. A'. Y. Hot- 
 pital Gazette, Oct 15, 1877. 
 
 The appearance of this book is another proof of th 
 rapidly increasing amount <>f honet, valuable work 
 that is now being done in the various branches of 
 
 and mostly unknown subjects are treated. To the medical scienceiu this country. Dr. Burneit is to be 
 specialist the work is of the highest value, and his j commended for having written the best book ou the 
 sense of gratitude to Dr. Burnett will, we hope, be j subjpct in the English language, and especially for 
 proportionate to the amount of benefit lie can obtain j the care and attention he has given to the scientific 
 from the careful study of the book, and a constant | side of the subject. N. Y. Mem. Jaurn., Dec. 1S77. 
 reference to its trustworthy pages. Edinbu. gh 
 lied. Jour., Aug. 1878. 
 
 rFAYLOR (ALFRED S.),M.D., 
 
 Lecturer on Jfed. Juritp. and Ghemittry in Ouy't Hospital. 
 
 POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Third American, from the Third and Revised English Edition. In one 
 large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Just Issued.) 
 The present is based upon the two previous edi- being described which give rise to Isgai investiga- 
 
 tions; "but the complete re vision rendered necessary 
 by time has converted it into a new work." This 
 statement from the preface contains all that it is de- 
 sired to know in reference to the new edition The 
 works of this author are already in the library of 
 every physician who is liable to be called upon for 
 medieo-legil testimony (and what one is not?), so that 
 all that is required to be known about the present 
 book is that the author has kept it abreast with the 
 times What makes it now, as always, especially 
 valuable to the practitioner is it conciseness and 
 practical character, only those poisonous substances 
 
 tions. The Clinic, Nov. 6, 1S75. 
 
 Dr. Taylor hat brought to bear on the compilation 
 of thu volume, stores of learning, experience, and 
 practical acquaintance with his subject, probably far 
 beyoud what any other living authority ou toxicol- 
 ogy could have amassed or utilized. He has fully 
 sustained his reputation by the consummate skill 
 and legal acumen he l.as displayed in the arrange- 
 ment of tne subject-matter, and the re^lt is a work 
 ou Poisons which will b* indispensable to every stu- 
 dent or practitioner in law and medicine. The Dub- 
 tin Journ. of Med Set., Oct. 1S75. 
 
 TOY THE SAME AUTHOR. 
 
 MEDICAL JURISPRUDENCE. Seventh American Edition. Edited 
 
 by JOHH J. REESE, M.D., Prcf. of Med. Jurisp. in the Univ. of Penn. In one large 
 octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Lately Issued.} 
 
 It is beyond question the most attractive as well 
 
 THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 
 
 DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 
 
 volumes, cloth, $10 00; leather, $12 00 
 
 This great work is now recognized in England as the fullest and most authoritative treatise on 
 every department of its important subject. In laying it, in its improved form, before the Amer- 
 ican profession, the publisher trusts that it will assume the same position in this country.
 
 HENRY C. LEA'S PUBLICATIONS (Miscellaneous). 
 
 31 
 
 THOMPSON (SIR HENRY), 
 
 * Surgeon and Professor of Clinical Surgery to University College Hospital . 
 
 LECTURES ON DISEASES OF THE URINARY ORGANS. With 
 
 illustrations on wood. Second American from the Third English Edition. In one neat 
 octavo volume. Cloth, $2 25. (Just Issued.) 
 
 B 
 
 7 THE SAME AUTHOR. 
 
 ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 
 
 THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
 third and revised English edition. In one very handsome octavo volume, cloth, $3 60. 
 ( Lately Published.) 
 
 DOBERTS (WILLIAM), M.D., 
 
 *** Lecturer on Medicine in the Manchester School of Medicine, etc. 
 
 A PRACTICAL TREATISE ON URINARY AND RENAL DIS 
 
 EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Sec- 
 ond American, from the Second Revised and Enlarged London Edition. In one large 
 and handsome octavo volume of 616 pages, with a colored plate ; cloth, $4 50. (Lately 
 Published.) 
 
 TTUKE (DANIEL HACK), M.D., 
 
 J- Joint author of " The Manual of Psychological Medicine," ice. 
 
 ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 
 
 THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
 Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Lately Issued.) 
 
 -DLANDFORD (O. FIELDING), M.D., F.R.C.P., 
 
 J-J Lecturer on Psychological Medicine at the School of St. George's Hospital, Stc. 
 
 INSANITY AND ITS TREATMENT: Lectures on the Treatment, 
 
 Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
 United States on the Confinement of the Insane. By ISAAC RAY, M. D. In one very 
 handsome octavo volume of. 471 pages; cloth, $3 25. 
 
 It satisfies a want which mast have been sorely i actually seen in practice and the appropriate treat 
 feltby the busygeneralpractitionersof thiseonntry. } ment for them, we find in Dr. Blaxidford's work a 
 It takes the form of a manual of clinical description i considerable advance over previous writing)- on tl e 
 of the various forms of insanity, with a description subject. His pictures of the various forms of mect) 
 
 of the mode of examining persons suspected of in- 
 sanity. We call particular attention to this feature 
 of the book, as givingit a unique value to the gene- 
 ral practitioner. If we pass from theoretical conside- 
 rations to descriptions of the varieties of insanity as 
 
 disease are so clear and good that no reader can fail 
 to be struck with their superiority to those given i n 
 iidinary manuals in the English language or (so far 
 as our own reading extendsjin any other. London 
 Practitioner, Feb. 1871. 
 
 EA (HENRY C.). 
 
 'SUPERSTITION AND FORCE: ESSAYS ON THE WAGER CF 
 
 LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised 
 and Enlarged Edition. In one handsome royal I2mo. volume of 552 pages. Cloth, 
 
 $2 60. (Just Ready ) 
 
 The appearance of a new edition of Mr. Henry C. 
 Lea's "Superstition and Force" is a s.gn that our 
 highest scholarthip is not without honor in its na- 
 tire country. Mr. Lea has met every fresh demand 
 for his work with a careful revision of it, and the 
 present edition is not only fuller and, if possible, 
 more accurate than either of the preceding, but, 
 from the thorough elaboration is more like a har- 
 monious concert and less like a batch of studies. 
 The Nation, Aug. 1, 1878. 
 
 Many will ba tempted to say that this, like the 
 'DeclineandFall,"isone of the aucriticizable books 
 Its facts ate innumerable, its deductions simple and 
 inevitable, and its cktvaux-dn-fritie of references 
 bristling and dense enough to make the keenest, 
 stoutest, and best equipped assailant think twice 
 before advancing. Nor is there anything contro- 
 versial in it to provoke assault. The author is no 
 
 polemic. Though be obviously feels and thicks 
 strongly, he succeeds in attaining impartiality. 
 Wheti er looked on as a picture or * mirror, a work 
 such as this has a lasting value. Lipfrincott'f 
 Magazine, Oct. 1S78. 
 
 Mr. Lea's curious historical monographs , of which 
 oue if ihe most important is here reproduced in an 
 enlarged form, have given him an unique position 
 among English and American scholars. He is dis- 
 tinguished for bis recoudite and affluent learning, 
 his powar of exhaustive historical analyst*, tl.e 
 breadth and accuracy of his researches among the 
 rarer sources of knowledge, the gravity and temper- 
 ance of his statements, combined with singular 
 earnestness of conviction, and his warm attachment 
 to the eaue of human freedom and intellectual pro- 
 gress. .iV. . Tribune, Aug. 9, 1878. 
 
 TOY THE SAME AUTHOR. (Late'y Published.) 
 
 STUDIES IN CHURCH HISTORY THE RISE OF THE TEM- 
 
 PORAL POWER BENEFIT OF CLERGY EXCOMMUNICATION. In one large 
 
 royal 12mo. volume of 516 pp.; cloth, $2 75. 
 
 The story was never told more calmly or with . has a peculiarimportauceforthe English tndent,a c d 
 er-ater learning or wiser thought. We doubt, indeed, ! Is a chapter on Ancient Law likely to be regarded as 
 ff any other study of this field'can be compared with ! Inal. We can hardly pas. from our mention of such 
 lais for clearness, accuracy, and power. - Chicago works as these-with which that on Sacerdotal 
 Krnn.in.rr Dc 1870 C ilibacv" should be i uelnded without notinjr < c e 
 
 *M:Sla.^ 
 
 ^ys&srszst p-er 1 : TS ; on*- *.* 
 
 Clergy, and Excommunication, the record of which I
 
 32 
 
 HENRY C. LEA'S PUBLICATIONS. 
 
 INDEX TO CATALOGUE. 
 
 American Journal of ihe Medical Sciences . 1 
 Abstract, Monthly, of the Med. Science* . . 3 
 
 Allen's Anatomy ' 7 
 
 Anatomical Atlas, by Smith and Homer . . 7 
 Abbton on Che Kectnm and Anns . . .28 
 
 Attfield's Chemistry 11 
 
 Aah well on Diseases of Females . . .2:3 
 
 Ashhuriit's Surgery 25 
 
 Browne ou Ophthalmoscope 29 
 
 Browne on the Throat IS 
 
 Burnett ou the Ear 30 
 
 Barnes 011 Diseases of Women . . . .22 
 Bellamy's Surgical Anatomy 1 
 
 Bryant s Practical Surgery . . . .27 
 
 Bloxam's Chemistry 11 
 
 Blandford on Insanity 31 
 
 Basham on Kenal Diseases 18 
 
 Briuton on the Stomach .... 18 
 
 Barlow's Practice ol Medicine . . . .14 
 Bowman's (John E.) Practical Chemistry . . 10 
 Bowman's (John E.) Medical Chemistry . . 10 
 
 Bristowe's Practice 16 
 
 Bamstead on Venereal 19 
 
 Burn stead and Cullerier's Atlaeof Venereal . 10 
 Carpenter's Human Physiology . . 8 
 
 Carpenter on the Use and Abuse of Alcohol . 13 
 
 Cornil and Rauvier )4 
 
 Carter on the Eye 29 
 
 Cleland's Dissector 7 
 
 Classen's Chemistry 10 
 
 Clowes' Chemistry 11 
 
 Century of American Medicine .... 5 
 Chadwick on Diseases of Women . . .23 
 Charcot on the Nervous System . . . .17 
 Chambers on Diet and Regimen .... 18 
 Chambers's Restorative Medicine . . . IS 
 Christison and Griffith's Dispensatory . . is 
 Churchill's Svstem of Midwifery . . . 21 
 Churchill on Puerperal Fever . . . .21 
 Condie on Diseases of Children . . . .21 
 Cooper's (B. B.) Lectures on Surgery . . 25 
 Callerier's Atlas of Venereal Diseases . . TO 
 Cycloptedia of Practical Medicine . . .14 
 Dalton's Human Physiology .... 9 
 
 Davis's Clinical Lectures 14 
 
 Dewees on Diseases of Females . . . .21 
 Drnitt's ModernSurgery . ... 26 
 
 Danglison's Medical Dictionary ... 4 
 Dunglison's Human Physiology ... 9 
 Ehis's Demonstrations in Anatomy ... 7 
 Erichseu'e System of Surgery . . . .28 
 Emmet ou Diseases of Woineu . . . .23 
 Farquharson's Therapeutics . ... .11 
 
 Fenwick's Diagnosis 14 
 
 Finlayson's Clinical Diagnosis . . . .17 
 Flint on Respiratory Organs . . . . 18 
 
 Flint on the Heart 18 
 
 Flint's Practice of Medicine la 
 
 Flint's Essays 15 
 
 Flint's Clinical Medicine 15 
 
 Flint on Phthisis IS 
 
 Flint on Percussion jg 
 
 Fothergill's Handbook ofTretrnent . . ig 
 
 Fothergill's Antagonism of Therapeutic Agents . 16 
 F^wnes's Elementary Chemistry . . .10 
 Fox on Diseases of the Skin . . . .20 
 Fuller on the Lungs, &c. ... 18 
 
 Green's Pathology and Morbid Anatomy . . 14 
 
 Gibson's Surgery 25 
 
 Glnge's Pathological Histology, by Leidy. . 14 
 
 Gray's Anatomy 6 
 
 Galloway's Analysis 10 
 
 Griffith's (R. E.) Universal Formulary . . 12 
 
 Gross on Urinary Organs 26 
 
 Gross on Foreign Bodies in Air-Passages . . 2ti 
 Gross's Principles and Practice of Surgery . 26 
 
 Habershon on the Abdomen 16 
 
 Hamilton on Dislocation* and Fractures . . 29 
 Hartshorne's Essentials of Medicine . . i.i 
 Hartsnorne's Conspectus of the Medical Sciences fi 
 Hartshorne's Anatomy and Physiology . . 9 
 Hamilton on Nervous Diseases . . . .17 
 Heath's Practical Anatomy .... 7 
 Hoblyn's Medical Dictionary .... 4 
 Hodge on 'Women 21 
 
 PAfiS 
 
 Hedge's Obstetrics 24 
 
 iolland's Medical Notes and Reflections . . 14 
 
 Holmes's Surgery 28 
 
 Uolden's Landmarks tt 
 
 Corner's Anatomy and Histology ... 7 
 
 Hudson on Fever 18 
 
 Hill on Venereal Diseases 19 
 
 Ilillier's Handbook of Skin Diseases . . 20 
 /ones (C. Handheld) on Nervous Disorders . 18 
 
 Kirkes' Physiology 8 
 
 Knapp's Chemical Technology . . . . 11 
 Lea's Superstition and Force . ... 31 
 Lea's Studies in Church History . .31 
 
 Lee on Syphilis 19 
 
 Lincoln ou Electro-Therapeutics . . .18 
 Irishman's Midwifery ...... 25 
 
 La Roche on Yellow Fever. . /' 1* 
 
 La Roche on Pneumonia, &c 18 
 
 Laurence and Moon's Ophthalmic Surgery . 29 
 Lawson on the Eye ... .29 
 
 Lehmann's Physiological Chemistry, 2 vols. . 9 
 Lehmann'e Chemical Physiology ... 9 
 Ludlow'e Manual of Examinations ... 5 
 
 Lyons on Fever 18 
 
 Medical News and Library 2 
 
 Meigs on Puerperal Fever 22 
 
 Miller's Practice of Surgery . . . .23 
 Miller's Principles of Surgery . . . .23 
 Montgomery on Pregnancy 
 
 Neill and Smith's Compendium of Med. Science 5 
 Neligan's Atlas of Diseases of the Skin . . 2 
 
 Obstetrical Journal - 
 
 Parry on Extra-Uterine Pregnancy . . . 2.5 
 
 Pavy on Digestion 1 
 
 Pavy on Food 1 
 
 Parrish's Practical Pharmacy . . . . 1 
 
 Pirrie's System of Surgery 25 
 
 Playfair's Midwifery 24 
 
 Quain and Sharpey's Anatomy, by Leidy . . 
 Roberts on Urinary Diseases . . .31 
 Ramsbotham on Parturition . . . .25 
 Remsen's Principles of Chemistry ... 9 
 
 Rigby's Midwifery 21 
 
 Rudwell's Dictionary of Science . . .5 
 
 Snmson's Operative Surgery . . . .25 
 Swayne's Obstetric Aphorisms . . . .21 
 
 Seller on the Throat 18 
 
 Sargent's Minor Surgery . . . . 28 
 
 Sharpey and Quain's Anatomy, by Leidy . 
 
 Skey's Operative Surgery 26 
 
 Slade on Diphtheria IS 
 
 Schafer's Histology 7 
 
 Smith (J. L.) on Children 21 
 
 Smith (H. H.) and Homer's Anatomical Atlas . 7 
 Smith (Edward) on Consumption . . .18 
 Smith on Wasting Diseases in Children . . 21 
 
 gtille's Therapeutics 12 
 
 Siille & Maisch's IMspensatory . . . .13 
 Sturges on Clinical Medicine .... 14 
 
 Stokes on Fever . 14 
 
 Tanner's Manual of Clinical Medicine . . 3 
 
 Tanner on Pregnancy 24 
 
 Taylor's Medical Jurisprudence 
 
 Taylor's Principles and Practice of Med Jnrisp 30 
 
 Taylor on Poisons 30 
 
 Tuke on the Influence of the Mind . . .31 
 Thomas on Diseases of Females . . . .22 
 Thompson on Urinary Organs . . . .31 
 
 Thompson on Stricture 31 
 
 Todd on Acute Diseases 14 
 
 Woodbary's Practice 13 
 
 Walshe on the Heart IS 
 
 Watson's Practice of Physic .... 13 
 
 Wells on the Eye 29 
 
 West on Diseases of Females . . . .20 
 West on Diseases of Children . . . .20 
 West on Nervous Disorders of Children . . 21 
 What to Observe in Medical Cases . .14 
 
 Williams on Consumption 18 
 
 Wilson's Human Anatomy 7 
 
 Wilson on Diseases of the Skin . . . 20 
 
 Wilson's Plates on Diseases of the Skin . . 20 
 Wilson's Handbook of Cutaneous Medicine . 20 
 Wohler's Organic Chemistry .... 9 
 Winckel on Childbed . .... 23 
 
 HENRY C. LEA Philadelphia.
 
 Date Due 
 
 CAT. NO 24 161
 
 A r\r\r\ '" " 
 
 WI 100 
 HllU o 
 
 1879' 
 Habershon, Samuel 
 
 On diseases of the abdomen. 
 
 WI 100 
 Hill* o 
 
 1879 
 Habershon, Samuel 
 
 On diseases of the abdomen , 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664