SVo^Ck ^ CORNELL UNIVERSITY THE Sflouif r Urtennarg SItbrarg FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. STATE VETERINARY COLLEGE 1897 CORNELL UNIVERSITY LIBRARY 3 1924 104 225 76 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104225176 DISEASES OF THE INTESTINES AND PERITONEUM. BY JOmST SYER BRISTOWE, M.D. J, R. WARDELL, M.D., J. W. BEGBIE, M.D. S. O. HABERSHON, M.D. T. B, CURLENG, F.R.S., asd W. H. RANSOM, M.D. NEW YORK WILLIAM WOOD & COMPACT ^ 1879 '/?c Gny's Hospital Beports, voL ii. Second Series. OBSTRUCTION OF THE BOWELS. 47 total suppression of urine; and there is no doubt that in many cases of obstruction high up, the same phenomenon is manifested. He argued that the great diminution of this secretion, in his and in similar cases, was caused by the constant vomiting which is always present in obstruc- tion of the upper part of the small intestine, and by the little available absorptive surface which is presented, combining to prevent the entrance of fluid into the vascular system, and the supply of an adequate amount to the kidneys for the maintenance of their secretion. And he argued further, that the abundant discharge of limpid urine which is frequently observed in cases where the seat of obstruction is low down, is to be ex- plained by the presence of entirely opposite conditions. Further obser- vation, however, seems to show that although there may be a tendency on the whole to a diminished secretion of urine when the impediment is high up, and to an increased, or at all events fairly abundant secretion when the impediment is low down, the urine is in many cases abundant or scanty apparently quite independently of the seat of obstruction. Dr. Brinton, indeed, suggests that the diminished secretion of urine which is frequently met with, and the variability of which phenomenon he fully recognizes, is rather due to a kind of vicarious secretion into the bowel above the seat of obstruction, to which also, rather than to ingesta, he no doubt rightly attributes most of the distention of the bowel and much of the vomit. Mr. W. Sedgwick,' however, apparently with more reason argues that the diminution or suppression of the urinary secretion is re- lated to the suddenness and intensity of the symptoms, and is immedi- ately due to the reflected influence of the abdominal sympathetic cen- tres. On the whole, even if we adopt Mr. Sedgwick's views, it may prob- ably be accepted as generally true that diminished secretion of urine^- often, however, temporary — attends those cases in which the symptoms are of sudden occurrence and acute; and that a fairly abundant secretion of this fluid characterizes cases which are chronic in their course; and that, mainly on these very grounds, suppression or diminution of urine is far more common in cases in which the small intestine is obstructed, than in those in which the impediment occupies the larger bowel. (y) The Mode of Invasion is often of great value in reference to diagnosis. Internal strangulation and intussusception always begin sud- denly, with more or less acute and severe symptoms. Obstruction by gall-stones might be expected to be preceded by symptoms inditative of the passage of a gall-stone from the bladder into the duodenum, and by further symptoms arising in the course of its journey to the spot at which it becomes finally arrested; and sometimes, but by no means always, the history of such premonitory symptoms can be pretty clearly obtained. Stricture, on the other hand, and in a less marked degree obstruction from compression of the bowel, are in the great majority of cases preceded for a more or less considerable length of time by symptoms which point to what is going on, and which for the most part have a resemblance to those which attend the fatal attack. {g) The Duration of Life after the commencement of symptomss which lead to belief in the presence of one of the maladies under consid- eration varies considerably in different cases. The continuance of life is compatible with the persistence of mere, though complete, colic or rectal obstruction of several weeks' or even months' duration. _ But death as a rule supervenes much earlier in proportion as the impediment is situated " Med.-Chir. Trans., vol. li. 48 DISEASES OF THE INTESTINES AND PERn"0NEU3I. nearer to the stomach. When, however, enteritis is associated with ob- struction, then, wherever the obstruction may be, the progress of the case is always very rapid, and, dating from the commencement of the enteritio symptoms, rarely occupies more than a week, often only three or four days. Hence internal strangulations, obstructions by ga,ll-stones, and intussusceptions in which strangulation occurs (more particularly there- fore intussusceptions of the small intestine), are usually fatal within a few days after the commencement of symptoms; while obstructions from stricture or compression, and generally also those from intussusception affecting the larger bowel, for the most part present a comparatively chronic progress. (A) Statistics. — There are certain striking facts deducible from the statistics of obstructive diseases, which it is always well to bear in mind. First, as regards age and sex. It is a well-ascertained fact that obstruc- tion by gall-stones always occurs late in life, generally over fifty, and about four times as frequently in women as in men; it appears also that intussusception may occur at all ages, and is at all ages somewhere about twice as common in males as in females, but that of intussusceptions in- volving the large intestine (which form pretty nearly two-thirds of the total number of fatal intussusceptions), probably fully one-half occur in children under seven years of age; it appears further that stricture (if we omit strictures due to congenital malformation) is a disease of adult life and occurs indifferently in both sexes. Next, in reference to the portion of intestine involved. Stricture, as a cause of death, belongs almost with- out exception to the large intestine, and not only so, but at least three- fourths of the total number of strictures are situated below the middle of the transverse colon; compression and traction belong essentially to the small intestine, and may be regarded, as Dr. Fagge observes, in a practi- cal point of view as the strictures of that tract; internal strangulation occurs more particularly in connection with the small intestine, or with the caecum and sigmoid flexure; gall-stones, with hardly an exception, become arrested somewhere in the jejunum or ileum; and the large intes- tine is involved in intussusception at least twice as often as the small intestine alone. Lastly, with respect to the relative frequency of the several lesions, it may be well to quote Dr. Brinton's figures, based on 500 deaths from obstruction; according to which it appears that out of 100 cases, 43 are cases of intussusception, 17 are cases of stricture, 4*8 are cases of impaction of gall-stones, 27'3 are cases of internal strangula- tion (including, however, all those cases which have been here described as compressions), and 8 are cases of torsion, in regard to which the opin- ion has been previously expressed that they are simply cases of uncom- plicated enteritis. (i) Finally in respect of TVeatment, there are a few established prin; ciples which must guide us in all cases of sudden obstruction of the bowels, and especially in all cases where that sudden obstruction is at- tended with symptoms of enteritis. First, purgatives however mild can do no good, may do immense harm, and must be altogether discarded. Secondly, opiates and other sedatives must be administered largely, or at least sufficiently largely to produce some visible effect in relieving pain and giving rest, and should in most cases be administered by subcuta- neous injection. Thirdly, but little food and stimulus should be adminis- tered by the mouth, for they are almost always immediately rejected, or if retained fail to be absorbed, and then add only to the bulk of faecal matters distending the bowel above the seat of obstruction, in either case OBSTEUOTION OF THE BOWELS. 49 adding to the patient's distress and tending to hasten death. Food given by the mouth should be in small quantities, fluid, and easy of absorption and digestion. There is no reason, however, in many cases, why we should not endeavor to support the patient's strength by nutritious ene- mata. Fourthly, operations for the relief of intestinal obstructions are rarely followed by satisfactory results; nevertheless, if there seem a chance, however remote, of lengthening the life of a patient who is other- wise doomed to speedy death, few would hesitate to catch at that chance. In some forms of obstruction an operation must from the very nature of things be at least useless, as for example in simple enteritis, in torsion, in most cases of compression of the bowel, and in the impaction of gall- stones; but there can be no doubt that if an operation were performed at an early date, internal strangulations might be relieved with fair success, and intussusceptions might be retracted with frequent benefit. Dr. Fagge is doubtless judicious in recommending an operation for the retraction of ileo-caecal intussusception, for reasons which have been given previously j and there can be no doubt that if the evidence points at all strongly to internal strangulation, an early resort to surgery should be had. It need scarcely be insisted on that no patient suffering from sudden obstruction with enteritic symptoms, in whom an external hernia, whether strangu- lated or not, exists or has existed, should be allowed to die without undergoing an exploratory operation at the seat of hernia. 4 ULCERATION OF THE BOWELS. Bt John Stbe Beistowb, M.D., F.R.C.P. Ulceeatioit of the bowels, using the word in its widest sense to indi- ^'ate all those cases in which the mucous membrane is partially — no matter how or why — destroyed, is a lesion of very common occurrence, sometimes induced by the extension of disease from the exterior of the intestine, more commonly the result of morbid processes commencing in its mucous and sub-mucous tissues. I. Pathologt. — (a) Ulceration beginning from within. — Ulceration which originates in connection with the mucous membrane may be found at any part of the intestinal tract; but there are certain situations in which it is met with much more frequently than elsewhere: these are the duodenum, the ileum (especially towards its outlet), the caecum, ascending colon, sigmoid flexure and rectum; in other words, the commencement and the termination of both the larger and the smaller bowel. The causes of ulceration are very various, and are not always easy to define, and still less easy in practice to recognize. Some forms of it are no doubt distinctly the result of the liquefaction or destruction of some specific deposit, as in enteric fever and in tuberculosis, and perhaps, in the latter stages of syphilis; and some, as possibly the dysenteric, are due to some specific kind of inflammation. But in a considerable number of oases the causes of ulceration are local; the bowel is wounded by some sharp body which has been swallowed, or is rubbed and irritated by some partially arrested solid mass, or is fretted by the constant passage over it of acrid fluids, or presents some localized point or points of inflammation, which own no more manifest cause than does a pustule of impetigo, a bleb of pemphigus, or an ordinary boil. It may, however, be conceded, that even in these latter cases the general condition of the patient has often much to do, at all events indirectly, with the production of the ulceration: that, for example, on the one hand the fluids which irritate are often irritating in consequence of being unhealthy; and, on the other hand, the fretted bowel often inflames or ulcerates under their influence, because it was previously congested, or its circulation was sluggish. Many forms of inflammation of the skin are attended with an excessive production of epidermis, or with the exudation of matter into or beneath the epidermis, and thus become characterized by the development of squamse or of crusts, on the removal of which a more or less raw surface is left, and beneath which ulceration is apt to take place. The varieties of cutaneous inflammation, here very briefly indicated, are for the most part easy of separate recognition, yet they not infrequently merge one into the other. But on mucous surfaces the distinctions between scaly, vesicular, and even pustular affections are rarely, if ever, very obvious, the 52 DISEASES OF THE INTESTIlfES AND PERITONEUM. delicacy and moisture of the epithelium interfering alike with the forma- tion of a mere dry scale and with the limited accumulation of fluid be- neath it. I have used the term " croupous " on another page, to indicate those forms of intestiaal inflammation in which the mucous membrane is found covered with an opaque adherent film, composed of corpuscular elements, derived partly from its surface, partly from its glandular invo- lutions; but I have used it in no specific sense, and believe that, in many cases at least, the film, or false membrane, is homologous with the _ scurf of pityriasis, the scales of lepra, or the vesicles of eczema. Ulceration of the bowels not infrequently commences with " croupous "inflammation: a linear or irregularly polygonal or stellate patch of more or less intense congestion and tumefaction makes its appearance, which soon becomes covered (excepting, perhaps, at the edges by which it may be extending) with an opaque whitish or buff-colored exudation, which is somewhat friable and granular on the surface, and extends by rootlets into the Lie- berkllhnian follicles; the patch of exudation after a time separates, and leaves sometimes a sound surface, sometimes a slight excoriation, or even a distinct ulcer, manifested by a somewhat cupped grayish or yellowish surface and a well-marked margin of congested mucous membrane. Ul- cers commencing thus may be met with in any part of the bowels, but are much more common in the large intestine than elsewhere. In the small intestine they chiefly affect the free edges of the valvulae conni- ventes, and in the large intestine either the projecting ridges formed by the intervals between the sacculi, or those which correspond to the longi- tudinal muscular bands. They are very apt to occur, particularly in the large intestine, in the course of pneumonia, and in cases in which the patient is dying from many forms of chronic disease, such as Bright's dis- ease of the kidneys, cirrhosis, cancer, chronic phthisis; and, from the peculiar position which they occupy, there is reason to believe that they depend, partly at least, on irritation by the intestinal contents. Occa- sionally we find large tracts of bowel more or less deeply congested, and studded with irregular patches or bands, or an imperfect network, consist- ing partly of croupous exudation, partly of consecutive ulceration. In other cases ulceration commences either from distinct mechanical injury or from more gradual erosion; the ulcer then being roundish, or more or less irregular in form, varies in size, presenting a more or less congested and well-defined, but not necessarily thickened, margin, and a more or less irregularly excavated shreddy grayish surface. Such ulcers may be observed when gall-stones or other solid bodies have lain for some time in contact with a portion of intestinal surface ; they occur also in the large intestine, when it has been long distended with accumulated faecal contents. In several oases of long-continued constipation, I have seen the mucous surface of the larger bowel studded with tracts varying from about one to twelve square inches in area, consisting of groups of circular ulcers of the kind now under consideration from half an inch downwards in diameter, and separated from one another by a network formed of con- gested and partly undermined bands of mucous membrane. Sometimes, again, ulcers obviously originate in patches of sub-mucous suppuration, as we see occasionally in pyaemia, or in patches of sub-mu- cous slough, like an ordinary funmcle. Among these may, perhaps, be reckoned the ulcerative inflammation of the follicles of the colon, which Rokitansky describes, and which seems by many to be considered tha earliest stage of dysentery. The follicles first enlarge to between the size of a tare and a pea, and become surrounded by a dark red halo of conges- TJLCERATION 01- THE BOWELS. 53 tion, and then, undergoing suppuration, discharge their contents into the bowel by an ulcerated opening, which eventually enlarges, and forms a cucular ulcer with overlapping edges. When the follicles are widely afEected, the mucous membrane presents in the first instance a generally congested tuberculated surface, upon which, after a short time, groups of small tolerably deep circular ulcers make their appearance. In other cases, again, ulceration is produced by the separation of a slough. In various parts of the small intestine, but perhaps most com- monly in the duodenum and jejunum as well also as in the oesophagus and stomach, circumscribed patches of intense congestion or of extravasation of blood appear in the substance of the mucous membrane, the patches shortly dying, and coming away either bit by bit or in mass. The forma- tion and separation of such patches are often effected with little obvious change in the parts immediately surrounding them ; there is often no un- wonted congestion observable, and the pits which are formed by their removal for the most part speedily become effaced. I believe they are most commonly seen in cases of small-pox, typhus, and other such dis- eases. A^ somewhat similar condition is sometimes observed in the val- vules conniventes, and still more frequently in the transverse projections from the interior of the larger intestine, the free edges of which then pre- sent a line of ulceration, which looks as though it had been formed by a mere splitting of the diseased mucous membrane, and presents either an ashy or a j'ellow flocculent surface. But sloughing to a much more serious extent is sometimes met with, especially in the large intestine; patches of surface become livid, or brown, or nearly black with congestion, and then their central region assumes a gray or ashy color, gets shrunken, depressed, and softened, and soon breaks down into a soft shreddy substance, which partly becomes detached and partly adheres to the floor of the excavation, and to the not yet broken- down edges, which latter tend to spread, and to involve more and more of the surrounding tissues. Occasionally extensive tracts of the mucous sur- face of the large intestine are covered with sloughing patches, originating in the manner just described. It is not pretended that all non-specific ulcers arise in one or other of the modes here enumerated, or that the several varieties enumerated are even in the beginning in all cases essentially distinct from one another. Still less do they necessarily maintain these distinctions in the later stages of their progress. Fully formed ulcers indeed present a considerable vari- ety of appearance, dependent mainly on the processes which are taking place in them. Thus, when they are in process of healing, we find the general surface smooth and clean, or it may be granulating, the edges little if at all thickened or congested, perhaps puckered, and sloping more or less obviously to the surface of the ulcer with which they are continu- ous; when they are sluggish, the edges are more or less tumid and rounded, and it may be overhanging, and the general surface smooth, or somewhat irregular and flocculent; and again, when they are spreading, the surrounding mucous membrane presents more or less intense congestion and swelling, and the immediate edge of the ulcer is either flocculent and ash-colored, or presents a vivid red, raw, bleeding wall, or forms a more or less complete rim of distinct gangrene. The floor of an intestinal ulcer is generally constituted by the sub-mucous tissue, but not infrequently the transverse muscular fibres are distinctly exposed, especially in an ulcer which is still spreading; and when the ulcer tends to perforate the bowel the muscular coat itself becomes opaque, eroded, and in parts destroyed. 54 DISEASES OF THE INTESTHTES AKD PEEITOITEITM. The account just given applies to individual ulcers. But very fre- quently, and much more frequently in the large than in the small intestine, numerous ulcers are present at the same time, and tend to increase either in number or size and to coalesce in a greater or less degree; and then, according to the stage to which the ulceration has advanced, we meet in different cases with either a number of roundish ulcers separated by an imperfect network of mucous membrane, or interlacing networks of ulcer- ation and of mucous membrane, or islets of mucous membrane in an expanse of ulceration; or lastly, extensive tracts from which the mucous coat has been wholly removed. In these cases the transverse muscular fibres are often freely exposed, and the remains of mucous membrane are red and swollen and rounded, and form tubercular excrescences. The bowel, moreover, is frequently much contracted. Some of the specific forms of intestinal ulceration have been elsewhere considered. There is only one, indeed, tubercular ulceration which needs anything like minute description here. Still it may be convenient briefly to advert to some of the more important features which do, or are sup- posed to, distinguish them severally. I am not aware that syphilitic ulceration has been surely recognized in the alimentary canal, except in the neighborhood of its inlet and outlet; intestinal ulceration, however, is often met with in persons who have died when under the influence of the syphilitic virus, and it seems at least reasonable to suppose that in some of these cases the ulceration, even though it presents no visible dis- tinctive mark, owns a syphilitic origin. Dysenteric ulceration occupies the large intestine, and occasionally invades also the lower part of the ileum. The mode of origin of the tropical form of the disease is variously described by many, including the late Dr. Baly, it is considered to arise in inflammation and suppuration of the solitary glands; by others it is believed to originate in a croupous form of inflammation; and no doubt it sometimes commences with intense general inflammation, pass^g at once into gangrene. But, however it may begin, it tends to the rapid destruction of extensive tracts of mucous membrane, and to that chronic condition of more or less extensive rawness which has been above referred to. In typhoid fever a deposit takes place in the solitary glands, and in Peyer's patches (more frequently in the latter than in the former), which become congested, softened, and form flat wheal-like elevations. At the end of a few days, it may be a week, the bulk of the enlarged gland begins to slough, a line of ulceration forms around the slough, and this latter acquires a peculiar yellow or brownish hue. In a short time the slough separates, leaving a circular or sinuous ulcer with congested tumid edges, and an excavated surface, limited either by the sub-mucous tissue or by the transverse muscular fibres. Then usually the edges begin to resume the normal thickness and color of mucous membrane, and to blend gradu- ally with the contiguous surface of the ulcer, which itself fills up and con- tracts, and ultimately heals with a scarcely or not at all visible cicatrix. At other times the ulcer remains irritable or sluggish, or spreads both in surface and depth, either by gradual erosion, or by sloughing, or by the phagedsenio process. And then sometimes hsemorrhage, sometimes per- foration of the bowel takes place. Typhoid ulcers vary in size from about that of a split pea to that of the largest of Peyer's patches. They are always most marked immediately above the ileo-cffical valve (to which part they are sometimes limited), and extend thence, gradually decreasing in number and size, upwards through the' ileum and occasionally the jeju- num. They occur in the large intestine in about half the total number of TJIOEEATION OP THE BOWELS. 55 oases, being then of smaller size than those in the ileum, and diminishing in number from the cascum downwards. Tubercular disease of the mucous membrane of the bowel is one of the most frequent forms in which the tubercular diathesis reveals itself, and certainly the most frequent cause of intestinal ulceration. It occurs in rather more than one half of the total number of cases of pulmonary con- sumption, and rarely if ever independently of it; and it is often associated with peritoneal and other varieties of abdominal tubercle. It afEects pri- marily the same structures as are affected in enteric fever, namely, Peyer's patches and the solitary glands; and in the small intestine therefore is always most advanced and most abundant immediately above the ileo- cecal valve, from whence upwards (although it may extend throughout the ileum and jejunum) it gradually diminishes. It affects the csecum more than any other part of the large intestine, involving also the ileo- csecal valve and the vermiform appendage; but it may form patches throughout the whole of the colon. The large intestine and small intes- tine are affected by it with equal frequency, and they are both affected in combination about twice as frequently as they are each affected separately. The tubercular material is deposited, either in the form of gray granules or of yellow cheesy masses, in the substance of the congested and swollen glands, and generally soon undergoes softening, producing a small pretty deep ulcer with thickened elevated overhanging edges. When several of these deposits have softened side by side, as happens in Peyer's patches, the ulcerated area presents in the first instance a kind of honeycombed appearance, the small ulcers being separated by more or less complete bridles of yet undestroyed and thickened mucous membrane, and the general margin, which is also thickened, presents a sinuous or scolloped outline. Tubercular ulcers generally tend to spread by the successive deposition and softening of tubercles at their edges, the tubercles not being then necessarily limited to the glands; and by this process they often extend over a considerable area. In the large intestine the whole mucous membrane of the caecum is sometimes thus destroyed, and often very extensive tracts of ulceration are found to stud the surface of the colon at more or less distant intervals. In the small intestine tubercular ulceration has a remarkable tendency to spread in the transverse direction and frequently forms bands from half an inch to an inch or more wide, occupying the whole circumference of the bowel. Many of these art sometimes met with at short distances from one another throughout the greater part of the small intestine. In most cases the ulcers still go on enlarging up to the patient's death, and occasionally they lead to haemor- rhage or to perforation. Sometimes, however, they cicatrize more or less perfectly: some cicatrizing indeed while others are spreading or new ones are forming. But, owing to the extensive destruction which tubercular ul- ceration occasions, cicatrization is generally attended with considerable con- traction; so that sometimes in the small intestine, in the caecum, or in the colon, the calibre of the bowel becomes in consequence so much diminished as to produce a real stricture. Sometimes, again, tubercular deposits dry up or become absorbed without ever undergoing actual ulceration; and it is not a rare thing to find, in cases of chronic phthisis, both in the large and small intestines, small, irregular elevated patches, sometimes associated with ulceration or the remains of ulceration, which present a dark grayish hue and a cicatrix-like appearance, the surface being studded with small granules, the edges being puckered and prolonged by irregular bands into the membrane around, an appearance having some resemblance to that 56 DISEASES or THE INTESTINES AND PEIMTONETJM. produced by superficial lupus. The peritoneal surface corresponding to tubercular ulcers of the mucous membrane is generally studded with mi- nute gray granulations and the lymphatics ramifying in the walls of the same part, and those extending between it and the nearest mesenteric glands are often filled with opaque white creamy or cheesy contents. It may be added that extensive chronic ulceration of the large intestine, which has all the characters previously described as belonging to the later stages of dysentery, or of non-specific forms of intestinal ulceration, is often met with in phthisical patients; in whom there is no tubercle in any part of the bowel except the ileum, and where therefore it may be a question whether the ulceration originated directly in the breaking down of tubercle, or whether, as seems most likely, it took its origin in simple excoriation caused by the constant passage of irritating secretions from the tubercular bowel above, just as the mucous membrane of the trachea becomes so often excoriated in the course of pulmonary phthisis. Many intestinal ulcers doubtless cicatrize and leave behind them no traces of their former existence, or, at most, a smooth depression with puckered edges. In other cases, however, and indeed in a large propor- tion of them, results of more or less serious importance foUow. Sometimes, where a vast continuous extent of surface has been de- stroyed, as we see occasionally in the rectum and other parts of the large intestine, the mucous membrane never does become restored; and even in cases where the destruction of tissue has been much more limited, the ulcer may assume the character often presented by the chronic ulcer of the stomach, and be ready, as that is, to break out again and again under apparently the most trivial provocation. But generally when a large ulcer heals wholly or in part, some degree of contraction of the calibre of the bowel is the consequence, — contraction which takes place both in length and in breadth, but which from obvious causes manifests itself most conspicuously in the latter direction. Stricture, in fact, often follows such contraction, but especially, and indeed almost exclusively, when the ulceration which has given rise to it has occupied the whole cir- cumference of the bowel, as it does often in tubercular disease, and always after the separation of a mass of invaginated bowel. Another very common sequence of ulceration is perforation of the in- testinal walls at the seat of ulceration, and the consequent communication of the interior of the bowel either with the peritoneal cavity, or with that of some hollow viscus. j The most frequent of these communications is that with the peritoneum. Perforation occurs more frequently in enteric fever than in any other kind of disease, taking place generally somewhere in the lower three feet of the ileum, and rarely in the colon. It occurs occasionally only in the course of tubercular ulceration of the bowel, and then also generally in the lower part of the ileum. It is induced some- times by the constant fretting kept up by the pressure of some hard irri- tating body, such as a gall-stone or some other form of intestinal concre- tion. Sometimes it follows upon the ulceration and softening of the mu- cous membrane, which attend the undue distention taking place often in the bowel above an impediment. Sometimes, again, it results from the sep- aration of freshly united surfaces, as in intussusception. And indeed it may happen in the course of any form of ulceration, or weakness, whether dependent on mere thinning, or softening, or ulceration, or gangrene. The actual perforation, at least so far as regards the peritoneum, which is al- ways the last part to yield, is due generally, perhaps always, to laceration, And although the result of the lesion is general and, with few exceptions, TTLCERATION 01" THE BOWELS. 57 rapidly fatal peritonitis, the lips of the perforation and the contiguous portion of bowel are almost always found adherent by lymph to some neighboring visous. Indeed perforation into the peritoneum is sometimes staved off, or wholly prevented, by the previous occurrence of localized adhesive peritonitis. It is by the intervention of such adhesion that a per forating ulcer of the bowel comes usually to communicate with some neighboring hollow visous. The ulcer, having first eaten its way through the thickness of the parietes of the bowel, next perforates the layer of adhesions, then the walls of the attached viscus; and thus establishes a more or less free passage between them, and permits a more or less ready interchange of contents. Sometimes an abscess-like cavity lies between the two organs which communicate, and forms the medium of their com- munication. Such communications, though generally perhaps perma- nent, are riot always so; and their closure is effected usually by the retreat of the bowel from the organ to which it is adherent, and the consequent formation of a hollow funnel-like passage between them, which becoming longer and narrower, finally closes at its narrowest end, or that furthest from the bowel. There are probably none of the abdominal viscera be- tween which and the bowels communication may not be established by means of ulceration beginning on the side of the bowel. Thus, not in- frequently, contiguous portions of the small intestine are found opening into one another, or small intestine into the transverse or some other part of the colon: and thus the rectum or sigmoid flexure, or even the small intestine, may be found to communicate with an ovary or with the uri- nary bladder; or the duodenum, and perhaps the transverse colon with the gall-bladder; or the stomach with the transverse colon; or again al- most any part of the intestinal canal may open through the abdominal parietes, forming a fascal fistula, or artificial anus. In some cases the per- forating ulceration begins in a diverticulum of the ileum, or in one of the false diverticula occurring sometimes in the large intestine. Mr. Sydney Jones' records a case in which ulceration of a false diverticulum in the sig- moid flexure led to a passage between that part of the bowel and the bladder. The results of some of these communications are perhaps of little importance; other communications, however, are not only of dangerous consequence, but also of much interest. Among these latter are espe- cially communications between the colon and the stomach or duodenum, which lead to the occasional or constant vomiting of actual faeces, and the escape of undigested food into the large intestine; and communications with the urinary bladder, which occasion the escape of flatus and of faeces into that viscus, with other consequences which are easy to foresee. (b) Ulceration heginning from without. — Ulceration of the bowel be- ginning from without occurs generally in connection with some abscess of which the intestine has been made to form a portion of the parietes. _ The abscess is sometimes distinctly peritoneal; sometimes occupies a visous which becomes adherent to the bowel at the point where perforation is about to take place. Sometimes the purulent matter infiltrates the cellu- lar tissue of the mesentery or of some other peritoneal duplicature, and thus reaches the intestinal walls. If the external abscess attacks a part of bowel covered with peritoneum, it generally causes the erosion of that membrane in the first instance to a comparatively small extent: then the matter undermines it, and accumulates between it and the muscular coat; soon the muscular coat becomes opaque, softened, and perforated in one ' Path. Trans, vol. x. 58 DISEASES OF THE INTESTINES AND PERITONEUM. or more spots, when again an accumulation of matter takes place between the muscular and the mucous membranes, which latter then forms a larger or smaller hemispherical bulging towards the interior of the bowel, on the convexity of which ulceration soon ensues, and the communication between the abscess and the bowel is completed. Or again, a hollow vis- cus may open by ulceration into the bowel, having first caused adhesion, exactly in the same way that the bowel opens into other organs. Bythe processes here indicated, peritoneal abscesses discharge themselves into various parts of the bowel; inflamed ovarian tumors communicate with the rectum, sigmoid flexure, or other parts; an ulcerated gall-bladder, or an abscess of the liver, perforates the duodenum or transverse colon; an ab- scess of the kidney or other form of retro-peritoneal abscess opens on the one side into the ascending colon and cascum, on the other into the descending colon, or, by burrowing beneath the peritoneum, reaches the rectum, and perforates that. In a similar way, too, an abscess of the liver, or even an empyema, may empty itself into the caecum or some other part of the large intestine, in or just above the pelvis. In a few instances, tubercular deposits commencing at the peritoneal surface gradually invade the whole thickness of the bowel, forming here and there large knots of tubercular infiltration of the intestinal walls, which gradually softening lead to the ulceration of the mucous surface over them, to the formation of a tubercular abscess, and even to a com- munication between the interior of the bowel and the cavity of the abdo- men. It may, perhaps, be added here, that malignant disease of the bowel not only causes ulceration of the mucous surface, but not infrequently produces perforation into the abdomen, and is, perhaps, the most frequent cause of complex and unusual communications between neighboring cavi- ties, and these and the external surface. II. Symptoms. — The symptoms which ulceration of the bowels pro- duces are so constantly associated with the symptoms of those morbid states of system on which the ulceration depends, and are so frequently mixed up with symptoms due to the various complications which follow upon ulceration, that we have seldom the opportunity of studying them in their simple form; and, indeed, if we omit all reference to the symp- toms of its complications, we leave very little to be said upon the symp- tomatology of ulceration. It may be stated generally, that ulceration of the bowels is attended in the first instance with more or less marked feb- rile symptoms, which assume, if the disease become chronic, a distinctly and indeed typical hectic character; that the affected bowel is more or less tender on pressure, a character which is especially observable if the ulceration be extensive, or if it occupy the caecum and other parts of the large intestine; that there is some impairment of nutrition marked by emaciation and debility, and feebleness of circulation; and that there is, above all, something abnormal in the action of the bowels and in the evacuations. The stools in ulceration of the bowels are generally liquid, contain an abnormal quantity of the fluid secretions of the bowels, and not infrequently more or less blood; they are, moreover, often pea-soup- like in color and consistence, and much more foetid than in health; fur- ther, they are usually passed much more frequently than natural, and the patient suffers from frequent colicky pains and from tenesmus. But all these symptoms are liable to much modification, and one or even all of them may be absent. Thus, sometimes ulceration is present, especially if it occur high up in the small intestine, without occasioning any obvious TJLOERATIOW OF THE BOWELS. 59 disturbance of the bowels. I recollect very well the case of a man who died from gradually increasing emaciation and debility, with no symptoms sufficiently characteristic to point to any one organ as the seat of the dis- ease, and in whom after death the only visible lesion was pretty extensive chronic ulceration at the upper part of the ileum. The bowels, indeed, may be constipated from first to last, as we now and then observe in cases of enteric fever, and as happened in a case of extensive ulceration of the large intestine which I have quoted in another article, and in which death, and probably the ulceration itself, were due to simple constipation. Ulcer- ation of the larger bowel is much more constantly associated with the pas- sage of frequent and thin evacuations than is ulceration of the small intestine : these may be purely diarrhoeal when the upper part of the large intestine is alone involved, but assume a more and more decidedly dysenteric character in proportion as the ulceration affects its lower part; in which latter condition the evacuations, though frequent and passed with extreme tenesmus, are scanty, mucous, and often sanguinolent, and occasionally only_ containing a little true fsecal matter. It is in this dys- enteric form of disease, moreover, that the evacuations become most offen- sive, the foetor being sometimes, even though no gangrene be present, putrid and almost insufferable. Besides the slight oozing of blood which tinges the evacuations in diarrhoea of a dysenteric character, hemorrhage to a considerable amount sometimes takes place, haemorrhage which may be continuous or recurrent, and sufficient in quantity to destroy life. This accident is not very infrequent either in enteric fever or dysentery, and occasionally results from the perforation of a comparatively large vein or artery. There is little to add, even in regard to the diarrhoea which attends tubercular disease of the bowels, excepting that as the in- testinal disease is mostly a progressive one, the diarrhoeal symptoms, having once declared themselves, tend to become progressively more and more severe, and that it is for the most part in those cases of phthisis which are attended with intestinal complication that the emaciation is most rapid and becomes most extreme. This is not the place to discuss the various symptoms which are caused by stricture, and by perforation of the bowel, and by the communication of the bowel with other organs, nor to enter upon the description of those symptoms which attend typhoid or dysenteric ulceration. III. Tbbatment. — The Treatment of ulceration merges in the treat- ment of the various diseases with which it is connected, and admits, in- deed, of but little independent remark. But putting all its complications out of the question, our aim in the treatment of ulceration would seem to be, first, to promote the healing of the ulcer, and to prevent, as far as pos sible, the local mischances which are apt to follow; second, to check thi abdominal discomfort and the diarrhoea which so rapidly weaken the patient; and third, to support his strength directly by all means at our disposal. Whether there are any medicines which are capable of being made to act directly on an ulcer seated at a distance from either outlet may be a matter of doubt; still, from our knowledge of what drugs are useful in ulcers of the stomach and of the lower end of the large intestine, we are justified at least in hoping that some benefit, however infinitesimal, may result from the employment of the same medicines in the treatment of the deeper-seated disease. On these grounds, bismuth, nitrate of sil- ver, iron, copper, the mineral acids and other remedies, have been fre- quently employed, and often with apparent benefit. But rest, which is so useful an adjunct in the treatment of so many diseases, is of inestima- 60 DISEASES OP THE INTESTIITES AISTD PERJTOlfEUM. ble value in the treatment of ulceration of the bowels. The violent and frequent peristaltic movements and writhings which the ulcers themselves give rise to, tend obviously to prevent them from healing, and add greatly to the danger of perforation; purgative medicines should therefore be en- tirely, or at least as much as possible, avoided, and further, the exalted peristaltic movements which attend the disease should be restrained. For this purpose various astringent medicines may be used, — lime, tannic acid, chalk, and vegetable astringents; but far more useful than these, as a rule, is opium, in one or other of its various preparations. There are probably few simple combinations more generally useful than the aromatic powder of chalk and opium, and the compound kino powder. But it is well to bear in mind that opium cannot always be taken in these cases. Chronic ulceration of the bowels is often attended with an irritable condition of the mucous membrane of the mouth and stomach, manifested by dryness, soreness, and, perhaps, cracking of the tongue, and heat at the stomach, •with nausea — conditions which the use of opium unfortunately often in- tensifies. If opium then cannot be administered, astringent medicines •with carminatives must be alone employed; or some other form of seda- tive, such as hyoscyamus, belladonna, Indian hemp, hydrocyanic acid, &c, must be resorted to. Opium may often be given with advantage in the form of suppository or of enema. It need scarcely be added that it is never desirable by these means to produce prolonged constipation; and that to obviate this contingency, either the medicines which have pro- duced it must be left off or given in diminished doses, or simple enemata must be employed. It is obvious that the various measures which have just been enumerated, while they check peristalsis, act with equal efficacy in fulfilling the second indication of treatment, — namely, the arrest of diarrhoea. Our third and last object, the maintenance of the patient's strength, must be attained by the exhibition of tonic medicines, and the careful administration of food and stimulants. The form of tonic to be given must obviously be made to accord with the treatment selected to restrain peristalsis and diarrhoea; it must also be adapted to the condi- tion of the patient, as regards his general health and his digestive func- tions. In the same way the diet must be regulated : nothing should be permitted which is known to disagree with the patient; everything should, be well cooked, well masticated, and easy of digestion, and food should be given in moderate quantities, and at regular if not frequent intervals. Farinaceous foods are in many cases most suitable, but eggs, fish, and fowl may often be used with great advantage. Butchers' meat is some- times wholly inadmissible. For stimulants, nothing, perhaps, is better, in a general way, than brandy and water, sherry, or madeira. For reasons which are sufficiently apparent, and which have indeed been already indicated, the remarks on the treatment of ulceration are intentionally meagre, and point rather to general principles than to details. CANCEROUS AND OTHER GROWTHS OF THE INTESTINES. By John Stee Beistowe, M.D., F.R.C.P. (1) Cancerous disease, to any serious extent, much more rarely affects the intestines than the stomach, and the small intestine much more rarely than the large. Of all parts of the intestinal canal, the rectum seems to be the most frequently thus affected, the sigmoid flexure next. Yet the bowels are very often the seat of a trivial amount of cancerous deposit; for peritoneal cancer, vs^hich is a not uncommon form of disease, is almost always attended with more or less involvement of their serous surface. Cancer rarely originates in the substance of the intestinal walls; but in- volves them by extension from the serous membrane, from the mesenteric and other abdominal lymphatic glands, from the connective tissue of the iesSer omentum, venter ilei, or pelvis, or from the stomach, or the pelvic genito-urinary organs, especially the uterus and vagina. When commenc- ing from the peritoneum, it makes its appearance in that membrane in the form of lenticular or tubercular elevations, which tend to increase in num- ber and to enlarge, and then to coalesce, so as to form a tolerably smooth or somewhat nodulated lamina of various thickness. Generally the can- cerous deposits appear first, and are most abundant in the vicinity of the lines along which the peritoneum leaves the bowel; and whether the dis- ease begins in the peritoneum or in the substance of the mesentery and similar processes (but especially in the latter case), the sub-serous connec- tive tissue becomes largely infiltrated and thickened, and the bowel firmly fixed to it or set as it were in it. It is naturally in the loose tissues around the lower part of the rectum, the cjecum, and the duodenum, that the de- velopment of sub-peritoneal cancer is most abundant; and sometimes these parts are thus reduced to mere channels, excavated, as it were, in the sub- stance of a solid mass. Cancerous disease of the outer surface of the bowel may be almost universal; or it may affect tracts of bowel of various lengths; or, again, a band of cancerous deposit may encircle the bowel at some point (generally, in this case, the lower part of the large intestine), while merely a few isolated cancerous nodules are scattered at distant intervals over other parts of the peritoneum. Cancer beginning on the outer surface tends no doubt, sooner or later, to invade the tissues internal to it; but although there is certainly a great tendency in it to spread laterally, it is remarkable how frequently, even in extensive peritoneal cancer, the muscular and mucous coats escape. When the disease extends inwards, growths of cancer, continuous with those, placed externally, perforate the muscular coat, which generally be- comes at the same time increased in thickness and marked with vertical bands, of which some appear to be simply fibrous. Subsequently the . 62 DISEASES OF THE INTESTTNES AKD PEEITOIIEUM. disease invades the sub-mucous tissue, in whioh it spreads both laterally and vertically, forming a more or less well-defined, rounded, or nodulated tumor, at first beneath the mucous membrane which is still movable over it, then involving that membrane, and rendering it smooth and fixed. At this stage nodules of cancer, having no apparent continuity with preexist- ing cancerous masses, are apt to appear in the substance of the mucous membrane. Then soon ulceration takes place, which is sometimes pre- ceded by the formation of a kind of false membrane on the diseased sur- face, and is often attended with more or less sloughing of the cancerous mass. The diseased tract thus becomes excavated, and then presents either a hard, smooth, cupped surface, or one in which fungous granula- tions are intermixed with sloughing hollows; the edges being thickened, and either oaUous and tolerably smooth, or sprouting out with cancerous ■excrescences. The direct ill-effects of cancer of the bowels are various. In some uases, especially when the mucous membrane is involved in some consid- erable area, diarrhoea of a more or less uncontrollable character contrib- utes to hasten the patient's death; in other cases, and generally when the large intestine is the seat of disease, and a limited portion of bowel only is involved, stricture takes place; in other cases, serious or fatal nsemorrhage arises, either from the general surface of an ulcer, or in con- sequence of the erosion of some large vessel in the progress of the ulcera- tion; and in other cases, again, the bowel opens into the peritoneum, and extravasation of its contents and peritonitis ensue, or communications take place between it and other portions of bowel, or other organs, giving rise to special symptoms of more or less urgency and danger. The different kinds of cancer affect the bowels in much the same pro- portion as they affect the stomach; and present, as they do in the latter organ, certain specific peculiarities which may be briefly adverted to. Scirrhus tends to produce contraction of the parts which it involves, and is especially that form of cancer which causes stricture. The ulcer which it yields is very often smooth and excavated; but sometimes, when scir- rhus extends from the outer part of the bowel to the mucous membrane, it assumes in the latter situation the character of soft cancer, and forms there projecting growths, or an ulcer with a tendency to sprout. Enceph- aloid cancer presents various degrees of softness and vascularity, and rarely causes obstruction of the bowel, except by the formation of a tumor, or series of tumors, springing from its mucous aspect and project- ing into its cavity. The tumors are rounded, or lobulated, or even vil- lous, and have a great tendency to ulcerate or slough, and bleed. The melanotic variety of encephaloid rarely affects the intestines except sec- ondarily, and in the form of minute discrete black spots, scattered for the most part over the peritoneal surface. Epithelial cancer occasionally involves the rectum by spreading to it from the uterus and vagina; and occasionally, also, arises independently in the lower part of that tube. I am not, however, aware that it ever originates, or is indeed found, in other parts of the intestinal canal. Colloid cancer, or (if it be preferred) colloid disease, affects the bowel usually like scirrhus and encephaloid, from the peritoneal surface, and gradually, like them extending through the intestinal walls, spreads pretty widely in the substance of the mucous membrane, at the surface of which it appears in the form of groups of minute vesicles, reminding one of patches of herpes or of eczema, or (if the fibraid element be in excess) in the form of whitish wheals not unlike those of scirrhus. These become eroded, or more or less excavated, but OANCEEOrS AND OTHEB GEOWTHS OF THE INTESTINES. 63 remain pretty smooth, and secrete in abundance the transparent glairy fluid, with which the interstices of colloid material are filled. Colloid cancer comparatively rarely involves the mucous membrane of the bowel, at any rate to a serious extent. It sometimes appears in the csecum, sig- moid flexure, or rectum, as a primary disease. Mr. W. Adams' records a case in which a colloid tumor, as large as the fist, springing from the posterior part of the rectum, projected into it, and caused symptoms of stricture. It is difficult, if not impossible, to discuss the symptoms and treat- ment of intestinal cancer apart from the symptoms and treatment of abdominal cancer generally, or from those of cancer of the stomach and »ectum, or from those of its chief local consequences, — namely, obstruc- Uon and perforation; it is, moreover, needless, for these are all considered at length in other articles. (2) Mbroid infiltration and thickening, identical with the fibroid form jf so-called " scirrhous " pylorus, is met with occasionally in the bowels, where also it constitutes one form of " scirrhus." Its chief, perhaps only, •seats are the sigmoid flexure and rectum, where it produces results re- sembling in almost every particular those which have been described as belonging to true scirrhus. It seems, however, to difEer from' that in its purely local character, in the absence of all secondary deposits, as well as in its elementary constitution. (3) ViUoics growths are of occasional occurrence in the large intestine, particularly in the sigmoid flexure and rectum. They generally occupy a limited and well-defined area, which sometimes amounts to three or four square inches or more, and sometimes encircles the gut. The portion of the parietes corresponding to the villous surface is always infiltrated and thickened to a greater or less degree with a kind of fibroid material, which forms the basis from which the villous excrescences spring. The mucous coat and sub-mucous tissue are the parts principally thus afEected, and sometimes indeed grow out into a tumor with a constricted neck. The villi are abundant and close-set, easily distinguishable, especially if the tumor be floated in water, often of considerable length, conical, cylin- drical or club-shaped, and branching. As we have already seen, villous outgrowths are sometimes distinctly cancerous; but certainly most of those which have been met with in the large intestine seem clearly to have been of a benign character. The presence of a villous tumor some- times causes hasmorrhage from the bowels, or dysenteric diarrhoea; but its ultimate tendency seems always to produce obstruction. In most of the recorded cases death has been the result of stricture. Occasionally, when the growth is situated but a short distance from the anus, it admits of removal by operation. (4) Polypi, or outgrowths of a non-malignant character, are not very infrequently discovered post mortem attached to the intestinal mucous membrane, especially to that of the lower part of the Ueum, ascending colon, and rectum, and are sometimes present here in vast numbers. They seem generally to resemble ordinary cutaneous fibro-cellular or molluscous tumors, and consist, like them, of an outgrowth of connective tissue in- vested in a layer of mucous membrane, which still for the most part pre- sents its normal structure. It seems not improbable that they occasion- ally originate in connection with the edges of ulcerated patches; but they doubtless more frequently arise independently of any discoverable pre- ' Path. Soo. Trans, vol. i. 64 DISEASES OF THE INTESTINES AND PERITONE0M. existing cause. In an early stage they form mere rounded bead-like excrescences, looking like enlarged solitary glands; but they soon elon- gate, and generally at the same time increase in some degree iii other dimensions. When thoroughly developed, they form for the most part cylindrical outgrowths from about a quarter of an inch to an inch in length, and from the thickness of a probe up to that of a director, with extremities which are sometimes bulbous and cauliflower-like, and then highly vascular, and tending to bleed. Sometimes they occur in groups of two or three, or twc or three spring from the same pedicle. In the lower part of the ileum, similar bodies, but of a flatter and more leaf-like character, appear occasionally to be produced by mere elongation of por- tions of valvulae conniventes. The polypi which have just been described are, as far as I know, of little or no consequence; they occur in persons of all ages and of both sexes, and do not seem to cause any symptoms. Solitary polypi, however, sometimes attain a large size, and may then pro- duce great inconvenience, if not more serious mischief. Pedunculated fibro-cellular polypi from any size up to that of a small pear are now and then met with in the ileum, and are supposed to occasionally cause intus- susception; their most common seat, however, is the rectum, in which situation they cause irritation of the bowels, tenesmus, more or less copi- ous bleeding, and other discomforts. These solitary tumors are generally pretty smooth, but are sometimes lobulated or even warty, and mostly abundantly vascular on the surface. (5) Other growths in the intestinal walls are of no practical import- ance; they are rare, are not productive of symptoms, and do not there- fore call for description. Among them may be enumerated circumscribed sub-mucous deposits of fat; small cysts in the same situation; erectile tumors (Rokitansky ' considers the polypi above described as being erec- tile) ; and glandular tumors (in two cases " I have met with tumors in the small intestine which resembled the pancreas accurately in structure). Lastly, it may be mentioned that calcareous matter is sometimes deposited in small masses, either on the peritoneal or mucous surface, or in the sub- stance of the intestinal walls. ^ ' Path. Anat. Syd. Soc. Tians. ToL ii. * Dr. Montgomeiy, Path. Soo. Txans. vol. zii. p. 130. DISEASES OF THE C^CUM AND APPENDIX VERMIFORMIS. By John Stee Beistowb, M.D,, F.R.C.P. The caecum and its appendix are liable, in a greater or less degree, to all those affections which have been described as incidental to the intes- tinal canal generally. But while some occur here comparatively rarely, or are of trivial consequence when they do occur, others (owing partly to the connections and position of the organs, partly to their capacity and shape, and partly to their structural peculiarities) involve them with ex- ceptional frequency, or induce results which are characteristic either in their gravity or in some of the other features which they present. I. Gbnbeal Account of Diseases of C^cum and Appendix. — Inflammation in its simpler forms affects the caecum at least as frequently as it affects any other part of the gastro-intestinal mucous membrane. Dysenteric inflammation is only less common here than it is in the rectum and sigmoid flexure. Ulceration of a non-specific kind is perhaps more often met with in the csecum than in any other named tract of bowel. The ulceration of enteric fever is always more extensive and more ad- vanced in the caecum than in the colon or rectum, and occurs in it about half as frequently as it occurs in the ileum. Tubercular disease, which affects the large and small intestine with equal frequency, is also generally more severe in the caecum than in other parts of the large intestine. Can- cerous diseases are not very uncommon in this part. And again, the de- generative results of chronic inflammation, and of lardaceous and other forms of deposit, and polypoid growths, occur equally in the caecum and in the colon and lower part of the ileum. The Ueo-caecal valve and ver miform appendix are for the most part involved whenever the caecum h the subject of any of the morbid processes which have just been enumer ated. The margins of the valve are indeed not infrequently destroyed by ulceration. And the appendix especially rarely fails to present more or less ulceration when typhoid or tubercular deposits occur in other parts of the large intestine. Strictures of the caecum form (according to Dr. Brinton) 4 per cent, of fatal strictures of the large intestme. Some degree of contraction at this part is, however, a good deal more common than these figures would seem to indicate. The causes of contraction are, cancerous or other deposit or growth in the walls, and the cicatrization which follows ulceration, especially tubercular and dysenteric ulceration. Dilatation of the caecum occurs casually, as dilatation occurs in other parts of the intestinal tract, from the temporary accumulation of faecal matters, or flatus, or both. And it occurs also, as in other situations, as a result of obstructive disease in some part of the bowel below it. In this case the dilatation may be- 5 66 DISEASES OF TECE rFTTESTnTES AND PEEITONBDM. come very great; and according to circumstances the parietes may be thinned or hypertrophied. It is a point of some importance that not in- frequently, even when obstruction is pretty low down, the caecum is more largely dilated than the length of bowel between it and the seat of ob- struction. Perforation of the caecum is far from uncommon. Sometimes this ensues on long-continued distention, either from thinning, softening and sudden laceration, or from the ulceration which so frequently attend® dis- tention. Sometimes it is caused by simple perforating ulcer, or by the irritation of some foreign body which has been swallowed, has traversed the small intestine safely, and has become arrested in the caecal pouch. Sometimes it oecursi in the course of dysentery, enteric fever, and tuber- culosis. Sometimes it is a result of cancerous ulceration. And some- times it depends on diseases outside the bowel, such, for example, as can- cer occupying the venter ilei, or the extension of a psoas, renal, hepatic, pleural, or other abscess. Perforation may take place directly into the peritoneum, lighting up fatal peritonitis'; or it may establish a communi- cation between the cavity of the bowel and the sub-serous cellular tissue of the venter ilei, or some adjoining part, and lead to the formation of a faecal abscess; or again, it may cause a communication with some adhe- rent coil of small intestine. We can scarcely speak of stricture of the appendix vermiformis; yet occasionally, as a result of ulcerative destruction of the mucous membrane or of other morbid processes, the whole organ becomes shrivelled up or atrophied. Dilatation, too, sometimes occurs when its orifice is obliter- ated or obstructed. Then the appendix becomes elongated and plump toerhaps as thick as the little finger),, presents often false diverticula (resembling on a small scale those of a sacculated bladder), and is dis- tended with a glairy transparent fluid, the secretion of the mucous mem- brane. Again, the appendix is apt to become perforated. This accident may be caused in any of the several ways in which the caecum itself be- comes perforated. It occurs sometimes perhaps as a result of mere ordi- nary ulceration. Dr. Murchison' records a case in which it happened in the course of typhoid fever, but where there was no escape of faecal mat- ter. Leudet^ states that out of thirteen cases of perforation of the appen- dix, which he observed, six were due to tuberculosis. This statement, however, is certainly not in aeoordanee with general observation. The usual cause indeed of perforation is undoubtedly the presence of some concretion which, by fretting the surface with which it is in contact, ex- cites ulceration, to which the perforation is consecutive. Fasces habitu- ally find an entrance into the appendix; but their entrance and escape constitute a normal process on which as a rule no ill consequences super- vene. Together with the faeces, however, insoluble bodies of small size^— «eeds, bristles, pins, pieces of bone, shot^are apt to enter the appendix; and some of these, from their pointed or angular form, or from their size, become retained and cause ulceration. Perforation has been caused by bristles, by pins, and by pieces of bone : and indeed it was formerly gen- erally believed that the foreign bodies causing perforation were all of ex- ternal origin, and for the most part cherry or dater-stones, or stones of a similar character. There seems no doubt, however, that bodies of this ' Path. Trans, vol; xvii. p. 137. * AicMt. Gen. Ang. and Bwt, 1859, and New Sydenham Society's Year Book for 1860. DISEASES OP THE C^OUM AWD APPENDIX VEEMIFORMIS. 67 bulk rarely find their way into the appendix, and that what have been mistaken for them have been concretions resembling them somewhat in size and shape, but differing from them in origin and in constitution. The concretions generally met with vary from perhaps the size of a small pea to that of a date-stone: they are sometimes of waxy consistence and lus- tre throughout; sometimes brownish, for the most part fsecal, and lami- nated; sometimes again composed almost entirely of earthy phosphates; they consist obviously of the admixture, in unequal proportions, of ordi- nary faecal matters and of the secretions from the mucous membrane of the appendix, and have obviously formed in the situation in which they are_ found, either round a nucleus of solid matter which has been first pre- cipitated and concreted there, or round some comparatively small body of extraneous origin. Sometimes two or three of these concretions are pres- ent at the same time. Perforation of the appendix occurs at any part, sonietimes at or near its base, sometimes at its point or within half an inch of it, sometimes again in some intermediate spot. The resulting orifice varies in shape and size. Perforation may take place directly into the peritoneal cavity, causing generally acute and rapidly fatal peritonitis, sometimes a circumscribed peritoneal abscess; or actual perforation may be preceded by adhesion of the appendix to neighboring parts, and the: formation of a limited abscess either among the adhesions or in the Sur- rounding structures. It may be added here, in order to complete' our summary of diseases- incidental to the cascum and appendix: that the most common form of intussusception, and the most frequent in children, is that in which the caecum is engaged; that the csecum is occasiona,lly the subject of internal strangulation, and that more frequently its appendage takes part in the production of strangulation of other parts of the intestine; and lastly, that the caecum and its appendage, together or separately, are not very infrequently contained in an ordinary hernial sac. II. — ULCBEATioiir AisTD Peefoeatiok or THE C^cuM AND Vebmipoem: Appendix. — (a) Pathology. — The terms "Typhlitis " and " Perityphlitis," — ^the former signifying inflammation of the walls of the caecum, the latter inflammation in the tissues surrounding the caecum,r — are used frequently, though somewhat vaguely and indiscriminately; but I believe are generally applied to those cases in which there is perforative ulceration either of the caecum or of its appendix, and in which, therefore, there is either limited suppuration in the neighborhood of these parts, or sudden peri- tonitis. The perforation in the great majority of cases, no doubt, occurs in the appendix vermif ormis : sometimes, however, it occurs in the caecum itself, beginning there generally from ulceration of the mucous membrane, but occasionally from an abscess situated upon its outer surface. The results which ensue have already beea briefly enumerated. In some instances the ulcer perforates that portion of the bowel which, corresponds to the mesenteric attachment, or,, if occurring elsewhere in the bowel, the area in which perforation is about to take place becoiites' adherent to some viscus in the vicinity, or to some portion of the parietes of the true or false pelvis. The morbid process may stop at that point; or the escape of faecal matter and flatus into andi among the tissues may lead to the formation of an abscess, with more or less surrounding inflam- mation and induration. In the latter event the abscess usually enlarges pretty rapidly, and in enlarging takes a course dependent more or less oni its original position,, in one case descending into the pelvis^ and opening perhaps into the rectum,, in another passing out withi the pyriformis; muscls' 68 DISEASES OF THE INTESTD^ES AND PEEITOWETJM. and presenting in or below the buttcck, in another forming a lump in the groin immediately above Poupart's ligament, or passing along the inguinal canal towards the scrotum, or along the psoas and iliacus muscles into the upper part of the thigh. But indeed, when once an abscess has formed, although it may tend as a rule to elect one of several courses, there is scarcely any conceivable direction which under certain circumstances it may not take. No doubt it generally presents itseK in the groin as a hardness or lump superficial to the position which the c£ecum normally oc- cupies. An abscess of this kind may empty itself and become healed by discharging its contents either through the orifice in the caecum which gave rise to it, or through an opening at any one of the spots at which, as has been shown, it may present; or having burrowed largely it may form a sinus or series of sinuses which never become obliterated. The communication between the abscess and the caecum is sometimes main- tained, at other times is more or less speedily obliterated. In other cases the bowel ruptures directly into the peritoneum, exciting at once acute peritoneal inflammation. This may be so severe as almost directly to prove fatal: but in most cases the patient survives sufficiently long to allow of the more or less complete obliteration by adhesion of the general cavity of the peritoneum, and the formation in the vicinity of the perforated bowel of a circumscribed peritoneal abscess. It is not improb- able that in some cases the perityphlitic abscesses, the course and progress of which have been already discussed, are really peritoneal abscesses. And it may be added that the abscesses originally unconnected with the peritoneum not infrequently open suddenly into it and evoke, as does the sudden rupture into it of the caecum or of its appendix, sudden and severe inflammation there. The statistics of " Typhlitis," using this term as expressive of all the morbid conditions which have just been described, are not very easy to obtaia. But as regards the statistics of that section of typhlitis which relates to perforation of the caecal appendage followed by fatal results, they seem to show very conclusively that this accident occurs chiefly in early life, and much more frequently in males than in females. Thus, in ten cases analyzed by Bamberger,' eight were males, two females; eight were below thirty years of age, two above thirty. In thirty-two cases collected by Dr. Crisp," twenty-nine were males, three females; five were under ten years, thirteen between ten and twenty, seven between twenty and forty, and seven between forty and sixty. And in eight cases recorded in the " Pathological Transactions " since the publication therein of Dr. Crisp's paper, five were males, three females; and their ages ranged from thirteen to thirty-four. The duration of typhlitis must obviously be very various. When the perforation takes place directly into the peritoneum, death for the most part ensues speedily — generally indeed in from three days to a week; life may, however, even in this case be prolonged in consequence of the for- mation of a circumscribed peritoneal abscess, to two or three weeks or more, and it is not impossible that under the latter condition recovery sometimes takes place. In seven of Bamberger's cases the duration of the illness varied between twenty and fifty days. But when a faecal abscess forms in the tissues in the neighborhood of the csecum no definite > TTebei die Peiforation des wnimfoTmigen Anhangs. : Schmidt's Jahrb. 1859, vol. d., p. 184 ' Path. Trans, vol. x., p. iSl. DISEASES OP THE C^CUM AND APPENDIX VEEMIFOEMIS. 69 limits can possibly be assigned to the duration of the case; sometimes the patient recovers pretty speedily; sometimes, the case, having got appar- ently into a chronic state, proves suddenly fatal with symptoms of peri- tonitis; sometimes again the patient lingers for months, or even years, with a constantly discharging abscess or a succession of abscesses, {b) _ Symptoms. — The symptoms which attend and indicate typhlitis are mainly either those of acute peritonitis, or those of local suppuration, or a complex of both. In those cases in which sudden rupture takes place into the peritoneum, there are very often no premonitory symp- toms whatever; occasionally, however, some localized uneasiness or pain, due to the ulceration which is taking place, or to some inflammation of the peritoneal surface corresponding to the seat of ulceration, precedes for a longer or shorter time the violent outbreak. The patient, while in the enjoyment apparently of perfectly good health, and at the moment probably of making some muscular effort, is attacked with sudden acute pain in the region of the caecum, followed speedily by collapse, and the diffusion of pain and tenderness over the whole extent of the abdomen. The symptoms in fact of acute peritonitis are almost instantaneously set up, symptoms which only differ from those of idiopathic peritonitis in the suddenness of their invasion and the severity of the collapse, and differ in no degree from those which attend rupture of the bowel from other causes, rupture of the stomach, or rupture of the bladder. It is needless to dwell on the character of the abdominal pain and tenderness, and on the tympanitic condition of abdomen which ensues, on the dorsal decubi- tus which the patient is generally compelled to assume, on the quickness and shallowness of his respiratory acts, on his feebleness of pulse, shrunken and anxious expression, and for the most part frequent vomit- ings and hiccough. But it may be observed, that in spite of, or rather perhaps in consequence of, the unbearableness of his pain, the patient sometimes assumes positions and makes contortions of his body which might seem to be incompatible with the presence of acute peritonitis; that sometimes the peritonitic indications remain pretty strictly limited to the neighborhood in which they commenced, and that very frequently indeed they do not extend above the line formed by the transverse colon; and that sometimes as the case proceeds, even towards its fatal issue, general peritonitic symptoms almost entirely subside, leaving perhaps a distinct fulness and dulness and tenderness, due to the formation of a circumscribed abscess, in or about the right lumbar or iliac, or the hypo- gastric region. In those cases in which an abscess forms in the neighborhood of the ceecum, there are in the first instance pain and tenderness in the region of the caecum, together with rigors and other general symptoms of inflam- matory fever. Generally, too, there is some distinct fulness and tender- ness to be felt. The symptoms indeed are for the most part those which might be caused by suppuration, of whatever origin, occupying the venter of the ileum. When the abscess extends downwards into the pelvis, or remains deep-seated, the case is naturally obscure. When, however, it tends to point anteriorly, we find the fulness and hardness become grad- ually more and more pronounced; the fulness in fact grows into a more or less distinctly hemispherical tumor over which the integuments become cedematous and congested. Sometimes, even at this stage, the swelling gradually subsides and disappears, owing to the abscess having dis- charged itself into the bowel; but more frequently it still enlarges and ultimately opens externally, discharging a greater or less amount of foetid 70 DISEASES OP THE INTESTINES AND PEKrrONBtJM. pus, sometimes having a distinct faecal odor, or even obviously containing fascal matter and bubbles of gas. It must, however, be remembered, that not infrequently the communication with the bowel has been cut off, be- fore the abscess opens externally, and that the absence of ordure or of gas does not necessarily show that the abscess has not commended in per- foration of the bowel. Sometimes the abscess, after having discharged itself externally, gradually fills up, and complete and permanent recovery takes place. Sometimes, after it has healed externally and appears to have been cured, it forms afresh and presents in the same, or some other, situation. In other cases it remains as a permanently open fistula, or as an artificial anus. In these latter cases symptoms of hectic come on, the patient becomes thinner and feebler, and though in some cases life may be prolonged for a considerable period, death generally ensues from grad- ual exhaustion at the end of a few months, or at the outside a year or two. There are, however, many cases in which the perforation of the bowel causes abscess in the first instance, and peritonitis subsequently, either in consequence of a fresh intestinal perforation, or of a rupture of the abscess into the peritoneum, or of the mere extension of inflammation by con- tiguity. These are the cases in which, for the most part, perforation of the caecal appendix is said to be preceded by premonitory symptoms; and there can be no doubt that it is chiefly by taking these into consideration that cases of perforation of the appendix are estimatea by Bamberger and others to have a duration so much longer than we know belongs to mere peritonitis the result of perforation. It might naturally be supposed that any disease, affecting so important a part of the alimentary canal as the caecum, would be attended with some disturbance of the functions of that canal. It does not appear, however, that there is any constant disturbance. Sickness is very often entirely absent. Constipation is mentioned as having been present in many cases at or about the time of perforation; but there does not seem to be any definite connection between these two conditions. And diarrhoea not uncommonly supervenes in the course of the disease; but this again would seem to be for the most part a mere accidental phenomenon. There are many diseases, or incidents of disease, with which typhlitis may be confounded. It may be worth while briefly to call attention to some of the more important of them. Acute peritonitis of idiopathic ori- gin may sometimes, from its suddenness and severity, and from its happen- ing to take the lower part of the abdomen as its starting-point, be thought to have its origin in perforation of the appendix. So also may the peri- tonitis caused by perforation of the bowel in enteric fever, especially in those cases in which the febrile symptoms are slight and the patient is not compelled to give up work until the sudden rupture takes place. The same also may be said of all those cases in which peritonitis arises from the perforation of a hollow visous, or of an hydatid or other abscess, from the laceration of the cyst of tubarian or ovarian pregnancy, or from the extension of inflammation from various pelvic organs, especially those of the female. Again, the local suppuration which attends many cases of typhlitis may in some one or other of its stages be easily confounded with abscesses of other kinds, which form in, or find their way into, the region of the ciBcum; among which maybe enumerated, psoas abscesses, and abscesses extending from the kidney, the spinal canal, and the pleura. It maj- similarly be confounded with ovarian tumors or inflammation, with cancerous tumors of the venter ilei or glands in the vicinity ofthecsecum, and even under some circumstances with aneurismal tumors. • DISEASES 01" THE O^OTJM AND APPENDIX VEEMIE0EMI8. 71 (c) Treatment. — The treatment of typhlitis may be dismissed in a few ■words, not because it is unimportant, but because it resolves itseK into the treatment of enteritis and the treatment of a localized suppuration: the former of which has been discussed elsewhere La this volume; the latter of which is mainly a surgical question. As regards those cases in which there is a direct communication between the bowel and the peritoneum, our main reliance must be placed upon opium; which must be adminis- tered, partly with the object of relieving pain, partly with the object of restraining intestinal movements and preventing further escape of faecal matters. For similar reasons, all purgative medicines must be most carefully avoided. In reference to the employment of local measures, such as leeching, fomentation, and the like, no special observations need be made. It is most important of course to administer nourishment and stimulants; and owing to the comparative absence of vomiting, their administration by the mouth can for the most part be much more readily carried out than in cases of enteritis or of obstruction. It is, however, at the same time essential that the bowels should not be overloaded, and therefore that the food which is thus given should be nutritious, capable of easy digestion and absorption, and given in small quantities at frequent intervals. But here indeed, as in many other cases of stomach and bowel disease, it is important to consider how far we may supplement or replace the duties of the stomach and smaller intestine in the absorption of nutriment, by the regular employment of nutritious enemata. When we have to deal with a case of inflammation, circumseribed in the situation of the cascum, it need scarcely be said that leeching, poulticing, fomentation, and other local remedial measures will naturally be called into requisition; and that, so soon as there are clear indications of the presence of pus, an opening should be made for its evacuation; and that the abscess having been once opened should if possible be kept open, until we have evidence that its deeper parts or ramifications have become healed. In cases of this kind also the use of opium, though not so universally imperative as where there is peritonitis, is generally desirable if not indispensable; and in them also, purgatives, though not perhaps to be absolutely prohibited, should be employed exceptionally only, and with the greatest caution, — ^indeed there can be little doubt that if constipation be sufficiently obstinate to call for medical relief, relief will be afforded best, and by far most safely, by the use of enemata. Lastly, in these cases, as in all cases where there ia abundant and long-continued suppuration and hectic, it is of paramount importance that the patient should be sustained by abundance of nutri- tious food, that he should have habitually a fair proportion of stimulus, and that the use of tonic medicines, especially vegetable bitters, and tonio treatment genera.lly, should be systematically enforced. COLIC. Bt J. Waebueton Bbgbie, M.D.j F.R.C.P.E, Thb term Colic is derived from the Greek KZXov, the colon, or large intestine, DEriN-iTiOK. — The essential character of Colic, as ordinarily under- stood, is severe pain in the abdomen (in a restricted view, in the colon), augmenting for a time in severity, and then gradually subsiding; occur- ring in paroxysms, not stationary, but, on the contrary, moving from place to place, accompanied by a sense of constriction and tearing, for the most part also by that of expulsion, _ The term Colic is now used in nearly the same way as the ancient writers employed that of KraXtKos, It is, however, abundantly evident that the disease described under that name, by Aretseus, for example, was of a much more serious nature than ordinary colic; it was indeed a fre- quently fatal disorder. In treating of Colics, Ilept KwXlkZv, the learned Cappadocian physician remarks: KokiKol Si] KTeivovrai eiXom koI arp6<^m dfeojs. By Linnaeus, among the early nosologists. Colic is placed in the class " Dolorosi," and is thus defined: "Intestini dolor umbilicalis cum tormini- bus." Vogel, using a similar expression to denote the class, explains the disease as follows: "Dolores: Colica, dolor spasticus intestinorum cum obstipatione, nausea, et vomitu." Sauvage more simply and briefly styles Colic" Dolor intestinorum;" and Cullen, correctly assigning the disease a position in the class " Neuroses " of his nosological system, of which "Spasmi"is the third order, has thus described it: "Dolor abdominis, prseoipue circa umbilicumtorquens; vomitus; alvus adstricta." By French and German writers the terms " Colique " and " Die Kolik " are respect- ively employed when treating of this disease. A vast variety of painful spasmodic affections have been described under the name of Colic. Of these it may only be necessary to adduce as illustrations the following: "Colica Hepatica," "Colica Nephritica," " Colica Uterina," as applied to spasmodic pain, sudden in its occurrence, and apparently affecting the liver, kidneys, or uterus. These expressions are eminently faulty, and it is desirable that their use should be entirely abandoned. It is to the consideration of the true or simple Colic, the " Colica spas- modica " of not a few writers, that the present article wUl be devoted, " Lead Colic," or " Colica Piotonum," and for which many other syn- onyms have been employed, will be separately considered, while the occur- rence of CoHc, or of colicky pains, as a symptom of different abdominal affections, inflammatory and otherwise, will be noticed in the descriptions of these maladies themselves. Stmptomatologt of Colic, — As has already been stated in the defi- 74 DISEASES OB" THE INTESTINES AND PEEITONEirM, nition of Colic, pain is its essential and most characteristic feature. This pain is seldom continued or uniform for any length of time, but, on the contrary, is marked by the occurrence of remissions or intermissions, and likewise by exacerbations, which are frequently of very great, even intense severity. So extreme is the pain of Colic at times as to cause persons of heroism to utter loud groans and cries. While the whole abdomen or any part of it may be the. seat of suffering, the peculiar twisting pain is spe- cially experienced in the situation of the umbilicus, as CuUen observed; " praecipue circa umbUicum torquens." ' Great restlessness and frequent turning of the body, changing from place to place, distinguish the sufferer from Colic. He does not rest in bed, but is prone to rise and pace up and down the room; bending forwards, he presses his hands over the belly; and when the pain augments in severity is glad to fling himself on his face on the bed or sofa. Usually, while the pain lasts, the trunk is flexed, the upper part bent forward over the lower. If the patient be in bed and lying on the back, the lower limbs with bent knees are often brought in contact with the abdominal parietes, and are thus retained for some time by his hands. A position of this kind is meant when French writerSj in reference to the sufferer from Colic, use the expression, "le malade se pelotonne," the patient rolls himself into a ball. By very^ firm pressure over the abdomen, as by lying on the belly, the pain is sometimes miti- gated or even for a time removed, and this circumstance is of some impor- tance in distinguishing a spasmodic from an inflammatory pain, in so far as the latter is invariably aggravated by pressure. The form of the abdomen is altered during the continuance of Colic. There may be, and this condition is fully the more frequent, distention, with which there is associated the development of flatus on a large scale, or the parietes of the abdomen may, on the other hand, be retracted. The condition of a distended colon, the seat of pain, may be mistaken for that of gastric distention and pain. When the former, however, occurs, as a phenomenon of the attack of Colic, there are present also other indications of intestinal suffering, such as irregular contractions which may frequently be felt by the hand or seen, borborygmi, and specially the sense of bearing down towards, and constriction at, the anus. Besides, as Dr. Wilson Fox" has pointed out, pain arising from the large intestines is seldom felt so much at the ensiform cartilage (the common seat of gastric uneasiness) as in the right or left hypochondriac regions, while there exists a distinct difference between the notes to be elicited on percussion, from the two or- gans; that from a distended colon being the less prolonged, and having a higher pitch. Great general depression is capable of being produced by an attack of Colic. This is seen in the frequently pale countenance of the sufferer, whose pulse also is found to be extremely feeble, while the surface of the body is bedewed with a cold and clammy perspiration. The relation of constipation to Colic is most important. A confined condition of the bowels is usually, though not invariably as some writers have asserted, associated with Colic; and not unfrequently, when the bowels have been ' A recent, perhaps the most recent, French writer on Colic (M. Martinean), in de- Bcribing the pain, remarks : " La douleur est toute speciaJe. Les malades en proie.3 line colique eprouveiit une douleur vive, exacerbante, mobile, ayant una grande ten- dance a s'irradier. BUe se traduit par une sensation de constriqfcion, de resserrement, de tortillement, ou par uue sensation de deohirure et mfime d' expulsion. — ffamecm ZHepionncdre de Medecine et de OM/rwrgie pratigue, vol. viii. " The Diagnosis and Treatment of the Varieties of Dyspepsia, p. 53. COLIC. 75 efficiently acted on by medicine, the pain, which may have been of the severest type, entirely disappears. Neither is this latter however, the constant result, for,_ notwithstanding the operation of laxative and cathar- tic remedies, the pain Lq some instances proves persistent. Such cases are infinitely less alarming than those in which obstruction of the bowels con- tinues, while the abdominal pain either diminishes or disappears, for in these _ circumstances the occurrencCj sooner or later, of a regular attack of ileus is to be apprehended; whUe in the former case, the free movement of the bowels, although not immediately, and it maybe not even speedily, bringingrelief to suffering, is surely succeeded by such before any length- ened period has passed. In some instances of Colic, a confined condition of the bowels is really the cause of the attack of painful spasm, while in others the constipation is the effect of the spasm. In the more protracted oases of Colic, a general febrile state is liable to be induced. Vomiting may accompany Colic, but is by no means a constant or characteristic symptom of this disorder. Much importance is to be attached to the pulse in Colic, for by its condition we are not unfrequently able to distin- guish between a simple, although severe spasmodic affection, and an in- flammatory disorder. It is to be remembered moreover, that in some cir- cumstances the latter is not unapt to supervene upon the former. Now, in Colic, while the suffering is even intense, the pulse may be little if at all altered. Assuredly it is by no means uncommon to find the pulse under such circumstances remaining tranquil, and in fact altogether nor- mal. Smallness of the pulse, associated with marked depression of the circulation generally, hardness and irregularity, are, on the other hand, of sufiiciently frequent occurrence in cases of Colic' The respiration is hur- ried, and frequently unequal. The voice is apt to be affected in cases of marked severity; it becomes hoarse, while at times it is so enfeebled as to be almost obliterated. The accession of Colic is by no means uniform or exact. The disease may be established suddenly, even abruptly, and with- out any apparent cause, or it may come on gradually, succeeding the oc- currence, for a time longer or shorter, of abdominal uneasiness, and very probably of occasional cramps, which are clearly traceable to some suffi- cient cause. Not less variable are the progress and duration of the malady. It may exist for days, or last only for hours, or even minutes. These irregularities are largely determined by the precise causes of the attacks. An irregular intermittence is a characteristic feature of Colic; the duration of the painful seizures, and of the intervals which separate them, being subject to great variety. Pathology of Colic. — Although the relation of the abdominal pain and spasm in Colic to nerve irritation, is obscure, the following remarks appear to be called for. It has been clearly shown by carefully conducted experiments, and is now admitted, that the pneumogastric nerves possess an influence on the movements of the intestinal canal. Such experiments as those referred to have exhibited the contractions of the muscular coats of the intestines under the application of electrical irritation to the vagi, of as rapid and violent a character as those of voluntary muscles, when their motor nerves have been subjected to a similar irritation. Again, when on irritating the ganglionic plexuses surrounding the aorta, by means of the rotary apparatus (durch den rotatorischen Apparat), the small intestines and colon, which had been previously wholly inactive, ' In describing the pulse of Colic, Henoch remarks, " Der Puis ist klein und hart- lioh." (KiTTiilr der Unterleibs-Kranlth eiten. 1 76 DISEASES OF THE rNTESTTNES AND PEEErONEUM. when the current began to operate were seized with universally active movements, which continued for a long time after the current was inter- rupted. It is of further interest to note, that among central portions of the nervous system it is the meduUa oblongata which, when irritated by the galvanic current, excites in a decided manner the movements of the stomach and the intestinal canal. Budge saw the same result produced in rabbits, but in a less degree, by irritation of the cerebellum. The spinal cord and cerebrum possess no such influence. All experimenters' have described the movements of the intestinal canal as distinctly peri- staltic or vermicular.' M. Martineau, in his interesting article on Colic to which reference has been made, has pointed out that while the pneumo- gastric nerve is more especially distributed, as is well known, to the stom- ach and liver, a portion of the right nerve passes to the semi-lunar ganglia to anastomose with the splanchnic nerves of the great sympathetic, and thus to form the solar plexus. Galvanization of the solar plexus and of the superior mesenteric ganglia equally causes contraction of the small intestine and more rarely of the large. Valentin has made the very im- portant observation that an irritation of the fifth nerve, at the base of the skull, invariably gives rise to peristaltic movements of the small intestine, especially of the duodenum and upper part of the jejunum. Such being proved experimentally, we can understand the occurrence of intestinal spasm or Colic, as the direct consequence of some forms of cerebral irrita- tion. And although, as Romberg has remarked, little is known respecting the influence which is exerted by the affections of the spinal cord and brain, upon spasms of the bowels, the very potent operation of the emotions, fear and fright especially, but in some instances also joy, in increasing the movements of the intestines is thoroughly appreciated. Etiologt of Colic. — Certain temperaments appear to predispose to the occurrence of Colic. Of these the nervous and lymphatic are the most distinguished. Sedentary occupations act in the same manner. The influence of age and sex is sufficiently marked to be worthy of notice. In youth and adult age. Colic is more common than in advanced life, and among females it occurs more frequently than among males. Among the exciting causes of Colic, one of the most frequent is the presence of some indigestible article of food in the bowels. The influence of cold in pro- ducing attacks of Colic is also remarkable, and particularly, it has been noticed, cold applied to the feet. There are some individuals who are certain to suffer from an attack of Colic, if by any means their feet have become cold. The association of biliary derangement with the occurrence of intestinal spasm is not uncommon, and this particular form of the dis- ease has been designated " Bilious Colic." Its distinctive features are the vomiting of bUiary matters, and the presence of a more or less icteric tint of the conjunctivae and surface of the body. Lastly, under this head, it is to be held in remembrance that in some instances the existence of a gouty or rheumatic habit of body plays a decided part in the origination of attacks of Colic, although it may probably be admitted that such con- stitutional disorders are stUl more potent in determining the true enter- algia or neuralgia of the bowels, a disease which is to be distinguished from Colic. Tebatment of Colic. — To relieve pain, and generally speaking to act on the confined bowels, are the chief indications for treatment in Colic. In the milder instances of the disease, unaccompanied by any notable de- ' Romberg, Lehibuch der Nervenkrankheiten des Mensohen ; DarnLkrampf. COLIC. 11 rangement of the " primae vise," this can usually be accomplished by the external application of warmth, or of rubefacients, such as mustard and turpentine, and by the administration of a little stimulant, or carminative mixture. A small quantity of brandy with hot water, a teaspoonful of the compound tincture of cardamoms in warm water, or twenty drops of the compound tincture of chloroform, will be found very serviceable for this purpose. Preparations of peppermint, ginger, and cloves may also be similarly employed. In more severe cases of Colic, or in instances where the remedies already mentioned have failed to relieve the pain, it will be necessary to administer anodyne medicines, and as early as possi- ble to evacuate the bowels. The preparations of opium are most useful among the former; the compound tincture of camphor or English pare- goric — in doses of thirty to sixty minims — or a full dose of laudanum. With these a dose of castor-oil, or compound rhubarb powder (Gregory's mixture), should be given, and repeated after a short interval if relief to pain and solution of the bowels be not obtained. A tablespoonful of castor-oil with twenty-five drops of laudanum in peppermint water, or two teaspoonfuls of Gregory's mixture with a tea- spoonful of compound tincture of camphor, and a similar quantity of aromatic spirit of ammonia in a small wineglassful of cinnamon water, will be found most available prescriptions in such cases. When the attack of Colic has speedily succeeded the taking of some indigestible article of food, it may be advisable to produce vomiting by the administration of an emetic of ipecacuanha wine, or by draughts of hot water. Should the bowels not respond to the mild remedies already mentioned, it will be necessary to have recourse to the use of stronger cathartics. Of these, sulphate of magnesia, particularly with the addition of a little sulphuric acid, as Henry's salts, and senna, also the compound jalap pow- der and calomel, may be regarded as the chief. The employment of laxative enemata should also be had recourse to. A large injection of warm water will frequently be found most useful in relieving the pain, and in effectually acting on the bowels in cases of Colic. The prophylactic treatment of Colic consists in a careful regulation of diet, particularly in the avoidance of all indigestible articles of food, and in the protection of the surface of the body from the injurious influence of cold. Wearing flannel over the abdomen, and the warm covering of the feet, are especially to be enjoined. COLITIS. Bt J. Waebueton Bbgbije, M.D., F.R.C.P.E. There seems to be some ground, at all events for supposing that the large intestine may be the seat of inflammatory action, differing in essen- tial particulars from the dysenteric process which will be immediately described. To indicate the simiple inflammation of the colon, as distin- guished from dysentery, the term Colitis has been employed. Golonitis has been used in the same sense. The French have the word Golite, and the Germans the expression JEhtzundung des Schleimhautes des Kolons. In dysentery the mucous membrane of the rectum and colon is prima- rily involved while the pathological changes which are so eminently char- acteristic of the disease are wrought in it. In Colitis, on the other hand, there is in all probability a commencement of inflammation in the sub- mucous or connective tissue, which underlies the mucous membrane, the glandular structures of the latter being in the first instance uninvolved. The result, however, is a diffuse gangrenous inflammation of the mucous membrane; and when this has occurred, there is no possibility of distin- guishing the ulceration thus formed from that which has resulted from the dysenteric process. It is, however, to be borne in mind that the most experienced physi- cians and ablest writers have differed in respect to the essential pathology and the characteristic morbid appearances in dysentery. The necessary ex- istence of ulceration has, for example, been denied by some, and the special participation of the glandular structures of the colon, so commonly con- ceived to hold true of dysentery, has been equally opposed by others. In these circumstances it must be admitted that great difficulty at present exists in the way of correctly distinguishing between the different forms — if there really be different forms — of inflammatory disease affecting the colon, and renewed investigation with careful examination of the various Structures and tissues entering into the anatomy of that portion of the intestine, is required before any satisfactory conclusions on the subject can be arrived at. DIARRHCEA. By S. O. Habbeshok, M.D. DiAERHCEA 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 dis- tinctive appellations, as Diarrhoea crapulosa, biliosa, mucosa or catarrh- alis, dysenterica, and choleraica, to which might be added nervosa, and colliquativa. Diarrhoea crapulosa is that state in which there is an unnatural fluid- ity and excess of fsecal 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 discomfort, but, on the con- trary, 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 se- quence 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 un- changed by the gastric juice, and irritate the intestine. Again, active mental or bodily exercise immediately after a meal, which has been suit- able both as to quality and quantity, may interfere with the proper so- lution of food, and lead to its hasty passage into the duodenum. When the alimentary canal becomes in this way loaded with undissol- ved ingesta, pain of a griping and twisting character ensues, from irreg- ular peristaltic action and from distention. The abdomen becomes full; the skin and complexion sallow; the tongue is furred; the pulse is com- pressible; headache and giddiness are often present; the sleep is disturb- ed; the bowels act frequently and irregularly, and the motions contain undigested substances, with fluid fteces 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 lientery is used to designate the condition in which the food is passed almost unacted upon, either by the gastric or intestinal secre- tions, 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 occurrence among the out-patients of large hospitals; and in not a few cases leads to a fatal termination. JBilious Diarrhoea is also a form of disease produced by the effusion 6 82 DISEASES OP THE INTESTINES AND PERITONEUM. of irritating 'substances into the intestine; not, however, from without, but from the liver, and possibly from the pancreas and follicular glands. The secretion of the liver becomes either excessive in quantity, or ir- ritating in quality; and the contents of the canal are apparently hurried onward, and evacuated as frequent loose and bilious dejections. 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 dis- eases 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 becomes 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 diarrhoea 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 pros- tration 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 modifications; thus, the motions in diarrhoea are sometimes in a state of fermentation; they are watery, frothy, and only contain fluid faecal 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 condition subsided under the use of cusparia, sul- phuric acid, and opium, with occasional starch injections, but it was fol- lowed by very severe pain in the course of the colon, and by frothy, yeast-like evacuations. For this state I used injections of charcoal,' | ij. to about a pint of thin barley-water, with great relief; the character of the evacuations improved, and in a short time became naturally fascal, the pain diminished, and the strength increased. I afterwards gave the pa- tient 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 evacuations; in jaundice this may be the case; it is so in cholera; and towards the close of chronic disease the liver may cease to pour out 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. There is, also, a form of diarrhoea arising from the inhalation of nox- ious 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 circulated and acts as a poisonous agent on that vital fluid, and if concentrated, 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 ' See Dr. Theophilus Thompson's Lestures on Phthisis. DIAEEHOEA, , 83 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 diarrhoea. 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 structure with the ulcerated ileum, the irritating excreta, as well as the changed and probably acceler- ated peristaltic action of the small intestine, tend to excite over-action of the colon, and thus to set up diarrhoea. Catarrhal and mucous diarrhoea arise from a state of slight inflamma- tory disease, closely allied to ordinary coryza, affecting the mucous mem- brane of the large intestine. The secretion is at first checked, but after- wards greatly increased, and a watery feculent mucus is discharged mixed with the ordinary fseces. 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 affected, considerable tenesmus is produced; the pain and febrile excitement 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 irritation, 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 quan- tity of mucus, and a little blood is often observed; these are especially present when irritation occurs very low down in the rectum, 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, per- haps, 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 with 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 among those in whom chronic or more exhausting disease has existed. This catarrhal diarrhoea not unfrequently becomes a chronic disease, the more severe symptoms cease, but still the bowels do not act in their normal manner; constipation often ensues, and afterwards a fresh loose- ness of the bowels, and this alternation is oftentimes repeated, or the more solid motions are followed by. a discharge of mucus coating the fseces; sometimes the mucus is passed in considerable quantity after the evacua-- tion, or it forms an elongated flake or cast of the intestine. I have ob- served this condition following severe disease of the intestines of a dysen- teric character, and it is sometimes associated with a state of chronic con- gestion of the liver; again, it is often perpetuated by the presence of haemorrhoids, and by ovarian disease. It may exist for many years with- out causing much derangement of health. Morbid anatomy. — Many instances have been known of fatal diarrhoea in which the appearance of the mucous membrane has been normal, its congestion has entirely disappeared, and a thin mucus only has been 84 DISEASES or THE INTESTINES AND PERITONEUM. 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. I 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 wherever 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 ether 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 dys- entery, and the lesser degrees of irritation which we have considered under the term of catarrhal diarrhoea might be regarded as a form of dys- entery of the mildest character. In dysentery, however, the diseased mucous membrane rapidly passes into a state of ulceration, and blood is discharged with the fsecal excreta. In Choleraic Diarrhoea a thin, very abundant watery mucus is dis- charged 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 appear- ance was presented. 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 spe- cific spores. Some very careful and prolonged observations, 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 irritable, so that everything is at once rejected from it; the alvine evacuations 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 pro- found collapse, even after one evacuation of the character of rice-water, DIAREHCEA. 85 but as the prostration subsides, in favorable cases, I have never observed the febrile excitement which is secondary to true cholera. Another kind of diarrhoea is that which has been correctly called Seroits, and which Is frequently observed in albuminuria. A dropsical 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 mode- rate is beneficial in its results. It is the action we often seek to produce artificially by powerful hydragogue cathartics, so as to diminish the quan- opi,cr/jiOL, — are many interesting remarks regarding the symptoms and treatment of Dysentery, also the prognosis to be founded upon it, to be met with. Aretseus has described Dysentery with his usual conciseness, and even more than his usual ability. In Cselius Aurelianus, but still more in Celsus, much information may be found regarding Dysentery, as the disease was known in the days of these celebrated Latin writers. Coming down to modern times, Sydenham, Ramazzini, Morton, Huxham, Cleghorn, Morgagni, Zimmerman, and Sir John Pringle (in his celebrated treatise on Diseases of the Army), are among the more distinguished of the numerous writers on Dysentery.' Dysentery is placed by Cullen in class first, " Pyrexiae," and of it the fifth order, " Profluvia." Of the latter his definition is " Pyrexia cum ex- cretione aucta naturaliter, non sanguinea." Dysentery, Cullen defines as follows: "Pyrexia contagiosa; dejeotiones frequentes, mucosae, vel san- guinolentfe, retentis plerumque fascibus alvinis; tormina; tenesmus." " It is customary to distinguish between acute and chronic Dysentery, also bet*eer) epidemic and non-epidemic or sporadic Dysentery. To the ' For a full and instructive account of the history and geographical distribution of Dysentery, see Hirsch, " Handbuch der historisch geographischen Pathologie," article "Euhe," vol. ii. p. 194. ' Synopsis Nosologie Methodiose, p. 308. 96 DISEASES OF THE INTESTIlirES AND PEBITONEUM. non-epidemic disease we are now to direct attention — ^the epidemic Dysen tery having been already considered by Dr. Maclean. Symptomatology. — The essential characters of Dysentery are severe pains of a griping nature in the belly, followed by frequent and bloody stools, defecation being accompanied by much straining and tenesmus. The later symptoms are the most characteristic. Watch a patient af- fected by Dysentery at stool: he sits a long time, straining; his features are distorted by the pain he suffers; the discharge from the bowels may be, often indeed is, but scanty: still he sits. The strong desire to remain at stool, accompanied by griping and straining, is expressed in the word tenesmus. Scarcely can such patients at times be persuaded to leave the stool and return to bed, until they feel so faint as to be unable longer to maintain the sitting posture, and sometimes while on the stool they faint. Straining and tenesmus do not occur in diarrhoea, they are peculiar to dysentery; and so also are the other symptoms, named in Cullen's defini- tion; the passage of blood and mucus, the faeces being for the most part retained, or after a time passed in the form of small, often hard, scybala. Aeiite Dysentery. — The disease in this form may occur without any premonitory symptoms ; more commonly, however, it is preceded by such. General uneasiness, lassitude, impaired appetite, disagreeable sensations in the abdomen, confined bowels, or a loose condition of the bowels, are among the more frequent of the preiponitory symptoms, These may have existed for a few days, when a chill is experienced, or sometimes a chill or rigor is the very earliest indication of departure from a healthy state. To these succeed the febrile symptoms, heat of skin and quickness of the pulse. Much variety exists in respect to the degree of the general or constitutional disturbance which accompanies the local affection in Dysentery. That may be very slight indeed; the disease may even run its course without fever. On the other hand, the constitutional disorder may be severe, and is not unfrequently profound, assuming an adynamic or typhoid character. In the simpler variety of the disease, there are at ■the commencement griping pains in the belly, those pains to which the iname of " tormina " is now generally applied. This term was first used by Celsus.' " Proxima," he says, " his inter intestinorum mala tormina esse consueverunt : Suo-evTepta GrrcecS vocatur." The tormina are felt in different parts of the belly, and, like the pain of colic, yield at one time, to return again, perhaps more severely than before. With the tormina there occur discharges, usually slight, from the bowels, and by these a partial relief to the pain is experienced. To the tormina and diarrhoea succeeds the tenesmus; and this term may be understood as including the frequent desire to go to stool, and the reluctance to leave it, with the very distressing feeling of bearing down, and burning sensation in the rectum. In every marked case of Dysentery the tenesmus is a prominent as it is the most distressing symptom. The discharge from the bowels ' Liber iv. oh. xv. The desoription of the disease given by Celsus is so accurate as to merit perusal ; the earlier sentences may ; e quoted. " Intus intestina exnlceran- tur ; ex his oruor manat, isque modo cum stercore aliquo semper liquido, modo cum quibusdam quasi mucosis excemitur ; interdum simul qusedam carnosa descendunt ; frequens dejiciendi cupiditas, dolorque in ano est ; cum eodem dolore exiguum ali- qnid emittitur ; atque eo quoque tormentum indenditur ; itque post tempus aliquod levatur ; exigua requies est ; somnus interpellatnr ; febricula oritur ; longoque tem- pore id malum, cum inveteraverit aut, toUit hominem aut, etiamsi finitnr, excru- ciaii."' DT8EWTBEY. 97 affords little relief when the tenesmus is great. The calls to stool of course vary greatly in frequency: in some instances they are almost incessant. Occurring in children, particularly, but occasionally also in adults, aa a con- sequence of the frequent evacuations, and the tenesmus by which they are accompanied, is prolapsus of the anus, which in itself requires care- ful management, and may become a very troublesome sequela of the dis- ease." The discharges from the bowels in Dysentery are peculiar and charac- teristic. At first they are usually feculent, if not entirely, at least chiefly so; but very soon, becoming very scanty in amount, they are found to be composed of mucus, or of mucus mixed with blood, and sometimes of nearly pure blood. When the inflammation of the bowels has advanced to a certain stage, it is common to notice the appearance of vitiated bile^ in the stools, and likewise of shreddy-looking portions of fibrine or false membrane. The odor of the evacuations in Dysentery is one sui generis^ quite peculiar, and highly offensive. Not unfrequently there is sympa- thetic irritation of the bladder, and a frequent as well as difficult micturi- tion. While the chief part of the pain in Dysentery is experienced during the movement of the bowels, it is not limited to that time — pain is present in the abdomen generally aggravated by pressure. When, in addition to the tenderness over the left side of the belly, corresponding to the posi- tion of the sigmoid' flexure, there is pain felt over the epigastrium and down the right side, it may be conjectured that the disease has implicated the large intestine in its entire extent, and is not limited, as happens in milder instances, to the rectum and descending portion of the colon. More or less of fever accompanies Dysentery. In mild oases the fever- ish disturbance, as already stated, is slight, but, on the other hand, in the more decided instances of the disease, the constitutional disturbance is evidenced by the quickness of the pulse, the augmented temperature of the surface scanty secretion of urine, and the coated condition of the tongue. In the milder cases of Dysentery there is no special implication of the nervous system; the pulse in such, although frequent, is full and of good strength: neither nausea nor vomiting, except of occasional occur- rence, are present; and although the local malady may be severe, the dis- ease wears throughout a sthepic character. But it is not always so; an asthenic or adynamic form of Dysentery also occurs, characterized by a frequent, small, and feeble pulse, pallor and coolness, rather than warmth of the skin, the occurrence of a clammy moisture over it, anxious expres- sion of the countenance, sunken eyes, dryness and glazing of the tongue, suppression of the voice, hiccough, delirium, prominence of the abdomen and rapid sinking. With these indications there is unusual violence in the local symptoms, particularly as regards the frequency of the discharges from the bowels. These ultimately become exceedingly offensive and watery. They present the appearance of water in which raw flesh has been washed, and are known by the name of " lotura carnium." The dis- ease may thus prove fatal in a few days. Dr. Wood speaks of such cases as very rare, and only seen during epidemics.' The latter observation is no doubt correct, but only to a certain extent, for these instances of rap- ' " Durch die heftigen Anstrengungen wird auch nicht selten, zumal bei Kindern, eln Prolapsus ani herbeigefiihrt der sich entweder von selbat weider znruokzieht odei reponirt werdeu muss." — Henoch, Kliriik der Unterleibs-Krankhdten, Ruhe, Band 3, p. 335. » A Treatise on the Practice of Medicine. By George B. Wood, M.D. VoL i. p. 62S. 7 98 DISEASES OF THE INTESTINES AND PEEITONEUM. idly fatal dysentery, although more common in the epidemic pi y valence of the disease, are occasionally met with in the non-epidemic malady. It has occurred to the writer to witness one or two very rapidly fatal cases of Dysentery, in which a remarkable depression of the nervous sjrstem was evident from the very commencement of the disease. In the ordinary form Dysentery tends to a favorable termination, and usually before the lapse of a week or eight days there are indications of amendment. The acute disease sometimes terminates in chronic dysentery. Chronic Dysentery is characterized by the frequency of the evacua- tions, which, at the same time, are usually very scanty. As in the acute affection, so in the chronic, the discharges are attended by local suffering and tenesmus. Mucus, or mucus mixed with blood, sometimes with puru- lent matter, constitutes the bulk of the evacuations; feculent stools occur when the disease, instead of implicating the entire colon, is limited to the rectum, or involves with it only the descending portion of the former. Chronic dysentery may last for months or years. In some instances it appears to produce wonderfully little influence on the general health and strength of the invalid, but as a general rule the sufferer from chronic dysentery is emaciated, pale, and weakly; and the disease is not unapt to prove fatal, through the exhaustion consequent upon its long continuance, or owing to the establishment of a state of continual or hectic fever. Among the morbid conditions which are connected with, or result from, attacks of Dysentery, whether acute or chronic, affections of the liver oc- cupy a chief place, and to these attention will be called in treating of the pathological anatomy of the disease. Anaemia, more or less marked, results from Dysentery. The writer remembers to have seen a case of anasmia of a very typical character, in which the blood impoverishment was due to a long-continued attack of Dysentery. To the occurrence of paralysis in conjunction with Dysentery, Romberg has called attention,' and he quotes a passage from an old dissertation by Fabricius : " De paralysi brachii unius et pedis alterius lateris dysentericis familiari," '' in verifica- tion of the remark. J. P. Frank refers to thie same occurrence; ^ and although Graves * has not specially mentioned Dysentery as a form of in- testinal disease giving rise to a reflex paraplegia, he has emphatically done so in reference to Enteritis. By Zimmerman' and Joseph Frank' allusion is made to paralysis of the arms and legs occurring after Dyseiiteuy. MoEBiB Anatomy. — As Dysentery is essentially a disease of the large intestines it is in the colon and rectum that we look for the morbid ap- pearances characteristic of its occurrence.' The mucous naembrane in these ' " Auch bei der Dysenterie," remarks Eomberg, " ist das Vorkommen der Paralyse beobaohtet wordeu." — Lehrbttch der NenenkrankJieitem des Menschen: Spinale Lah- ^ Disputationes ad Morborum Historiam et Curationem faoientes quaa oollegit edidit, et recensuit Albertus Haller. Tomus primus, p. 97. * ' ' Tantum vero ad gradum doloris in abdomine vehementia apnd hos vel illoB eveMtur, ut ab eo non minus ao in colica satumiaa brachii aut pedis unius vel alteiiua paralysis sequatur." — De Curandis Hominum Morbia. Auctore Joanne Petro Frank, Liber v. De Profluviis, pars ii. p. 497. * Clinical Lectures, Edition 1864, in one vol. p. 415. * Von der Rnhe unter kem Volke in Jahr 1765. ' Praxios Medicse TJniversse Prsecepta. Auctore Josepho Frank. De Paralysi. ' Ths mucous membrane of tbe colon, says Rokitansky, is the seat of the dysenterio process ; and we may state it as a rule, that its intensity increafles from the Ciscal valve downwards, and consequently is met with in the most fully-developed state in the sigmoid flexure and in the rectum. It not unfrequently passes beyond the csBcal valve towards the ileum, but is here only seen in its mUdest form. DTSENTEKY. 99 portions either presents the appearance of having been diffusely inflamed, being everywhere much reddened, thickened, and at parts ulcerated, or, with the absence of diffuse inflammation, there exists remarkable promi- nenceof the solitary glands and mucous follicles. There exist three separate and distinct forms of ulceration affecting the mucous surface of the intes- tines — the tuberoiilar, the typhoid, that met with in enteric fever, and the dysenteric. Apart from other characteristic differences in these affections, the last-mentioned is nearly limited in its occurrence to the large bowel, while the two former are especially met with in the small intestines, and particularly in the ileum. The size of dysenteric ulcers varies. They are sometimes small, and present a nearly circular form, or they are larger, irregular in shape, having an abrupt border, are covered by a dark-colored slough, and appear as if formed by the coalescence of several smaller ulcers. It is not uncommon to find considerable portions of more or less dense lymph, coating the reddened and thickened mucous surface. Por- tions of false membrane having precisely the same appearance are some- times passed at stool; but these, while still adherent to the bowel, do not when removed usually disclose an ulcerated surface. A truly sphacelated condition of the mucous membrane is occasionally met with, and pieces of gangrenous mucous membrane, sometimes of considerable size, have been passed in the evacuations in certain cases of Dysentery. Perforation of the bowel, which is of no uncommon occurrence in the progress of typhoid ulceration, and occasionally takes place in tubercular disease of the bowels, is very rarely indeed met with in Dysentery: the mucous, sub-mucous, and muscular coats of the colon suffer in this disease, but the peritoneal covering is not so apt to be involved. The mesenteric glands in Dysentery are frequently found tumefled and presenting a dark-bluish color. They may be softened, but are very rarely indeed the seat of sup- puration. Even when much enlarged, they have not been distinguished by the presence of any peculiar morbid product such as occurs in the typhoid and tubercular tumefactions of these glands. Rokitansky describes the dysenteric process as divisible into four natural degrees or forms.' The anatomical characters of the first or lowest form are, swelling, injection, and reddening, softening (red and bleeding), serous exudation in the shape of a delicate vesicular eruption, and consequent branny desquama- tion of the epithelium (the latter appearance probably led Linnaeus to term Dysentery " Scabies intestinorum interna "). In the second form, a larger surface of the bowel is involved, but still presenting a deeper de- velopment at one part than another — there is copious infiltration of the sub-mucous cellular tissue, giving rise to a greater or less number of prominences, which correspond to those parts of the mucous membrane at which the morbid process is most conspicuous. The intestine is generally in a state of passive dilatation, distended by gas, and occupied by a dirty- brown fluid, composed of intestinal secretions, epithelium, lymph, blood, and fseces. The coats of the bowel are thickened, and the sub-mucous tissue especially in a state of tumefaction. In the third stage, the prom- inences are more thickly set, and the result is an uneven lobulated ap- pearance. The mucous membrane investing these prominences is in part converted into a slough, or it may have disappeared, so as to ex;pose the infiltrated sub-mucous cellular tissue to which the remnants of the mucous membrane remain attached, in the shape of solitary dark-red, flaccid, and bleeding vascular tufts, or as dilated follicles which are capable of easy 1 A Manual of Pathological Anatomy. Sydenham Society's Edition, vol. ii. p. 83. 100 DISEASES OF THE INTESTINES AND PERITONEUM. removal. The contents of the intestine are now of a dirty-brown or red dish, ichorous, fetid, flocculent and grumous character. In the fourth and highest degree, the mucous membrane has degenerated into a black, fri- able, carbonified mass, portions of which may be subsequently voided in the shape of tubular laminae (so-called mortification of the mucous mem- brane). The sub-mucous cellular tissue appears to be infiltrated with sero- sanguinolent fluid, or dark blood; or it is pale, and the blood contained in its vessels is converted into a black solid mass. Purulent infiltration of the sub-mucous tissue is also found. The affected portion of the bowel, which contains a putrid fluid resembling coffee grounds, may be either in a state of passive dilatation, or (and this is more frequently the case) col- lapsed. Tn the higher degrees of the dysenteric process the muscular coat of the colon suffers; its tissue becomes condensed, pale, ashy, and friable. In the same degrees, the peritoneal covering does not completely escape, it presents a dirty-gray discoloration, has lost its lustre, and here and there dilatation and injection of its capillary vessels is visible, while occasionally it is covered by a thin brownish ichorous exudation. These characters afford the means of recognizing the existence of an advanced stage of Dysentery, while as yet the intestine has been unopened, and the mucous surface unexposed. Rokitansky has some very interesting observations on the termination of Dysentery. Provided disorganization of the mucous membrane has not occurred, a cure results through the return of normal cohesion, and the generation of a new layer under the desquamated epithelium. In the more intense degrees of the dysenteric process, and when disorganization has taken place, the mucous membrane having undergone more or less destruction, one or two results ensues — either a real cure of the loss of substance, with consolidation of the abraded portions of the intestine, follows, or the entire process assumes a low chronic form, the specific nature of the disease is lost, and an inflammation atonic in character, with suppuration of the intestinal coat, occurs. Dys- lentery is fatal through the more or less rapid, or more or less penetrating^ destruction of tissue and coincident exhaustion. When cure results, the loss of substance having been inconsiderable, new tissue is formed, and may so contract as to bring the edges of the mucous membrane into appo- sition with one another, while a cicatrix remains, which has the appearance of a large number of agminated warty excrescences of the mucous mem- brane between which the sero-fibrous basis from which they proceed may be detected. On the other hand, in those instances of the disease which have been distinguished by an extensive loss of substance, the approach of the edges is impossible, and the deeper layers of the tissue which takes the place of the mucous membrane are frequently condensed into fibrous bands, which form projections into the intestinal cavity, interlaced with one another, and not unfrequently encroach upon the calibre of the intes- tine, in the form of valvular or annular folds, thus giving rise to a variety of stricture of the colon. Reference has already been made to the participation by the liver in disease in connection with Dysentery. Abscess of the liver has been supposed by some authorities to have an intimate relationship to the dys- enteric process in the colon. Of the not unfrequent association of the two diseases there can at all events be no question. Dr. Parkes' found^ in twenty-five cases of Dysentery, seven to be affected with hepatio abr ' Bemarks on the Dysenteiy tuid Hepatitis of India, 1846. DTSElirTEET. 101 « Bcess. In the large work of Mr. Annesley,' there are twenty-nine cases of abscess of the liver recorded, and of these no fewer than twenty -onej or nearly three-fourths, had ulceration, more or less extensive, in the large intestine, while in two other cases there were appearances of con- striction and contraction which were reasonably ascribed to the existence of Dysentery at some former period. Annesley regarded the Dysentery as the result of the disease of the liver, or hepatitis. By certain writers, among whom Dr. Abercrombie' and the late Dr. William Thomson of Glasgow' may be mentioned, the concurrence of the two diseases has been regarded as accidental. The former observes: "Dysentery is often accompanied by diseases of neighboring organs, especially the liver, in which are to be found, in some cases abscesses, in others, where pro- tracted in their duration, chronic induration. These are to be regarded as accidental combinations, though they may considerably modify the symptoms." A third view, and one which has been popular in this coun- try since it was ably upheld by Dr. Budd,' is that the inflammation of the liver terminating in abscess is the result of purulent absorption from the dysenteric process in the colon. Many years ago, Andral and Louis, apparently unsuspecting any connection between hepatic abscess and] ulcerated intestines, noticed the co-existence of the former with ulcera- tion in the large intestines and in the lower end of the ileum in two cases, in the lower end of the ileum alone in one case, in the stomach in four cases, in the gall-bladder in one. In one of the cases in which the stom- ach was affected, Andral concludes with reason that the ulcer was caused by the hepatic abscess bursting into the stomach. But excluding this observation, there resulted seven out of fifteen instances of hepatic ab- scess, in which there existed at the same time ulceration in some part of the extensive mucous surface which returns its blood to the portal vein. These observations of the French pathologists were very far indeed from being singular. Thus Dr. Oheyne, of Dublin, in writing of the Dysentery in Ireland, remarks that in the majority of his dissections the liver was apparently normal, but that in two cases he found abscesses in its sub- stance. But while the occasional intimate connection of hepatic abscess with Dysentery, and of which Dr. Budd's theory in all probability assigns the true cause, has been determined, it must also be admitted that ab- scess of the liver frequently occurs in tropical countries wholly unconr liected with Dysentery, not acknowledging a pyasmic origin, and not re- sulting from mechanical injury. Dr. Murchison, of London, in his papers on the Climate and Diseases of Burmah,' pointed out that, in many cases, abscess of the liver met with in tropical countries occurred independently of these three causes. Dr. Morehead,' while admitting the occasional oc- currence of hepatic abscess, according to Dr. Budd's explanations — that is, by the transmission to the liver of pus or vitiated secretion originating in an ulcerated intestinal surface, — is satisfied that, as a general proposi- tion, such a view is altogether at variance with the results of clinical re- search in India. Seventeen cases of hepatic abscess are detailed by Dr. ' Researches into the Causes, Nature, and Treatment of the more prevalent Dis- eases of India and of Warm Climates generally. By James Annesley, 3 vols. 4to. London, 1828. ^ Researches on the Pathology of the Intestinal Canal. 1820. ' Practical Treatise on the Diseases of the Liver and Biliary Passages. 1841. * On Diseases of the Liver, 1845. ' Edinburgh Med. and Surg. Journ. 1854. • Clinical Researches on Diseases in India. 3 vols. 102 DISEASES OP THE nSTTESTIlTES AND PEEITONEUM. Morehead in which no intestinal ulceration existed. Frerichs, moreover, is of the same opinion, although by no means denying that, in certain cases, dysenteric as well as other forms of ulceration of the bowels may originate phlebitis of the coats of the portal veins, and so induce hepatic abscess.' The abscess of the liver which is found in intimate connection with Dysentery is the multiple abscess, small but numerous collections of pus. This form of purulent deposition Dr. Murchison has very distinctly shown to differ from the ordinary abscess of the liver which occurs in warm climates. In the latter case there is but one abscess which may attain a very large size, or in a few instances there may be two or three collections. Thus the pyomnic or multiple abscess, which is the common form of hepatic suppuration .in this country, is to be distinguished from the tropical abscess of India and other hot climates; and while the latter may co-exist with Dysentery, such connection is wholly accidental. On the other hand, the multiple hepatic abscess, although by no means of frequent occurrence in India, is sometimes met with, but only, as Dr. Murchison has pointed out, in connection with Dysentery or some other source of purulent absorption. The only marked instance of hepatic ab- scess in connection with dysentery which has fallen under the writer's immediate observation was that of a soldier in a Highland regiment, who, while serving in India, became affected by the latter disease, which ulti- mately assumed a chronic and inveterate form. He was ordered home, and during his voyage to England the liver became much enlarged. Greatly emaciated and reduced in strength, and still suffering from fre- quent loose stools, he sank shortly after reaching this country. Exami- nation of the body after death revealed the existence of a very large number of small abscesses scattered throughout the entire substance of the liver, the tissue of which was in different parts the seat of consider- able induration. Etiologt. — Neither in its acute nor chronic form is Dysentery now a common disease of this country. The decline in the frequency of its occurrence has also been accompanied by a diminution in the sever- ity of its attacks. From producing a very considerable annual mortality, • as was the case in the seventeenth century. Dysentery now occupies a very low place among the causes of death. Essentially a disease of hot cli- mates, its prevalence is, in these, observed to depend to a considerable ex- tent on meteorological changes, while in temperate climates Dysentery is emphatically an autumnal malady. The continued exposure of the body to an elevated temperature predisposes to the occurrence of Dysentery; this it does, in all probability, by an injurious operation on the mucous membrane of the whole alimentary canal leading to its increased excita- bility, and by disordering the function of the liver: thus exposed, the sud- den reduction of temperature, which so frequently takes place in the night season of our autumns, acts as a direct exciting cause of the disease. Thus, while heat predisposes to Dysentery, cold excites it. Unwholesome food has a potent action in the production of Dysentery. In this way un- ripe fruits, or even the ripe fruits when inordinately consumed, also vege- tables, acid wines, and impure water, have particularly been supposed to act. There can indeed be no doubt that most of the- slight, and some even • "Eine oausale Abhiingigkeit der Hepatitis von Darmverachwarung let also keiues- wegs festgestellt, -weim auoh die Miigliohkeit niohti gelaugnet warden darf , dass aus- nahmsweise unter begunstigenden tjmstanden dysenteriscbe und andere Darmvei- Bohwarui^en Phlebitis der Pfortaderwurzein und hierdurch Leberabsoesse erzeugen konnen." — Klinik der LAerhranklieiten, Zweiter Band, p. 113. DTSENTEET. 103 of the severer oases of Dysentery which we meet with, are occasioned by a distinct error in diet, or are traceable to the introduction into the ali- mentary canal of some substance or fluid of a deleterious or, directly irri- tating nature. The not unfrequent connection of Dysentery with ague, and their observed alternation, have led to the impression that the former disease, like the latter, acknowledges an origin in malaria. That Dysen- tery may be produced by exhalations from putrid animal and decaying vegetable substances may perhaps be admitted; but the probability is that the relation of this disease to intermittent and remittent fevers, formerly insisted on, was not, strictly speaking, etiological, but to be ac- counted for by the disordered state of the portal circulation, which, oc- curring in ague, led indirectly to the inflammatory affection of the colon. The contagious nature of Dysentery has been asserted by some authori- ties; facts are, however, entirely wanting to prove the communication of the disease from person to person, in the sporadic form of the disease, with the consideration of which we are occupied; and in regard to the epidelmic Dysentery, it may be admitted that the experience which ap- pears at first sight to justify this conclusion, admits of another and more satisfactory explanation. Teeatment. — Dysentery in its acute form demands an energetic treat- ment; it is not a disease which can with safety be entrusted to the " via naturae medicatrix." Confinement to bed is of primary importance, the very rest favoring the arrestment of the malady, as much as movement of the body promotes its progress. Blood-letting was formerly practised in the treatment of Dysentery, and when pain is severe, and continues unre- lieved by warm applications and rubefacients, local blood-letting by means of leeches applied over the track of the colon may still be had recourse to. The application of a few leeches to the verge of the anus has been recom- mended by some authors, and in the experience of the writer has ap- peared to be beneficial. An indication of great importance in the treatment of Dysentery is to free the bowels from all irritating accumulations. This is best done by the employment of the gentler laxative medicines. Strong cathartics are not to be used. Castor-oil has been almost universally regarded as the best remedy for this purpose. Where much pain exists the oil may from the first be combined with a little laudanum; in the more advanced stages of the disease it will be prudent to associate the latter with it at every dose. The alternation of laxatives and opiates in the treatment of Dys- entery has been highly praised by many practitioners. " It is the prac- tice of some physicians," writes Sir Thomas Watson, " to prescribe laxa- tives and opium together; but in this complaint it is better to alternate them." ' Opium by not a few has been regarded as the " summum reme- dium " in this disease. It was the favorite remedy of Sydenham in meet- ing the formidable Dysentery of his generation, and it is in allusion to its efficacy that the " prince of English practical physicians " rapturously exclaims — " And here I cannot but break out in praise of the great God, the giver ,of all good things, who hath granted to the human race, as a comfort in their afflictions, no medicine of the value of opium, either in regard to the number of diseases that it can control, or its effi- ciency in extirpating them So necessary an instrument is opium in the hands of a skilful man, that medicine would be a cripple without it; and whoever understands it well, will do more with it alone ■ Lectures on the Prmoiples and Practice of Physio, vol. ii. 104 DISEASES OF THE INTESTENES AND PEEITOlTEirM. than he could well hope to do from any single medicine. To know it only as a means of procuring sleep, or of allaying pain, or of check- ing a diarrhoea, is to know it x)nly by halves. Like a Delphic sword it can be used for many purposes besides. Of cordials it is the best that has hitherto been discovered in nature. I had almost said it was the only one." ' Opium may be administered either in full or in small doses, and each of these methods has its supporters. It may be given alone, or com bined with ipecacuanha in the form of Dover's powder. Ipecacuanha it- self is again largely employed, and more especially of late years in India. We say again largely employed, for it is worthy of remark that ipecacu- anha, originally known as a medicine about the middle of the seventeenth century, was first used as a remedy in Dysentery. Brought to Europe from BrazU by Piso, and some time afterwards made the subject of exper- iment in Paris by Adrien Helvetius, it was long known as the " radix anti-dysenterica," ' the "pulvis anti-dysentericus." Subsequently to its original employment in France, in doses from one to three drachms, it was used in this country and its colonies by Sir John Pringle and other phy- sicians, in doses varying in amount, that ordinarily given being a scruple. More recently the names of Mr. Mortimer, Mr. Twining, Mr. Docker, and several other Indian surgeons, have been identified with the practice of exhibiting ipecacuanha in Dysentery. The therapeutic action of the remedy has been variously ascribed to its nauseant, its diaphoretic, and its laxative or purgative effects. The latter was the view entertained by the distinguished writer Sir John Pringle. Dr. Maclean thus expresses him- self in regard to it: "It is probable that ipecacuanha owes much of its usefulness in this disease to its action as an evacuant. It is a blood depu- rant of an effective kind. It appears to increase the secretion of the whole alimentary canal, as well as of the liver and pancreas: under its use tor- mina and tenesmus disappear, and feculent evacuations are more quickly restored than by any other known remedy." ' Dr. Morehead has always used ipecacuanha' in Dysentery from a consideration of its efficacy being due to its laxative action. This physician counsels the exhibition of the ipecacuanha according to the plan of the late Mr. Twining,* viz. " from six to three grains, combined with blue pill from five to two grains, and ex- tract of gentian from four to two grains, every third, fourth, sixth, or eighth hour, and to continue it steadily till amendment takes place. The proportion of the dose and the frequency of its repetition must depend on the acuteness of the symptoms. The duration of the treatment, and the gradual diminution of the dose and of the frequency of its exhibition, must be contingent on the rapidity and permanency of the amendment. It must also be kept distinctly in view that, whilst the treatment by ipe- cacuanha is being pursued, it is often necessary — according as the state of the pulse or the uneasiness of the abdomen on pressure may indicate the necessity — to apply leeches; and also — according to the character and scantiness of the evacuations, and the greater or less fulness of the abdo- men — to give castor-oil occasionally in moderate doses." The reliance on the therapeutic action of ipecacuanha is most conspicuously exhibited, however, in the plan of its use suggested by Mr. Docker, and adopted by ' Medical Observations : Dysentery. * For an interest iug account of the early history of ipecacuanha, see " Traite Thera- peutique et de Mafciere Medicate," par A. Trousseau et P. Pidoux, vol. i. p. 666. ' Reynolds' System of Medicine, vol. i. article Dysentery. * Besearches on Diseases in India, vol. i. p. 560. DYSENTERY. 105 Dr. Maclean,- and now generally followed in India. " The patient should be at once ordered to bed, and as quickly as possible brought under the influence of ipecacuanha in large doses. Some insist on the propriety of first giving a full dose of Battley's sedative, tincture of opium, or a few drops of chloroform, with the intention of making the stomach tolerant of the remedy, and restraining nausea and vomiting. I believe that the sedative in some cases is useful, and acts in the manner just described. On the other hand, I have often seen ipecacuanha do its work well, and with little disturbance of the stomach, without opium. Should it be de- termined to premise opium, thirty drops of the tincture should be given, and in half an hour followed by from twenty-five to thirty grains of ipe- cacuanha, which should be given in as small a quantity of fluid as possi- ble; a little syrup of orange-peel covers the taste as well as anything else. As already advised, the patient should be kept perfectly still, and abstain from fluid for at least three hours. If thirsty, he may suck a little ice, or a teaspoonful of cold water at a time may be allowed. It is seldom that under this management nausea is excessive, and vomiting is rarely trouble- some, seldom setting in for at least two hours after the medicine has been taken. The abdomen should be covered with a large sinapism, or a sheet of spongio-piline sprinkled with a little turpentine after being wrung out of hot water. In from eight to ten hours, according to the urgency of the symptoms and the effect produced by the first dose, ipecacuanha in a re- duced dose should be repeated, with the same precautions as before. All who have had opportunities of trying this mode of treating Dysentery can bear testimony to the surprising effects that often follow the administra- tion of one or two doses of ipecacuanha given in this manner. The tor- mina and tenesmus subside, the motions quickly become feculent, blood and slime disappear, and often, after profuse action of the skin, the pa- tient falls into a tranquil sleep and awakens refreshed. The treatment may require to be continued for some days, the medicine being given in diminished doses, care being taken to allow a sufficient interval to admit of the patient taking some mild nourishment suited to the stage of the disease." If the writer be entitled to express an opinion regarding the use of a remedy which he has had but few opportunities of employing in the treatment of Dysentery, but has very frequently prescribed in cases of de- praved action of the chylopoietic viscera, he feels inclined to ascribe the eminent therapeutic virtues of ipecacuanha to its direct action on the se- cerning function of the liver. The employment of mercury in Dysentery is as warmly defended by some practitioners as it is condemned by others. In all stages and forms of the disease Dr. Maclean deprecates its use, while Dr. Wood asserts that no remedial influence is more effectual in Dysentery than that of mercury. Anything like the production of profuse salivation is certainly to be avoided; and although favorably influencing the progress of Dysentery in some cases, chiefly through its action on the liver, it will generally be admitted that in ipecacuanha, and in the employment of mild laxatives alternately with opiates, we possess more efficacious and certainly safer remedies. It is in the more chronic form of Dysentery that such powerful astrin- gents as acetate of lead, sulphate of copper, sulphate of zinc, the Indian Bael fruit, haematoxylon, and the sulphuric acid, are chiefly useful. Among alterative remedies copaiba and turpentine, creasote and nux ' Reynolds' System of Medicine, vol. i. p. 130. 106 DISEASES OP THE rNTTESTTJOlS AND PEErTONETJM. vomica, have been commended. Quinine will favorably influence the prog- ress of malarial Dysentery, when employed as an adjunct to other reme- dies; and iron, in the form of the pernitrate more especially, is called for when fluidity of blood as evidenced by haemorrhages and cutaneous pete- ehise exist; just as in scorbutic Dysentery, when chronic, mUk and fresh fruits are indispensable articles of treatment. Enemata of warm water cautiously introduced into the rectum are fre- quently grateful to the patient, and are useful in the early stages of Dys- entery in bringing away hardened scybalous masses, the continuance of which in the bowels is attended by much irritation and suffering. Opiate enemata, and those containing ipecacuanha, and various astringents, may sometimes be employed with good effects. In Dysentery assuming a typhoid or adynamic type, it is necessary to support the patient's strength by the exhibition of stimulants; but these are, as a general rule, not well borne in this disease, and should always be administered with the greatest degree of caution. The diet in Dysentery is of much importance. When the disease is comparatively slight and unattended by serious febrile symptoms, most farinaceous foods may be allowed. When, however, the severer form of the disease is in existence, bland drinks are alone admissible: milk with lime water, or Carrara water, may be regarded as the chief article of diet, and generally speaking is the one most relished by the patient. Grreat attention should be paid to preserving the cleanliness of the patient, the dress, and bed-clothes, and in keeping the atmosphere of the sick-room as pure as possible, impregnated as it must from time to time become with the offensive odor of the discharges. The use of Condy's fluid, of weak chlorine vapor, or of carbolic acid for this purpose, is inval- uable. Sponging the surface of the body with tepid or warm water is desira- ble, and is usually found most grateful by the patient. It may be added in connection with the treatment of chronic Dysen- tery, that change of air is frequently more efficacious than the use of drugs. Removal to the sea-coast, or a voyage, is specially to be recom- mended. A flannel belt round the abdomen is an article of clothing which the convalescent from Dysentery, as well as all those who are prone to suffer from this disease, should adopt and constantly wear. DUODENUM. By S. O. Habeeshon, M.D. The symptoms which have been regarded by some writers as proceed- ing from disease of the duodenum have by others been referred 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 pecu- liarities of its position and structure deserve our careful attention. Ex- tending 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 perito- neum, 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 vena cava; 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 sec- ond portion; and the vena portre, 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 pan- creas 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 je- junum, 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 mu- cous coat is covered with villi, which commence at the duodtenum, and soon become exceedingly numerous; so also the valvulse conniventes are gradually developed, till we find them as large as in the jejunum. The whole of the surface is studded over with Lieberkilhn's follicles?' iV9t|Un- frequently, 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 duodenum, and which pp , situated be- neath the substance of the mucous membrane; these commence a few lines from the pylorus, and extertd about as far as the common bile-duct; their function is not definitely known, but they are believed to resemble minute salivary or pancreatic glands. It sometimes happens that the soli- 108 DISEASES OP THE INTESTINES AND PERITONEUM. tary 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 differ- ence. 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 curva- ture of the stomach; this associates that part of the duodenum very inti- mately with the stomach. Besides this nervous supply 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 coro- nary extends into the first part of the duodenum, so that in the arterial supply we find the same association. IState 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 duodenum, is the cause of the discomforts associated with these forms of dyspepsia, we have no data on which to form an opinion. Corvisart 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 duodenal dyspepsia as arising from an abnormal condi- tion 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 sev- enth month, and the caecum was preternaturally free. In a Cyclopean monster, I found the viscera of a double fcetus in a single peritoneal cavity; a double oesophagus was united in a single stom- ach, with a large convexity extending across the abdomen; 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 constitu- ting a sort of hernial protrusion. In the museum of Guy's is one of these, situated near thfe opening of the duct into the duodenum. ''Some believe that the duodenum becomes distended with flatus, or with retained chymfe, as the result of indigestion; and where there is mechanibal 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 distention which has been supposed to arise from the duodenum will generally be found to be distention of the stomach or the transverse colon; for the duodenum passes quickly to a lower level, and I believe its contents at once gravitate into the jejunum. DUODENUM. 109 As to the strictly pathological states, we find congestion sometimes active, more frequently passive; ulceration, cancer, and lastly mechanical 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 in- staijces a careful investigation might have pointed out their existence during life. _ Great congestion of tJie 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 he- patio disease; but there are other cases in which we find active congestion, especially in acute pneumonia. The latter state of acute hypereemia is illustrated in the following case: Case LXXXV. — Inflammation of the Bronchi, of the Bile-ducts, or Biliary Hepatitis, d;c. Acute Congestion of the Duodenum.— Thomas H , set. 43, was admitted into Guy's Hospital March, 1853; 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 intemper- ate. 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 vom- iting in the morning, and the bowels had at times been much relaxed; be- fore admission jaundice came on; he had had more anxiety of mind than usual, and gradually became languid and icteric. For four days his legs had swollen, afterwards his abdomen, and his strengtii 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 dehrious at night, and slept but little; the motions were light in color, the bowels relaxed, the urine contained lithates and the coloring matter of bile. Three days after admission he was more prostrate, an,d was delirious; the pulse was very compressible; he had pain in the right hypogastric region, and on the following day he died. On ijispection 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 con- siderable 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 were con- siderably distended with flatus, and the liver extended several inches be- low the ribs. The duodenum contained bloody mucus, the linuig mem- brane was very m,uch congested, and in some parts ecchymosed. The lower part of the small intestine contained clayey faeces. There was a considerable quantity of fat in the omentum, and in the abdominal pa- rietes. The liver weighed 7 lbs. ; its surface was smooth, and of a deep green- ish-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 portae; the capillary vessels in Glisson's capsule were much dijstendedj and some of them were quite turgid with blood. 110 DISEASES OF THE INTESTHSTES AND PEEITONEUM. The smaller biliary vessels contained tenacious mucus, and their lining membrane was congested; this state of the bile-ducts contrasted remark- ably with the pale color of the veins. The cells of the liver were gorged ■with fat, some of them were distended with oil-globules; other hepatic cells appeared ruptured, and granules with oil-globues 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 fibrinous 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 afEection of the chest came on subsequent to his admission into the hospi- tal, and consequently after the jaundice. There was 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 contained; 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 in- crease the congestion of the mucous membrane. The very congested state of the duodenum near the entrance of the bile-ducts indicated an ex- tension of disease from the duodenum to the bile-ducts, or vice versd ; it was much more localized 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 adminis- tration of mercury, but rather from salines with sedatives. After hums 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 observations of Dr. Wilks, recorded in the 'Guy's Reports' for 1856. I witnessed many of the cases to which he refers; and although in some the first part of the duodenum was hyperaemio, in none did I observe ulceration. 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 thir- teen days after admission. The duodenum contained two small 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, set. 4, died nineteen days after, a severe bum 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 ecchymosedj DUODENUM. Ill 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. Em- bolism and necrosis of tissue from blood extravasation after congestion have been suggested; as we have already mentioned, in stating the hy- pothetical 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 hsema- temesis and prostration. In some instances death took place from peri- tonitis 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 administered freely, and these have probably con- duced 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 pigment, 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 explana- tion of this state being, that gastro-enteritis, or long-continued hyperasmia, has been followed by the deposition of hsematine or pigment in the sub- stance 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 afterwards complained of pain at that part; he was admitted into Guy's in a typhoid state, and died two days afterwards. There was suppuration in the brain, and gray discoloration of the mucous membrane 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 distention of the vena portas; and we also find a less general condition of congestion of the first part of the duodenum in disease of the pylorus, whether it be simple fibroid degeneration and hypertrophy, or true can- cerous 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 perfoiration 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 indicative of sim- ple disfease of the contiguous viscera, that definiteneiss and certainty can- not be attained. The vomiting and pain connected with hepatic disease and gall-stone are possibly due partly to the condition of the duodenum. In the latter there is probably spasmodic 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 112 DISEASES OF THE INTESTINES AND PERITONETTM. in violent vomiting indicates that the first and second portions of the duodenum have been involved. Instances are not unfrequently met virith 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 occasion- ally jaundice follows, which appears to strengthen the former supposition. After intemperance, also, violent bilious vomiting, a furred state of the tongue, loss of appetite and loathing of food, diarrhoea, tenderness of the right hypochondriac region, are followed by jaundice; and we are prone to regard the duodenum as being in, at least, a state of great hypersemia. Exposure to cold, with great mental anxiety, tends also to promote this state of duodenal disease; and the mischief appears to be propagated 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 Sur- gical Journal ; ' see also Dr. Stokes, in the ' Encyclopaedia of Practical Medicine.' Congestion of the duodenum is best relieved by diminishing portal and hepatic engorgement, and by stimulating the abdominal excretory organs to increased action. These objects may be attained by giving saline and mercurial purgatives, by aperient enemata, and by the appli- cation of leeches to the anus ot 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, espe- cially 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 abdominal excretory glands; but to give mercury so as to pro- duce salivation, or to prescribe it in every instance where bilious fluid is rejected, appears to be an unwise course. The most bland nourishment should be given, and abstinence from stimulants should be enjoined; ice and cold drinks often afford great relief when vomiting distresses the patient. In acute hyperasmic states, salines, as the solution of potash, the bicarbonates of potash or soda, the carbonates or the citrate of mag- nesia, may be given with diuretics in effervescence or otherwise, as the individual case may require. But in chronic hyperjemia, 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 a-cute 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 congested, and cover- ed 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, lime-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; some- times it is merely superficial, and is associated with other diseases, as DUODENUM. 113 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 depressed 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 al- most 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 aggravation of which were at- tributed 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 frequent; she was pregnant, and died in a short time from peritonitis; a small ulcer was found in the duodenum.' The vomiting was probably 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 ulcer- ation, 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 enlarged. 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 melaena. 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 duo- denum, 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 ulceration was associated with disease of the gall-bladder; in others, with 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 hEemorrhage, as well as of hsemate- mesis. The treatment of these cases is similar in all respects to that recom- mended for corresponding gastric disease. ' Dr. Hodgkin on ' The Pathology of Seions and Hucous Membranes.' 8 114 DISEASES OF THE INTESTINES AND PERITONEUM. Case LXXXYI. — Ulceration of the Duodenum. Perforation. — George E , set. 30, a man of light complexion, and of steady and tem- perate habits, was admitted into Guy's Hospital, October, 1851. He was by trade a surgical instrument maker, and accustomed, when at work, to exercise pressure against the umbilicus. Four months before admission he had slight expectoration 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 druggist'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 collapse; the pain of which he complained passed in the course of the ureter. On the following morn- ing he was exceedingly depressed, the skin hot, the abdomen tender, and there were the symptoms of general peritonitis ; vomiting of coffee-ground fluid came on, and pulsation was felt at the scrobiculus cordis, which sug- gested the idea of aneurism. He survived fifty-six hours. On exami- nation, 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 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 aphthous ulcers were observed, and two small ones were covered with coagula. The remaining parts of the small intestine were healthy; so also the csecum, colon, kidneys, spleen, and liver. In the chest there were old pleuritic adhesions on both sides, espe- cially on the left, where there was also a small vomica, with indurated lung, and thickened 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 hsemoptysis; 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 considerable distance to the hos- pital, tended to induce increased extravasation and peritonitis; the judi- cious 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 perforation; 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 ileum, or appendix cseci, 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 consid- ered 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 DUODENUM. 115 a short time after a meal, the period at which such accidents are gener- ally found to occur. Case LXXXVII. — Chronic Ulcer in the Duodenum. Carcinoma of the Liver. Jaundice. Granular Kidneys. Obliteration of the JBile- Duct. — George C , set. 46, was admitted into Guy's Hospital December 14, 1853, and died January 4th. For a fortnight he 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 ob- literated 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 surface irregular and granular. The disease in the duodenum was not discovered till after death; the cancerous condition of the liver, inducing pressure on, and obliteration of the ducts, and the albuminuria appeared sufficient to explain all the symp- toms. 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 mentioned. Case LXXXVIII. — Strumous Disease of the Abdomen. Perforating TJlcer of the Duodenum and Coecum. — Jane B , set. 18, was admitted into Guy's Hospital February 19, 1860, and died October 4th. 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 oedematous. 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 enor- mously 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 commu- nicated with the first portion of the duodenum by an opening about a quarter of an inch 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 waa healthy, so also the kidneys. The spleen contained a softening strumous mass. The liver also was fatty. 116 DISEASES OF THE INTESTINES AND PEPJTONEUM. Although the history of this case is imperfect, I have introduced it as an illustration not only of the obscurity of strumous disease in its earlier stage, but as an instance of irritation of the duodenum and colon, followed by ulceration and perforation, and producing peritonitis, at first of a local, but afterwards of a general character. The perforations in both situa- tions 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 caecum. In an interesting case of hsematemesis under my care in Guy's Hos- pital in 1875, the haemorrhage 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 portae com- municated by an ulcerated opening partially filled by clot; the common bile-duct and hepatic duct were also divided; the hepatic artery was ob- literated.' It is probable that this perforation of the duodenum was from without, as was also the case in a patient under my care in 1866. 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 neighborhood of the ascending colon, . along which it extended to the duodenum, 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. Case LXXXIX. — Gall-stone. Ulceration of Gall-bladder and Duo- denum. Large Gall-stone impacted in the Jejunwm. Death from Soemor- rhage. — A. B. , set. 56, had suffered from loss of appetite and mental depression for some time, due to family anxiety and trouble. He was a strong, muscular man, rather stout, and he had generally enjoyed good health. On November 39th, 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 ap- petite, and the tongue was furred; a purgative was given and saline med- icine. 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 15th 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 Christmas to visit his friends; the skin, however, did not completely regain its color. On January 13th 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 the 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 normal; the abdomen was full, but there was no tenderness; he complai,n- ed of soreness across the abdomen, just above the umbilical region, and ' See 'Path. Trans.,' vol. xxvii., 1876. DUODENUM. 11? hardness could be felt at the scrobiculus cordis, which ■wfas 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 colooynth. On the 16th he was rather easier, but there was no action from the bowels; the pain increased in the afternoon; the cal- omel and colooynth were repeated, and an injection used. On January ITth there was still no action of the bowels; a dose of castor oil was fol- lowed by violent vomiting of brown acid fluid; no flatus was passed; the pulse was 80, temp. 98°, the respiration easy; the abdomen was full and supple, 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 scybala. Still there was no free action from the bowels; the pulse was 80, temper- iture still normal, the abdomen as before; the urine was normal in color, tolerably free in quantity, sp. gr. lOl?, and it contained a trace of albu- men. 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 uri- nary bladder being distended a catheter was introduced, and about a pint of urine drawn ofE. 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 30th, 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. Ooodhart 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 \\ x 1^ inches. It moved about in the bowel under external manipulation with considerably free- dom, 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 faecal 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 faecal matter, and was easily crushed between the fingers. Nothing else abnormal was found till the duodenum was reached. On raising 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 duodenum 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 118 DISEASES OF THE INTESTINES AND PERITONEUM. yet no peritonitis was present. Dissecting out the gall-bladder and the vessels of the portal fissure, it was found that the fundus of the gall-blad- der, 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 implicated, 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 extremity opened into the abscess imme- diately 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, the 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 hae- morrhage could, therefore, only be attributed to a venous oozing from the surface of the ulcer in the gall-bladder and the duodenum, and the slough- ing cavity outside. The liver substance was unaffected by the ulcerative 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 fatty. From the observations I had 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 haemorrhage was different 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 haemorrhage such as we have in engorgement of the por- tal 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 obstruction of the intestine, for purga- tives 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 obstruc- tion, and this opinion was confirmed by the post-mortem examination, and also that the haemorrhage 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 haemorrhage. 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 gall-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 imme- diately beyoTid the duodenum. The following is a table of the cases in which we have found ulcera- tion of the duodenum. DUODENUM. 119 Bex. Age. Disease or injury. Cause of death. Remarlcs. P. 13 Bum. Tetanus. Thirteen days after ; stomach. M. 4 Bnm Haemorrhage. Eochymosed ulcer oa, the tongue. M. •• Soalrl Exhaustion. Branne glands swol- len. F. 30 Primary disease. Portal pyaemia. M. ift) Amyloid visoera. Scrofulous pyelitis. M. Diseased knee. Hsemorrhage. M. 55 Hydrocephalus . Convulsions. Hypertrophy and dila- tation ; stomach. F. 55 Renal disease. Large white kidney. i)'. la Disease of hip. Hsemorrhage from ulcer. M. 30 Primary disease. Perforation, peritonitis. M. 4« Oanoer of liver, &o. Exhaustion from cancer, &o. F. 18 Tabes mesenterica. Abscess behind cffi cum, &c. M. 56 Grall-stone. Haemorrhage ; gaU-stone impacted. Ulcer due to the pas- 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 gener- ally very defined and ceases abruptly at the commencement of the duo- ' denum, such is not constantly the case, for the disease sometimes extends onvyard into the pyloric portion of the duodenum. Again, it is oftentimes very difficult to state precisely 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 symp- toms of cancer of the stomach; still the first indications are those of dyspepsia and malaise, sallowness of complexion, mental depression, fol- lowed by nausea, vomiting, and sometimes pain, several 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 afEected, or the pancreas, or the lymphatic glands. Pulsation communicated 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 in- cense. In primary pancreatic disease the tumor is generally more central; the evacuations have been found sometimes to contain fat,' and until pressure take place on the duodenum, or the disease extend to the stomach, and to the lymphatic glands, the symptoms are less pronounced. Pyloric disease is indicated by more persistent vomiting than we find in simple duodenal disease. Occasionally local ulceration, with chronic thickening, takes place at the union of the transverse and ascending colon, or cancer- ous disease may be developed at this site, and subsequently perforate the duodenum. (See " Cancer of the Colon.") The formation of adhesions with the duodenum in these latter instances sometimes causes partial mechanical obstruction; vomiting is produced, and thus the diagnosis is ' The observations of Bernard tend to show that this symptom would be a constant one, if the duct were always obstructed. 120 DISEASES OF THE INTESTINES AND PEKITONETTM, rendered unusually diflScult; such was the case in an instance whiot we shall presently give. In all these maladies there is emaciation, pallor, cachexia. Lastly, we must refer to numerous diseases of the omentum and of the liver as complicating the diagnosis. Here, however, the diffi- culty 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 hypochondrium, and the enlarged gland may be often felt vidth tubera projecting from its surface. The termination of cancer of the duodenum is generally one of pro- gressive emaciation and cachexia. If enlarged glands press upon the bile-ducts, jaundice will be added to the symptoms; if perforation or ijloughing takes place, local abscess occasionally forms, which, by giving resonance on percussion, adds increased difficulty in forming a correct ■Jiagnosis. 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 complexion comes on, or jaundice, it is very unwise to give mercurials; they hasten degenerative changes, ex- haust the patient, without any mitigation of bis sufferings, and tend to hasten the fatal termination. Case XC — Cancer of the Duodenum. (Reported by Mr. C. Long- more.) — James R , aet. 40, was admitted under my care into Gruy's Hos- pital, June 33, 1858, and died July 5th. 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 en- joyed good health till Christmas of the preceding year. The first symp- tom 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 ab- dominal 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 reso- nance around it; on pressure very slight pain was produced. Over the cartilage of the tenth rib there 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. 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 infu- sion 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 DtJODENUM. 121 this day, he vomited about two quarts of bitter bilious fluid, but became more comfortable after its rejection; although a sensation of intense thirst came on. On the 28th he had become jaundiced, and complained of great pain across the loins, of an aching, dragging character. On the evening of the 3d July vomiting of cofEee-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 sixteen hours after death. There was rigor mortis; the whole body was jaundiced; 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 duo- denum was quite destroyed by cancerous ulceration, and a large slough occupied the position of the first portion. The interior of the intestine communicated with the cancerous mass beneath it; the cancer tumor was altered in structure, and contained blood. The gall-bladder was dis- tended 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 Glisson'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 prob- ably first affected; but, although really behind the duodenum, the intes- tine did not cause resonance, probably on account of its becoming early implicated in the disease. The subsequent symptoms arose from pressure on the bile-ducts and the vena portse, and from the degeneration of the cancerous growth. Mr. John Dix, of Hull, has recorded a very interest- ing case somewhat allied to this; and in which there was a tumor appar- ently 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 bound- ary " 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 referable to de- rangement of the hepatic and digestive functions. She had suffered, be- fore 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, under my care in Guy's in 1873, aged forty-five, suffered eighteen months before admission from violent vomiting and purging; for a week he was jaun- diced, 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 122 DISEASES OF THE INTESTUCfES AND PEEITONEUM. the duodenum, and we have witnessed such cases ip 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 symp- tom. We have also seen the duodenum perforated in cancerous disease of the CEBcum, 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. Mechanieal obstruction. — Other parts of the intestine are much more liable to obstruction of a mechanical character than the duodenum. In the course of several years we have observed, or have found recorded, iso- lated 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 coat? 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 Jirst portion of the duodenum and adjoining vis- cera, either the inferior surface of the liver and gall-bladder, or the trans- verse 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 distention 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.— CArom'c Peritonitis. Acute Perit07iitis. Tubercular Deposit 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 , set. 38, was admitted into Guy's Hospital under my care, April 15, 1861. He was a married man, by trade a cooper, and he had resided at Dock- head. About seven years previously he suffered from severe pain at the epigastric region ; and for several years since that time he had had pain at the same part, but less acute in its character. He had never had any hismorrhage from the stomach, but he had complained of slight pain in the dorsal region, between the sixth and eighth vertebree. 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 food, and was especially aggravated by constipation. On admission he was very much emaciated, with a sallow complexion, and on the forehead there was a bronzed condition of his skin; the skin at DUODENUM. 123 the elbows was also slightly discolored. There was moderate tenderness at the scrobioulus cordis; the abdomen was rounded and supple; no tumor could be felt; the bowels were rather confined; the pulse was very com- pressible; 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 30th 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 vomit- ing, till June 11th, when violent pain and symptoms of acute peritonitis came on, and he sank on the 13th. lith.-^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 covering the costal surface. The left lung itself was very small; but there were no tubercles in it. The right pleura was free from adhe- sions 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 abdo- men, 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, stom- ach, and duodenum being united firmly to the under surface of the liver. The coils of the small intestine presented considerable injection at their lines of contact; but neither was lymph effused, nor had the serous mem- brane lost its shining color. Numerous tubercles were present on the se- rous 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 ijanoreas, 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 de- posit. 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 duo- denum contained grayish-green fluid and mucus. The mucous membrane of the stomach did not present any abrasion, thickening, nor ulceration, nor was the pylorus hypertrophied; there was a little arborescent injec- tion. 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 ^ny injection; it did not extend into the mus- cular 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 ad- hesions had looped up the intestine. On the gastric side of this constrio- 124 DISEASES OF THE INTESTINES AND PEEITONEUM. tion 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 caecum and appendix also were normal. In the ascending colon the solitary glands were very distinct, 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. The rest of the intestine was normal. The supra-renal capsules, the kidneys, and the liver, were healthy; two or three strumous tubercles were, however, sit- uated on the peritoneal surface of the liver. In mechanical duodenal obstruction from the second cause, impaction of a gall-stone, the symptoms resemble those produced by internal strangu- lation 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, can- •lot have a stercoraceous odor nor appearance. The diagnosis is generally obscure and difficult; but where the symptoms of the passage of a gall- stone, namely, intense pain in the hypochondrium, vomiting, and subse- quent 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 subsequent 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 duodenum, or in the upper part of the jejunum. In obstruction from diseased lymphatic glands in the neighborhood 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 intestine 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 wpper partof the Jejunum, thirty inches from the Pylorus. — The calculus is in the mu- seum of Guy's. The case was under the care of Ebenezer Pye Smith, Esq., and is recorded in the * Pathological Transactions ' of 1854. The patient was a stout woman, ast. 63. She had good health till three months before death, when she suffered slight pain in the right hypochondrium, which continued a fortnight, unaccompanied by sickness or prostration. She recovered, but continued her usual sedentary habits; five days before her 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 composed of inspissated bile, and measuring four and a half inches in the circumference 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 extended from the gall-bladder into the duodenum, below the bile-ducts. DUODENUM. 125 The case just recorded of gall-stone with haemorrhage ai.d 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, re- covered. There are in these cases three symptoms which especially deserve at- tentictn, as guiding us to a right diagnosis, when viewed in connection with the previous history. The absence of abdominal distention, 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 distention of the abdomen is an important sign of oc- cluded intestine in the early part of its course. In obstruction of the large intestine, or even at the lower part of the small, the abdomen be- comes enormously distended, and the peristaltic movements can often be observed in spare persons through the parietes; this is especially the case in disease of the sigmoid flexure of the colon. The stoutness of the pa- tient sometimes renders this sign less observable; again, where this duod- enal 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 strangulation 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 con- tinued, the matters are of a stercoraceous character. Still, in acute peri- tonitis, 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, ac- companied with vomiting and constipation; this severe character of pain we do not find in intestinal obstruction, but it must be acknowledged, 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 bj Dr. Barlow in the 'Guy's Reports' for 1844: — The patient, aged fifty- one, a year before her death had the symptoms of gall-stone, and the bow els afterwards became constipated; a short time before her death exces sive pain, vomiting, and constipation came on, with scanty urine and col lapsed abdomen. The gall-bladder and duodenum were firmly adherent, the two upper thirds of the duodenum were contracted, thickened, anci 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 within the range of the absorbing 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 vomiting is also less severe. Dr. Barlow has, in the paper previously cited, dwelt upon the impor* 126 DISEASES OF TIIE INTESTTNES AND PEEirOIfEUM. tanoe of bearing In mind, that in ischuria renalis, violent vomiting', con' stipation, 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 duod- enum; 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, grad- ually increasing emaciation, with constipation; and these symptoms are slowly developed during several months. A tumor can generally be felt near the region of the pylorus. The following very interesting case was regarded as one of cancerous 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 gen- eral symptoms resembled those of organic gastric change. Case XCIII. — Disease of the Pancreas. Suppuration and Gangrene. Pressure on the Duodenum. — James P , set. 60, by occupation a pub- lican, and resident at Camberwell, was admitted under my care on July 4, 1861. 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, which 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 suffered from any hfematemesis. The pain was situated at the epigastric and umbilical regions, and extended to the spine; it was of an acute kind, and had not the gnawing character of pain often de- scribed by patients affected with ulcer of the stomach. On admission he was very much emaciated, with an anxious counte- nance, sallow complexion, and sunken eyes; his skin was hot and dry, and he complained greatly of thirst; the tongue was furred, the pulse frequent and sharp, the respiration normal; he had slight cough, but it did not dis- tress 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 percussion; no fluctuation could be felt, and it had slight pulsation anteriorly from contact with the aorta, but no general aneurismal thrill. There was resonance between the tumor and the liver, as well as between the tumor and the spleen; in fact, both the hypochon- driac regions were more than usually resonant. Pressure on the tumor produced a feeling of nausea; the bowels were constipated; and the ap- petite 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 wdth brandy, and chloric ether, TTlx., with nitrate of bismuth, gr. x., in mucilage mixture. July 5th. — He was slightly relieved by the medicine, but the vomit- ing continued ; the ejected matters consisted of deep-green fluid, con- taining a large quantity of mucus, of squamous epithelium, and some nucleated cells (from gastric glands). These attacks of vomiting dis- tressed him greatly; every kind of food was rejected at once, but the medicine and ice partially relieved his distress; his prostration, however, DUODENUM. 127 increased; hiccough distressed him; and he had an offensive taste in the mouth. July 8th. — He was extremely restless and prostrate, and the vomited matters were of very deep-green color. At 9 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 emaci- ated. The thoracic viscera were healthy, excepting old pleuritic adhe- sions. 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 per- foration. By dividing the peritoneum 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 pos- terior part was a black slough about two and a half inches in length; some concrete yellov^ matter was also found on its walls. The abscess rested on the spine, the crura of the diaphragm, and on the superior mesen- teric and splenic veins as they formed the vena portse. It extended on the left to the spleen. The pancreas for two to three inches towards 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 observed 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 con- tained 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 also that of the duodenum; but 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 ascer- tained, 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 ad- vanced. Acute peritonitis, from the transudation of offensive 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; some- times it is towards the surface, and a rounded tumor is then felt on the anterior abdominal parietes; or it extends through the diaphragm into the lungs. In a case under the care of Dr. Rees, in Guy's, the cyst 128 DISEASES Off THE INTESTUTES ATH) PEEITONEUM. opened into the duodenum. Hydatids were both vomited and passed by stool, and the former symptom was very severe. The patient was ex- ceedingly 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 remains 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 Twick- enham; 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 con. tinued for three weeks. Eight months before admission his appetite be- came ravenous, but he lost strength and became emaciated; for seven weeks he had been confined to his bed from severe pain about the umbili- cal 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 ' Patho- logical Transactions' of 1851 and 1853: — 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 oasts composed of agglutinated and interwoven masses of string and hair. Gastric Solution of Duodenum. — The mucus of the duodenum is fre- quently found in an acid condition after death, which is probably due to some of the gastric juice slowly gravitating through the pylorus; 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 , set. 4, was admitted July 16, 185& and died on the 23d. He was an anasmic child, with large head; on ad mission he was in a semi-comatose state, and the pupils were widely di lated; he had occasional vomiting, but no convulsions; six weeks previouslj he had had measles, and one week afterwards hydrocephalus graduallj became developed; he was in an almost hopeless condition on admission. Inspection was made fourteen hours after death. The arachnoid waa covered with a slight layer of lymph, so as to give it a greasy appear ance, 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 membrane being destroyed; but in the duodenum the intestine was quite divided, all the coats destroyed, and the end of the first portion termi- nated in an irregular 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. DISEASES OF THE RECTUM AND ANUS. By Thomas Blizaed Cueling, F.R.S. Asr acquaintance with the numerous disorders of the lower bowel is absolutely necessary to qualify the medical practitioner to form a right diagnosis and judgment of the diseases of adjacent organs, as well as of the alimentary canal. Thus, complaints of the rectum are liable to be mistaken for affections of the uterus and even of the bladder; a discharge from a fistula in ano has been supposed to proceed from the vagina. Pa- tients have been treated for obstinate diarrhoea, when the actual disease has been stricture in the lower bowel, or a lacerated perinseum and sphinc- ter; and obstructions referred to the abdominal intestines have been dis- covered when too late to exist in their pelvic termination. The following is a table of the diseases of the rectum and anus; they can be treated of only very concisely in the space allotted to this subject: — Congenital Im- perfections; Haemorrhoids; Prolapsus of the Rectum; Irritable Ulcer; Irritable Sphincter; Nervous Affections of the Rectum; Villous Tumor of the Rectum; Polypus of the Rectum; Fistula; Chronic Ulceration; Stricture; Cancer; Atony; Anal Tumors and Excrescences; Prurigo Ani. Congenital Impeefections op the Anus and Rectum. — These may be classed as follows: — 1. Imperforate anus, without deficiency of the rectum. 3. Imperforate anus, the rectum being partially or wholly defi- cient. 3. Anus opening into a cul-de-sac, the rectum being partially or wholly deficient. 4. Imperforate anus in the male, the rectum being par- tially or wholly deficient, the bowel communicating with the urethra or neck of the bladder. 5. Imperforate anus in the female, the rectum being partially deficient, and communicating with the vagina or uterus. 6. Im- perforate anus, the rectum being partially deficient, and opening exter- nally in an abnormal situation by a narrow outlet. 7. Narrowness of the anus. A few other congenital deviations have been observed, but they are of very rare occurrence, the seven forms enumerated above being those most commonly met with. The classification of these imperfections is founded on states which can generally be recognized during life. Unfortunately the condition of the terminal portion of the intestinal canal, and its relations to the parts around, cannot be predicated with any certainty. In cases of imperforate anus, or of anus opening into a cul-de-sac, the intestinal canal may terminate in a blind pouch at the brim of the pelvis, the rectum being wholly wanting; or an imperfect rectum may form a shut sac, descending to the floor of the pelvis, or as low as the neck of the bladder in the male, or the commence- ment of the vagina in the female. It is known that the anal portion of the bowel is developed distinctly from the upper portion, and that the two afterwards approximate and unite, the diaphragm or septum disappearing 9 130 DISEASES OF THE INTESTINES AND PEKITONEUM. by interstitial absorption. A failure in this process is the cause of the sec- ond form of congenital imperfection. The cases of imperforate anus in which the rectum communicates with the urethra or vagina depend on the original existence of a cloaca, the malformation being due to an incom- plete separation during foetal life. These conditions are the result of an arrest of development at different stages. The blind pouch in which the intestinal canal terminates is sometimes connected to the anal integument, or to the anal cul-de-sac, by a cord prolonged from the bowel above. These cases are not, like the preceding, the result of a non-formation of the_ rec- tum, but are produced by an obliteration of the bowel, which was origin- ally well formed; the obliteration being a pathological change due proba- bly to ulceration and adhesion which had taken place during intra-uterine life. These imperfections of the rectum can be remedied only by operative measures which vary according to the nature of the irregularity; and this treatment unfortunately often fails in obtaining a vent for the faeces, or in securing a permanent and sufficient passage. In cases of failure m reaching the bowel at the natural site, life may still be preserved by mak- ing an artificial anus either in the left loin or in the left groin. For sev- eral reasons the latter is the best situation for the operation in infants." Hjemokbhoids. — The hasmorrhoidal veins distributed in the sub-mucous tissue at the lower part of the rectum communicate in loops, and form a plexus which surrounds the bowel just within the internal sphincter. The veins are best seen when somewhat congested, their deep purple hue being very apparent through the thin mucous membrane with which they are in close contact. The plexus is then found to be about three-quarters of an inch in length, and composed of veins of various sizes, arranged for the most part lengthwise and in clusters, being especially collected in the longitudinal folds of the rectum. The plexus does not extend lower than the external sphincter, but veins branching from it pass between the fibres of the internal sphincter, and descend along the outer edge of the former muscle close to the integuments surrounding the anus. These veins are very liable to become dilated and varicose, giving rise to the disease termed hoemorrhoids or piles. When the plexus beneath the mucous membrane is thus affected, the haemorrhoids are said to be internal. When the veins beneath the integuments outside the muscle are enlarged, the haemorrhoids are called external. Both external and internal piles very frequently co-exist. We may distinguish two kinds of external piles. 1. A sanguineous tumor. 2. A cutaneous excrescence or growth. The sanguineous tumor consists of a softish elevation of the skin near the margin of the anus of a rounded form, and of a livid or slightly blue tinge. On cutting into it we find a dark-colored coagulum enclosed in a cyst. This kind of pile is generally single, and seated at the side of the anus, but a second may form at a subsequent period. The second form of external pile consists of flattened prolongations of skin. They are generally the chronic results of the first form, a projecting fold left after absorption of the coagulum having undergone further growth. The cutaneous excrescence contains no clot, and no enlarged or varicose veins; but clots and dilated veins may often be found at its base. There is sometimes only a single broad flat excrescence at the side of the anus; but there are often two, one on each side, and occasionally more. Similar excrescences occur as the result of ' See " Observations on the Eectum," by Mr. Curling. 3d edit. p. 231. DISEASES OF THE EECTTTM AND ANUS. 131 irritating discharges from the bowel, and are common in stricture and ul- ceration of the rectum. The changes in structure consequent upon internal haemorrhoids vary a good deal. In general the lower veins of the hsemorrhoidal plexus are dilated irregularly, or into pouches, which are filled with dark compact coagula. _ A bunch of varicose veins crowded in the lower ends of the longitudinal folds produce prominent projections of the mucous mem- brane, and deepen the pouches between the folds. Two or three of these prominences unite so as to form a transverse fold just within the sphincter. After a time the mucous membrane and sub-mucous tissue become greatly hypertrophied. Thus are developed elongated processes of a polypus form, and projecting transverse folds. The arteries, which are abundantly sup- plied to the lower part of the rectum, enlarge considerably, so that the mucous membrane involved is not only thickened, but extremely vascular. Such are the changes found in dissection, but the description conveys only a faint and incomplete impression of the condition of the parts observed during life. Internal piles seldom attract attention until they have become devel- oped so as to protrude at the anus in defecation. They then exhibit a re- markable diversity of appearance according to their number, size, and con- dition. The protrusion may consist of only one good-sized pile, found usually towards the perinasum or front of the anus. A single pile, con- sisting of a bright red projecting membrane connected with a loose fold of integument, and readily extruded, often forms in young persons, espe- cially women. More commonly, there are three distinct prominent growths differing in size, one at each side of the anus, and a third in front; the lat- ter, the perineal, being the largest. In old-standing cases they may be more numerous. The distinction between the piles is commonly well- marked, but not always; for the piles sometimes merge into each other, the protrusion forming a circular prominence. The aspect of extruded piles depends much upon their condition, whether congested, inflamed, or constricted by the sphincter. In a relaxed condition of the sphincter, they form softish tumors of a red granular appearance; but when pro- truded and congested, they constitute large tense tumid swellings of a deep red color and smooth surface, which readily bleed. When hsemor- rhoids of large size are fully protruded, the integuments at the margin of the anus become everted, and form a broad band girting the base of the tumors externally. External and internal piles often co-exist, the sphincter forming a nar- row band separating the two. But the two forins may merge into each other, the difference being recognized by the character of the covering, mucous membrane or skin, the line of junction being visible on the sur- face of the tumors. Internal piles are confined to the lower border of the rectum. They never occur, as has been asserted, higher i;p the bowel, so that when they are entirely removed there is very little liability to a re- currence of the disease. Haemorrhoids is a disease of middle and advanced age. They rarely occur before puberty, and but few persons in after-life altogether escape them. All those circumstances which determine blood to the rectum, or which impede its return from the pelvis, tend to produce this disease. In many persons there is a natural predisposition to haemorrhoids, and this may be hereditary. The complaint, indeed, often occurs in members of the same family who inherit the local weakness of their parents. But a predisposition is more frequently acquired by sedentary habits, indul- 132 DISEASES OF THE INTESTIITES AND PEEITONETTM. gences at table, and excitement of the sexual organs, which explains the well-known circumstance that haemorrhoids are more prevalent in the higher classes of society than amongst the laboring population. The lat- ter take plenty of exercise, live a good deal in the open air, and are little liable to constipated bowels. Haemorrhoids, though common in both sexes, occur more frequently in males than females. Few women bear children without becoming in some degree affected by them; but the uri- nary and genital disorders of the other sex, combined with freer habits of living, are still more fertile sources of piles. The symptoms produced by haemorrhoids vary a good deal in dififerent subjects, and in different stages of the complaint. External piles cause a feeling of heat and tingling at the anus. A costive motion is followed by a burning sensation, and the excrescence becomes slightly swollen and ten- der on pressure, so as to render sitting uneasy. This congested state of the pile may subside, or it may lead to inflammation and considerable en- largement of the hsemorrhoid, which then forms an oval tumor, red, tense, and extremely tender. The irritation produced by costive evacuations, or by friction in sitting and cleansing the part, sometimes gives rise to ulcer- ation on the inner surface of the pile, causing a sore which extends a lit- tle within the circle of the sphincter. This is liable to occur particularly to those growths at the margin of the anus which hold a middle place be- tween iuternal and external piles. The pain in these cases is rather se- vere, being a burning sensation lasting for some time after defecation. Internal piles, when slight, may exist for years, causing little incon- venience besides slight bleeding after a costive motion, and occasionally a feeling of fulness, heat, and itching, just inside the anus. When small they protrude slightly with the mucous membrane in defecation, returning afterwards within the sphincter. When of larger size, they always pro- trude at stool, and require to be replaced, the patient usually pushing them up with his fingers. In a lax state of the sphincters, and a loose and hypertrophied condition of the mucous membrane from which they spring, piles come down, even when the patient stands or walks about. When thus exposed to view they appear very prominent, of a rounded form, and often of a deep purple or violet hue, have a soft feel, and are evidently very vascular, bleeding readily when handled. If free from con- gestion, they exhibit a florid red color, with a rough, granular surface. In consequence of the friction and pressure to which they are exposed, their mucous surface becomes abraded, and furnishes a mucous discharge tinged with blood which soils the linen. They are often so sore that the patient is obliged to lie down, sitting causing great uneasiness. Persons frequently suffer no inconvenience from piles until, irritated by a costive motion, smart purgation, or the excitement of wine, they become congested and inflamed, and cause spasm of the sphincter muscle. Patients then have what is termed an " attack of piles "—that is to say, they suddenly experience a sensation of heat, weight, and fulness just within the rectum, followed by considerable pain at stool, and sometimes irritation about the bladder. Piles in this state are liable to be strangu- lated and constricted by the external sphincter, and haemorrhoids of large size have been known to slough off, the patients being relieved of the com- plaint by a sort of natural process, after much pain and suffering. In general the extremities only of one or two of the larger haemorrhoids perish, and the patient, though experiencing relief, is by no means cured of the complaint. One of the most common symptoms of internal haemorrhoids, indeed, DISEASES OE THE EECTUM AND ANTTS. 133 that from which the name of the complaint is derived, is hsemorrhage, which occurs when the bowels are evacuated. The bleeding varies greatly in amount. Sometimes the motions are merely tinged with a few drops of blood; in other instances the quantity lost is considerable, several ounces being voided at stool. The bleeding may be irregular, occurring only after costive motions, or in certain states of health; or it may take place daily, going on even within the bowel, and producing the usual symptoms of derangement from continued losses of blood. The complex- ion becomes blanched, and the lips appear waxy. The patient loses flesh and strength,_ has a quick and small pulse, suffers from throbbings in the temples, palpitations and difficulty of breathing on making any exertion, and at length thelegs and feet become oedematous. The character of the bleeding also varies; it is sometimes venous, sometimes arterial. There are persons who are liable to discharges of blood from the haemorrhoidal veins either at regular periods or when from good living or want of exer- cise the habit is fuller than usual. In these cases from three to six ounces of blood, or even more, pass away at stool, following the evacuation, and the blood which is voided is of a dark color and evidently venous. Such discharges must not be rashly interfered with. I had under my care, a gentleman, seventy years of age, who had been subject to hsBmorrhoidal discharges for many years, usually in the spring and autumn. After lasting a week or ten days they generally ceased, but not always, and when faint and weak from their continuance, he was in the habit of ar- resting them with cold-water injections. The discharges at length ceased, but in six months afterwards his urine became albuminous, and a year later he died suddenly after an attack of epistaxis. Periodical losses of this character relieve congestion of the liver and kidneys, help to ward off attacks of gout, and prevent fits of apoplexy, so that in many persons they are rightly regarded as safety-valves. Persons who suffer from in- ternal piles sometimes experience a pretty copious discharge of blood from the rectum. The bleeding shortly ceases, and all uneasy symptoms sub- side. This haemorrhage is also venous. The escape of blood unloads the congested parts and the patient gets relieved. But the bleeding which most commonly occurs from internal piles is undoubtedly arterial, taking place from arteries enlarged by disease. The vessels on the spongy sur- face of the mucous membrane readily give way when blood is determined to the part in defecation or when abraded by the passage of hard fasces. An a,rtery of some size, exposed by ulceration, continues to pour out blood, weakening the patient, and giving rise to the symptoms above described. Sometimes a small artery on the prominent part of a protruded pile may be observed pumping out blood. That hsemorrhage of this character is good for the health is quite a mistaken notion, and it is important that the practitioner should distinguish the bleeding taking place as a conse- quence of local disease from that which arises from a constitutional plethora or congestion of the intestinal organs. When piles are small, and cause but little inconvenience, the treatment is very simple. In all oases attention should be paid to the habits of living. Persons with this complaint should take wine in great moderation, if at all, and they are in most instances benefited by abstaining entirely from stimulating drinks. Many individuals never suffer from piles, except after taking a glass of spirits and water, or a few glasses of wine. Such persons should become rigid water-drinkers. Active exercise in the open air should be taken daily, and the patient should avoid sitting too long at the desk, because it is by prolonged sedentary occupation and neglect of . 134 DISEASES OF THE IITTESTINES AND PEEITONETJM. the rules of health that haemorrhoid complaints are induced, which explains why literary persons so often suffer from them. Chairs with cane seats are to be recommended. The bowels must be carefully regulated, so as to avoid hard and costive motions, as weU as frequent actions. Irritating the rectum by repeated purging is more hurtful even than constipation. On the other hand, when the liver is congested, or its secretions are slug- gish, and when the bowels are costive, a mild cathartic, by clearing the intestines, especially the large, unloads the congested vessels and relieves the piles. Lenitive electuary, rendered more active when necessary by the addition of the tartrate of potash, will probably answer the purpose. The foreign mineral waters, the Piillna or the FriedrichshaU, taken in the morning, fasting, agree well with many patients, and ensure a comfortable relief. "When the intestines require fully unloading, a draught containing rhubarb powder and the tartrate or sulphate of potash answers without producing local irritation. Half a pint of cold spring water thrown into the rectum in the morning after breakfast has a very beneficial effect on the haemorrhoids by constringing the vessels and softening the motions before the usual evacuation. The relief afforded by this treatment, com- bined with care in the mode of living, is often remarkable. Ordinary venous bleeding may be stopped in this way, using iced water, or some astringent such as a solution of tannic acid or infusion of rhatany. When the bleeding is of an arterial character, astringent injections are not so successful, and operative treatment often becomes necessary. When there is a slight slimy discharge from the surface of an exposed internal pile, benefit may be derived from the application of mild citrine ointment or the application of the solid sulphate of copper to the part. External piles, when large and troublesome, and internal, when of such a size as to protrude at stool, and to be subject to inflammation, ulceration, and frequent bleeding, can be removed only by operation. Pkolapsus of the Rectum. — In describing the changes occurring in piles, it was remarked that internal haemorrhoids slip down and project at the anus. The descent of these growths is often attended with more or less eversion of the hypertrophied mucous membrane of the lower part of the rectum. In relaxed states also of the sphincter muscle and coats of the bowel, loose folds of mucous membrane are liable to protrude and to require replacement. This protrusion and exposure of the thickened mucous membrane with or without internal haemorrhoids has been erro- neously described by writers as prolapsus of the rectum. In the true prolapsus, however, there is a great deal more than an eversion of the internal surface of the bowel. The gut is inverted; there is a "falling down " and protrusion of the whole of the coats — a change in many re- spects analogous to intussusception, but differing from it in the circum- stances that the involved intestine, instead of being sheathed or invagin- ated, is uncovered and projects externally. The length of bowel protruded in prolapsus varies greatly, from an inch to six inches or even more. The shape and appearance of the swell- ing depend partly upon its size, and partly upon the condition of the external sphincter. When not of any great length, the protrusion forms a rounded swelling which overlaps the anus, at which part it is contracted into a sort of neck. In its centre there is a circular opening, communi- cating with the intestinal canal. An inversion of greater extent usually forms an elongated pyriform tumor, the free extremity of which is often tilted forwards or to one side, and the intestinal aperture assumes the form of a fissure receding from the surface of the tumor, owing to the DISEASES OF T:^E KEOTUM AND ANFS. 135 traction, exerted upon it by the meso-rectum. In a relaxed state of the sphincter the surface of the protrusion has the usual florid appearance of the mucous membrane; but in other cases it is of a violet or livid color, and tumid from congestion, the return of blood being impeded by the contracted sphincter. The exposed mucous membrane is often thickened and granular, and sometimes ulcerated from friction against the thighs and clothes. A thin film of lymph may be occasionally observed coating its surface. On examining the section of a large prolapsed rectum from a child, I found the coats of the protruded bowel greatly enlarged; the areolar tissue was infiltrated v^ith an albuminous deposit, the muscular tunic hypertrophied, and the mucous membrane much thickened and dense in structure, especially at the free extremity of the protrusion. These changes account for the difiiculty in reducing the parts, and in retaining them afterwards, so often experienced in the treatment of this complaint in children, the bowel having become too large to be conve- niently lodged in its natural position, and, like a foreign body, exciting the actions of expulsion. The atonic and relaxed state of the sphincter muscle in these cases is well shown by the facility with which one or two fingers can be passed through the aaus even in children. Prolapsus of the rectum is observed most frequently in children between the ages of two and four, but is liable to occur at a later period of life. In infancy it is produced by protracted diarrhoea; the frequent forcing of stool so weakening the coats and connections of the rectum, and relaxing the sphincter, as at length to lead to inversion of the bowel. The straining efforts to pass water consequent upon stone in the bladder often give rise to prolapsus in early life. In adults the descent results chiefly from a weakened condition of the sphincter and levator ani mus- cles, and a general relaxation of the tissues of the part. The rectum being imperfectly supported by the perinaeum, the eversion at stool grad- ually extends until an actual inversion takes place, and this may increase until it forms a protrusion of considerable size. Prolapsus in adults is more common in women than in men. In the former it results in a great measure from weakness in the parts consequent upon child-bearing. The annoyance and inconvenience occasioned by a prolapsus of the rectum vary considerably under different circumstances. Thus the bowel may descend only in a very slight degree at stool, and disappear by a natural effort afterwards, or it may come down only occasionally, admit- ting of being easily thrust back, and, when returned, will remain in its place until an attack of diarrhoea or the effort to pass a costive motion causes it to fall again. Prolapsus sometimes occurs after every motion, and even when the patient stands or moves about, forming a large red unsightly tumor exposed to friction, feeling sore, soiling the linen with a bloody discharge, and required to be pushed back frequently during the day. Or the gut may be constantly protruded, being fixed so as not to admit of replacement. There are cases on record in which a prolapsed bowel has become strangulated and inflamed, and has even mortified and sloughed off, similar to what sometimes happens to an invaginated mtes- Young persons generally outgrow this complaint by the period of puberty; and common as is prolapsus in early life, it is rather rare in grown-up subjects. I have known, however, of persons, who have had this disease in childhood, and lost it, becoming affected with a return ot it in after-life from the effects of a diarrhoea. In adults prolapsus is com- monly attended with a slimy discharge of mucus tmged with blood, and, 136 DISEASES OF THE INTESTINES AND PERITONEUM. in some instances, with troublesome bleeding. The haemorrhage does not occur from any particular spot, but as an exudation from the congested mucous surface when the bowel is protruded at stool. As the ' cause producing the bleeding is constantly recurring, there is sometimes consid- erable difficulty in arresting it, local applications having little effect so long as the bowel continues to descend. In children, irritability of the bowels and diarrhoea must be checked and disordered secretions corrected by suitable remedies. Attention must be paid to diet, and when the powers are feeble benefit wiU be derived from quinine or steel. In slight cases it will be sufficient to direct the nurse, when the rectum comes down at stool, to place the child on its face across her lap, and to return the parts by taking a soft cambric handkerchief or sponge wetted in cold water, in both hands, and by gentle but steady compression to push the protruded gut back into the pelvis. The relaxed state of the membrane may be corrected by administering regularly every evening an astringent injection, such as the decoction of oak bark with alum, the infusion of rhatany, or the muriated tincture of iron diluted. The child should also be kept at rest in bed, and be made to relieve its bowels in the recumbent posture until the strong tendency to prolapsus has been corrected. The chief difficulty is to retain the parts after they have been reduced. A piece of sponge or cotton wool, moist- ened in an astringent lotion, may be lodged at the anus and secured there by approximating the buttocks by means of a broad strip of adhesive plaster applied across from one side to the other, and further secured with a T bandage. When the surface of the prolapsed bowel is ulcerated, it should be painted with a solution of nitrate of silver. In cases of stone, the prolapsus generally disappears after lithotomy. Prolapsus in the adult requires surgical treatment to contract the opening of the anus by escharotics or operation. In old and unhealthy subjects the trouble may be remedied by a well-fitted rectum supporter. Ieeitablb Ulcee and Fissuee. — The mucous membrane of the lower part of the rectum is arranged in longitudinal folds, which disappear in the expanded state of the bowel. These folds terminate below at the ex- ternal sphincter. Just within this structure and between the folds, the mucous membrane is slightly dilated, variously in different subjects, but in many to such an extent as to form small sacs or pouches. Beside these folds, and in the spaces between them, there is a series of short projecting columnar processes, about three-eighths of an inch in length, separated by furrows or sinuses more or less deep, which are arranged around the lower part of the rectum. In the evacuation of the rectum, foreign bodies or little masses of hardened fseces are liable to be caught or detained in the pouches just described. It is in these little sinuses thus exposed to irrita- tion, abrasion, and rent, that a superficial circumscribed ulcer is formed. On examining the ulcer without distending the rectum, the lateral edges only being presented to view, the breach of surface has the appearance of a. fissure — the term commonly given, but improperly, to the sore, which though often originating in a rent is obviously more than a mere cleft or fissure in the mucous membrane of the bowel. Such an ulcer may occur in any part of the lower circumference of the rectum, but is usually found at the back part. It is quite superficial, and though sometimes circular is generally of an oval shape, its long axis being longitudinal and its lower extremity extending within the circle of the extended sphincter. On tactile examination the breach of surface and size of the sore can be read- ily distinguished. With the speculum, the ulcer being fully exposed is DISEASES OP THE RECTUM AND ANUS. 137 clearly seen not to be a mere fissure but a superficial sore. The surface is of a brighter red than the surrounding membrane, and has the usual indented appearance of an ulcer. A small pedunculated pile or polypoid growth, attached to the opposite side of the bowel, is frequently found in these cases. The growth lodges in the ulcer, adding to the irritation and the difficulty of cure. The amount of suffering produced by this superficial ulcer varies a good deal, but the sore is generally extremely sensitive, and occasions severe distress. It is so situated tjfiat the feeces, in their passage out- wards, rub over its surface, and the painful contact excites spasm of the sphincter muscle, causing a sharp burning pain, and often a forcing sensa- tion, which lasts for two or three hours, the distress being usually greater after defecation than during the act; and in some instances, an interval, varying from five to ten minutes or more, elapses between the evacua- tion and the occurrence of pain. The pain is sometimes so acute that patients resist the desire to pass motions, and allow the bowels to become costive in dread of the sufferings brought on by evacuating them. I have known persons to deprive themselves of food in order to avoid an action. In one case, the intensity of suffering led the patient to adopt the danger- ous course of inhaling chloroform whilst sitting on the close stool, and he could not be persuaded to go to the closet without this remedy. The irritable ulcer occurs usually in middle life, and is. more frequent in women than in men. It is met with as often in single as in married women. Though the symptoms are characteristic, the sore is often over- looked. On the attempt to separate the margins of the anus, or to dilate the sphincter to get a view of the ulcer or even to introduce the finger, spasm with an aggravation of pain is, in most cases, immediately excited, and the orifice becomes strongly contracted, and forcibly drawn in. When this is the case, it is better to desist, and to get an assistant to administer chloroform. Under its influence the sphincter yields completely, and the practitioner is able to ascertain the exact seat, character, and extent of the ulcer. In cases free from spasm, a good view may be obtained by simply dilating the anus with the two forefingers or by introducing a speculum. The irritable ulcer seldom heals under the influence of local applica- tions. The treatment necessary is an incision through its centre, includ- ing the superficial fibres of the sphincter muscle, in order to place this muscle at rest, to enlarge the passage and displace the sore ; thus remov- ing those sources of irritation which prevent its healing. An incision is not invariably required ; but in all cases in which the pain is considerable, and in which there is much spasm of the sphincter, the attempt to pro- cure the healing of the sore by local applications so often protracts the patient's sufferings, and so constantly ends in failure, that it is not desira- ble to make it. In cases complicated with a pedunculated pile or polypus, this growth must also be excised. When the suffering is moderate, a cure may be attempted by giving a laxative to ensure soft evacuations, rest in the recumbent posture, and the application of mercurial ointment with morphia, belladonna, or chloroform. Ieeitable Sphincter Muscle. — Persons occasionally suffer pain in defecation, especially during solid motions, increasing afterwards, and last- ing half an hour or an hour. It is described as a forcing sensation, or a feeling as if the bowel were unrelieved. The anus is strongly contracted and drawn in by the action of the sphincter. Any attempt to examine the part induces spasm; and the finger passed through it is tightly grasped by 138 DISEASES OF THE INTESTINES AND PERITONEUM. the muscle, as if girt by a cord. In cases of old standing, the muscle be« comes hypertrophied and forms a mass, encircling the finger like a thick unyielding ring. This irritability and hypertrophy of the sphincter some- times produces serious trouble in defecation, owing to the expulsive pow- ers of the bowel being insufficient to overcome the impediment caused by this muscle to the passage of the fseces. Irritability of the sphincter occurs commonly in hysterical females, or in nervous susceptible women, who are accustomed to watch and to inten- sify every sensation. The treatment required is mUd laxatives, the local application of an ointment containing chloroform, opium, or belladonna, and the occasional passage of a bougie coated with a seda,tive ointment. The bougie gives great relief in those cases in which an irritable sphincter ofEers resistance to the passage of the fasces. In obstinate cases a partial or complete division of the sphincter may be necessary to remove the difficulty. Neevous Affections of the Rectum. — ^The symptoms as well as the causes of these complaints are usually obscure, and the diagnosis is often perplexing. On analyzing the symptoms, they appear to consist, in some instances, in an irritability, or a too frequent inclination to relieve the bowels; in others, in a morbid sensibility or undue tenderness of the part; and more rarely in an exaltation of sensibility independent of contact, constituting neuralgia. 1. Irritable Mectum. — In derangements of the alimentary canal, and of the organs connected with it, the faeces are often unhealthy and irritating to the mucous membrane ; consequently when passed into the rectum they excite uneasiness, with an urgent desire to void them. Pressing and pain- ful calls are also experienced when the bowel is ulcerated and in other ways diseased. In " the irritable rectum " there is an inclination, more or less urgent, to empty the bowel, usually at inconvenient times, although the mucous membrane, as well as the faeces, are healthy, and often when there is little or nothing to expel. Thus, a country rector experienced an urgent desire to relieve the rectum in church, just before and during the performance of divine service, notwithstanding an effort in the closet had just previously proved ineffectual. He was subject to it also when attend- ing public meetings and whilst riding in a railway carriage. Persons liv- ing in the country and going daily to business by railway are sometimes annoyed by a desire to go to the closet just as the train is coming up, and during the journey to town, but it passes off as soon as they arrive at the counting-house and get engaged in business. The complaint is often con- nected with an anxious fidgety state of mind, against which patients may often successfully struggle. My patient, the rector, got relief from a gen- tle aperient on the Saturday, and a mild opiate suppository administered on Sunday morning. 3. Morbid Sensibility of Rectum. — Several cases have fallen under my notice in which uneasiness has been experienced at a particular spot in the rectum, being complained of, chiefly, during or after defecation. The fixity and sometimes severity of the pain, and its aggravation from pressure, have naturally led to the suspicion of the existence of some lesion in the mucous membrane, such as an ulcer: but on careful examination, no breach of sur- face has been discovered; nothing has been observed except in some in- stances slight elevations and increased redness and vascularity at the spot affected, and occasionally abrasion of the mucous membrane. The com- plaint consists chiefly in an exalted sensibility of the nerves of the part, but the alterations in appearance just described indicate that there is also DISEASES OF THE EECTUM AUD ANUS. 139 some slight and superficial structural change. The remedies for the com- plaint are chiefly local. Sedatives, such as opium and belladonna, passed into the rectum give relief, but more permanent benefit may be derived from applications calculated to alter the character of the part, such as the sulphate of copper or a strong solution of the nitrate of silver applied through a speculum. I have in several instances cured severe morbid sensibility in this part by two or three caustic applications. 3. Neuralgia of the Beetum.— The two forms of nervous affection already described would be included by some writers under the general term of neuralgia, the sensibility of the rectum being in a measure per- verted or augmented; but it will be remarked, that in the first no actual pain is experienced — there is merely an irregular and often causeless desire to evacuate the part; while in the second, the uneasiness consequent upon the augmented sensibility is either produced or aggravated by fric- tion and pressure. In true neuralgia of the rectum, the pain is severe, but quite independent of contact. There is no tenderness. In the cases of neuralgia which have fallen under my notice, the pain was not char- acterized by paroxysms, by a suddenness of attack and disappearance, or by any regular intermittence, nor was the pain of an acute kind, but it was described as a continuous enduring pain, or a constant gnawing sen- sation, suificiently severe to interfere seriously with the comforts and even the business of life. The pain was in no degree mental, for the patients were not persons of an anxious nervous temperament, and, unlike the two other forms of nervous affection, occupation and amusement had little in- fluence in mitigating their troubles. The remedies calculated to g've relief are such as are useful in neuralgia elsewhere, as quinine, steel, arsenic, bromide of potassium, local sedatives, and hypodermic injections, and they are as uncertain in removing the affection of the rectum as in curing neu- ralgia of other parts. In some instances it is impossible to refer nervous complaints of the rectum to either of the forms just described, morbid sensibility and neu- ralgia being so combined as to prevent any distinction being drawn. Villous Tumor of the Rectum. — A growth similar to the villous tumor which occurs in the bladder and on other mucous surfaces sometimes forms in the rectum. It was first described by Mr. Quain under the name of a " peculiar bleeding tumor of the rectum ; " but as it closely resembles the outgrowths found in the bladder called villous, I prefer the latter term. The tumor springs from the mucous membrane generally by a broad base, is soft in structure, and composed of a number of projecting papillae or villi. On minute examination it is found to vary in structure according to the proportion of the fibrous or vascular elements entering into its composition. The villous tumor is innocent in character, and is not apt to return after complete removal. Its chief peculiarity in the rectum as in the bladder is a remarkable disposition to bleed. This growth is a rare disease, and occurs only in adults. When it projects at the anus, it exhibits characteristic projecting processes of a deep red color. The breeding to which this growth gives rise and the slimy discharge render its removal very necessary. If the tumor be attached high up, and a ligature can be applied round its base, this is desirable, as it would be dlfiicult to arrest bleeding after excision. Polypus of the Rectum occurs in two forms — the soft or follicular, and the hard or fibrous. The soft polypus forms generally in early life. Its essential element is a considerable agglomeration of elongated follicles. There is a network of small vessels on its surface which is also furnished 140 DISEASES OF THE INTESTINES AND PERITONEUM. with papillae. The polypus is attached to the mucous membrane of the rectum by a narrow peduncle which varies in length. The polypus is gen- erally single, but several have sometimes been found. The follicular polypus usually makes its appearance external to the anus in children after a stool, and it resembles a small strawberry, being of a soft texture, granular on its surface, and of a red color. It produces no suffering, but causes usually a slight bloody discharge, which, occurring after every motion, excites attention. In some instances the bleeding is sufficient to weaken the patient. The description of the complaint by the mother or nurse is apt to mislead the practitioner and to induce him to conclude that the case is common prolapsus. The growth can generally be detected by the finger passed into the bowel; and when the peduncle ' s long enough, the tumor is forced out at stool, and its nature can then ' )e ascertained without difficulty. The follicular polypus occurs very rarely (n the adult. The treatment of polypus in children is very simple and always effectual. The tumor should be strangulated by a ligature secured around the pedicle and then returned within the bowel. This causes no pain, and the polypus comes away with the motions two or three days afterwards. Excision is not quite safe, as it is liable to be followed by bleeding. The fibrous polypus is of a pear shape, with a peduncle more or less long and thick. It varies in firmness, seldom bleeds, but occasions a slight mucous discharge; and when the peduncle is long, or the tumor low down, it protrudes at the anus after stool, and requires replacement. When lodged within the bowel, it causes a sensation of unrelief, as if a foreign body or feculent lump required discharge. The polypoid growth some- times becomes congested, and when protruded in this state its peduncle is liable to become girt by the sphincter, which causes great, pain. The suf- fering is stUl greater when, as frequently happens, the polypoid growth is complicated with an ulcer within the circle of the sphincter. The polypus, coming in contact with the ulcer, irritates it, and prevents its healing. The polypus must be removed by ligature or excision; and if an ulcer also exists, it must be divided at the same time. Fistula. — The loose areolar tissue around the lower part of the rectum is occasionally the seat of abscess, which bursts externally near the anus. But instead of the part healing afterwards like abscesses in other situa- tions, the walls contract and become fistulous, and the patient is annoyed by a discharge from the opening. Such is the complaint termed fistula in ano. The abscess giving rise to fistula sometimes forms with all the characters and symptoms of acute phlegmon, suppuration taking place early, and the matter coming quickly to the surface. But more frequently a thickening appears at a spot near the anus with scarcely any sign of in- flammation, and but little local pain, and is gradually resolved into a fluc- tuating swelling, which being opened discharges a fetid pus. On intro- ducing a probe at the external orifice of a fistula formed in either way, it may pass through a small opening in the coats of the rectum into the bowel; the case is then called a complete fistula. When there is no in- ternal opening, the complaint is named blind external fistula. The external orifice is usually but a short distance from the anus, its situation being often indicated by a button-like growth, and it is in the centre of this red projecting granulation that -the opening is found. The aperture, how- ever, is not always so marked, and being very small — a mere slit concealed in the folds of the anus — it cannot be detected without careful search. The abscess, before breaking or being opened, may have burrowed to some DISEASES OF THE EEOTUM AND AWTTS. 141 distance, and the external orifice may then be placed two or three inches from the anus in the direction of the buttock or pferinseum. An abscess may make its way into the bowel before bursting externally, but the inner opening is generally formed after the external, and is small in size. The sinus burrows close to the mucous membrane of the rectum, which forms a thin barrier between the bowel and the sinus. Ulceration ensues at one point, and thus is formed the internal orifice of the fistula. The orifice is most commonly just within the sphincter: a fact established some years ago by M. Ribes, and fully confirmed by later observation. The inner opening, however, sometimes forms higher up the rectum, as I have clearly ascertained both in the living and dead subjects. Ulceration of the mucous membrane, from the wound of a fish bone or from other causes, may perforate the bowel just within the sphincter, and, allowing the escape of feculent matter into the areolar tissue around, may give rise to abscess and fistula. Fistula occurs in phthisical subjects, originating in tubercular ulceration of the mucous membrane and perforation of the bowel. In these cases the inner orifice is usually large in size, and there is sometimes a second opening. Though the inner orifice is most commonly found just within the sphincter, the fistula itself often extends some distance up the side of the rectum, as far as two or three inches, or even higher, and it may burrow in different directions. When the sinuses are tortuous, or pass in different directions, there may be more than one inner opening. Sometimes there is an external orifice on each side of the anus leading to fistulous passages which pass to the back of the rectum, and communicate with the gut at this part by a single orifice, so as to form a sort of horse- shoe fistula. The matter is liable to lodge in these complicated sinuses, to give rise to inflammation, and to lead to fresh abscesses and additional fistulous passages. In old-standing cases, the walls of the fistulous passages become dense and callous, feeling gristly to the finger. In all cases of complete fistula the occasional escape of a little feculent matter into the passage is amply sufficient to prevent the part healing, even if the actions of the levator and sphincter ani and the movements of defecation did not also interfere. Authors have described hlind internal fistula, in which an opening into the bowel leads to a fistula without any external orifice. Such cases are rarely met with. The external opening sometimes closes for a short time, the spot being indicated by redness and induration ; but sooner or later it re-opens, and the discharge returns, or a fresh opening is made at some distance off. It may happen, however, that the original ulcerated opening in the rectum being large, the matter from the abscess in the areolar tissue outside finds its way so readily into the bowel that the abscess does not burrow towards the surface. The situation of the suppurating cavity may be ascertained externally by a sort of hollow or indistinct fluctuating feel. A bistoury plunged into this will render the fistula complete. A blind internal fistula is very liable to be overlooked. I have met with several instances in which this has happened. In one case, the discharge, which was abundant and kept the linen constantly soiled, was supposed to proceed from the vagina. An anal fistula is at all times an annoying complaint. Even when the seat of the disease is free from all inflammation and tenderness, the patient is troubled with a discharge ^vhich stains the linen and keeps the part uncomfortably moist. The discharge is usually a thin purulent fluid^ at other times it is thick, and in complete fistula tinged browc from admixture of feculent matter. The discharge is more or less copious in different cases, and varies also at different times. It occa- 142 DISEASES OF THE ITTTESTINES AND PERITOBTEaM. sionally becomes so thin and scanty that the patient supposes the fistula is about to close, when he is disappointed by fresh irritation being- set up, and the complaint becoming as annoying as ever. Anal fistula is a disease of middle life, and occurs more frequently in men than in women. It is occasionally met with in young children, but rarely forms in advanced life, owing partly to the laxity of the rectum and sphincter in old people rendering the mucous membrane less liable to irritation and injury, and partly to the relief obtained by discharges from the hasmorrhoidal veins when congested. The treatment necessary during the formation of the abscess, which precedes the establishment of a fistula, is rest in the recumbent posture, fomentations or the hip-bath, a poultice to the part, and mild laxatives. As soon as fluctuation can be felt, the prominent or central part should be punctured freely to prevent the matter burrowing in the loose areolar tissue, and thus to limit the extension of the sinuses. Fomentations and poultices must be continued until inflammation has subsided and the sup- purating sac has become fistulous and indolent. An examination may then be made. This, as well as the cure of anal fistula by operation, is entirely surgical. Chkonic Ulceration of the Rectum. — The rectum is subject to ulceration in dysentery and other diseases, the mucous membrane being destroyed to a greater or less extent. Chronic ulcers of a tubercular character also occur in this part, but they are generally small in size. Several cases of ulceration in the rectum, the origin of which must be ascribed to syphilis, have fallen under my notice, and this symptom is probably less rare than is commonly supposed. Syphilitic ulcers are usually large in size, and often involve the deeper structures of the coats of the rectum, so that the healing process is very apt to cause a serious contraction of the passage. The chief symptoms referable to chronic ulceration of the rectum are — a purulent discharge from the anus more or less copious; motions gener- ally loose and mixed or coated with a slimy fluid, and streaked with blood; soreness in passing stools and occasionally tenesmus. The pain in defeca- tion varies considerably, being in some cases severe, in others very slight. Indeed, it is surprising how little suffering is often caused by the actions of the rectum and passage of the faeces in cases of large ulceration of the mucous surface. The suffering much depends on the position of the ulcer. Whether it be large or small, if it extends low down, so as to come within the grasp of the sphincter muscle, the pain is generally severe and persistent after defecation, and, in addition to other treatment, an incision through the lower margin of the ulcer is often, required to release it from the actions of the sphincter. The character, position, and extent of chronic ulceration in the rec- tum must be ascertained by examination with the finger and with the speculum. The surgeon will be able to feel a rough, uneven surface, more or less indented or depressed, and frequently hardness and consoli- dation of the walls of the rectum. The appearance of the sore in the lower part of the bowel may be seen through a glass speculum with an open end made oblique and large. This instrument is also very useful for the application of local remedies. The treatment suitable to chronic ulceration greatly depends on the nature and extent of the disease, apd upon the constitutional condition of the patient. In severe cases, I always keep the patient at rest in the recumbent position. In extensive destruction of the mucous surface with DISEASES OE THE EECTUM AWD ANTTS. 14S relaxed and copious discharges, especially when the disease originates in dysentery, vegetable astringents, such as simaruba, krameria, and bael, combined with the mineral acids and opium, are generally of great ser- vice in restraining the tenesmus and irritating evacuations and discharges. The subnitrate of bismuth with magnesia and anodynes often affords great relief. In many oases sulphate of copper with opium may be given with advantage. When the ulceration is consequent on syphilis or scrofula, the remedies appropriate to these diseases are required. The diet must be carefully regulated. _ The local treatment consists in the repeated application of weak solutions of nitrate of silver, and anodyne injections with mucilage, or anodyne suppositories. Steictuee of the Rectum. — The rectum, like other mucous canals, as the oesophagus and urethra, is liable to obstruction from contraction of its walls, forming the disease called stricture. The contraction may be Very limited in extent, and the stricture is then termed annular; or the contraction may include a portion, miore or less considerable, of the bowel. The sub-mucous tissue is the chief seat of disease, and is con- densed and converted into close-set fibrous tissue. The thickening of the coats of the bowel may be confined to part only of its circumference, or may be greater on one side than on the other, contracting the canal irregularly and forming a winding passage; or the induration, instead of being limited to a small portion of the bowel, may involve the greater part of the whole of the gut. The peritoneum investing the contracted bowel generally retains its healthy structure and appearance. Above the stricture the rectum is usually dilated and thickened. The enlargement results, not from a yielding of the intestine, but from a general hypertro- phy of the walls of the bowel, and particularly of the muscular coat. The mucous membrane at this part is rarely healthy. It is red and tumid, or eroded and ulcerated, the diseased surface supplying during life a puru- lent discharge. There are often ulcerated apertures leading to fistulous passages which extend for some distance and open externally near the anus or in the buttock. The bowel below the stricture is generally more or less diseased, and frequently studded with small excrescences arising from partial hypertrophies or irregular growths of the surface and folds of the mucous membrane. These excrescences tend to narrow the canal below the stricture. The seat of stricture in the rectum is at about an inch and a half to two inches from the anus, and easily within reach of the finger. In twenty-eight cases I found the stricture at this distance in twenty-one. In two in was nearer the anus, and in five at a greater distance. In three of the latter the stricture was at the point where the sigmoid flexure terminates in the rectum. In two instances I have met with double stricture. The pathological changes causing stricture originate in chronic inflam- mation of the mucous and sub-mucous areolar tissue of the rectum. It is seldom possible to fix on the exciting cause, but it is well known that the part is exposed to numerous sources of irritation. Women, in whom the disease is much more common than in men, have sometimes ascribed its origin to a difficult labor, by which no doubt the bowel may be injured, so as to set up chronic disease. In twenty cases of women with stricture of the rectum I ascertained that the disease commenced shortly after a labor, and in some instances was attributed to an injury at that time. Injuries such as a kick, and violent use of an enema tube, have also been known to give rise to stricture. Strictures sometimes originate in the 144 DISEASES OF THE INTESTINES AND PERITONEUM. contraction consequent upon the healing of ulcers or wounds in the bowel, more commonly indeed than is generally supposed. In extensive dysen- teric and syphilitic ulceration of the lower bowel the passage is liable to become seriously contracted in this way. I have met with several cases of stricture of this kind." The rectum may also be obstructed by an out- growth of fat, or by an infiltration of fat in the coats of the bowel. Thia is a very rare form of stricture. There is a specimen of it in the Museum of St. Thomas's Hospital, and Mr. "Worthington has related a case in tht Transactions of the Pathological Society (vol. xv.). In the Museum oi the London Hospital also there is a large fibrous and fatty tumor devel- oped outside the rectum and contracting the passage. Stricture of the rectum is a disease of middle life, being seldom met with in young persons except as a consequence of some injury. It is rare also in old people. The disease generally occurs between the ages of twenty and fifty. The earliest symptom of stricture is, generally, habitual constipation with difficult defecation when the motions are solid. The difficulty being readily removed by a solvent purgative, the nature of the case is not usually suspected at this early period. As the contraction increases, the constipation is overcome with difficulty, and the patient acquires the habit of straining. The stools are observed to be small in calibre, and are often voided in small lumps. The mucous surface, irritated by the disturbance in the functions of the rectum, becomes inflamed and exco- riated. This renders the action of the bowels painful, a burning, sensa- tion lasting for an hour or more after stool. There is also a secretion of brown slimy mucus, which escapes with the motions and soils the linen. The gases involved in the intestines not escaping readily, give rise to flatulent distention of the abdomen, especially in the course of the de- scending colon, and to disagreeable efforts for relief. The bowels often remain constipated for days together, and then a spontaneous mucous diarrhoea, excited by the fascal collection or by a strong cathartic, softens the motions and enables the patient to void the accumulated mass, its passage being attended with pain. In other instances, the patient is teased with frequent fluid evacuations, and urgent desires to pass them. As the disease makes progress and ulceration ensues, the discharges be- come purulent and bloody, and the sufferings are much increased, the passage of motions being likened by the patient to a feeling as if boiling water was passing through the rectum. At this period, pain is often felt in the sacrum. The discharges are sometimes so copious that the stric- ture is overlooked, the case being mistaken for one of protracted diarrhoea. Ulceration often leads to abscesses and fistula, sinuses in the buttocks and labia being common complications of old-standing stricture of the rectum. The appetite and even the general health often remain good for a long time. The disease is very chronic; and so long as a passage for the mo- tions can be obtained, the patient continues to follow his avocations, suf- fering more or less at different periods. The derangement of the diges- tive functions, the irritation kept up by the disease, and the exhausting discharges from the lower bowel in the course of time undermine the con- stitution and bring on hectic symptoms. The appetite fails, the body emaciates, profuse night-sweats ensue and the stricture directly or indi- rectly becomes the cause of death. This is sometimes hastened by a lodgment of hardened faeces, or of some foreign body just above the stric- ' See my " Observations on Diseases of the Eeotum." Third edition. P. 119. DISEASES OP THE EEOTIJM AND ANUS. 145 ture, so as to block up tlje bowel and occasion the symptoms of internal obstruction. Such an obstruction is sometimes the cause of an examina- tion of the rectum, ana thus leads to the detection of a close stricture previously unsuspected. In order to detect a stricture it is necessary to make a tactile exami- nation. On exposing the anus small flattened excrescences are usually observed at the margin of the aperture. These cutaneous growths re- semble collapsed external piles, except that they are redder in color, and are kept moist by the escape of a thin discharge from the bowel. They originate in the irritation kept up by this discharge. The finger, well ' greased, being passed carefully and gently into the rectum, will be arrested on reaching the stricture, so that the point only can enter. If the contraction be somewhat recent and not very close, the finger may be carried with a gentle boring motion through the stricture so as to ex- amine its whole extent. If the practitioner encounters much resistance or gives much pain, he must not venture to force the barrier, but must he content with ascertaining the seat and degree of contraction. In strictures high up in the gut, the rectum below may be found quite healthy, but it is often dilated and baggy with weakened expulsive powers. In strictures low down, the interior of the rectum is often abun- dantly studded with the small excrescences which I have described, which communicate to the finger the feeling of a number of rough irregu- lar eminences, more or less hard, thickly lining the surface. This condi- tion is invariably attended with a profuse discharge from the bowel of pus and slimy matter mixed with blood. A stricture high up in the rectum, and beyond the reach of the finger, is sometimes difiicult of detec- tion. In a suspected case the bowel must be explored by a flexible in- strument. When the passage is free, a good-sized flexible gum elastic tube may always be passed into the colon. The point is apt to impinge on the sacrum, or to be caught in a fold of the bowel; but if some warm fluid, water or linseed-tea, be injected somewhat forcibly through the '" tube, a space is formed, admitting the easy transit of the instrument. In stricture, pain is felt when an instrument reaches the point of contrac- tion, and a flexible one is arrested or passed on with more or less diSi- culty. In examinations for stricture it must be borne in mind that the rectum is liable to be compressed and obstructed by disease of the neigh- boring viscera — by an enlarged or retroflected uterus, fibrous tumors of this organ, a distended ovary, an excessively hypertrophied prostate, — an hydatid tumor between the bladder and rectum, or an outgrowth of fat, such as I have described. The main object in the treatment of a stricture in the rectum is to re- move the chronic induration and to dilate the contracted part sufficiently to admit a free passage for the faeces. The dilatation of the stricture is to be effected by mechanical means — by the passage of bougies, and sometimes by operation as well. The treatment, therefore, is chiefly sur- gical. An organic stricture fully established is universally admitted to be most difficult of remedy, and several high authorities, such as Dupuy- tren. Dr. Bushe, and Dr. Colles of Dublin, doubt the possibility of the disease being cured. These writers have undoubtedly taken too unfavor- able a view of the results of treatment. In addition to the dilatation, means must be adopted to relieve the irritability of the part, to insure the regular passage of soft evacuations. An opiate suppository or injec- tion may be lodged in the bowel at bed-time; and if the motions are cos- tive, some confection of senna, castor-oil, or PuUna water may be taken 10 146 DISEASES OF THE INTESTINES AND PERITONEUM. in the morning, in doses just suflSoient to obtain an action of the bowels without purging. Castor-oil is often of great service. In small doses it softens the feculent masses, and lubricates the passage without weaken- ing the patient. Cod-liver oil is also an excellent remedy. It nourishes the patient and softens the motions, rendering aperients unnecessary. The diet should be nutritious, and consist principally of animal food, so as to afford a small amount of excrementitious matter. It is no needless caution to advise patients to be careful to avoid swallowing plum-stones. Accumulations in the bowel above the stricture may be prevented by the occasional passage of an elastic tube through the contraction and an in- jection of soap and water. We sometimes meet, especially in hospital practice, with old, inveterate, and neglected strictures, in which the dis- ease is too far advanced and the mischief too great to admit of relief by dilatation. In such cases, when the sufferings are severe, I have pro- posed the operation of lumbar-colotomy, and have performed it in two cases.' Cancee of the Rbctum. — The coats of the rectum are subject to cancerous degeneration in the three forms of scirrhous, encephaloid, and colloid. The disease invades the coats to a greater or less extent, pro- ducing contraction of the canal, and it is liable to increase until it narrows the passage to such an extent that only a probe can pass through it. Fungoid growths sometimes spring from the mucous membrane at the side of the rectum and project into the bowel. Occasionally the bowel becomes blocked up and occluded by fungous masses. In other cases the changes which ensue have a contrary effect, degeneration and softening causing the coats to yield and increasing the calibre of the canal. A description of the progress of cancer of the rectum, and of the changes that occur in the advanced stage, is a description of the disorganization and invasion of all the tissues of the part, and of the organs in its immediate neighbor- . hood, in various degrees in dlEEerent cases. In some instances the carci- nomatous bowel becomes wedged in the pelvis, agglutinated and fixed to the surrounding parts, forming one mass of disease. Frequently soften- ing and ulceration cause fistulous communications with neighboring parts — with the vagina in the female, and with the bladder or urethra in the male; or the peritoneum may become perforated and an opening made into the abdominal cavity. When the passage is contracted, the intestine above becomes dilated and hypertrophied as in simple stricture. Carci- noma may attack any part of the bowel, but it generally affects the lower portion within three inches from the anus. It is liable to occur also, though less frequently, at the point where the sigmoid flexure terminates in the rectum. The disease is sometimes limited to the rectum and ad- joining parts, though the lymphatic glands in the pelvis and lumbar region often become affected, the liver being invaded by tubercles and the peri- toneum also studded with scirrhous deposits. Cancer of the rectum generally commences insidiously. Its early symptoms are so similar to those of simple stricture, that the nature of the disease cannot be determined, or may not be suspected, until a con- siderable change has taken place in the condition of the bowel. The patient is troubled with flatulency, has difficulty in passing his motions, and strains in the effort to void them; and as the disease makes progress, he experi- ences pains about the sacrum, which gradually increase in severity and dart down the limbs. By this time probably some alarm is excited, and ' Vide London Hospital Beports, vol. iii. DISEASES OF THE EECTUM AND AITTJS. 147 an examination may be called for. The practitioner on introducing his finger into the rectum may easily detect a contraction more or less rigid ; and should he feel any irregular nodules about the stricture, any hard solid tumor, or encounter a resistance like cartilage, or meet with softish tubercles which leave a bloody mark on the finger, then he would be able to decide on its being carcinomatous. At a later period no difficulty could be experienced. There is a hard mass of disease in which it may be difficult to discover the orifice of the passage, and sometimes round fun- goid growths which bleed readily when touched. The disease may extend as low as the anus. An irregular red-looking growth sometimes protrudes externally, blocking up the passage or displacing the anus. The stools become relaxed and frequent and contain blood, and in passing cause a scalding pain and give rise to severe suffering. There is often a thin of- fensive discharge, and as. the disease invades the sphincter, incontinency ensues. The loss of retentive power is often a great trouble in cancer of the rectum. This arises not only from the disease invading the anus and destroying the sphincter muscle, but occurs also when cancer is developed higher up in the bowel, the lower part being free. This may be explained by the carcinomatous disease pressing or destroying the nerves supplying the sphincter and so paralyzing it. The sufferings also increase. Severe shooting pains are referred to the groins, back, or upper part of the sacrum, and sometimes extend down the thighs and legs. The constitution suffers in due course. The patient acquires the blanched sallow look, anxious countenance, and emaciated appearan<3e commonly observed in persons suffering from malignant disease. If complete obstruction does not accel- erate a fatal termination, other troubles may arise. In consequence of a communication becoming established between the rectum and urethra or bladder in males, flatus and liquid fiBces escape from the urinary passage, and in females motions are discharged from the vagina. The passage of part of the intestinal contents by these unnatural channels greatly increases the misery of the patient's condition, rendering him an object of disgust to himself and offensive to those about him. An ulcerated opening into the peritoneum, allowing the escape of feculent matter into the abdomen, may excite peritonitis and thus bring the case to a fatal termination; or the powers of life gradually giving way, the patient becomes hectic and exhausted, worn out by this painful and distressing malady. There is great variety, however, in the degree of suffering, and even of constitu- tional derangement, attending the disease. Whilst in some cases the suf- ferings are excruciating, in others they are comparatively slight. In my experience patients suffer less from the disease when developed high up in the rectum than when formed near the anus. Cancer of the rectum occurs generally in midde life. The earliest age at which I have met with it is twenty, the patient being a young man in the London Hospital. It is commonly believed that this disease attacks women more frequently than men. This does not accord with my experi- ence of cases seen in hospital and private practice. Of seventy-three cases of which I have preserved notes, fifty-seven were males and sixteen females. All that can be obtained from remedies is palliation of the symptoms, ease from pain, and support under the wearing effects of this terrible dis- ease. The patient should remain at rest, chiefly in the recumbent posture, and take a nourishing but not stimulating diet. The general health may be supported by tonics. The bowels must be kept open and the motions rendered soft by Piillna water or small doses of castor-oil. If the stricture 148 DISEASES OF THE rNTESTIJiTES AND PEEITONETJM. be close, injections may be necessary through a long tube to break up the feculent masses. The greatest care is necessary in the passage of the tube, as if force be used the carcinomatous mass may yield and the tube be driven into the abdomen. Bleeding may be checke^ by injections of sulphate of copper and tannic acid. Pain can be alleviated by opiate and belladonna injections, or by small doses of morphia taken night and morn- ing, their strength being gradually increased as the effects of the remedy diminish. Subcutaneous injections of morphia also are effectual in giving relief. So great were the sufferings in a recent case, that after a time as much as 3^ grs. were thus injected twice a day. In cancerous disease of the rectum attended with great suffering from incontinency and constant scalding discharges, I have advocated and per- formed in several cases colotomy in the left loin. By diverting the pas- sage of the fasces, the local distress can be in a great measure prevented", and I have reason to believe that the progress of the disease al;^o may be retarded by the removal of a source of almost continual irritation. I have established an anus in the left loin in several cases of cancer in which no obstruction existed, in order to mitigate the symptoms, with a satisfactory result in prolonging life and preventing suffering.' Epithelial Cancee op the Anus aito Rectum. — The anus, like other parts, where a junction takes place between the skin and mucous membrane, is liable to epithelioma. The affection is comparatively rare, and has seldom been noticed by writers. It is easily recognized by the ordinary characters of the sore. In the few oases which have fallen under my notice, the disease extended into the rectum, but there was no reason to doubt that its original seat was the anus. The only treatment applica- ble to this affection is caustics or excision. I prefer the latter, as more sure and thorough. Though more common at the anus, epithelioma may occur in any part of the mucous membrane of the rectum. When occur- ring up the bowel, the disease is apt to produce slight bleeding, but it is much less serious than scirrhous and medullary cancer. The latter pro- duce sooner or later some contraction or obstruction in the passage, and show a tendency to involve the parts around. In epithelial cancer I have never noticed any impediment in defecation, and have invariably found the passage free and unobstructed. Neither do patients complain of the distressing pain, referred usually to the sacrum, which persons affected with scirrhus of the rectum so commonly experience, nor suffer painful tenesmus and defecation, which add so much to their distress in this form of the disease. There is also an absence of the cancerous cachexia, of the emaciation and pale and anxious countenance so frequently remarked in malignant disease. Epithelial cancer in the rectum may go on for years, but the patient becomes exhausted at last from repeated small bleedings. The haemorrhage is best restrained by injections of solutions of sulphate of copper, chloride of zinc or tannin. Atony of the Rectum. — In paraplegia the forces which expel the faeces and the retentive functions of the sphincter are both destroyed; consequently, the motions, if sufiBciently liquid, on reaching the lower bowel escape involuntarily. I have not met with any well-marked case of paralysis of the rectum independently of palsy of the lower half of the body; but several instances of loss of tonicity or defective muscular power in the lower bowel, rendering it incapable of properly extruding its con- tents, have come under my notice. An atonic contfition of the rectum ' Tide liondon Hospital Reports, vols. ii. and iy. DISEASES OF THE KEOTUM AND ANTJS, 149 may be produced by the too free and frequent use of enemata, the quan- tity thrown up being so large as to dilate the bowel and impair the power of its muscular coat. This condition is apt to give rise to faecal accumu- lations. Cases of this kind are not very uncommon, yet they are liable to be overlooked by practitioners. It appears that the rectum becomes gradually dilated and blocked up by a collection of hard dry faeces which the patient has not the power to expel. Some indurated lumps from the sacs of the colon, on reaching the rectum, perhaps coalesce so as to form a large mass ; or a quantity accumulated in the colon on descending iato the lower bowel becomes impacted there. In several instances a plum- stone has been found in the centre of the mass. Such a collection gives rise to considerable distress and alarm, producing constipation, a sensation of weight and fulness in the rectum, tenesmus and forcing pains. In cases of some duration, when the hardened faeces do not quite obstruct the passage, they excite irritation and a mucous discharge which, mixing with recent feculent matter passing over the lump, causes the case to be mistaken for diarrhoea. Injections have no effect in softening the indu- rated mass. They act only on the surface and return immediately, there being no room for their lodgement in the bowel. On digital examination the bowel is found to be distended and blocked up with a large lump which feels almost as hard as a stone. In such cases the only mode of giving relief is by surgical interference. The mass requires to be broken up and scooped out. Sir James Simpson has described this affection under the head of "b^U- valve obstruction of the rectum by scybalous masses." ' Some years ago I saw a lady who for eighteen months had been unable to relieve her bowels without aperients and without passing her finger into the rectum. On examination I detected a hard elongated mass which was forced down in the effort of defecation and obstructed the anus until the finger pushed it back. I broke up this mass, and after the bowels had been relieved by injections the difficulty was entirely removed. Anal Tumors and Excrescences. — Besides the flaps and folds of integument consequent on external piles, other growths are developed in the immediate vicinity of the anus. These tumors of a fibrous texture sometimes form in the subcutaneous areolar tissue, and as they increase become pedunculated. They seldom exceed the size of a chestnut, though I have known one to weigh half a pound. They have a firm feel, and their surface is in general irregularly lobulated. These growths may be easily and safely removed by excision. Warts are not unfrequently developed around the anus, and they sometimes grow so abundantly as to constitute a considerable cauliflower- looking excrescence. They then form projecting processes of various sizes densely grouped together, many being of large size, with their sum- mits isolated, expanded, and elevated on narrow peduncles more or less flattened. I have seen a mass forming a tumor as large as the closed fist, separating the nates, and almost blocking up the passage for the faeces. When abundant, they give rise to a thin offensive discharge. They origi- nate in the irritation consequent on want of cleanliness, and occur gener- ally in young adults of both sexes. I once saw a large crop of these growths in a child only four years of age. In some persons there is so strong a disposition to the formation of warts, that without great atten- tion it is difficult to prevent their formation. If few in number and small in size, they may be destroyed with strong nitric acid. They usually re- ' Edinburgh Monthly Journal of Medical Science, April, 1849. 150 DISEASES OF THE INTESTINES AND PEEITONETTM. quire however to be removed by excision, which is the quickest and most effectual mode of treatment. Great cleanliness and the application of astringent lotions will be necessary to prevent their reproduction after- wards. Peueigo Ani. — Itching at the anus is a common symptom in several disorders of the lower bowel, but it may also occur as a distinct affection, as independently of any other disease of the part, being due to a peculiar hyperaesthesia of the skin. Prurigo ani is caused by worms in the lower part of the rectum, and by congestion of the haemorrhoidal veins. In women it is consequent on affections of the womb. Patients suffer most after taking stimulating drinks, and during warm weather and when heated in bed. The itching is extremely teasing and annoying, especially at night, when it sometimes keeps the patient awake for hours. Rubbing the part to arrest the irritation only aggravates the mischief afterwards, yet few persons have sufficient self-control to prevent their seeking tem- porary relief by friction, and some, though capable of restraining them- selves whilst awake, fret the part unconsciously during sleep. The fric- tion thus resorted to excoriates the skin at the margin of the anus, so that in chronic cases the skin becomes dry, harsh, and leathery, cracks from slight causes, and ulcers and fissures are produced, which are but little disposed to heal. In most instances this complaint, after proving trouble- some for an hour or two at night and in the day after stimulants, ceases, and the patient has long intervals of rest and ease. But in the worst forms of the malady, the torment is most distressing. It lasts throughout the night, so that the patients get little but broken sleep, and after a time the general health suffers seriously, and life is rendered truly miserable. In some of the cases which have fallen under my notice, I could discover no local cause whatever to account for the prurigo. It seemed to be purely an affection of the nerves of the part. The patients are generally healthy. One gentleman who had been subject to it for years, found that it was connected with his state of mind. When much engaged and pros- perous in business, he suffered little from it. He was sometimes free for a whole month, and then became troubled for many nights in succession. In cases of this kind the complaint, after proving troublesome for years, has been observed to subside as age advances. In prurigo ani the habits of living should be regulated. The patient should sleep on a mattress, and be as lightly covered as is consistent with comfort, cold bathing or sponging should be daily resorted to, and suffi- cient exercise taken in the open air. Stimulants and hot condiments must be strictly avoided. The actions of the bowels are to be regulated if ne- cessary by medicine, and after each evacuation the parts should be cleansed with soap and water. Every effort should be made to avoid friction, and the patient should be assured that if he yields to his inclinations, his com- plaint will be rendered worse and more difficult of cure. In all cases, the condition producing this troublesome symptom must be the chief object of attention, such as worms, congestion, &c., but there are certain reme- dies which are specially adapted to relieve the irritation. The itching attendant on piles may be arrested by smearing the anus with some mer- curial ointment, as the dilute citrine, or one containing the gray oxide of mercury, or by lodging in the parts a piece of cotton-wool soaked in a lotion of oxide of zinc. Lotions of carbonate of bismuth and glycerine, of borax and morphia, or of carbolic acid, are often efficacious in this com- plaint. The application to the anus of strong solution of nitrate of silver' (gr. XX — § j) with a camel's hair brush once daily often gives relief, espe- DISEASES OF THE EEOTUM AND ANUS. 151 cially in cases where the skin is made rough and sore by rubbing. In some cases great benefit has been derived from chloroform ointment. It pro- duces a smarting sensation when first, applied, but this is soon followed by ease. In persons of weak constitution benefit has resulted from full doses of quinine, and in certain cases liquor arsenicalis with steel has helped to relieve the irritation. I have sometimes found it necessary in severe oases to order suppositories of morphia at bed-time. The complaint is often very obstinate, and much perseverance is required on the part of the practitioner, and also of the patient, to efEect a cure. INTESTINAL WORMS. Bt W. H. Ransom, M.D., F.R.S. Inteoductobt Hxmabks. — No definition of the disease, such as stands at the head of each article in this volume, is requisite or appropriate in treating, from the point of view of the practical physician, of the parasitic worms which inhabit the human alimentary canal. But it may be desira- ble briefly to indicate the general scope or plan of this article, as well as the limits within which it will be restrained. In most diseases, as for instance in the exanthemata, a brief summary of the more constant phenomena may serve at once as a definition and means of diagnosis; but, as the external agents or exciting causes of those phenomena escape our search, the etiology of such diseases is little more than an investigation of the conditions favorable to their occur- rence, with speculations upon the nature of the exciting cause : while the pathology is limited to a consideration of the relations existing among the phenomena observed during life or after death, and between these and the favoring conditions. But in the medical study of parasites the whole question of "the changes from a condition of health " is viewed from quite another stand- point. Here we can begin with the exciting cause, which we can isolate, compare, experiment upon, and learn the natural history of, before we study its effects. The extension of knowledge may possibly hereafter en- able us so to approach the study of cholera or scarlet fever. In this article the order thus indicated will be followed; the names and zoological position of the worms found in human intestines being first stated, the more important species will be described and their life histo- ries traced, with only so much of detail as may be required for the pur- poses of the medical practitioner. Afterwards the changes of function or structure which they produce, the conditions which favor their occurrence, the mutual relations of the observed phenomena, the methods of detect- ing, expelling, and avoiding these pests, will be treated of. Those parasitic animals belonging to the Gregarinida and Infusoria, as well as the accidental or occasional but not truly parasitic inhabitants of our intestines, such as insect larvae, will be excluded from consideration here on account of their at present comparative insignificance clinically. The Trichina spiralis ^'iQ. also be passed over, because, although it attains its state of sexual maturity in human intestines, its importance to the phy- sician depends upon the habit which its larvse have of perforating the tis- sues and becoming encysted in the muscles. Moreover the very great importance which has recently attached to this worm justifies the devotion to it of a separate article. 154 DISEASES OF THE INTESTINES AND PERITONEUM. It is diiBcult, if not impossible, adequately to appreciate the relation of intestinal worms to thieir bearers without including in the investigation the lower animals. To do so here would, however, be foreign to the de- sign of this work, and the reader who seeks for fuller information on this subject will do well to consult the works of Ktickenmeister, Von Siebold, Davaine, Cobbold, and especiaCy of Leuckart. I may however draw at- tention to two prominent results of the comparative study of Entozoa. They are so widely diffused that scarcely any species of animal is known which is not, at least sometimes, infested by them; and notwithstanding the fact that they can, and do, often injuriously and even fatally influence the animals they infest, yet in the majority of cases the observer is struck with the apparently trivial inconveniences they produce. HisTOEY. — The intestinal worms, or some of them, have been known from very early times. Hippocrates mentions the tape-worm, and Aris- totle described in addition the round-worm and the seat-worm. During the classical and middle ages the doctrine of spontaneous generation held general sway, and was thought to afford a satisfactory explanation of the then known facts as to the occurrence of Entozoa. Although Swammer- dam' and Redi' shook the foundations of this doctrine in its application to insects and their larvae, they did not venture to apply their views to the Entozoa. The first great step towards sounder views was made by Pallas,' who taught that Entozoa, like other animals, sprang from similar parents, and were propagated by means of eggs which were transmitted from one host to another. But in the absence of direct evidence these opinions were for a time borne down by the authority especially of Rudolphi* and Bremser,' who reverted to the doctrine of spontaneous generation. Soon, however, the progress of biological science, aided by improved means of research, and directed into new channels, broke down this doctrine at once and for all time, at least in its application to intestinal worms; and the re- searches of Mehlis (1831),' Von Siebold (1835),' and Esohricht (1837),' confirmed the main proposition of Pallas, and justified the conclusion of Eschricht, that Entozoa during their reproduction generally undergo a metamorphosis and a migration. Then followed the brilliant discovery of alternation of generations by Steenstrup (1843),' the researches of Von Siebold (1848)," and Van Beneden (1850)," and the true life history of the Tretnatoda and Cestoda was understood. It remained to furnish direct proofs of the correctness of the new views, and these were given by Ktick- enmeister (1853)," who fed carnivora on flesh containing Gysticerci and produced tape-worms, and by feeding herbivora vnth ova of Tsenise pro- duced Gysticerci. Many other zealous and able investigators in this coun- try, as weU as in France and Germany, have confirmed his results, and otherwise extended our knowledge of the intestinal worms. Prominent ■ Bibel der Natur. Ausdem HoU. iibersetzt. 1753. ' Esperience intome agl' Insetti. 1718. » Neue Nord. Beitrage. 1781. * Entozoor, hist. Natur, voL t. 1808. ^ Ueber lebende Wiirmer im lebendeu Menschen. 1819. ' Oken's Isis. 1831. • Arohiv f iir NaturgesoMchte. 1835 . ' Nova Acta Academ. G. L. , vol. xlx. 1887. ' XJeber den Generationswechsel. 1843. '" Jahresberioht im Arohiv fiir Naturgesohichte. 1848. " Les Vers Cestoidea. 1850. " Frager Vierteljahrschrift. 1853. INTESTIKAL WORMS. 155 among these stand the names of Haubner, Leuokart,' Dujardin," Davaine,' and Cobbold. The opinions of medical men as to the clinical importance of intestinal worms have varied with the changes of biological theory, usually lagging somewhat behind, but depending mainly upon it. So long as the doctrine of spontaneous generation in any of its forms was believed to account for the presence of Entozoa a mysterious dread of their power for evil pre- vailed, and evidenced itself by the multitude of grave diseases attributed to them. Indeed few maladies afflict humanity which were not sometimes attributed to intestinal worms, even by prominent men in their day. This was due not alone to the common tendency to magnify the un- known, but also to the uncertainties of diagnosis, the absence of a patho- logical anatomy, and the frequency with which worms were observed to pass away in the course of serious diseases, the subsequent recovery from which being imputed to their escape. In the latter half of the eighteenth century an extreme reaction took place among those who gave themselves specially to the study of Entozoa, so that it was maintained that they were beneficial to their hosts, or at most only very rarely and accidentally injurious. The physicians as a rule, however, still clung to the older views, and in doubtful cases found a ready and satisfactory explanation of the symp- toms in the assumption of an irritation by imaginary worms. Even Ru- dolphi and Bremser, whUe opposed to the prevalent medical opinion, sought to explain the actual symptoms which attended the presence of worms in the intestines by the hypothesis of a pre-existing diathetic state (Helminthiasis), which they believed to be a necessary condition of the spontaneous development of worms. Only in the present generation have sound views on' this subject prevailed, and only since the discoveries of Ktickenmeister and his followers has a satisfactory knowledge of the life history of human intestinal worms enabled the physician to appreciate their true importance in medicine, to ascertain their presence with cer- tainty, and in most instances to point out how they may be avoided. Out of at least thirty-one Entozoa which are at present known to in- habit our bodies, thirteen infest the alimentary canal. Of these seven belong to the order Cestoda :^- 4. Tania flaw-puuDtata, Weinland. 5. Tmnia eUiptica, Batsoh. 6. Bothriocephalm latus, Bremser. 7. Bothriocephalm cordatus, Leuokart. 1. Tmnia solium^ Linnaeus. 3. Toenia medio-candlata, Kuokemneis- ter. 3. Tamia »iaraa,Von Siebold. And six to the order JVematoda : — 8. Ascaris lumbricoides, Linnaeus. 9. Aseofis mj/stax, Rudolphi. 10. Oxyuria vermiovlaris, Bremser. 11. Boehmius duodenalia, Leuckarfc. 13. TriehooephaMs dispar, Rudolphi. 13. Trichina spiralis, Owen.* Oedeb cestoda. Parenchymatous worms, without mouth or alimentary canal, with a so-called water-vascular system. They develop by budding from a pear- shaped larval form (scolex) to a long, jointed, tape-shaped colony of indi- viduals (strobila). In their reproduction they suffer an alternation of ' Die menaohliohen Parasiten, &o. 1863-68. ' Histoire Naturelle des Helmintlies. 1845. 2 Traite des Entozoaires. 1860. * See article Trichina spiralis. 156 DISEASES OE THE INTESTINES AND PEEITONHTJM. generations. The individual members of the colony (proglottides), or sexually ripe animals, increase in size and complexity of structure, al- though otherwise resembling each other, the further they are removed from the head, near to which a continuous formation of new joints takes place by budding. The head, which is the same in the adult as in the larval form, is furnished with two or four suckers, and commonly also with a coronet of booklets, which serves for attachment. They infest in their adult state the alimentary canal of vertebrate animals only. The ovum yields a globular embryo furnished with three pairs of booklets, and develops into the Scolex ( Gystic&rcfus) in the tissues or in parenchymatous organs, usually of food animals, and is thence passively transferred with the food into the intestine of its definitive bearer, where it assumes the adult form. T^NiA SOLIUM (Linnaeus) Was at one time believed to be "the common tape-worm of man," but it is now known that at least one other species is included in that expres- sion. , ■ ■ ■ (nupilinii' iv;'.:-.i«i!;n- I''- (IHifft: %■■ wfim ■ Ir il Fio. 2.— Head of T. soil- um. (Davaine.) I^a. 3.— Coronet ol hoaks, magnifled. (Leack- arC.) Fig. 1. — Taenia solium natural size. (Davaine.) Fio. 4.— Separate hooks, more WgWy magnified. (Leuckart.) I>escription.— The adult worm (Strobila, Fig. 1) commonly attains a length of from 7 to 10 feet,' but is .often much longer. The number of ' This is Leuckart's raeaBurement, but there is a wide divergence among authorities on this point. Davaine makes the common length from 20 to 26 feet. INTESTINAL WOKMS. 157 joints increases with the length; a worm measuring 7 ft. 6 in., counted by Leuckart, had 749 joints. The head (Fig. 2) has a somewhat globular form, measures about -j^ in. to -^ in., is marked anteriorly by a mode- rately prominent rostellum, bearing a crown of about twenty-six hooks, and by four projecting suckers. The threadlike neck is nearly an inch in length, and to the naked eye is not distinctly jointed; it passes gradually into a jointed, continually widening band of a whitish color, of which the earlier segments are so much shorter than broad that one-half of the whole are found in the anterior ninth of the chain. Slowly the joints increase in length more than in breadth, so that they assume a square form about the end of the anterior third. Mature joints. Proglottides or Gucurhitina (Fig. 5), measure about \ in. in length and \ in. in breadth, being now longer than broad. They are flat and thin, with a quadrangu- lar outline, are furnished with a longitudinally placed tubular uterus, having seven to ten branches on each side, within which are seen developing ova. Male and female organs of gener- ation are present in the same joint, and open by a common aperture near the centre of one or other border, now right, now left. The sexual organs are already distinctly visible in the joints at one-ninth of the whole length from the head, the ova are impregnated about another ninth lower down the chain, and soon afterwards the eggs enter the uterus. The water-vascular system consists of a single longitu- dinal canal at each border, and one transverse, near the pos- terior edge; it is continuous from one segment to another throughout the chain. The cystic worm known as Gysticer- cus celluloscB is the larval form, or Scolex (Figs. 6, 7); it is commonly found in the flesh of pigs, but occasionally also in other animals, and even in man: the adult colony has only been found in man. The eggs (Fig. 8) are globular in form, measure when free about -jj^-,; in., Fio. B. — Bipe joints of T.soUum^ mag- nified, (Leuck- art.) Fio 6.-C«8ticercu3 cetmom, natural size and position. (Leuckart.) , (Leuckart.) have a thick firm shell of a brownish color, radially and concentrically stri- ated, and when taken from the uterus often an outer capsule with a more oval outline (Fig. 8, a). The contained embryo is globular, and furnished with three pairs of booklets. A moderate-sized tape-worm has been cal- culated to contain about 5,000,000 of ripe ova. n . ^ ^• Zife Mstori/.^The normal habitat of T. solium is the small intestine 158 DISEASES OF THE INTESTIITES ANT) PEKETOITEUM. of man: Kflckenmeister has seen it while yet alive firmly attached by suckers and coronets to the mucous membrane. Formerly it was be- lieved that it was always solitary, and this error perhaps explains the statements made by the older authorities of the occurrence of worms of enormous length. It is now known that although commonly one, two, or three are found together, yet various numbers, up to forty at least, may be present. From the lowest end of the band — which hangs a variable distance down the intestines, and may reach the colon — ripe joints spontaneously separate and escape with the faces, either singly, or united into short lengths. Frequently, also, ripe ova escape by rupture from the joints into the intestine and mingle with its contents. The free joints in moist and warm situations move about for a time, and by this and other acci- dental agencies the ova are widely disseminated ; doubtless the vast ma- jority fail to find suitable conditions fo^ their development, and therefore die; but a small proportion of joints or ova are taken with the food into the stomach of a pig, or much more rarely into that of a man; where, after digestion and rupture of the shell, the embryo (pro-Scolex) escapes, and by diligent use of its armature perforates the tissues of its involun- tary host, and ultimately settles down in some, to it, suitable locality, generally the cellular tissue of the muscles, but sometimes the liver or the brain. The embryo there remains quiet, in some organs is encysted, undergoes a metamorphosis, and becomes the well-known Gysticercus eel- luloscB of measly pork (Figs. 6, 7). As usually found, it has the head and neck inverted, and its characters are difiicult to observe, but when everted is seen to have a head and neck like that of T. solium, with a vesicular caudal appendage. This metamorphosis requires about two months and a half for its completion; afterwards the Cysticerci remain without further change, but capable of further development, if the proper conditions are supplied, for a period not yet certainly known, but which has been estimated at from three to six years. When the flesh of pigs so infested is eaten raw or imperfectly cooked, the Gysticercus is partly digested in the stomach, so as to lose its vesicu- lar annex; it then passes into the small intestine, and, attaching itself, becomes developed in about three to three and a half months into the adult form already described, which may continue to infest its bearer for ten, or even, it is said, thirty-five years. It would take too much space here to recount the evidence upon which this summary statement rests; but i| may be said in brief that Ktlckenmeister, -Leuckart, and others have, notwithstanding some opposing statements, placed it beyond reason- able doubt by a carefully devised and executed series of experiments, in which pigs have been infected with Cysticercus cellulosm by eating ri'pe joints of Toenia solium, and men have been infected with tape-worm by eating measly pork. This biography of T. solium, illustrates that of other parasites of the same group, and the study of each has thrown light upon the others: for this reason, and to show the relation between the food of animals and their parasites, the following short list may be permitted a place here: — Gysticercus fasciolaria in the mouse is the larval form of Tosnia erassicoUes in the cat. Gysticercus pisiformis in the rabbit is the larval form of Toenia ser- rata in the dog. INTESTIlSrAL ■WOKMS. 159 Cysticercus tenuicolKs in sheep, oxen, &c., is the larval form of Tmnia marginata in the dog. Ccmurus cerebralis in sheep is the larval form of Tomia ccmurus in the dog. Cysticerms tmnim medio-canellatOB in the ox is the larval form of Taenia medio-canellata in man. Symptoms.— ThQTe, can be no question that a large proportion of per- sons infested with this tape-worm are unconscious of any departure from the state of perfect health, but there is as little doubt that in some instances functional derangements occur which are referable to the local irritation it produces. In a much smaller number of cases and under exceptional conditions, even structural changes are produced by it. The functional _ derangements belong to two groups, (a) Those ex- cited in the part irritated, and its immediate neighborhood. Such are, various uncomfortable sensations in the abdomen, pains resembling colic, sometimes felt when the. stomach is empty, at others after certain articles of food, variable appetite, now excessive, now failing entirely, slight diarrhoea, or constipation, &c. (6) Those of reflex origin. These are itching of the nose or anus, headache, giddiness, ocular spectra, tinnitus aurium, pdpitation, cardialgia, increased flow of saliva, nausea, lassitude, pains in the limbs, and an uncertain flow of spirits. In women, disordered menstruation, spasmodic and convulsive movements, hysterical fits, and even epileptic and maniacal attacks, have been said to be due to their irritation. In long-continued cases, Ktlckenmeister thinks wasting has been produced. This somewhat grave list of symptoms contains little or nothing that is characteristic of the nature of the irritative cause, and must be received with some caution, on two grounds: one, that patients not unfrequently exaggerate their sensations when they either have had, or have suspected themselves to have had, worms of any kind; and the other, that the symptoms enumerated have in great part been collected and handed down to us from earlier times, when medical men, not yet familiar with the results of comparative helminthology, shared, to some extent, the common mysterious dread of Entozoa, and too hastily attrib- uted the observed phenomena to the influence of worms, which were indeed present, but not necessarily acting as exciting causes. In support of this assertion, it is sufficient to recall the fact that many healthy per- sons are infested with tape-worms and present no symptoms; and also, that many persons suffering from various diseases have tape-worms, and these more than other persons are apt to expel them, and thus mislead. It may, nevertheless, be readily granted that those who have a deli- cate or irritable mucous lining to their intestines, or who are of a nervous temperament, and abnormally liable to reflex excitement, do suffer some, perhaps many, of the symptoms here recounted, and that in stronger per- sons the same may happen if the worms are very numerous. But it is worth remembering, that paroxysmal maladies, such as convulsions, mania, &c., are peculiarly liable to give rise to errors in reasoning as to their causes, so that very rarely could it be aflirmed that they were caused by a tape-worm when their cessation coincided in time with its expulsion. In some cases, proportionally few in number, when abscesses have formed in connection with an obstruction of the intestine, a tape-worm has escaped from the opening, and may have been partly, or perhaps solely, the cause of such obstruction and abscess. There is another fortunately rare, but grave, consequence of the pres- 160 DISEASES OE THE INTESTrCiTES AND PEEITONETJM. ence of a tape-worm; it may give rise to the development of the Cyeticer- CVS celluloscB in the tissues or organs of its bearer, and thus even destroy life. This may conceivably take place when, as a consequence of violent vomiting, some of the ripe joints are carried up into the stomach, where the digestive fluids might set the embryo free; or in the case of children or dirty people, by conveying the escaped segments or free ova, upon the hands or with the food into the mouth, and thence into the stomach. Diagnosis. — When a patient presents such a conjunction of symptoms as, in the absence of other indications, excites a suspicion of tape-worm, its presence can only be ascertained by an inspection of the stools. The ripe segments (Fig. 5) or the ova (Fig. 8, b) will with a little care almost certainly be found in the faeces, and from them the species may be deter- mined with sufficient exactitude for the requirements of the physician. Etiology. — The exciting cause of the disease is manifestly the worm, a foreign irritating body in the intestine. The favoring conditions are the adult age, possibly the female sex, certainly some occupations, such as those of the cook or the butcher, the habit of eating raw or underdone pork, ham, sausages, &c., and a residence in Europe, India, Algeria, North America, and probably wherever the pig is domesticated. Pathology. — Leuckart has shown by observations on the dog, that local congestions of the mucous membrane, separation of the epithelium, and even minute superficial sores, may result directly from- the activity of a tape-worm. If it be admitted that T. solium may cause similar local changes in man, there is no difficulty in connecting the deranged functions of the alimentary canal with the worm as their cause, if we grant either an exceptional delicacy of the bearer, or an unusual number of worms. The remote functional disorders present no more difficulty, if pre-existing abnormal proclivity to reflex movements be granted. 2Veatment. — The indications for treatment follow in the clearest man- ner from the foregoing. The worm as exciting cause must be got rid of, and the effects then commonly subside ; but should they persist for a time, they can be successfully met by suitable diet and the treatment for irrita- tion of the intestines. An immense number of substances have, at various times, enjoyed a reputation for the possession of anthelmintic powers, too often without any accurate distinction of the kind of worm, so that with the rise of a more accurate diagnosis, as well as, perhaps, of a more critical spirit in modern times, the number of accepted remedies for tape-worm has rather diminished, and a general demand has arisen for a re-examination of the claims of most of the reputed agents. The Male Shield-feest {Aspidium Jilix mas) is perhaps the oldest and most widely known vermifuge, and of late has grown into much favor, especially in this country. The dose is from 60 to 100 grs. of the powder of the dried rhizome, or from 3 j. to 3 ij. of the liquid extract, given upon an empty stomach, pre- ceded and sometimes followed by a purgative. It has been said to act by killing the worm; it certainly has a violent and irritating action upon the lining membrane of the stomach or bowels, often causing vomiting, and in large doses purging, with slimy and even bloody stools. The Bark of the Pomegeanate Root (Punica granatum), also an ancient and extensively used remedy, is recommended by Bamberger as the best and least disagreeable in its action of all the remedies for the ex- pulsion of tape-worm. He insists upon its being used fresh, and consid- ers the old and dry bark almost inert. He prepares the patient by spare INTESTIlirAL WOEMS. 161 diet and aperient medicines, and then gives a pint of a decoction much like that of the British Pharmacopoeia (equal to 2 oz. of bark) in three doses, at short intervals, early in the morning. Kiiokenmeister uses a still stronger decoction, and gives a quantity equal to 4 oz. of the pome- granate bark, with 20 grains of the ethereal extract of male fern added. The German authorities generally employ powerful, not to say violent measures, for the expulsion of tape-worm, but how far this may be due to the greater resistance which some species present is unfortunately not yet certain. Kousso— the flowers and tops of Brayera anthelmintica. — In doses of i to ^ oz. or more it is a quick and good anthelmintic, much used in Abyssinia for the species of tape-worm there prevalent. It is not much used in Europe, perhaps on account of its cost, of the difficulty of obtain- ing it, and of the inconvenient form in which it is usually administered. Kamxda, from the fruit of the Rotleria tinctoria, oil qf turpentine, and a number of other agents, have been recommended, but it is not desira- ble to notice them here. Some rare instances occur in practice, in which treatment by any or all of the above-mentioned drugs fails to expel the worm so as to prevent its recurrence, which takes place probably when- ever the head and neck remain attached. Some cases indeed are recorded in which even the expulsion of the greater part of the band is not efEeoted; and this not only when moderate doses have been used, but even after elaborate'preparation, vigorous treatment, and free subsequent purgation suQh as Wawruch and other German authorities have advised. No very satisfactory explanation can be offered of this singular power of resistance occasionally met with; but in presence of the admitted failure of violent irritating remedies, it would seem prudent in such cases to continue mod- erate doses of male fern or pomegranate for longer periods of time, in con- junction with rigid prophylactic rules, to prevent the possibility of reinfec- tion. Prevention. — Each person can secure himself against Tpenia solium by eating only such pork, ham, sausages, &c., as are well cooked; but the public health is not so easily cared for; it requires that pigs infested with measles should not be sold as food, and doubtless fewer pigs would suffer from measles were greater care taken to remove or destroy human excre- ment. The Gysticercus cellulosce when a human parasite, is treated of in an- other part of this work. T^NiA MEDio-CANELLATA (Kilokenmeister). I)eSGription. — This worm was formerly held to be an unarmed variety of T. solium, but Ktlckenmeister and Leuckart have recently established its specific distinctness both. by observation and experiment. It has a gen- eral reseniblance to, but is larger and firmer in texture than, T. solium; not only does the whole band (Strobila, Fig. 9) commonly attain a greater length, but the segments are more numerous, and larger in all their dimensions. The unripe ones are broader than long, the ripe ones longer than broad.. The contained uterus (Fig. 10) is more finely divided than in T. solium, having from 20 to 35 branches on each side. The common sexual aperture is placed alternately on either border, nearer to the poste- rior margin than in T. solium,. The head is large (Fig. 11), measuring about -jij in.. (Davaine); has neither rostellum nor coronet of hooks; is furnished with four very powerful and prominent suckers; and, according U 162 DISEASES OF THE INTESTINES AND PERITONEUM. to Leuckart, a fifth smaller one in the usual position of the rostellum {Fig. 15). Kilckenmeister also figures a central canal connected with the water vascular system. Fis. 10. — ^Bipe joint of T. medUnxmeUata. (Leuckart.) Pig. 11.— Head at T. medio-canellata, magnl- fled. (Davaine.) Fio. 12.— Ovum of T. mf , dio-canelicUa. (Davaine.) . Fia. 18.—CVBH:En JV^EMATODA. ^ Elongated, slender, often thread-like worms, not distinctly jointed, or provided with appendages; with a separated alimentary canal, a terminal 166 DISEASES OF THE INTESTINES AND PERITONEUM. mouth, an anus ( Gordiiis excepted) near the cau- dal extremity, opening on the ventral aspect. The integument is marked by two lateral longitudfrial bands, and often by a dorsal and a ventral one; in the former are embedded the nerves with their ganglia, and the excretory tubes which open in the surface about the level of the pharynx. The fe- male aperture is placed near the central region of the body, that of the male near the anus, and con- joined with it ; it is furnished with retractile spiculae, usually two or more. The male is smallfer than the female. The development is direct and the meta- morphosis inconspicuous; so that the embryo has the general aspect of a nematode worm. The order is rich in species, and furnishes as many parasites as all the other Helminthoids put together, They 2 infest invertebrata as well as vertebrata, and no & organs escape their invasion. g ■ ^ AscAEis LUMBEicoiDES (LinnEBUs). Common I round-worm. i Description. — A large nematode worm, during I life of a reddish or brownish tinge, and of a firm, I" elastic texture (Fig. 20). The female reaches 15 I in. in length by \ in. to \ in. in breadth; and the I male 10 in. by ^ in. (Leuckart).' The cylindrical I body, covered by a cuticular layer and marked by f fine transverse rugse, tapers towards both ends, but I more rapidly towards the head; in which is placed '^. the terminal mouth, surrounded by three nearly 1 equal prominent muscular and tactile lips ( Fig. 21), « each nearly as high as broad, and marked off at its f base by a distinct groove. The inner surface of ■? each lip is beset with about two hundred very mi- g nute microscopic teeth. The triangular mouth con- ^ ducts to a muscular oesophagus, and this to a sim- £ pie, almost straight intestine, without distinction of stomach. The lateral longitudinal bands, much more distinct than the median, divide the muscular mass into nearly equal areas, and give attachment to their fibres, as well as support the ' nerves and excretory tubes. The caudal extremity, short and conical, terminates in a point, and in the male curves strongly towards the ventral aspect, on which is seen the cloacal aperture with two often projecting spiculae (Fig. 22). These are connected with a short, ejaculatory duct, which is continuous with a seminal vesicle, and a single long, tortuous, tubular testis; the whole male generative organ forming a tube eight times the length of the animal. The vulva in adult females opens about the junction ' These measuiements exceed those given by Davaine. INTESTIITAL "WORMS. 167 of the anterior and middle third of the body, it conducts to a short vagina, this to a uterus, which soon divides into two long horns, directed back- wards; each of these leads to a short oviduct, which serves also as a recep- taculum serainis, and thence to a very long, tortuous, tapering ovary. The female generative tubes are eleven times the length of the adult animal. The ova are oval in form, and have a thick, firm, elastic, brownish shell, the surface of which is generally nodulated. No comniencement of development is seen in their interior when deposited. They measure -j^^ in. by jj^ in, (Fig. 33, a and b). Life History. — So fertile is the round worm, that, at a moderate cal- culation, its yearly production of ova may be taken at 60,000,000, so that over 160,000 are daily discharged into the intestine of its bearer by one adult female worm. As, however, several are often present together, it is easy to understand that the stools of an infested person are so thickly strewn with the eggs as to make their discovery by the microscope an easy matter. Although the migrations of the embryo of Ascaris lumbricoides, and the true history of its development, are not yet ascertained with sufficient exactitude, the labors of Schubert, Verloren, Davaine, Leuckart, and others, permit the following history to be given as an approximately cor- rect statement of the facts. The ova deposited with the fseces very slowly develop an enibryo in damp earth or water. The process may be complete in a month if artificial warmth be applied, but in nature it usually requires Fia. 22. Fia. Fia. 21. — Head of Ascaris lumbricoides^ magnified. (Davaine.) Fig. 22. — Caudal extremity of male A. lumbricoides^ magnified. (Leuckart.) FiQ. 23.— Ova of A. Imnbricoiaes, from the stools ; a recently deposited ; 6 longer delayed In the stools. Shells tuberculated. from five to eight months, and it may be delayed for a year or two by cold or dryness. Neither frost nor complete desiccation, however, kills the embryo, and the contained ova of dried females develop under suitable conditions. The ova do not normally hatch in a free state; Davaine has preserved them in water for five years without any visible change in the embryo, or spontaneous escape from the shell. In this stage the embryo has the general aspect of a nematode worm, with an alimentary canal, a commencing generative system, and a terminal boring, embryonic tooth. The next stage of their development is not known. Davaine maintains that the ova with their contained embryos are swallowed with impure water, and develop directly into the adult form if received into the intes- tine of a suitable bearer. But direct experiments do not support this view; dogs, rabbits, oxen, pigs, and men have been fed with large num- bers of the ova of A. lumbricoides containing living embryos without any infection resulting. Similar experiments conducted upon horses, dogs, 168 DISEASES OF THE INTESTINES AND PERITONEUM. and cats with the ova of their peculiar round-worms have had similar negative results, and it seems indeed almost certain that infection does not take place by a direct transference of the embryo-holding ova into the alimentary canal of the definitive bearer. It may be said also with some confidence that the embryos do not escape from the ova _to_ enjoy a free existence for a time. On analogical and other grounds it is a far more probable view that the ovum is taken up in some way by_ an invertebrate intermediate bearer, perhaps a worm, or the larva of an insect, and in. it the embryo passes through a necessary portion of its metamorphosis, and then enters the stomach of its future host in some passive mode with food or drink. _ _ ; Ascaris lumhricoides infests also the pig' and the ox: it is found in man all over the known world, but more abundantly in some countries tha,n in others. In the Southern States of North America, especially among the negroes, it attacks almost every one, young and old. In the West India Islands, Brazil, Finland, Greenland, in parts of Holland, Germany, and France, it is also very frequently met with. The rural population suffer more than the dwellers in towns, and the inhabitants of low and damp localities more than those who enjoy higher and dryer abodes. The poor, the young — excluding infants at the breast — the insane, and the . dirty, are peculiarly liable to be infested. In certain regions it has occa- sionally prevailed so much for a time as to produce a kind of endemic malady. The round-worm normally inhabits the small intestine, and there is some ground for the opinion that, unless a reinfection occurs, it escapes after some months. There can, however, be no doubt that it spontane- ously wanders towards the external apertures under certain conditions which are not well known, sometimes passing through the anus, the mouth, the nose, often with severe purging, vomiting, or sneezing. After death, also, this migration is not uncommon, and is probably induced by a defi- ciency of food, or the presence of some conditions unsuitable for the wel- fare of the worm ; but whatever induces it, it results in placing the worm occasionally in remote and singular localities, both during the lifetime and after the death of the sufferer. It creeps sometimes into the gall duct, gall bladder, or hepatic duct, more rarely into the pancreatic duct, and may give rise there to serious structural changes: it passes sometimes through an ulcer or other abnormal opening in the intestinal wall, and then is found after death in the peritoneal cavity, accompanied or not with the signs of peritonitis, according as it may have migrated during life or after death; it escapes sometimes with other intestinal contents from abscesses or fistulas in the abdominal walls, and appears, indeed, in some such instances to have caused the local disease. It has so marked a tendency to creep into small apertures, that several instances are recorded of its becoming fixed in the eyes of buttons and other similar small rings which had been swallowed by the patient, and this habit has even sug- gested the swallowing of such rings to act as worm traps. This migratory instinct has occasionally led the round-worm along fistulous channels to still more remote cavities or organs; for example, to the pleural sac, the Spleen, the kidney, the bladder, the muscles of the loin or neck, the spinal cord, the lung, the glottis, the trachea, and the Eustachian tube. In the more favored countries, usually from one to five worms are met with together, but often many more are present; cases are recorded in ' Lenckart considers this species identical with A. SwUla. uttestikal woEMS. 169 which various mimbers, from 300 to 3,500, have been expelled from one person -within a few months, and 1,000 were found present together in the intestine of an idiot by Cruveilhier Symptoms. — The round-worm is one of the most frequently met with, and is clinically more important than any other human intestinal worm. When it is present in moderate numbers, and occupies its normal position in the small intestines in a person otherwise healthy, there are often no discoverable disorders of structure or function. When present in greater numbers or. infesting a delicate person, it is accompanied by the symptoms of irritation of the lining membrane of the alimentary canal, and by con- sequent impaired nutrition and reflex phenomena. , Thus it may be at- tended with pain in the abdomen, especially in the umbilical region, nau- sea, impaired or variable appetite, mucous stools, and tumid abdomen. Sometimes, also, pallor of the surface, dilated pupils, swollen eyelids, squinting, irritation of the nostrils, grinding of the teeth during sleep, &c. : indeed, all the allied symptoms which have been attributed to tape- worm. But these are by no means constant effects of the presence of round- worms , in the intestine, nor are they peculiar to their irritation. They may be absent when worms are present in considerable numbers; and may be present when no worms infest the patient; or present with the worms but not caused by them. They have, therefore, little or no diag- nostic value. Sometimes, however, especially when the intestine contained these worms in very large numbers, they have caused grave local irritation as well as constitutional disturbance, and then post-mortem examination has shown evidences of local superficial congestions and inflammation so closely related to them in extent or position, as to leave no doubt of their causal relation. Thus cases are recorded where numerous round-worms, cohering to each other, gave rise to fatal obstruction and inflammation of the intestines^ and others in which they have excited serious and even fatal convulsions in susceptible persons. Although in these latter cases the reflex symptoms are probably in no essential point different from those caused by other irritations, it is important to trace them to the worms, if it can be done, because of the comparative facility with which the exciting cause can be removed. In the rarer cases in which the round- worm wanders during life into distant cavities, organs, or passages, the disorders they induce vary with the parts visited, and maybe of great severity, or even terminate fatally. Diagnosis.— When, for any reason, a patient is suspected to harbor round-worms, it has been a not unfrequent practice to employ the usual treatment for their expulsion — often a rather vigorous one— as a means of diagnosis; and should no worms be passed, it has been assumed that none were present: thus submitting the patient to treatment before the need for it is made out, and assuming, somewhat hastily, that the recognized treatment may be relied upon. • i • An easy and satisfactory method of diagnosis consists in the micro- scopic examination of the stools, in which, if the suspected person har- bors a mature female, the ova ' are readily seen. I published a case in the Medieal Times and Gazette for June lith, 1856, which so well illus- trates the value of this method for diagnosis, and its bearing on treat- ment, that I venture to give here the following summary of it: — > It is ourious to note that these ova have been described as cholera corpuHcles {Lancet, 1849, p. 532) ; and more recently as "oholeraphyton," m the Deutscln ■ KUnik, 1867. 170 DISEASES OF THE INTESTIITES AND PEEITONEUM, A girl, aged twelve years, had passed two round-worms before she came under observation, and had complained for six weeks of abdominal pains and disordered digestion. For convenience of observation she was admitted into hospital Feb. 14th, 1855; her stools then contained ova of Ascaris lumbricoides (Fig. 33). After nine days, during which she wa? treated by a mixture of bicarbonate of soda and infusion of quassia, with rest and good diet, she declared herself well, but had passed no worms. For ten days more she was treated by oil of male fern and castor oil, followed by scammony, without effect. For a further period of ten days she took infusions of quassia and senna, also without result. For five weeks more she was given turpentine and castor oil, or turpentine alone, at weekly intervals; and about the third or fourth day after each dose, except the last, she passed one or two worms, generally, but not always, motionless. The ova were still abundant in the stools, but the treatment failing to expel any more worms, she was given Dolichos pruriens for four days, until it caused nausea, when it was omitted; but for twelve days more she expelled occasionally one or two worms with the stools. The Dolichos pruriens was then repeated for eight days, and again omitted; after which she passed, in the following fortnight, three more worms. The ova were then found to be absent from the stools, and she was discharged. While under treatment she passed in all, seventeen round- worms; but during the last three months and a half she was in perfect health, and would have been discharged but for the observation of the ova in the fjBces. Davaine drew attention to the value of this method of diagnosis in 1857 (Comjo«e« Rendus Soc. JBiologie, 2° Sdrie, t. iv. p. 188); and Leuck- art says (J)ie m&nscMichen JParisiten, &c., B. ii. p. 251, 1867)^ " In the microscopic examination of the faeces we possess a means to determine the presence of the round- worm, which is as easy as it is sure; if it were more generally practised, many errors of diagnosis, and many useless, if not injurious treatments, would be avoided." The JStiology and Pathology of the disorders induced by round-worm have appeared on the surface during the previous observations. Treatment. — The indications are to relieve the irritation of the alimen- tary canal and improve the general nutrition where that has suffered, but above all things to expel the worms. Many of the substances which have obtained a reputation as anthelmintics have been much used for round- worm, but we have as yet no sufficiently exact knowledge of their action upon the different species of intestinal worms to enable us to estimate their true clinical value in the treatment of Ascaris lumbricoides. There exists, however, a very general concurrence of opinion, which I believe to be well founded, in favor of the use of santonica or worm-seed, the unex- panded flower-head of an undetermined species of Artemisia, as well as of its active principle,, santonin. The dose of worm-seed is from 60 to 120 grains, but it is not much used on account of its inconvenient form; that of santonin which is more used, is from one to three grains twice daily to a child, and from three to six grains for an adult. After a short course of this medicine, an aperient may be given with advantage. It is apt to produce a singular although but temporary perversion of vision if given in too large doses, or for too long a time, objects seeming to be yellow, blue, or green. The urine also may be tinged red after its use. Violent cathartics do not deserve much confidence, nor are the drugs employed for tape-worm (except, perhaps, turpentine) to be trusted to. Dolichos pruriens would seem to be worthy of further trial in some cases where santonin is not available, but of the numerous other substances INTESTIISTAL WOEMS. 171 ■which have been at times recommended for the treatment of A, kvm- brieoides, it is unnecessary to say more here. The Prevention of Ascaris lumbricoides cannot be so confidently treated of as was that of T. solium, because we are not certain how it enters our bodies; but whether we hold with Leuckart that an interme- diate bearer is essential, or with Davaine that it is not, and that we drink the ova in impure water, in all probability the careful cooking of all our foods and drinks would prove a good protection even in those coun- tries and districts in which this pest most abounds. It is not, however, probable that well-filtered water could convey the infection. AsCAEiS MYSPAx (Zeder) Is the common round-worm of the cat, and is identical with Ascaris mar- ginata ot the dog (Schneider). Description. — It is smaller and more slender than A. lumbricoides^ has two small lateral, cuticular, wing-like appendages near the head. The vulva in the adult female occurs about one-fourth of the whole length from the head. In man it has only been found parasitic in three trustworthy in- stances, which are recorded by Bellingham, Cobbold, and Leuckart. OxTUEis TEEMiCTTLAEis (Bremser), (Common seat-worm). Description. — A small whitish fusiform worm, the female attaining ■5^ in. in length by -^ in. in thickness, and the male about -J- in. in length by j-^ in. in thickness (Fig. 24). The head (Fig. 24 b, d) is furnished with three inconspicuous lips around a terminal mouth, and an elongated vesicular expansion of the cuticular layer on its dorsal and ventral aspects. The oesophagus is continuous, with a muscular stomach containing three teeth, and then follows a simple intes- tine. The surface is marked by fine transverse rug^, and the lateral longi- tudinal bands form a slight angular projection. The female has a long, awl-shaped, caudal extremity (Fig. 24 e) ; the vulva is situated about the junctipn of the anterior and middle thirds of the body, and conducts to a vagina, a bifid uterus, and this to two tubular ovaries. The male has a blunted tail end furnished with six pairs of papillae, and a single spiculum communicating with the anal aperture. The eggs (Fig. 25) are oval but flat- tened on one surface, measure -j^^-^ in. by j|^ in., contain at the time of deposition a developing embryo, and have a firm shell consisting of three layers, one of which is absent at one pole, so as to facilitate the escape of the embryo. A moderate estimate allows 10,000 to 12,000 ripe ova for the uterus of a single female. Life History. — The seat- worm, like the round-worm, is found allover the world, and is perhaps even more frequently met with. It is said to abound particularly in Egypt and in Greenland, It normally inhabits the Fio. 24. — Oxt/urls Vermicularis. a Natural size, b Head, magnified, c Tail, magnified, d Head, more magnified. (Davaine.) 172 DISEASES OF THE INTESTIITES AND PERITONEUM. colon 6f man only, especially in the neighborhood of the rectum, and is commonly found in large numbers, the males fewer than the females, and it often migrates spontaneously through the anus. The ova are dis- charged into the intestine of the infested person, and there undergo a further development, so that at the period of their escape with the stools, they usually contain a distinctly formed embryo. The frequent sponta- neous migrations of the ripe female also often lead to the deposition of the ova upon the skin and hair in the neighborhood of the anus. The ova deposited with the stools rather rapidly develop under favor- able conditions, especially moisture and the warmth of the sun; they are not killed by extreme cold or by desiccation, but a few days' delay in water kills them outright, and under ordinary circumstances they die in a few weeks unless their progress has been arrested by cold or dryness. It does not seem that they hatch in the free state. Kiickenmei^ter , and Vix conceive that all the transformations from the embryo to the adult form take place within the intestine of the infested person without any necessary migration, and at first sight this view seems to receive support from the fact that large numbers of seat-worms are commonly found together, and that various grades of development Fio. 25. Ovum of ^""^ ^^^^^ I"®* '^i*^- '^^'^ view, howevcr, is out of _ac- oxyuks 'vermicuia- cord with the general law of development in parasitic (iiuStr **'^" ■ animals, and does not suffice to explain the known facts. Leuckart insists that the emigration of the embryo is a necessary, condition of its future development, and has indeed almost proved the correctness of this view by observation and experiment, as well as by powerful arguments. His view is, that ova deposited with the faeces are abundantly and widely scattered in the dry state by winds and other agencies, and then are taken into our stomachs upon uncooked fruits and vegetables and in various other conceivable modes; there exposed to the digestive fluids, the embryos escape, are carried down into the colon and attain the adult form probably in about two weeks. A sort of self infection frequently may take place also; in persons already infested, it is easy to see how the ova upon the skin and hairs near the anus may be conveyed to the mouth by the fingers, after scratching to allay the vio- lent irritation which these small pests produce; and in other modes the eggs may find their way into the stomach from the soiled bed clothes or personal linen. These views explain some long-known facts which are not otherwise so easily understoood; for instance, the great length of time during which some persons suffer from seat- worms, and the liability to relapses notwithstanding repeated treatment; the frequency with which these worms are found inhabiting many members of one family or household, the greater liability of children, of dirty or insane people, and of persons who often eat uncooked fruit and vegetables, as well as the immunity of infants at the breast. Symptoms. — When only a few seat-worms are present they give rise to no inconvenience, and are usually only accidentally discovered in the stools. When they are more numerous or the patient is more sensitive, they cause an itching or tickling in the anus and its neighborhood, which is sometimes intolerable to the sufferer, especially at a certain hour in the evening. In the female it is peculiarly distressing, from the habit which the worm has of wandering into the vagina; but in both sexes inordinate sexual excitement sornetimes is produced. Although thera is sometimes evidence of local irritation in the shape of excess of mucus in the fseces INTESTIKAX WORMS. 173 and punctif orm redness around the anus, the cases of severe convulsion and other nervous disorders which have been re- ferred to the action of seat-worms must be received with much caution. Diagnosis. — Inspection of the stools will dis- cover the worms; and a microscopic examination will show the ova. Treatment.^PvohdMy any infected person who adopted the requisite precautions against reinfec- tion from himself or others would get well in a few weeks without treatment by drugs," but this period would be shortened by the use of aperients, and occasionally injections into the rectum of cold water, turpentine and castor-oil with gruel, and of preparations of wormwood, quassia, assafoetida, santonin, &c. Frequent external applications of mercurial or other ointments and lotions likely to kill the embryos might be employed also. Prevention. — From the foregoing history it may be learned that a sufferer from seat-worms should avoid touching the neighborhood of the anus, should be scrupulously clean ^ in person and cloth- ing; that persons not yet infested should avoid close personal contact, especially in bed, with those who harbor the worms, and should always adopt the caution of eating only well-cooked food. Family STRONGYLIDES. Fig. S6. — Male and female Doehmius duoaenalis, magni- fied. (Leuckart.) DoCHMius BuODENALis (Leuckart). This minute but dangerous parasite was dis- covered by Dujardin in 1838 in Northern Italy; its zoological position is scarcely yet settled, but its close affinity to the genus Dochmiics of Dujardin has been shown by Molin and Leuckart. Description. — It is a small somewhat cylindrical worm : the females measure -^ in. and the males -^ in. in length (Fig. 26). The terminal mouth is sur- rounded by a dilated capsule directed obliquely back- wards and furnished with four large teeth on its longer or ventral border, and with four smaller ones on the opposite or dorsal margin (Fig. 27). The bursa of the male is complex, the spicula two in number. The vul- va of the female is placed a little behind the centre. The eggs are oval, measure -^^ in. by ■^■^■^ in., and when deposited contain a yelk in process of cleavage. We know as yet but a part of its life history by direct observation, and infer the remainder from that of the better known and very closely allied J), trigo- nocephalus of the dog. The egg, after escaping with the stools, under favorable conditions hatches in a few days, and the embryo enjoys a free existence for a time in mud and ' This appears to be a daring statement in the face of past experience, but its prob- ability is measured by the evidence of the life history here given. '' The common Hindoo custom of washing after every act of defsscation is worthy of more frequent imitation in this country. ■ FlQ. 27.— Head ol Dochmius duodenalift^ magnified, showing the armature of the mouth dapsule. (Leuckart.) 174 DISEASES OP THE INTESTINES AND PERITONEUM. muddy water. It is taken into our stomach by drinking impure water without the intervention of any intermediate bearer, and there it' grows and develops to some extent before it passes on into the duodenum of jejunum, where the adult form is assumed. It then attaches itself by its powerfully armed mouth to the vUli of the mucous membrane, and sucks the blood of its host. Sometimes, under conditions not yet ex- plained, it becomes encysted between the mucous and muscular coats of the gut. It occurs in warm countries only, has been found in Italy (Du- bini), Brazil (Wucherer), and in Egypt (Pruner, Bilharz, Griesinger), where it is a very frequent and dangerous pest, infesting about one- fourth of the entire population. It is present in large numbers together, often by hundreds, sometimes by thousands, and then may cause frequent and dangerous haemorrhages into the bowels, followed by an antemic condi^ tion, which is often fatal, and to which the name of Egyptian chlorosis had been given before Griesinger pointed out its true nature. Doubtless its ova might be found in the stools of infested persons, but of the treatment which should follow a diagnosis so established little can be said, except that Griesinger recommends turpentine, and that santonin and such other substances as are believed to expel nemetode worms should be tried. Care should also be taken to consume only pure water or drinks which have been boiled, so as to avoid reinfection, and the patient might then be fairly expected to outlive the worm. Although to the practitioner in Britain this parasite is not of practi- cal import, it seems so probable that it may be found in India or some of the tropical British colonies, that I have ventured to include it here. Family TRICHOTRACHELIDES. Teichocephalus dispae (Rudolphi). Description. — The female measures about \^ in. the male about \^ in. in length. The anterior three-fifths of the body are threadlike, measur- ing ^-^^ in. only in thickness, and bear a simple terminal mouth without pap- illae. The posterior two-fifths, about j^ in. in thickness, contain the generative organs and the intestinal canal; in the male, it is spirally coiled, in the female slightly curved (Fig. 28). The caudal extremity is rounded off in the male, and bears a single blunt spiculum in a tubular protrusile sheath which is furnished with teeth. The vulva in the female opens about the level of the stomach into a vagina, the walls of which are furnished with teeth, and often prolapse. The large uterus contains thousands of eggs, which are elliptical in form, and have a nipple- shaped projection at each end. They measure ^^^y in. by ^Vr i"- (Fig. 29), and have a firm brownish yellow shell, a£^;mi^t^''(^^^T'^'^'"""'" ^^nting at each pole, so as to leave an aperture which is cldsed by a firm trans- parent nipple-shaped plug. As found in the stools the yelk shows no trace of commencing development. INTESTINAL WOKJttS. 175 lAfe History. — The Trichocephalus crenatus of the pig, and also that found in some monkeys, is probably the same as our T. dispar. It is met with in most, if not in all, European countries; in Syria, Egypt, and North America; it abounds in Italy, and in some Eastern lands; but is said to be comparatively rare in Copenhagen and in London (Cobbold). It does not gener- ally occur in large numbers together, although sometimes hundreds have been found. The head of the colon is its chosen residence, but occasionally it is sia. 29.— Ovum of t. dispar. met with in the intestines near. During the life of its host, it attaches itself by thrusting its long whip-like neck into the mucous membrane. The ova deposited with the stools, like those of Ascaris himbricoides, very slowly develop normally in damp earth or water, so that in warm weather and under favorable conditions the embryo is formed in about four or. five months; but in cold weather or exposed to temporary drought it requires a year and a half or more. In this state the embryo remains, and neither develops further nor leaves the shell to become free. (Davaine has preserved them alive in this state for four years.) Prom Leuckart's experiments upon the Trichocephali of sheep and pigs, it is highly probable that no intermediate bearer intervenes, but that we swallow the ova with their contained embryos in some accidental manner, as dust upon uncooked fruit, vegetables, &c. &c., and that the embryos escape into our stomachs after partial digestion of the shells, develop somewhat, and then travel onwards to the colon, where they be- come sexually mature in four or five weeks. No symptoms are known to be caused by T. dispar, although some writers have attributed severe reflex disorders to them when present in large numbers.' The worm may be readily shown to be present by find- ing the ova in the stools. A satisfactory treatment by drugs is not yet known, but there is consolation in the reflection that the parasite has probably a short duration of life, and that we may prevent further infec- tion by avoiding uncooked foods and drinking pure water. ' When Roderer and Wagler, about a century ago rediscovered this worm, Morgag- ni's prior observation having been forgotten, they supposed that it produced the typhoid fever then prevailing at Crottingen. It is not difficult to see how such an error arose, the worms having been found in the bodies of most of the victims of the fever, and nearly coinciding in seat with the local manifestations of the disease. In connection with this, it is noteworthy that the more modem theory of the etiology of typhoid fever receives an indirect support from the fact that every person who is shown to be in- fested with those very common Entozoa Oxyv/ris vermiaularia or Trichocephalus dispar is thereby demonetrated to have swallowed minute portions of his own or another per- son' sfseces.' PERITONITIS. By John Richaed Waedell, M.D., F.R.C.P. DEFrsriTioiir. — An inflammation of the serous membrane which invests the abdominal organs and lines the abdominal cavity. It may be partial or limited, or it may be diffused over the entire inner surface of the peri- toneal sac. Effusion is almost the invariable consequence, and examina- tion after death discovers serum, albuminous exudation, sero-purulent, pur- ulent, or sero-sanguineous fluid and organized adhesions. Pebliminaet Obsbevatioits. — Inflammation of the peritoneum is characterized by the kind of phenomena which are exemplified in the in- flammation of the other serous membranes. It may occur at all ages, in- every description of temperament, and under the most varied conditions of the system. It attacks the earliest infancy as well as the adult and those in advanced life, and both sexes are equally liable to the affection. It happens to the robust and plethoric, the cachectic and attenuated, and also to those whose constitution has been undermined and broken down; and whenever its distinguishing symptoms are really proclaimed it is one of the most formidable maladies with which the physician has to deal. It may come on suddenly with apparent and easily recognized symptoms, or it may supervene slowly and insidiously, and continue for a time without being detected. It may be primary when it is difficult or absolutely inca- pable of connection with any foregoing or coetaneous disease. It may be consecutive upon, or symptomatic of, some other morbid condition. It may present the sthenic or asthenic form. And it may be met with only in sporadic cases, or prevail as an epidemic. Every example of the com- plaint will, if carefully studied, exhibit some peculiarity — some cognizable difference in its physiognomy, if such term may be employed — dependent upon the degree of mal-nutrition, or the metamorphosis of the tissues, upon the operation of external agencies, the time of life, the amount of vital power, and the idiosyncrasies of the patient. It will be modified by the state of the depurative organs, and especially by that of the kidneys, because those deleterious and effete matters which ought to be carried off by the renal organs, when retained in the circulation, are particularly prone to institute the inflammatory process in serous membranes. When the disease is regarded in all its phases and its cardinal signs are duly ob- served, it exhibits a train of phenomena peculiar to its own morbid action; and if Peritonitis, like pneumonia and certain other diseases, which for- merly had always accorded to them an essentiality, is not to be deemed an essential complaint — a nosological entity, as some modem pathologists maintain — it certainly from its importance demands a distinct place in a comprehensive work like that of " The System of Medicine." The other authors did not distinguish the inflammation of this mem- 12 178 DISEASES OF THE INTESTU'rES AND PERITONEUM. brane as apart and disconnected, but only as associated and confoanded ■with the inflamed condition of subjacent organs and tissues, nor was it until the close of the last century that this distinction was made. Since that time the researches of Broussais, Bichat, Barron, Hodgkin, and more recently of Habershon, have extended our information, and given much precision to our knowledge on the subject. Sauvages remarks : — Enteritis mesenterica (Peritonitis) difficiUime distinguitur ab enteritide, quacum etiam scepe oompUoatur." ' CuUen says it is difficult to say by what symp- toms it can be recognized, and more recent authors have expressed them- selves in similar language; but, as will hereafter be shown, it unquestion- ably displays features by which it can be diagnosticated; John Hunter thus delivers himself on this subject: — "If the peritoneuni which lines the cavity of the abdomen inflames, its inflammation does not affect the pari- etes of the abdomen; or if the peritoneum covering any of the viscera is inflamed, it does not affect the viscera. Thus the peritoneum shall be universally ieiflamed, as in puerperal fever, yet the parietes of the abdomen and the proper coats of the intestines shall not be affected.'" That these propositions are sometimes verfied it cannot be denied, but according to my own experience in Peritonitis which has existed for a time, it well-nigh always happens that some of the organs and structures which it covers reveal the inflammatory products. Dr. Habershon, in a valuable article' on the etiology and treatment of Peritonitis, speaks with much boldness and decision on this question, and he bases his conclusions on the trusts worthy grounds of accumulated facts. " In 3,752 inspections recorded at Guy's Hospital," says this physician, " during twenty-five years 500 in- stances of Peritonitis occur, but we cannot find a single case thoroughly detailed where the disease could be correctly regarded as existing solely in the peritoneal serous membrane." He then divides them, firstly, into Peritonitis by extension from diseased viscera or direct injury; secondly, into those connected with blood changes, as in albuminuria, pyaemia, puer- peral fever, and erysipelas; and thirdly, into those caused by nutritive change, as in struma and cancer. This author then contemplates the af- fection, so-called Peritonitis, as nothing more than the local evidence of antecedent morbid changes pervading the whole system. Dr. Sieveking says it is the climax of nutritive derangements, certainly not to be sought for primarily, in the serous investment of the intestines.* The former of these authorities denies that it is ever idiopathic, but he would almost seem to discard that term from pathological phraseology, as he conceives it can hardly with correctness be applied to any disease spontaneously instituted within the organism, and not dependent upon external noxious agencies or parasites. Sometimes the lesion is but partial, in other instances it extends over the entire membrane, and doubtless it is at the outset only that it is lim- ited, and that its diffusion gradually supervenes. Its closest analogies are pleuritis and pericarditis, and Uke these affections it is broadly dis- tinguished by its tendency to effusion, adhesions by coagulable lymph, or the deposition of purulent or sero-purulent fluid. The pathologic condi- tions consequent upon Peritonitis, as of the other maladies now in- stanced, are sometimes inceptive of further disease, or they may be de- ' Classis iii. gen. xy. sp. iv. » On the Blood, p. 344. * Medioo-Ohirurgieal Review, No. xliii. * Cxoonian Lectures, SritisA Medical Journal, April 14, 1866. PEBiToirms. 179 fessiVe against worst results'i' they may eventuate in the union or binding down of organs and parts wh^eby their functions are seriously or even fatally interfered with; or this sajne tendency to albuminous exudation may, as in some instances of perforation, be conservative of life, the plas- tic deposit being the means whereby nature essays to effect reparation. But these and kindred considerations will be more fully considered when I speak of the pathology and morbid anatomy of the disease. Etiology. — The causes of Peritonitis are often traceable to wet and cold, damp feet, damp beds, chill winds, sudden alternations of tempera- ture, as when, after being in a heated atmosphere, the body is rapidly cooled, or to excessive fatigue — in fact to such general influences as are concerned in the production of inflammation in other viscera. It may, in a more direct manner, be induced — in a mechanical way — by invagination, strangulated hernia, surgical operations (as in paracentesis abdominis, and ovariotomy) ; by contusions, bruises, the wounds of cutting or blunt instruments; by displacement of some of the internal organs, or some unusual stretching or laceration of the membrane; — ^by the extrusion of certain matters into the serous sac, as in hepatic or splenic abscess, rup- ture of the stomach, bile-ducts, spleen, uterus, urinary bladder, ureters, the ovary or some part of the sub-diaphragmatic digestive tube. It may follow or be associated with the acute disease of some organ by contiguity of structure, as in gastritis, hepatitis, splenitis, in dysentery, or in typhoid fever when the lower third of the ileum or the vermiform appendix is ulcerated. Sometimes tumors, extra-uterine conceptions, or malignant growths by the induction of pressure, or ulcerative absorption, give rise to it. The abrupt suppression of habitual discharges, more especially of the catamenia and lochia, and the sudden retrocession of cutaneous erup- tions, have been enumerated; and contamination of the blood itself, re- sulting from the altered and imperfect action of certain of the excreting organs, enters, there are good grounds for believing, far more frequently and far more importantly as an element in the causation than has hitherto been supposed. Indeed, many attacks which we regard as idiopathic are dependent upon a common cause in the organism, but this membrane may sometimes have a greater proclivity to the condition of inflammation than any other part. Sometimes Peritonitis' is metastatic of rheumatism, ery- sipelas, and the exanthematous fevers. Broussais repeatedly knew it succeed intermittent fever, and it is occasionally connected with fevers of a malignant type. Symptomatology. — The invasion is often sudden, but the attack may come on slowly and covertly. In the acute sthenic form there are gener- ally rigors, followed by heat and flushings, a feeling of lassitude, aching of the limbs, head, or back, a sense of constriction and uneasiness at the epigastrium, thirst, nausea, and acute pains at some, especially the lower, part of the beHy. Pressure on the abdomen, coughing, sneezing, the evacuation of the bladder or bowels, or even the erect position, augments the pain; indeed whatever produces weight upon or stretches the mem- brane, of necessity aggravates the suffering. The pain is at first local- ized, but it soon becomes diffused over the entire abdomen, and is a prominent sign. As the disease progresses, the pulse becomes quick, hard, sharp, and tense, and rises from 130 to 130 in the minute. In some exceptional cases it does not ascend to more than 80 or 90, and is of tol- erably full volume; but as the rule it is firm, small, and cordy. The ' ' Sir Thomas Watson. 180 DISEASES OF THE UTTESTUTES AND PERirONEtTM. pulse is not always, however, a sure guide, as most serious attacks may be progressing under all conditions of the arterial circulation; and even pain on pressure, the most trustworthy of all individual symptoms, is not invariably to be relied upon, because it is not uniformly commensurate with the amount of lesion which' really obtains. The tongue is mostly moist and covered with a whitish creamy mucus, but occasionally it is dry. The bowels have a tendency to be confined, and the urine is scanty and high-colored. The skin is hot and dry at the earlier period of the disease, and becomes cool and bedewed with a clammy sweat before dis- solution. The patient lies in the supine posture with knees drawn up, and cannot turn on either side without increase of pain. He will say that he experiences a feeling of heat, pricking, cutting, or soreness in his inside; involuntarily he relaxes the abdominal muscles, and sometimes fomentations, and even the weight of the bed-clothes cannot be borne. The breathing becomes quick, shallow, and almost entirely thoracic, and instead of being 18 or 30 it may be 50 or even 60 in the minute. The downward pressure of the diaphragm ^is instinctively as much as possible avoided, because it moves the abdominal organs, and all movement gives pain. The passage of flatus along the bowels is followed by the same effect. With regard to the pain, which is a cardinal sign, it presents some differences; sometimes it is permanent, in other cases it is paroxys- mal, assuming a spasmodic character, and in a few rare examples it is not present in marked degree. As the rule, it is the chief and most reliable symptom. There is always between this disease and the features great sympathy. The face becomes pale, the cheeks collapse, and the eyes seem set and sunken in their foramina. It assumes the Facies Hippocratica, or what the French term the Facies Grippee. Nausea and vomiting often come on with the other symptoms, the ejected matters being a mucoid, biliary fluid; or, in the case of obstructed bowels, the vomited matters may be stercora- ceous. Tympanitis is never absent, and often very distressing. The loss of tone in the muscular coat, and the irritation which is conferred on the mucous surface of the alimentary canal, account for such condition. The distention varies in degree. In those whose bodies are flabby and resist- less it is often excessive, whilst in "the robust and muscular it is in less amount. If the diaphragmatic covering becomes inflamed, singultus often occurs; when the serous coat of the stomach is involved, sickness is urgent; if that of the urinary bladder, there is strangury; and the inflamed tunic of the kidneys will produce ischuria renalis. Percussion elicits the loud tympanitic note, especially in the umbilical and epigas- tric regions. When there is effusion of serum — which, of course, gravi- tates to the lower parts — the line of dulness can be most distinctly observed, and it is in some measure altered according to the position of the body. Palpation can only be had recourse to with great care, as the extreme tenderness and muscular resistance prevent much manual exami- nation. When effusion has taken place, and coagulable lymph has matted the intestines together and formed roughened deposits on the liver, spleen, or some tumor, and when albuminous concretions adhere to the parietal peritoneum, the flat hand laid on the abdomen feels a pecu- liar thrill or vibration, which is most distinct during inspiration. This sign only obtains when the lymph is thrown out on a resisting basis. Auscultation discovers a creaking friction sound, which is variable in character and intensity, and can only be present for a short time, as of course, on the advent of adhesion, nothing can be heard. The physical PERITONITIS. 181 signs of pericarditis and pleuritis are far more common. Death is ushered in by quick and thready pulse, cold and clammy surface, loss of heat in the feet and legs, accelerated and labored breathing and general declen- sion of power, the mind being often clear and collected to the last. Pem- berton says the patient frequently expires on the sixth, seventh, or eighth day. But it is equally true that the fatal issue often occurs in two or three days. In puerperal Peritonitis the average duration of the disease has been shown to be about thirty hours, and sometimes, as in perforation, it may be even less than ten hours. When the affection assumes a more chronic form, the patient may live so long as thirty or forty days. The asthenic type of Peritonitis occurs in the cachectic, and those whose vital powers have been undermined by some previous disease. It is that form which is seen as metastatic of erysipelas and rheumatism, and in connection with the exanthems, malignant fevers, puerperal women, and when there is perforation of some part of the digestive tube. It proclaims contamination of the blood and want of vital power. The effusion is sudden, large in quantity, of debased character, and notably deficient in organizable plasma. The pulse is soft and feeble, the sur- face soon becomes moist, and all the phenomena proclaim declension of vitality. When the disease terminates by resolution, a gradual improvement of all the symptoms becomes observable. The symptomatic fever declines, the pain is less urgent, and pressure can be borne on the abdomen; the skin is moderately moist, but not below the ordinary temperature; the tongue looks cleaner; the pulse is slower, fuller, and softer; the respira- tion is more normal, being less frequent and not so thoracic; the alvine evacuations are freer and more natural; and there is generally a copious secretion of urine, which contains an abundance of lateritious deposits. Sometimes moderate diarrhoea or diaphoresis are critical discharges. The sickness and vomiting cease, the tympanitis and feeling of distention obtain in less degree, and the patient can extend his legs and lie on either side with more freedom and ease. Lastly, the countenance, which had hitherto been so faithful an index of the complaint, looks calmer and more natural, it having lost much of the sunken, collapsed appearance above described. One of the most frequent results is effusion/ indeed, the affection can- not assume a well-marked and typical character without one or other of the inflammatory products being thrown out, and these, as to their pro- portion and quality, are varied in every individual example. In the ear- lier stage of the attack the effusion is but small, and not such as in marked manner to increase the size of the abdomen. It gravitates into the pelvis and the iliac fossse. It can be detected by percussion over the lower parts of the belly, and there are general signs which indicate its presence. When it increases, the pain becomes a less prominent symptom, the pulse is softer, there is a feeling of weight and dragging in the body, chilliness and a diminution of animal heat, the extremities having a tendency to become cool. In such cases as are metastatic of some other complaint, the effusion is much more rapidly generated and the serous proportion is relatively very large. Andral records an illustration which was metastatic of rheumatism, and which ran through its course to a fatal termination in three days, and the autopsy showed an enormous quantity of serum tinted with the coloring matter of the blood, and some floating flocculi and false membranes. When pus is secreted, rigors are a common symp- tom, with febrile exacerbation in the evening, and the pulse is quicker. 182 DISEASES OP THE INTESTINES AKD PEKITOITEUM. It is not, if in any notable quantity, absorbed. It finds an exit either by forming an ulcerated opening into the bowel, which is always fatal, or, which is much more common, it establishes a fistulous passage by way of the psoas muscle, or through some part of the abdominal walls. In this tendency to appear at the surface it seems to obey the law of an ordinary abscess. . . Inflammation 6f the peritoneum rarely ends in gangrene, and it is still more rare for any considerable portion of the membrane to become gangre- nous. When it has come on, it has generally been at or about the vermiform appendix, or when some part of the bowel has been unduly stretched or strangulated; and, according to Abercrombie, it is invariably accompanied with false membranes. The sudden cessation of pain, singultus, coldness of the surface, thready compressible pulse, general declension of strength, and the Hippocratic countenance, are indicative of this condition. Sometimes the acute gradually passes into the chronic form, when, as before remarked, the patient does not die untU after five or six weeks. He may live even several months. In such cases the effusion may not be absorbed nor yet evacuated, or a fistulous communication may have been produced, and all the conditions of asthenia usher in the mortal event. Again, in other examples, the serous fluid wUl be absorbed, the adhesions become firm and organized, or the sero-purulent or purulent matter be discharged, and slow recovery result. The phases which the inflammation of this membrane may assume are very varied; and it is only by the study of a large number of examples that the physician can anticipate and comprehend the modes of its prog- ress. Sometimes that cardinal symptom, pain, upon which such emphasis has been laid, only obtains at the outset; and notwithstanding its subsi- dence, the malady goes on. Occasionally, as in pleuritis, there may be little or no pain from first to last, whilst rigors and hectic and wasting pronounce still the seriousness of the case at a time long after that period when danger is generally thought to have passed away, and a large col- lection of pus is contained in the cavity; or the acute symptoms may rapidly subside under a properly directed antiphlogistic treatment, and the condition of simple ascites will only appear to be present; again, dis- ease instituted in some of the abdominal organs will greatly modify the affection after it has become chronic. In this state adhesions alter the configuration of the abdomen by large masses of fibrin being deposited together, by the soldering of the intestinal convolutions, the agglomeration of one organ to another, or by the formation of separate collections of matter in distinct septa resembling independent abscesses. It sometimes happens, too, that the belly becomes soft and flabby, and, iastead of im- provement succeeding this disappearance of the tension, convalescence is slow and protracted. From what has now been said, it is obvious that the chronic condition is far from being uniform in its phenomena, and that the pathological changes may be diverse and multiform. Vaeikties. — Broussais and some other authorities speak of the induc- tion of Peritonitis by the exudation of blood into the abdominal cavity without solution of continuity in any of the blood-vessels. I have never seen such an instance, and these examples must be extremely rare. Such sparse exceptions are to be associated with the haemorrhagic diathesis, the predisposing causes being the sanguine temperament and a marked ten- dency to inflammatory complaints. According to Broussais, the pulse is ■at first full, but soon becomes soft and compressible, the pain very acute, often intennittent, and coldness of the extremities and convulsions quickly PEEiToiaTis. 183 close the scene.* Laenneo was one of the first to draw attention to hsemor- rhagic exudations of serous membranes, and Rokitansky attributes such tendency to the tubercular cachexia, the diseased condition of the blood resulting from cirrhosis of the liver, the scorbutic constitution, and the dysorasia of drunkards. The effect of specific poisons, such as induce the various febrile diseases, and that anomalous condition of the blood now spoken of in which its fibrinous constituent is diminished, and its serous part augmented, are to be enumerated in the causation of this hsemorrhagic exudation. When the blood having this origin is discovered in the peri- toneal sac, it is in large quantity, very red, and in varying proportions mixed with serum. There is another description of Peritonitis which systematic writers have recorded, and to which the name of latency has been given. It has been said to attack those laboring under some other ailment, the feeble and attenuated, the aged, the insane, and such as exhibit a low degree of vitality. Its symptoms at the outset are masked and difficult of recogni- tion, and, when recognized of the asthenic type, the features present those distinguishing traits before insisted upon as being characteristic of this complaint. It is evident that such examples are nothing more nor less than secondary affections like unto pneumonia in albuminuria, pleuro- pneumonia when intercurrent in phthisis, pericarditis in rheumatism^ and arachnitis in continued fever. Non-plastic or JEJrysipelatous Peritonitis. — This is seen as the se»quel or complication of the exanthems, in adynamic fevers, and in puerpieral Peritonitis. Its essential condition is some hsemic change, and it is characterized by asthenia. It is met with in worn-out and undermined constitutions, in the unhealthy, and in those who have had some other malady. Its supervention is suddea, and it runs its course with great celerity. It does not bear an antiphlogistic or lowering treatment, an i is only benefited by stimulating and sustaining remedies. According to Abercrombie, "the symptoms are sometimes slight and insidious, but sometimes very severe; and they are chiefly distinguished by the rapidity with which they run their course, and by a remarkable sinking of the vital powers which occurs from an early period, and often prevents the adoption of any active treatment. A remarkable circumstance in the history of this affection is its connection with erysipelas, or with other diseasesof an erysipelatous character." " Illustrative of this form of the complaint he gives the instance of a woman who had erysipelatous inflammation of the throat, who was very suddenly seized with abdominal pain and vomit- ing, and who gradually sank in forty-eight hours. The necroscopy dis- covered a large quantity of pus in the peritoneal sac. And he gives other and similar examples. This physician also refers to an epidemic of ery- sipelatous character which occurred amongst the children in the Merchants' Hospital, Edinburgh, in 1824. The disease was of mild type. In all the cases there was throat affection, consisting of a raw, red appearance, swelling, and aphthous crusts. Two of the little patients speedily sank, and inspection revealed pus in the abdominal cavity. Abercrombie draws a comparison between this epidemic and one of diphtherite, as it was then named, which appeared two years afterwards, and he believed them to be congeners. The correctness of this opinion later years have confirmed. Between diphtheria and erysipelas there is great resemblance. They are ' Broussais, Hiatoire des Phlegmaaies ou .Inflammations ohroniques. 'Pathological Besearohes on the Diseases of the Abdominal Visoera, 3d edit. p. 181. 184 DISEASES OF THE INTESTINES AND PERITONEUM. both referrible to general blood change, and, as it has been well remarked, are associated with a large group of maladies which stand in close relation with pysemia.' The kind of Peritonitis spoken of occurs with a depressed vitalism, consequent upon toxsemic agents imbibed from without or formed within the organism by its own power of genesis; and the term non-plastio well applies to the ostensible difference which there is between this type, deSoient in organizable plasma, and the adhesive form of inflammation. Perforation of the Peritoneal Membrane. — There is no form of Peri- toDitis which is so fearful and fatal as that in which there has been positive solution of continuity of the membrane, because this accident generally implies the extrusion of some secretion or fluid or substance into the serous cavity. Several of the older authors mention this occurrence, and some vaguely attribute such openings to worms — a possibility, as we know from Andral's case, in which lumbrici passed into the cavity; but this event is exceedingly rare. There is no doubt that in nearly all these recorded iustances the real cause of such perforations was ulcerative^ de- struction, or cadaveric change, which former writers had not recognized with that facility and certitude which distinguish the acquisition of modern pathologists. Perforation may be produced in a great variety of ways,_by penetrating wounds made by sharp or blunt instruments, the crushing effect of accidents, lacerating the solid or hollow viscera, or the parietal peritoneum; corrosive poisons, the giving way of the uterine walls during parturition, the softening of a fibrous tumor attached to the uterus and the contents being extra vasated; the bursting of a Graafian vesicle, of a mesenteric gland, of a tubercular deposit, of the urinary or gall-bladder; from calculi, from the evacuation of some collection of purulent matter, as in empyema; burrowing through the diaphragm, in abscess, as before remarked, of the liver, spleen, or kidney, in pelvic abscess, and from other causes. Mr. Hulke lately recorded an instance of renal abscess bursting into the peritoneal sac, which occurred in an unhealthy-looking maid- servant who was admitted into the Middlesex Hospital for hip disease, and which ended fatally. The inspection discovered puriform serum in the peritoneal cavity, and the peritoneal surfaces were coated with a soft yellow lymph. The right kidney was a mere sacculated pouch, and it was ruptured at its upper end.'' The more common cause of perforation is ulceration, commencing in the mucous membrane, of some portion of the digestive tube, and penetrating through the muscular and serous coats. It may be referrible to softening of the intestinal wall (ramollissement ffUatiniforme), or to cancerous disease, especially when the cancerous deposit encroaches upon, or absolutely blocks up, the passage. When the accident is from this cause, it is mostly observed in the stomach, colon, or caecum. The symptoms are sudden, often violent. Frequently the patient at once falls into collapse. Andral says, that sudden increase of pros- tration and rapid change of the features are sometimes the only symptoms denoting the accident of perforation. Sometimes there is febrile excite- ment, as evinced by increased heat of surface, hard pulse, and urgent thirst. In the great majority of oases remedies seem inoperative; the disease rapidly becomes diffused over the surface of the sac; whilst vomit- ing, dorsal decubitus, quick and feeble pulse, loss of animal heat, and sunken and collapsed features, too truly indicate the powerful impress ' Dr. Russell Reynolds, art. Erysipelas, vol. i. » Lancet, Jan. 33, 1866. PERITONITIS. 185 which has been made upon the circulatory and nervous systems, the mental faculties, genera,lly, remaining unaffected to the last. In those very ex- ceptional cases in which recovery does take place the vomiting begins to subside, the distention to decline; the pulse becomes softer, fuller and slower; the face is less haggard, the patient sleeps more tranquilly, and the temperature of the body is more natural. < _ When the stomach is the seat of perforation, as it sometimes is, by simple or specific ulcer, the phenomena are precisely those which obtain when any other part of the sub-diaphragmatic tube gives way. Ulceration of this organ is most frequent in females. Dr. Brinton found that in 654 cases 440- were in females, and 314 in males. He also says that in the former sex one-half occurred between fhe ages of 14 and 30.' It happens to children. Dr. Lee kjiew perforation of the stomach of a girl of eight, and in that of a boy of nine years of age. The opening is most frequent at the splenic end, and that part is also most prone to gelatiniform softening. It may give rise to hasmorrhage. Habershon gives an example in which the splenic and pancreatic arteries were opened. It does not absolutely follow that death shall always eventuate, because adhesion may take place between the point of ulceration and the abdominal walls, or one of the solid viscera, or a communication may be established between the stomach and the colon, or the duodenum, or a gastric fistula may be formed externally, or through the diaphragm into the thorax. The last two named are very uncommon, but possible contingencies. Abercrombie gives an example of the kind of Peritonitis now considered. A young woman had been affected with dyspeptic symptoms and epigastric pain for some months. On Nov. 36th, 1834, she was heard to scream violently, and when approached was unable to express her feelings except by vio- lently pressing her hand against the pit of the stomach. The abdomen became tender and distended, and she continued in extreme suffering till the 37th, when she died twenty-nine hours after the attack. On the in- spection of the body the cavity of the peritoneum was distended with air, and likewise contained upwards of eight pounds of fluid of whitish color and foetid smell. There was slight but extensive inflammatory deposition on the surface of the intestines, producing adhesion to each other, and to the parietes of the abdomen. In the small curvature of the stomach was a perforation which admitted the point of the little finger.' This author gives another case in the person of an elderly gentleman, who was suddenly seized with excruciating pain at the stomach, accompanied by vomiting, coldness, and quick pulse. The abdomen became tense and tender, and he sank in thirty hours. Necroscopy exhibited near to the pyloric open- ing an ulcerated hole larger than a shilling, to which the liver formed a base, and. a little below the perforation of the calibre of a quill through which •* he contents of the stomach had escaped and caused fatal Peri- tonitis. ' Dr. Brinton gives the following relative proportions per cent, of the locality of perforations which ended, fatally by Peritonitis : — Posterior Surface 3 Pyloric Sao 10 Middle 13 Lesser Curvature 18 Anterior and Posterior Surface at once 28 Cardiac Extremity 40 Anterior Surface 85 'Abercrombie' s Diseases of Stomach, 3d edit. p. 84. 186 DISEASES OF THE rSTTESTTNES AND PEEIXOlirETIM:. The duodenum is less liable to this accident than the stomach; but iti serous tunic does sometimes give way under the ulcerative process. Mr. Curling was the first to observe that the glands of Brunner are apt to pass into ulceration during the progress of severe burns, and from this cause Peritonitis may in a secondary manner result. In twenty-two autopsies made by Louis in enteric fever, in only two cases was the villous surface of the duodenum found ulcerated. In fifteen examples of that disease ex- amined by Jenner, and in twenty by Murchison, no morbid condition was detected in this organ. Its ulceration in all its characteristics and conse- quences very nearly resembled that described of the stomach. Haber- shon says several cases have come under his observation, the early symp- toms of the ulceration being slight until fatal Peritonitis had been set up by perforation. In other instances violent vomiting produced the accident. Hodgkin relates the instance of a young woman, aged twenty-four, who was admitted into Guy's with urgent vomiting, small and feeble pulse, and who shortly after died of fatal Peritonitis caused by a small ulcer in the duodenum. Habershon gives an interesting example in a young wo- man, aged eighteen, admitted into Guy's February 19th, and who died October 4th, 1860. At first the prominent symptom was vomiting; after a time diarrhoea came on, and the emaciation increased. Examination of the body showed behind the first portion of the duodenum and close to the pancreas a collection of offensive pus, and a perforation a quarter of an inch in diameter was discovered. From the histories of six cases re- corded by Dr. Andrew Clark,' he concludes that the event is sudden, after food, and that the pain never leaves its place of origin. In the examples given by this physician there was no sensation of something having given way, nor of heat diffusing itself over the belly. This organ is more fre- quently perforated by secondary than primary disease. The malignancy of neighboring viscera is sometimes extended to its parietes, as in cancer of the stomach, liver, spleen, pancreas and lymphatic glands, and its con- sequent rupture is followed by Peritonitis, which ends f ataUy. With regard to the jejunum it is rarely found morbid, and assuredly no part of the digestive tube possesses such an immunity from disease. I have known no instance of its perforation. Neumann and Hufeland, however, have recorded an example of this event. Perforation more frequently occurs in the lower third of the ileum, and near to the Ueo-caecal valve, than in any other part of the intestiues. Of ten cases by Louis, it was within a foot of the valve. Of ten cases given by Stokes, in nine it was within twelve inches of the valve, and one was in the caecum. Of eleven by Murchison, nine were within twelve, and two within eighteen inches of the same place. Bartlett saw it forty-four, and Bristovr? seventy-two inches from the same place. The parts next in order of prevalence are the caecum and vermiform appendix. Louis was one of the earliest observers of the facts now noticed. It has long been broadly and familiarly known that the agminate glands which are proper to the ileum, and the solitary glands which are scattered throughout the villous coat of the digestive tube, are in enteric fever very prone to take on the ulcerative condition, more especially the patches of Peyer, and occasionally it happens that after the mucous and muscular coats have been destroyed, the peritoneum gives way. These glands are not in like manner predisposed to disease in the course of any other acute affection. The vermiform appendix has in repetition been found the seat of fatal ■ British MediccU JowncU, June 33, 1867. PEEITOKTTIS. 187 Peritonitis, not only in enteric fever, when sometimes only a very minute orifice can be discovered, but from the impaction of some foreign body, as the seed of fruit, a kernel, a piece of bone, a piece of indurated faecal matter, or even the single bristle of a tooth-brush. Of eight cases of per- foration given by Louis, seven were in the young and vigorous, and it may here be observed that more recent writers, as Jenner, Murchison, and Bristowe, have shown that it chiefly occurs between the ages of fifteen and twenty. Of the eight cases by Louis, with a single exception, the disease commenced with continued fever, nor did the febrile phenomena assume any severity of character until the advent of the perforation. In four there had been diarrhoea, but only in one were the bowels much har- assed. Tweedie says the state of the bowels, either as to the presence or absence of diarrhoea, is not to be depended upon, as it sometimes happens that the evacuations are healthy when the bowel gives way. Three were quite convalescent when the opening occurred, and a fourth appeared to have fully recovered from an attack of enteritis. Since Louis wrote his account, much information has been accumulated on this particular subject. It is now well known to all who have made the various forms of fever a special study, that there is no precise correla- tion between the gravity of febrile symptoms and the occurrence of per- foration. The diarrhoea may have been a distressing and persistent symp- tom, and yet the points of ulceration may not have been either numerous or deep; on the other hand, in cases regarded as mild forms of fevei the bowel may very unexpectedly burst, and this event is generally at a later date of the attack, or during convalescence. Tweedie has known it take place when the patient has so far recovered as to leave the house. Dr. Murchison lately published an apt illustration.' Some time ago I had under my care a girl in enteric fever who became quite convalescent, and at the end of six weeks, after eating a hearty meal of solid food. Peri- tonitis supervened, and she died in twenty-two hours. Peacock saw it come on so soon as the eighth, and Murchison on the ninth day of fever. Louis noticed it so late as the forty-second, and Jenner on the forty-sixth day. Of thirty-two cases given by Murchison, perforation occurred dur- ing the second week in eight cases; during the third week in six, during the fourth week in nine, and after the fourth week in nine.^ Louis says, if in acute disease, and in an unexpected manner, a violent pain in the abdomen supervenes; if this pain is exasperated by pressure accompanied by rapid alteration of the features, and more or less promptly followed by nausea and vomiting, we may believe and announce that there is perfora- tion of the intestine.' Pain is not a symptom in all oases continuous up to death. It sometimes notably abates, and in exceptional examples ceases entirely for several hours before dissolution. Jenner saw a patient in whom there was no pain at all, vomiting and cold extremities being the only symptoms. Tweedie asserts that the symptoms of this event are not uniformly well pronounced. The accident may be masked by delirium so considerably that the time of perforation and its absolute occurrence may be uncertain. Dr. Stokes gives particulars relative to nine cases which occurred under his own observation.' These happened during fever; one in catarrhal fever, two after acute enteritis, and in one case hypercatharsis produced by an overdose of salts was the cause. In several of these nine instances ' British Medical Journal, Dec. 2, 1865. ' On Fever, p. 508. » Becherches Anatomice-Pathologiqnes. * Cyclop. Praot. Med. 188 DISEASES OF THE INTESTINES AND PERITONEUM. there had been diarrhoea. He also comments upon a fact worthy of no- tice, that in three were produced irritation of the bladder and inability to pass urine. In all, inspection revealed ulceration of the muciparous glands; and respecting the time which the patient lived after the initia- tory symptoms of perforation, it varied from twelve to one hundred and twenty hours. Stokes also says that the average duration, deduced from nineteen cases which he had collected from various sources, was twenty- nine hours. Louis' patients lived from twenty to twenty-four hours. Murchison has known death follow in four hours, and not until one hun- dred and five hours. I have known it from seven to twenty-three hours. The period subsequent to the accident must needs be influenced by a vari- ety of circumstances, such as the character of the antecedent or coetane- ous disease, the vital powers of the patient, the extent of the orifice, and the kind and quantity of lymph thrown out, the part of the bowel, and the conditions favoring or opposing adhesion. If in a fever of the ady- ■ namic type, when the powers of the system are much reduced, the shook may be such as at once to usher in a fatal collapse. If the opening be in immediate apposition with another coU of the bowel, a solid organ, or the walls of the abdomen, the extrusion of the contents of the canal may for a time be arrested. Bristowe relates a case in which the patient lived fourteen days after perforation. I remember an instance in enteric fever in which there was a hole that would have admitted a swan-shot on the lower part of the ileum, but depositions of pearly lymph had so effectu- ally sealed up the opening that none of the intestinal contents had escaped. When, however, they do escape, the inflammation becomes so intense that remedies are generally powerless. Chomel, Louis, Rokitansky, and Jenner say it is always fatal. Tweedie, Todd, Ballard, Fox, Bell, and Murchi- son aver that they have known recovery. The last-named relates the in- stance of a girl of sixteen, who, on the thirty-first day of fever, was sud- denly seized with severe pain and tension of the abdomen, urgent vomit- ing, and all the symptoms of collapse. A grain of opium was given every second hour, and during the first thirty-six hours ten grains were taken. The patient made a tedious recovery, and was discharged from the hospi- tal fifty-five days after the commencement of the Peritonitis. In some exceptional examples, the more formidable symptoms will apparently subside, and life be preserved for even several days. This deceptive kind of amendment should not, however, throw the physician off his guard; he should not forget those grave and alarming indications which pronounced the existence of the accident, as it almost invariably proves that the mortal end has only been deferred, not averted. In the case observed by myself, if there was no absolute escape of the intestinal contents, the soft lymphic plug could not for any great length of time have sufficed to act as a barrier to extravasation. Some slight strain, as in the evacuation of the bowels, coughing, sneezing, or the mere motion of the body, might doubtless have been suificient to remove the non-organ- ized albuminous deposit, and render the opening free. Notwithstanding the well-nigh hopelessness of all cases in which there is positive solution of continuity, it is from pathological reasoning a possibility that recovery may succeed. Nature attempts to repair the lesion by throwing out plas- tic materials, and if these, — by utter rest, and by opiates subduing the peristaltic action of the bowels, — be allowed to lie in contact with the breach sufficiently long to become permeated with new vessels — ^to be org^nizea — ^the orifice may be repaired: such reparation, however, can only be effected when the hole is smaUj and then it is but a mere possibility. PEEITOIinTIS. 189 Though the first symptoms of perforation are nearly always distinct and temble, in exceptional cases they may be ill-defined and obscure; or they may gradually assume increased severity. They will be influenced by the size of the aperture; for instance, the solution of continuity, when It takes place in the appendix, is sometimes very minute, and the escape of irritant matters inconsiderable. The orifice may at first be small and by degrees enlarge, and relatively with the enlargement (and consequent greater extravasation of liquid and faecal contents) will increase the irrita- tion conferred to the sac and the more manifest phenomeija of inflamma- tion. Confirmative of these assertions. Dr. John Harley may be cited. "In some cases," says this physician, "the perforation has taken place so gradually, the aperture formed is so small, and the extravasation so in- considerable, that the symptoms of Peritonitis come on and attain their maximum very gradually, and without any sudden increase in the severity of the symptoms." ' The colon is occasionally perforated in fever, but it is much less prone to this_ result than»the parts last named. Chomel, Brinton, Forget, and Murchison mention five instances. In two out of these cases the opening was at the junction of the transverse and descending colon; and in the three others at the junction of the sigmoid flexure with the rectum.^ The last-named authority lately gave a good example of the giving way of the large intestine. " A young man of eighteen was admitted into the Fever Hospital, Aug. 23, 1865 ; he had been ill fourteen days, and on admission was very ill of typhoid fever with Peritonitis. The pulse was quick and feeble, the body enormously distended and tender, the motions frequent and watery, and the breathing thoracic. He died Sept. 7. Inspection discovered the entire surface of the peritoneum to be coated with a thin layer of lymph which could be stripped off with a knife. There were three perforations in the large intestine, one about three and a half inches below the valve, and two in the sigmoid flexure. There were no contents of the bowel in the serous sac." " With respect to the average of perforation in fever, Murchison states that out of 435 autopsies recorded by Bretonneau, Chomel, Montault, Forget, Waters, Jenner, Bristowe, and those made at the London Fever Hospital, it occurred in 60 cases, or in 13 '8 per cent." It probably hap- pens in about three per cent, of those who have enteric fever, and more frequently amongst males than females. In chronic dysentery, sometimes, after ulceration has destroyed the mucous and muscular coats, the peritoneum is penetrated. In such in- stances the special and general symptoms, which characterize the primary disease, point to a correct diagnosis. In cancer of the bowels perforation may occur: it is more frequent in the large than small intestines, and Rokitansky says the colon is almost exclusively th* seat of cancerous de- generation. I saw in consultation some time ago a gentleman laboring under diffuse Peritonitis, which had evidently been caused by a large hard tumor, the size of a cricket-ball, in the left hypogastric region. The stools were flattened, but the passage was evidently quite patulous. I gave it as my opinion that it was a case of cancer of the large bowel, A surgeon was at this juncture called in, and he strangely enough pro- posed Amussat's operation merely to give exit to the flatus, when largfe pieces of faecal matter were voided, but fortunately that suggestion was ' System of Medicine, vol. i. p. 570. " Murchison on Fever, p. 551. • British Medical Journal, Deo. 3, 1865. ^ On Fever, p. 511. 190 DISEASES OF THE INTESTINES AND PERITONEUM. overruled by two of the most eminent members of the profession. In the course of a few days the patient died. Perforation was announced by a sudden and terrible increase of pain, small pulse, sunken features, and cold extremities. The autopsy revealed abundant proofs of foregoing and present Peritonitis. There were several pints of serum in the abdo- men, which contained loose flocculi; the descending colon waa- ad'herent to the abdominal walls, and a little above the sigmoid flexure was a cleanly cut, punched hole, the size of a small pea, through which a large quantity of thin feculent matter had passed into the peritoneal sac. The upper third of the rectum, and the opening into the sigmoid flexure, were the seats of cancerous deposit, and the canal was patulous. Habershon divides perforations into two great classes, those which arise from disease commencing in the intestine itself, as by the ulceration of fever, dysentery, cancer, and the various forms of insuperable consti- pation; and those in which perforation is from without, as in strumous Peritonitis, ulceration of the stomach extending to the transverse colon, hydatids, and abscess of the liver, calculi, abscess in the other solid vis- cera or abdominal Walls, cancer, extra-uterine foetation, and external in- juries.' It may be caused by laceration of the gall-bladder. Barthez and Rilliet mention a case in a girl of twelve whilst in fever, and Murchi- son gives another instance in a young man of nineteen, who was suddenly seized with Peritonitis on the fifteenth day of the fever, and who died in twenty-six hours. It is rarely observed as the result of tubercle. Sir Thomas Watson, in his large experience, only remembers a single in- stance. Of fifty-six cases collected by Habershon, four only were from strumous disease. Jenner once knew a softened mesenteric gland give way during fever, and Buchanan saw a fatal case of Peritonitis from the bursting of a softened embolic deposit in the spleen of a typhous patient. Puerperal Peritonitis. — In the discussion of this part of the subject I may here observe that it is not my purpose to enter upon the considera- tion of puerperal Peritonitis as it occurs epidemically; but as I believe with many other writers that puerperal women are liable to a simple form of Peritonitis, its description necessarily comes within the limit of this article. Sporadic cases from time to time occur without the diffusion of the disease, but even then it is right to observe the utmost caution, as so much doubt is always involved with regard to its contagious nature. In- flammation of the serous covering of the uterus and its appendages may, I believe, supervene as an incidental circumstance, without the superad- dition of a specific poison. The great effort of the organism, the irritable condition of the body, after the exhaustion of expulsive endeavors, the long distention of the uterus and the abdominal walls, and their sudden contraction; the friction of opposed surfaces in the abdomen during labor, and the great excitation given to the circulatory and nervous sys- tems, may produce Peritonitis. Other causes operate in the production of this result, such as injuries inflicted during instrumental delivery, in turning, adhesion of the placenta, the use of cold affusions in flooding, and the improper administration of stimulants. Contamination of the blood, originating in the body itself, without reference to external agen- cies,^ as when absorption takes place from putrid coagula or a piece of retained placenta, is another mode by which the malady is originated. In uraemic poisoning, as before remarked, the serous membranes are pre- ' Diseases of the Abdomen, 2d edit. p. 530. PERITONITIS. 191 disposed to inflammation, and the blood vitiation during parturition re- sembles this cause. There is, I need scarcely say, still much conflict of opinion relative to the real nature of abdominal inflammation after child-birth. By some it is yet maintained that Peritonitis and puerperal fever are identical — that these terms express but one affection. It is true that in a large propor- tion of those who die of puerperal fever the peritoneum is inflamed, but this membrane is not ahim/s involved; and although this form of inflam- mation accompanies this disease far more frequently than any other form, yet puerperal fever is something still more. Of 233 autopsies of puerperal fever, given by Tonnelli, in 193 were traces of Peritonitis; in 29, or one- eighth, there were no traces whatever. Of 44 cases examined by Lee, the peritoneum and uterine appendages were inflamed in 32, or in the relative proportion of 8 cases out of every 11. Dr. Bartsch, in a report of the Midwifery Institution at Vienna, records the morbid appearances of 109 cases of those who died of puerperal fever, and in this report puerperal fever is distinguished from Peritonitis and metritis. " The cases of puer- peral fever," he says, " occurred seldom under the form of puerperal Peri- tonitis, but generally as inflammation of the uterine veins, giving rise to the production of pus in these vessels, and the general symptoms accom- panying its absorption." ' Let any one, says Fleetwood Churchill, com- pare a case of simple inflammation of the womb or peritoneum in child- bed with a case of epidemic puerperal fever, their symptoms, course, and the effect of remedies, and I do not think a doubt will remain upon his mind, that although the latter is a local disease, it is not exclusively so.' The symptoms common to this form of Peritonitis may corhe on in a few hours, a few days, or even so long as two or three weeks after delivery. Pains and rigors are generally the first indications, and pain on pressure is more distinctly felt at the hypogastrium than at any other part. The skin is hot, the cheeks are flushed, the pulse is quick, and the respiration hurried. The pain soon radiates from the hypogastrium into the iliac fossK, and then to the other parts of the abdomen. It is not always severe, and is sometimes characterized by paroxysmal attacks, the patient being free from suffering during the intervals; nor can it be said that this symptom pain is pathognomonic of puerperal Peritonitis, because post partum uterine pain may be urgent when there is no co-existent inflamma- tion, and there may be inflammation with little or no abdominal pain. Churchill asserts that he has seen five or six cases of intense Peritonitis as proved by dissection, in which there was neither pain nor tenderness; ' and Ferguson records that he has known nineteen cases in which there was no pain. The abdomen suddenly becomes large, more quickly and to a greater extent than in any other kind of Peritonitis, which may be accounted for by the often relaxed and resistless condition of the muscular system of parturient women, and because the abdominal walls have been so recently distended. At the onset of the attack, the uterus can be felt above the pelvic brim, soft, flabby, and uncontracted, but as the distention obtains in greater degree it cannot be distinguished. The lochia are at once diminished or suspended, or their absolute suppression may precede the inflammatory phenomena. If the milk has begun to flow, its secretion ' Lancet, April 16, 1836. ' Diseases of Women, Syd. Sdc, p. 35. ' Diseases of Women, 5tli edit. p. 783. 192 DISEASES OF THE INTESTrCTES AITD PEEITOITEITM. is arrested; if it has not begun, it is prevented. If the mammae hare been full and rounded, they fall in and are flaccid and smaller. The pulse varies, but it is always above, in the great majority of oases greatly above, the normal standard. In non-inflammatory, uncomplicated cases, the circula- tion may be accelerated, for a day or two, or two or three days, but there is a gradual declension of its frequency from the time of delivery. If, however, after delivery the pulse shall have fallen to, or near, its natural number, and it then suddenly begins to rise, accompanied by local pain, higher temperature, thirst and diminished secretions, the cause is often obvious. After-pains may be confounded with those of inflammation. They come on soon after delivery, but decrease in force and frequency as time wears away. Peritonitis does not come on so soon, and its symptoms become more and more proclaimed, instead of diminishing. After-pains are associated with a firmly contracted uterus; Peritonitis with a relaxed uterus. Remedies which relieve the former are useless or harmful to the latter. In the one affection the circulation may be natural; in the other it is never so. At the first the diagnosis is very diiBcult, because after- pains may be foUowed by inflammation, and for a time the symptoms be mixed up; but the progress of the case leads to a correct conclusion. When puerperal Peritonitis is accompanied with intestinal irritation and the inflammation has extended to the mucous membrane, sickness and diarrhoea may be urgent. When the malady terminates by resolution, the pain abates, the tympanitis declines, the pulse becomes fuller and slower and softer, the skin cooler and moist, the tongue cleaner, the lochia are re-established, the breasts become rounded and milk begins to flow, the legs can with more comfort be extended, and the patient can lie on her side. The conditions of approaching dissolution are — weak and thready pulse, varying from 130 to 160; the abdomen keeps distended and tender, cold clammy sweats come on, the extremities become cold, the breathing is quick, shallow, and thoracic, she lies on her back with legs drawn up, the features are sunken, and the mind often remains calm and clear to the close. Perityphlitis.— TYas particular form of disease has been more fully described by French than British pathologists. MM. Husson and Dance ' give an excellent account of the affection; and it is also well described by Dupuytren, Menitire and Duplay. Amongst the English authors may be named Copland,' Syme,' Craigie,* Farrall,' Burne,' Sellar,' and West.' The disease originates in the tunics of the csecum, and by some it has been named perica3cal abscess; the glands or follicles of this organ at the first become inflamed and then pass into the ulcerative condition. The ulceration of this part of the large bowel may insidiously destroy the mucous membrane, implicate the sub-mucous cellular tissue and perito- neal coat, and either cause inflammation and lymphic adhesion of the lat- ter, or its fatal perforation. When agglutination occurs the lesion may M^moire sur quelqnes Engorgements inflammatoires qui se d^veloppent dans la Fosse iliaque droite ; Repertoire d'Anatomie, &c. , t. iv. p. 74. Paris, 1827. ' Med. Diet. art. Caecum. * Principles of Surgery. * Pathological Anatomy, 2d edit. p. 632. > Ediiiburgh Medical and Surgical journal, vol. xxxi. p. 1. 1831. ' Medico-Chir. Transact, xx. p. 200, and xxii. ' Northern Jmirnal of Medicine, July, 1844. ' Diseases of Infancy and CMldhood, 5th edit. p. 656. 1865. PERITONITIS. 193 be arrested. Craigie defines the malady to consist in inflammation and suppuration of the cellular tissue conAecting the caecum to the quadratus lumborum muscle and other parts, or in inflammation and ulceration of the mucous membrane of the caecum; and Sellar says its pathological seat IS in the cellular tissue between the fascia of the iliacus internus and the coats of the c£ecum. _ The causes of perityphlitis may be referred to the peculiar position of the caecum, as well as to other circumstances. It is attached to the mus- cles of the right lumbar region, and its sacculated pouch depends below the ileo-c«cal outlet, and as all physiological anatomists observe, its con- tents have to be propelled against gravity; and it thus may become dis- tended with faecal matters, and such irritation be instituted by its disten- tion and pressure as to set up inflammation of the lining membrane. Again, hard and indigestible articles of food, the stones of drupaceous fruits, seeds, pieces of bone, and metallic, porcellanous, and vitreous fragments have been known to give rise to it. The complaint has in sev- eral recorded cases been present long before its nature has been discov- ered. Its earliest conditions are rendered manifest by the tumescence and dulness on percussion at the right iliac fossa. The circumscribed swelling may extend across to the umbilicus, and when such is the case Peritonitis is generally the accompaniment of other pathologic changes. The patient will complain of pain at the upper part of the thigh, and this has not the same freedom of motion as the other limb. It has repeatedly been found that there has been irregular action of the bowels, associated with colicky pains, which radiate from the iliac region. Dr. West says, that in chil- dren the bowels are mostly relaxed, and that pain in the stomach is an initiatory symptom; and he also remarks, that the prominence in the right flank sometimes assumes that of an elongated tumor, which reaches from the ramus of the pubis nearly to the hypochondrium, and has a brawny hardness.' When the ailment has for some time subsisted, lymph and purulent matters are deposited in the cellular tissues behind the caecum, and so long as the strong iliac fascia prevents the escape of pus, a deep and irreg- ular abscess is formed. The secretion at length most frequently passes through the cascal parietes at the part uncovered by the peritoneum, as recorded by Copland, Duplay, and others. In some instances it is infil- trated into the cellular tissue in front of the iliacus internus, and effects an exit near the anus; or it may pass into the folds of the meso-colon, or make a sinus and be evacuated externally, as in examples related by MM. Husson, Dance, and Meniere. Dupuytren knew it extend so high as the right kidney, and so low in the pelvis as to collect between the rectum tad bladder. The perityphlitic inflammation may be circumscribed and rather of the sub-acute than the acute type, with adhesion of adjacent sur- faces. When the matter perforates the serous sac, diffuse and fatal Peri- tonitis ensues. JPeritonitis of CMldren.^Acute Peritonitis seldom occurs in infancy and childhood. It has been more frequently observed in young infants than in children several years older. Some have declared it may affect the foetus; in all such instances syphilis in the mother has been regarded as the cause, nor is it improbable that a general taint in the mother should impart disease to the child. Irritation of the digestive surface is more' common in children than inflammation of the serous tunic. When Peri- ' Diseases of Infancy and Childhood, 5th edit. p. 657. 194 DISEASES OF THE INTESTINES AND PERITONETTM. tonilis does occur, it is generally as a complication or sequel. It may however, be primary as well as secondary; it may be partial or general, acute or sub-acute, and then pass into thfe chronic condition. When it appears it is mostly after one of the exanthematous fevers; more especi- ally after scarlatina or measles. Dr. West has not known more than half"- a-dozen instances of acute general Peritonitis in chQdhood.' It has pre- vailed among young infants when exposed to deleterious external agen- cies. According to M. Thore,' at the Hospice des Enfants Trouv6s, at Paris, six per cent, of the infant mortality was from acute Peritonitis. It usually came as the complication or sequel of some other ailment, and no child above ten weeks was attacked by it. The fatal end was gener- ally before twenty-four hours. Of sixty-three inspections in no case was there pus, but in aU a greater or less amount of- serum on which flocculi floated, and the intestinal coils and solid viscera were adherent. _ In seven- teen out of the sixty -three, erysipelas had preceded the Peritonitis. Pleu- ritic effusion was discover^jffim^ third of the examples. The usual symptoms 'l^e- pain in the bowels, which at first resembles common stomach-ache. ; It alternately subsides and returns, and there is mostly diarrhoea. In the course of a few days the pain becomes more fixed, and the child frequently complains of pain in the right side, and if old enough he indicates the locality by putting his hand on the c»cal or umbilical region. The pyrexial phenomena are proclaimed, the little patient looks haggard, he is restless and continually alters his position; pressure over the part makes him cry, and the abdominal muscles are tense. He lies on his back, often with legs extended, and the sickness is not so urgent as in the adult. According to Dr. West, when the affection is of caecal origin, the right leg is often drawn up and the left extended. Dr. George Gregory a long time ago described a form of marasmus, which he believed to be primarily disease of the peritoneum, and which he conceived to differ from what Pemberton terms " irritation of the intes- tines," and the kind of marasmus originating in the mucous membrane.' From being met with in scrofulous children, and an "imperfect kind of pus " being produced, he named it scrofulous inflammation of the peri- toneum. He regarded it to be distinguished by abdominal tenderness, shooting pains which at the first come on in paroxysms, but at length in- crease in frequency and violence. The pain on touch is first localized, and then becomes diffused. Inspection revealed pus and agglutination of the viscera. But the account of this author applies more to chronic than acute Peritonitis. In acute Peritonitis of children pus is a rare consequence; when it is formed it gravitates into the lower parts of the abdomen, and is deposited in one or more collections or septa. It may be evacuated by pointing externally, as in empyema, or effect an exit by the bowels, and it is possible recovery may follow, but such is a possibility rather than a probability. When it occurs consecutively, as after some fever, and when the powers of vitality are lowered, turbid serum with a few floating floc- cuK is the common product, as I have already observed when speaking of the non-plastic type of the disease. Complications. — This affection is often complicated with some other dis- ease. It may be complicated with gastritis, a disease which rarely or never ' Diseases of Infancy and Childhood, 5th edit. p. 654. * De la Feritonite chez les Nouveanx-nees, in the Archives 6«n. de M6d. Aognst and September, 1846. 8 Medioo-Chirurg. Trans, vol. xL p. 263. PEBITOKITIS. 195 occurs in this country as an idiopathic affection, although it is said to do so in warm climates. The physician will, in nearly all cases, discover from the history of the case, or collateral circumstances, the cause of the inflam- mation, Gastric Peritonitis may be fatal without the contents of the stomach being ppured into the serous sac, and without solution of continuity, espe- cially when it occurs in a secondary form. But in such examples the inflam- mation is only limited. Sometimes tumors press upon the organ and in- fl^jne its serous covering, or the inflammatory condition ma.y be there insti- tuted by contiguity, as when neighboring viscera, such as the liver, spleen, and intestines, are thus primarily diseased. Carcinoma, especially of the pyloric end, will sometimes, by the mechanical pressure, give rise to the re- swlt in question; when this happens the Peritonitis is generally of the more chronic description. In that form of ulceration of the stomach, which oc- curs mostly in young women, the general health is often not much affected. It is often in association witlf chlorosis, amenprrhoea, leucorrhoea, or sub- mammary pain, and the patient is apt to complain of a gnawing sensation at the epigastrium, accompanied with more or less of anorexia and vomit- ing. When the gastric peritoneum is rent or perforated by ulceration of tbC; inner tunics, the pain is excessive, the powers of life are rapidly sub- dued, and death is inevitable. When the peritoneum is inflamed in hepatitis it is generally in a, par- tial manner, and it continues to be circumscribed unless extravasation pf some description result, which is occasionally the case, and then the entire sac at once assumes the same morbid condition. Inflammation may begin in the parenchymatous structure and extend to the serous coat, and when such is the fact, the pain becomes more acute and defined, and the pyrex- ial symptoms are more pronounced. The right hypochondriac region is often full and tense, the normal lines of dulness are extended, there is pain on pressure and deep inspiration, and dyspnoea, coughing, and vomiting are; frequent accompaniments. The patient cannot lie on his left side, and the recti miiscles are rigid. When the convex surface is affected, the diaphragmatic investment assumes the same disease, and cough is a promi- nent symptom. The convexity may he inflamed without the appearance of jaundice. When the concavity is inflamed the stomach mostly becomes implicated, sickness is urgent, the gall-ducts are more or less obstructed, g,nd jaundice, in greater or less degree, is a common result. When the parenchyma i? alone inflamed, the pain is of a dull, aching character. When the serous tunic is involved, the pain is sharp and acute. When lymph in considerable quantity is effused, the organ becomes adherent to adjacent surfaces, and if the albuminous exudation gravitate to the lower part of the abdomen, agglutination of the intestinal folds occurs. When hepatic abscess points to the surface, partial Peritonitis, by pressure, is induced. The effused lymph is protective from the worse consequence of extravasation. Hyda,tid tumors may, like abscess, excite adhesive inflam- mation. Cancerous growths occasionally produce sub-acute hepatic Peri- tonitis, but the syniptoms are ill-defined and obscure. And the same re- marks apply to the tubercular masses in the capsule of the liver. Sometimes we observe acute splenitis as an intercurrent complaint during the progress of intermittent fever. But, as I have more fully in- sisted in the article on Diseases of the Spleen, this organ is infinitely mere prone to a ohronio form of cpngestipn. Sometimes, when during the cold stages the capsule becomes suddenly distended, such tenseness sp stretches thefibrpusand serous tunics as to usher in the inflammatory process; theji pain of sharp and stabbing character, increased by pressure, is felt beneatk 196 DISEASES OF THE rNTESTINES AND PERITONEUM. the left costal cartilages radiating through to the back; the skin is hot, the pulse quick and hard, the urine high colored and scanty, the tongue furred, the bowels are confined, and if the under surface of the diaphragm has become affected, cough and dyspnoea are associated symptoms. The patient lies partly on his back with trunk curved to relax the abdominal muscles. Towards evening there is exacerbation of the symptoms. Post- mortem examination reveals the serous investment thick and reddened, and the organ united to neighboring parts by albuminous exudation; and it is here not unworthy of remark, that in the peritoneal inflammation of this viscus, cartilaginous and ossific conversions are more frequent than in the peritoneal inflammation of the other solid abdominal organs. In enteritis, when all the coats of the bowel are inflamed, the disease may commence in the mucous membrane, at first sickness and purging being urgent. In such cases colicky pains come on at intervals, and mod- erate pressure produces little or no uneasiness, and at this stage of the malady it is often difficult to form a correct diagnosis. If the complaint make progress, if the skin become hot and dry, the pulse quick, the face flushed, and pain be felt on pressure, it is of great practical importance to distinguish the kind of lesion to which the disease has advanced, because remedies which would relieve the colic would be absolutely injurious in inflammation. Instead of diarrhoea there is often constipation; thus it is when mechanical obstruction of the gut is the cause of its being inflamed, as in intussusception, and when tumors block up the passage, and vomit- ing of stercoraceous matters proclaims the inverted action of the bowel. The general and special signs of the peritoneum being inflamed are the same as those above described. In children the complaint is frequent during dentition, and it sometimes comes on as the sequel in eruptive fe- vers. Crude and indigestible articles of food in these little patients are often the cause. Its advent is marked by languor and peevishness, the child is restless and complaining, green mucoid stools emitting an offen- sive odor are voided, the cheeks become flushed, the beUy tender, and all the conditions of peritoneal inflammation are superadded to a fever of the remittent type. And dissection sometimes exhibits the entire substance of a portion of the ileum presenting a gangrenous appearance in addition to the ordinary products of serous inflammation. In nephritis — which is in the great majority of instances brought on by calculus in the pelvis of the kidney, blocking up of the ureter, some irritant drug, or some blow or external injury — severe pain over the loins following the course of the ureter on the same side, and, in the male, re- traction of the testicle, high-colored urine, and nausea and vomiting are common symptoms; and, as is occasionally the case when ischuria renalis supervenes, uremic symptoms are apt to mask and obscure the otherwise more apparent features of peritoneal complication (perinephritis). The urinary bladder may be acutely inflamed {cystitis), the inflammation origi- nating in the mucous membrane, and being extended to the muscular and serous coverings. It is caused by calculi, irritant drugs, retention, surgi- cal operations, and external injuries, and the Peritonitis may be partial or general. Systitis is very rarely observed in the unimpregnated uterus; it may come on after monorrhagia by sudden suppression of the catamenia, long walks, wet and cold, and I have known it induced by the incautious use of topical applications. It is most frequent after delivery, and the fundus is the part mostly first affected. When the peritoneal investment becomes impucated the disease often assumes an alanning character. Ovaritis PERITOlilTia. 197 may be presented in one or both the ovaries without the uterus being in- flamed; in the_ larger number of examples, however, it is the complication of general Peritonitis, or antecedent uterine inflammation. Deep-seated pain in one or both of the pelvic cavities indicates the lesion, and when the peritoneum is affected the pain becomes exceedingly acute, and an aching, wearying sensation extends down into the groins and thighs. There is often frequent desire to micturate, and when the disease is con- tinued to the posterior portion of the peritoneum the rectum is rendered irritable, and there is constant inclination to evacuate the bowels. Puffi- ness or swelling is sometimes seen over the ovarian region, and that part is most painful on the least pressure, and the sickness and vomiting are often distressing. The comparatively recent establishment of that great surgical opera- tion ovariotomy, more especially as practised in this country, has proved that the peritoneal sac can be laid open, and its inner surface exposed over a great extent, and for a considerable time, without the production of such fatal results as it was formerly believed would inevitably follow. It now appears, from a large accumulation of cases, that in a healthy sub- ject, and especially in the unilocular tumor, and when there are no attach- ments, the peritoneum may be cut, and freely, without the consequent inflammation being always formidable. There are some other affections with which Peritonitis is occasionally complicated. In pericarditis and pleuro-pneumonia it sometimes happens that the inflammation spreads to the peritoneum: but in such instances it is often extremely probable that a contaminated state of the circulatory fluids constitutes the predisposing cause, and that the irritation existent in one of the great cavities is readily transferred to another, and that an adjacent membrane of similar structure, and under general predisponent circumstances, will take on the same morbid action. And, conversely, we know that Peritonitis often extends to the pleura, and it is not uncommon, as I have lately seen, to find hepatitis associated with dulness, moist crep- itation, and all the other physical signs significant of inflammation in the lower third of the right thorax; and when the spleen is greatly enlarged, or in acute splenitis, the same conditions obtain at the base of the left lung; pressure and the proximity of like structures being the cause of such extension. In empyema the diaphragm may be rendered convex to- wards the abdomen, pushing down the abdominal organs, and friction and pressure induce Peritonitis; and in the enlargement of the liver or spleen, or an encysted kidney, or an ovarian tumor, this partition may be thrust up so abnormally into the chest as to press upon and excite the pleuro- pulmonary tissues to active inflammation. MoEBiD. AjSTATOMTsr. — The morbid appearances of Peritonitis are very various, being modified by a number of circumstances ; such as the type, the primary or secondary character of the attack, the condition of the blood, the amount and kind of disease in the viscera, and more especially of the solid organs. Before speaking of inflammatory change, it may be observed that serous membranes may be simply congested, presenting a condition analo- gous but not amounting to inflammation, and this hypersemio state may be transient, temporary, or long-continued. When often returning or for some time existent it may give rise to excess of secretion, which is chiefly serous; nevertheless it may contain some coagulable matters, but their amount will be dependent upon the increase or diminution of the fibrinous and albuminous constituents in the blood. Such abnormal afilux of blood 198 DISEASES OP THE INTBSTIKB8 AND PERITONEUM. to this membrane may subside spontaneously, or there may be hsemorrhage into the sac, and such haemorrhage may be passive or active,— it may be by transudation or rupture. Exhalation into the peritoneal cavity some* times occurs, when a sanguinolent serum and an injected membrane are discovered. In visceral laceration considerable collections of blood of ' course may follow. The gases generated in the cavity of the peritoneum are sometimes in great amount; they are in nearly all instances the result of cadaveric change and the decomposition of the secretions. In empyema, gases are produced when there is no solution of continuity in the pleura; and the same may rpsult when there is pus in the abdomen and the peritoneum has maintained its integrity; but they may have tneir origin in ulceration of the intestines, or traumatic injury. . The first inflammatory change in the peritoneum is the loss of trans- parency and of that shining polished appearance proper to its healthy structure. This dulness or opacity is accompanied by diminution of the lubricating secretion, and Baillie, Bichat, and Knox affirm that the mem- brane becomes dry. But such dryness is more apparent than real, because when handled it feels moist and unctuous. The sub-serous vessels become injected, and may be seen through the fine membrane in hair-like streaks, arborescent and ramified, or in a confused net-work, and when much crowded a velvety appearance is imparted. The degree . or shade of red- ness depends upon the period of congestion, the kind of inflammation, and the condition of the blood. : When the hypersemia has for some time continuedj or in sthenic inflammation, the hue is light red; when the con- gestion is but recent, or the inflammation of • asthenic typCj the color is less vivid and may be darker and venoid. With the progress of the disease, vessels in the membrane which were colorless enlarge so as to admit red-blood globules. At various points smaU sub-serous sanguineous efEusions are seen in the shape of bloody puncta; sometimes these are so numerous as to exhibit a spotted or speckledap- pearance, or they may coalesce and form red configurated patches of vari- ous sizes. I have said that at the first there is diminution of the lubri- cating fluid. In the course of a short time (at periods differing according to certain conditions which obtain, such as the mildness or severity of the attack, the general powers of the system, and the like) this secretion is re-established, and if the malady end in resolution it manifests all the characteristics of the natural state; but if the complaint progress it is augmented in quantity and altered in quality. The free surface of the peritoneum is then bathed with a semi-transparent homogeneous fluid, and the sub-peritoneal tissue is surcharged with' a sero-albuminous secre- tion, and frequently the peritoneum proper can be stripped off with undue facility. This infiltration, however^ at length permeates the serous tunic, when -it and the filamentous layer become so confounded, that itis not easy to traceHhe line of union. Under such citcumstanoes the membrane is not only rendered opaque, but it looks thick andtumefiedj andif carefully examined it feels rough, has lost its lubricity, and close inspection detects a viscid albuminous deposit varying in thickness accordiAg to the duration and severity of the attack. The new or morbid seofetioii. which is effused soon separates into two distinct forms, — a thin and watery whey-like fluid, and a thick gelatinous, pulpy, or more solid portion; the former constituting serum, the latter coagulable lymph, or, as it is otherwise named, albuminous exudation or plasma. The relative proportions of the fluid and more solid parts Vary PEBITONins. 199 in each individual instance. Sometimes we find no serum whatever, and sometimes the efEusion consists almost entirely of serum, the only traces of the albuminous exudate being minute flocculi floating in the fluid and rendering- it turbid. In the inflammation of metastasis and low types of Peritonitis the efEusion is sometimes puriform or absolutely purulent. In acute sthenic Peritonitis the lymphic deposit is great. It is thrown down on the free surface of the sac in various amounts according to the condition of the circulation, and the violence of the inflammation. It may be a mere film, or in a layer several lines in thickness. It differs in color, being sometimes of a grayish red, but is more frequently of a yellowish Straw color. When abundant, it lies in smooth or corrugated plates ; it is also found in honeycomb arrangement, in bands or bridles constituting bonds of union of varying thickness uniting the viscera, or it may be en- circling the gut; it is generally seen in masses filling up the interspaces^ and when lying between the intestinal folds it assumes an ill-defined pri?- tllatic configuration. The viscera are not only glued and matted together, but there is mostly more or less of adhesion to the parietal peritoneum. When a portion of the adventitious stratum is detached from the perito- neum, the coherent surface of the new product exhibits an irregular villous character^ and it is speckled with small bloody puncta produced by torn Capillaries, and the sub-serous tissue is ecchymosed. The new formation being at first villous, becomes smooth and more dense, and at length assumes a structure and qualities analogous to the true peritoneum. If the exudation be submitted to the microscope new vessels are seen to permeate its substance, and more especially in the central portions. That they are connections or prolongations of the peritoneal capillaries is beyond dispute, although we cannot always trace their continuous struc- ture. It was believed by Hodgkin' that new vascular extensions are car- ried out into the exudation, and that subsequently towards the peritoneum they contract .and become nearly or quite invisible. This author is of opinion that the delicate parietes of the extreme vessels give way, that minute quantities of blood are received into the exudation, and that such are the first beginnings of those minute cavities which are destined to be- come vascular. It is quite evident that the plastic efEusion is an irritant to the serous surface, because when deposited on one part of the peritoneum, and any other opposing part comes in contact with it, such readily takes on the inflamed condition;, hence it becomes explicable, in one way at least, why Peritonitis is so liable to difEusion. According to the time which elapses after its production, and the vital powers of the organism, is the degree or completeness of the organization. From being a semi-fluid gelatinous substance it becomes more dense and solidified, the capillaries are more numerous, it contracts in bulk, its filamentous texture is more defined, and it enters into firmer and more intimate union with the organs or parts it covers or connects. Where there is much motion, it is sometimes disposed in a stringy or reticulated manner, and meshes are formed, filled with transparent fluid. Another morbid condition associated with these false membranes is that of serum or sero-purulent fluid being collected between the peritoneum and the false formation, until the latter is raised up and loosened from its attachments and set free in the sac. When these ad- ventitious membranes remain firm and adherent, the original serous mem- brane beneath them disappears, and their surface assumes the oharacter- ' Lectures on Serous and Mucous Membranes. 200 DISEASES or THE INTESTINES AND PEKITONEUM. istics of a veritable serous membrane, and it is difiSoult to distinguish the new from the old. , The former secretes a lubricating serum, is influenced by the same kinds of irritatioiij is liable to become inflamed, and in its turn to throw out true inflammatory products. _ ^ The attachments efEected by these formations may subsist through the remainder of life. They may be protective and conservative. In the sup- purative stages, when abscess forms in the solid viscera, this adhesive in- flammation is the method which nature observes for the harmless exit of pus. These bonds of union may continue with little or no inconvenience. By the lapse of time they become thin and contracted, and when health is re-established and the absorbents are active, they may partly or wholly disappear. Absorption begins with the subsidence of the inflammation,, and, as Rokitansky' remarks, it must, as a matter of course, be influenced by the thickness, that is to say the permeability, of the deposit. _ Before the time of the two Hunters it was not by pathologists gene- rally allowed that serous membranes secreted pus without solution of con- tinuity; in other words, without the presence of ulceration. Since then this fact has been universally acknowledged. It may be secreted from the inflamed peritoneum, or from the surface of those adventitious mem- branes which are formed in the cavity. William Hunter says it is gene- rally thinner than that of an abscess, and the containing surface is, more or less covered with a glutinous concretion or slough of the same color as the fluid, in some parts adhering very loosely, in others^ so firmly that it can hardly be rubbed ofE, but still the surface covered with these sloughs is without ulceration or loss of substance." Dupuytren and Villerme be- lieve that the false membranes are concrete pus, and Rokitansky is of opinion thai pus, under some inherent peculiarity, is a degeneration of plastic exudation. It is more frequently seen in the asthenic, sub-acute, and lower types of the complaint than in the sthenic. In the inflamma- tion of metastasis, when the blood is contaminated, in parturient women, and in children, it is most common. The fluid may be puriiorm, purulent, or sanious. It may be yellowish green, or brown, or reddish. The peri- toneum and sub-peritoneal tissue are much injected, and there is usually great infiltration of the tissues. In some instances it appears as if exud- ing from the entire inner surface of the peritoneum; in other cases it is associated with adhesions, and is discovered in distinct collections, bounded by organized septa, and resembling separate abscesses. It may be evacu- ated by ulcerative absorption through the abdominal parietes; by the same process it may pass into the digestive tube, the bladder, or vagina, or through the diaphragm into the thoracic cavity, or efEect an entrance into the bronchi, or it may find a way of escape by the psoas muscle. The pressure exerted by purulent collections is doubtless the main cause of ulceration commencing, but Craigie believes that in these cases sometimes ulceration may result without pressure, being merely the direct and obvious efEect of inflammation. My colleague at the Tunbridge Wells Infirmaryj Mr. Marsack, made (Sept. 18,. 1865) an autopsy on the body of a young woman, on whom he had six weeks previously performed ovari- otomy. The coils of the Ueum were welded together, and joined to the abdominal walls by organized adhesions. Between the layers of the great omentum were small independent abscesses of creamy pus. In the lumbar region was a bounded abscess-like collection which contained half a pint '- Pathological Anat., Syd. Soo. ^ Hedical Inquiriea and Observations, vol. ii. p. 61. PBEITONITIS. 201 of pus. At the sigmoid flexure ulcerative perforation was discovered.' Pressure, caused by a collection of purulent fluid, had been followed by ulcerative absorption of the tunics of the large bowel. When this secre- tion is effused in small quantity it may be- absorbed, but if in large quan- tity and without opening, irritative fever is induced, the symptoms of pyaemia supervene, and it is then uniformly fatal. Sometimes 'adhesive inflammation in Peritonitis gives rise to very peculiar pathological condi- tions. The stomach and transverse colon have, in several instances, been glued together, and ulcerative absorption has effected a communication between them, so that the fsecal contents of the large bowel have passed into the gastric cavity, and thence been expelled by vomiting. Two or more coils of the ileum may be soldered together, and an intercommuni- cating passage established in the same manner. In such examples the disease has generally become chronic. In the partial or localized forms of acute Peritonitis, when some fore- going visceral disease has extended through to the serous coat, and insti- tuted inflammation in that tunic, we not infrequently see circumscribed depositions of lymph cementing neighboring parts together while the remaining extent of the peritoneum is perfectly healthy. In hepatitis, when the convex surface is inflamed, strong adhesion is sometimes discov- ered. The spleen is in like manner united to the concave surface of the diaphragm, and the accretion may have assumed a cartilaginous or ossific character, the latter conversion being in that situation more frequently seen than in any other part of the abdomen. In simple ulceration of the stomach sometimes adhesive ulceration averts a fatal catastrophe by agglutination to one of the solid organs, or, as it has been repeatedly wit- nessed, by the production of an aperture into the colon, or sometimes into the duodenum; and, in a few rare instances, a canulous opening has been spontaneously made through the abdominal parietes, forming a gas- tric fistula^ In malignant disease of this organ, most frequently seen at the pyloric endj there is much soldering together of the adjacent parts; the peritoneum is opaque and vascular, and the sub-serous tissue is greatly injected and infiltrated not only with carcinomatous deposit, but also with serous fluid. The duodenum, as before remarked, occasionally exhibits partial Peritonitis from rupture, consequent upon ulceration of the mucous and muscular coats, as the result of extensive burns, but its serous investment is more frequently inflamed from the irritation and pressure resulting from cancer of the head of the pancreas. When the jejunum is found morbid it is almost always in connection with the lesion of other organs. With regard to the ileum, what has above been said relative to the perforation of its peritoneal covering was descriptive of its morbid appearances. In phthisis sometimes protracted colliquative diar- rhoea gives rise to ulceration in its mucous surface, but perforation in phthisis is exceedingly rare ; it is, however, in this complaint occasionally beheld on or near the vermiform appendix. In chronic dysentery the colon may give way, and in such instances there is great destruction of the other tunics proper to the bowel. Such examples occur in those who have died after long residence in tropical climates, and in association with some form of hepatic disease — very generally with abscess of the liver. In puerperal Peritonitis, according to Dr. Lee, the appearances of inflamniation are sometimes confined to the uterus, but they are much > Mr. Marsack'a Hoep. Case Book. 202 DISEASES OF THE INTESTE!fE3 AUD PEKITONETJM. more generally extended to other organs. The lymph is mostly thrown out in thicker masses upon the uterus than in any other situation, and this viscus seems to suffer in the greatest degree. In the sub-serous cel- lular tissue serum and pus are often deposited. The cellular tissue Sur- i-ounding the vessels of the uterus where they enter and quit the organ^ and that oonnecting the muscular fibres, is often surcharged with serum and purulent fluid;' The peritoneum becomes thick and vascular, more especially where it invests the uterus and pelvic viscera, and sometimes^ when the malady is intense, the serum is mixed with blood, and pus is found in the pel vis. When death has rapidly followed,' the lymphic exu- date is semi-fluid, or the surfaces which have become agglutinated are readily torn asund.er. The Fallopian tubes and ovaries are sometimes filled with pus or blood. In the Peritonitis of children the abdominal viscera are found matted together and adherent to the abdominal walls. In some cases the viscera are covered with a thin grayish opaque covering, which feels soft and unctuous, and a turbid, reddish serum in which small floccuH are floating is effused in varying quantity. In that strumous affection whichj according to Gregory, gives rise to Peritonitis, pus is secreted. And this physician asserts that sometimes the , abdominal cavity wiU be abol- ished, the viscera being united in one mass, and everywhere adherent to the parietal peritoneum, the latter in all its duplications being thickenedj and the soldered intestinal convolutions inter-eommunioating." When the peritoneum becomes inflamed consecutively after scarlet fever, measles, rheumatism, or some other fever, an excess of serous effusion is discovered, the albuminous portion -being inconsiderable or almost absent. The fluid is of whitish straw-color or of dirtyish red. DiAGNOsis.^-The more severe forms of acute Peritonitis are fully expressed^ and the disease cannot well be mistaken; but in the sub-acute and more partial descriptions, when the disease is not a primary but secondary complaint, or a complication^ it may be so masked, mixed .up^ and confounded with the symptoms of other morbid changes as to rendeJ the diiagnOsis very difficult. In all instances the physician should- pay marked attention.to the historyof the case, as well Jis to the objective and subjective symptoms, because there are affections which when super- ficially reviewed simulate this- complaint, and it has not infrequently hap- pened that the ignorant or off-hand practitioner has fallen into gravef error. The diseases which it most resembles are gastritis, enteritis, colic, rheumatism, neuralgia^ hysteria, obstruction of the gall-ducts, renal calcu- lus, and lead-poisoning. With respect to gastritis, it is in this country, as I have before observedj rarely or never met with as a purely idiopathic affection, Abercrombie means by this term infla,mmation of the mucous membrane, and it is in such sense that it is now employed. When the mucous coat takes on this morbid state there may be pain on deep pres- sure, the sickness is urgent, the thirst distressing, and fluids are con- stantly ejected. It can almost always be traced to some exciting cause. In Peritonitis there is more difficulty in the etiological conclusion, and iii the latter the pulse is smaller and more wiry. The inflammation may commence in the digestive surface and extend to the peritoneal invest- ment, and it then, of course, becomes partial Peritonitis. It occasionally' occurs when the gastric portion of the peritoneum is roughened by lym- • More Important Diseases of Women, p. 24. " Medieo-cAirnirg. Transaotione, vol ^ p. 366. PEEITONITIS. 203 phio exudations that auscultation can detect some friction sound; but this, however, is seldom heard. In the great majority of cases gastritis is referrible to acrid and corrosive poisons. Haller knew it produced by the patient having taken cold water when he was heated. It is frequently very difficult, often absolutely impossible, to diagnose Peritonitis from enteritis. Inflammation may begin in the mucous membrane and impli- cate the peritoneum, or Peritonitis may at length involve all the coats o* the bowel, when both diseases obtain. The vomiting is more urgent in enteritis, the bowels are often obstinately obstructed, and gangrene is sometimes the result. The pulse is of better volume than in Peritonitis, and as the rule the patient does not complain of so much pain. In Peri- tonitis, partly owing to the involution of the parietal peritoneum, the pain on pressure is more acute and superficial, the patient is more averse from motion, the respiration is more thoracic, and the features are more collapsed. In coKg, which may be from simple flatulence, the pain and distention may be severe, and even the face may be an index of sufEering. When there is very great distention pressure may increase the pain, but more com- monly pressure relieves rather than augments it; the circulation is lil^tle if at all affected, and there is no symptomatic fever. Frequently consti- pation and vomiting are associated with other symptoms; the patient complains of a twisting, wringing pain at the umbilicus, which comes on paroxysmally, and there are intervals when the sufEering is inconsiderable or absent. This condition of colic is, when regarded alone and as simple colic, not an important affection, but it sometimes comes on as the herald of a more grave disease, and ends by the development of inflammatory symptoms. In colica pietonum there is no apparent obstruction of the bowels, although there are the common symptoms of ordinary colic. There are constipation and abdominal pain, even violent pain — dolor atrox — but there are other symptoms, such as pain in the head and limbs, a blue, leaden line in the gums, and loss of power in the hands and fore-arms, and the patient is either a painter, or investigation discovers that he has in some way been subjected to lead poisoning. The abdominal muscles in rheumatism sometimes are rendered so excessively painful that moder- ate pressure causes great sufEering, and notwithstanding that examples are occasionally observed in which acute Peritonitis has thus supervened, yet such, instances are very exceptional, and ordinary observation will generally prevent any mistake in diagnosis. Negative facts will be our chief guide. In such cases the circulation is little affected, the pulse is large and full but not frequent, sickness and vomiting are not present, the countenance has not the pinched, anxious expression which it assumes when the peritoneum is inflamed, and if th'e abdomen be carefully examined the tenderness will be found more severe at the origins and insertions of the muscles; lastly, it will be shown upon inquiry and examination that rheumatism has recently obtained, or that its symptoms are stiU present in other parts of the body. Neuralgia is another affection which mimics Peritonitis. The pain is described as a tight girdle or ligature passing round the body, and impart- ing a feeling of constriction; it traverses the course of the genito-crural ner-v e, percussion on the spinal processes detects some tenderness, and the legs and genito-urinary organs are often more or less affected; agaiuj there is the absence of tympanites, pain on pressure, quick pulse, facial col- lapse, and other phenomena so expressive of Peritonitis, and which I have in detail described above. In that protean malady hysteria, which mocks 204 DISEASES or THE mTESTDTES AND PEEITOITEUM. this as it simulates so many other affeotions, the patient is apt to complain of increased pain almost before the hand has really touched the abdomen a,nd when it does touch it, the pressure does not, as in Peritonitis, augment it. The pulse is natural, the tongue clean, and the countenance does not bear the impress of severe and acute disease. The breathing is not thoracic, the legs can be extended, the decubitus is not dorsal, and borborygmi and intestinal flatulence are often present; again, upon inquiry, it will not infrequently be found that large quantities of pale or colorless urine have been voided, that the uterine functions are at fault, or that some ill-defined spinal symptoms obtain. A comparison of the leading features common to the two affections will leave but little' doubt as to the true nature of the ailment. In obstruction of the gall-duGts from calculi, inspissated gall, tumors, spasm, and other causes, the pain is paroxysm'al, often excruciating; and with the passage, of the obstructing body, and the restored patency of the canal, the suffering at once subsides. There is no pyrexia, the heart's action is little or not at all accelerated, nor is there distention or abdom- inal tenderness. In addition to such negative there are positive facts; thg symptoms of biliary disturbance are mostly present, the alvine de- jections are often light-colored, the urine is dark and porter-like, the con- junctivae are yellow, the skin is tawny, and the pain is localized beneath the margin of the right false ribs. In renal calculus the pain radiates from the back round to the abdomen, it comes on suddenly, courses down the direction of the ureters, in the male produces retraction of the testicle of the same side, and shoots down the thigh, when for a shorter or longer interval it declines or entirely subsides, and bloody urine is a common accompaniment. In puerperal Peritonitis the after-pains are associated with contracted, not relaxed uterus, which is the fact in Peritonitis; they gradually dimin- ish, and in thirty or forty hours have become much less in force and fre- quency. Inflammation of the peritoneum commences at the ordinary date of the after-pains' decline. The remedial agents which relieve hysteralgia do not arrest acute Peritonitis. JSiphemeral fever is distinguished by its' brevity, its milder aspect, by the mammae remaining of normal size, and those serious conditions which mark the advent of an inflamed peritoneum are wanting. Lastly, in speaking of the diagnosis of this affection, it must be borne in mind that under grave cerebral disease, when nervous sensi- bility is obtunded, the peritonitic symptoms may be rendered very obscure, and under such conditions diagnosis may be impossible. Peognosis. — The opinion to be arrived at relative to the result of this disease will be modified and determined by a variety of considerations, and in every case a different array of facts will be presented, all the bearings of which should be carefully scanned. The asthenic is less auspicious than the sthenic type, and when it is the inflammation of ^metastasis the chances of recovery are less. In Mn/auoraSfe cases, in despite of the best- ordered means of treatment, there is a progressive aggravation of all the cardinal symptoms; the pain does not decline, nor do the distention and the tenderness abate; the breathing is more hurried, shallower, and en- tirely thoracic, the pulse becomes thready and intermittent, the sickness is excessive, the bowels are generally confined, distressing singultus super- venes, the surface becomes cool, is clammy and relaxed, the legs and feet are cold, the patient falls down in bed with knees drawn up, lies on his back, the Hippocratic countenance is more marked, and often the mind is clear to the end. He sinks by asthenia. In those instances when we can PERITONITIS. 205 pibgnostieate & favorable termination, there is remission of pain and ten derness, decline of the distention, the sickness comes on at longer inter- vals, and at length abates; the pulse is slower and fuller, the temperature of the body equable and warm, the respiration is not so quick, and the diaphragm descends lower down, and the patient can turn on his side. When we have reason to believe that there is perforation of the bowel, rupture of the liver or spleen, the urinary or gall-bladder; when we sus- pect the evacuation of an abscess or the effusion of blood, our prognosis must be unfavorable, and recovery under such conditions is well-nigh hopeless. In the consecutive form, when the strength has been under- mined by a previous malady, the probabilities of a fatal issue are great. In puerperal Peritonitis antecedent haemorrhage and the amount of ex- haustion induced by parturient efforts would influence our decision. Teeatmestt. — In every example of acute peritoneal inflammation, the remedies should be prescribed with a just reference to the emergencies of each particular case, because no trite and exact rules can be given admissi- ble of universal application. The date of the disease, the powers of the patient, the kind of pathologic action going on, and the antecedent cir- cumstances so far as they can be ascertained, in conjunction with other facts, must needs modify our resources, and be suggestive in the selection ^ of those agents which are accounted as the most effective auxiliaries in combating the affection. That this disease, like many other ailments, when seen at the outset, and treated according to science and experience, can be guided and carried to a successful termination is of such every-day proof as not to require being insisted upon here. And on the other hand, if its progress be unrestrained by ignorance or timidity, it soon passes be- yond the control of the most vigorous handling and the nicest skill. It is eminently one of those complaints which does not admit of vacillation and delay, promptitude and decision of purpose being of paramount importance. In an acute attack of inflammation of the sthenic type, in the strong and hitherto healthy, and especially those who have lived in the pure air of the country, our best ally is blood-letting; but it is by far the most suc- cessful when performed at the commencement of the malady — as soon as possible after the pulse has become hard and quick, the pain urgent, and the disease established. It is then, by making a decided impression upon the circulating organs, that there is the greatest chance of the inflamma- tory action being cut short, and of those morbid processes being arrested which so quickly follow the development of the affection. Nor should we be deterred from the use of the lancet by the mere smallness of the pulse, because it may feel constricted, hard, sharp, wiry under the finger, for with the free^emission of blood it will increase in volume and become soft and more natural to the touch. Many authorities, and some of high reputation, have spoken of the number of ounces which ought to be drawn at a first, second, or even third depletion, but there is no just rule as regards quan- tity, One patient wiU bear a much greater loss of blood than another, even when the two cases seem to bear a close resemblance. Our real and only reliable guide must be the effect produced by the abstraction. An influence must be made upon the heart's action, and the patient should, if possible,, be bled in the erect position. Abercrombie recommends one or two small bleedings at short intervals after the first in order to keep up the good results of the primary depletion. There is no doubt if ten or a dozen hours are allowed to elapse after the first use of the lancet, and be- fore a second visit, that in such long interval the pulse may recover its strength, the initiatory symptoms in full force return, and a larger quan- 206 DISEASES OF THE INTESTINES AND PEEITONEUK. tity of blood will require to be lost. In a disease so perilous the patient should at the outset be seen every two or three, or at least every three oi four hours. It is within the first twenty-four hours that blood-let- ting is of the most avail. When effusion has set in and progressed to some extent, blood-letting is more likely to be harmful than useful. In the young and the robust, in those of ruddy complexion and high arterial action, and those who live in the purer air of the country, bleeding is much better borne, and it may need to be repeated. The dwellers in urban communities, especially amongst the badly nourished and ill clad, such as present themselves at the hospitals of the metropolitan cities and large towns, very rarely, if ever, require general blood-letting, and when it is had recourse to, a smaller quantity is followed by the desired effect. After the lancet has been used it is excellent practice to follow it up by local depletion. Cupping is of course, from the pressure it would give, inapplicable; but twenty, thirty, or even forty leeches at one time ma^ be applied to the abdomen, and often with the greatest benefit. Fomentations, by means of flannels immersed in hot water, and wrung out as dry as pos- sible, the heat and moisture being kept up by their being covered with a large piece of oiled silk, is good treatment, and the flow of blood can thus for some time be promoted; or a large linseed-meal-and-bread poultice, or a bran poultice, produces a soothing effect. In the use of these applica- tions, however, care should be taken to constantly renew them before they become cool, and when they are discontinued a dry hot flannel of three or four folds should be placed upon the abdomen. Another very valuable mode of treatment at this juncture is the employment of terebinthinate epithems. Two or three dessert-spoonfuls of the spirits of turpentine may be sprinkled over the wet flannel, or a large piece of spongio-piline the size of the abdomen may be wrung out of hot water, and the turpentine in like manner sprinkled over it; and these may be repeated two or three times if the patient can endure the applications. I can bear testimony to the very excellent effects of the external use of turpentine, which I have very frequently in this mode re