repeated paroxysms of convulsion, and she died in a state of the most extreme emaciation, after an illness of eight or nine months duration.

"Inspection.-No disease could be discovered in the brain, and the lungs were quite healthy, except some very old adhesions of the pleura. The intestinal canal was throughout so thin, as to be transparent like goldbeater's leaf. On the mucous membrane there was in many places a tenacious mucus of a dark brown colour, but no disease could be discovered in the membrane itself, and no morbid appearance could be detected in any organ."

Dr. A. does not attempt to explain the case, indeed the only conjecture he can offer respecting it is, that some morbid condition of the mucous membrane interfered with digestion, and prevented the nourishment of the body. Whether this be or be not the fact, we are sure that we have seen others of no very dissimilar character. We remember, for instance, a case of chronic dysentery or rather diarrhoea, for the motions were never tinged with blood, which obstinately resisted every kind of remedy, and on dissection no disease of the least consequence could be discovered in the body. In another instance of vomiting, fetid evacuations, and extreme emaciation, dissection after death revealed no morbid appearances of any moment. Those who have seen much of morbid anatomy will acknowledge that such cases are not of the rarest, and they offer a humiliating commentary on the imperfection of our art, as well as on the extravagant fanaticism of the ultra apostles, of what we may term sectio-cadaverism.

"I have seen some other cases which showed similar characters, and proved very tedious and unmanageable. The peculiar character in all of them was the remarkably dark colour of the evacuations, which nothing had any effect in correcting. The last case that occurred to me seemed to derive most benefit from the sulphate of iron; and this remedy, which in general makes the evacuations very dark or nearly black, made them in this case decidedly lighter than their usual colour. Another seemed to derive benefit from small

quantities of mercury. The patients had in general a peculiar emaciated withered aspect, with a dry state of the skin, a weak pulse, and a variable and capricious appetite; but no actual disease could be discovered capable of accounting for their unhealthy appearance."

CASE 5. (CXXVI.):-Ileo-vesical Communication, from the Metastasis of Rheumatic Inflammation. A lady, æt. 63, was seized, June 1829, with rheumatic symptoms accompanied by an erythematic blush on the ankles. In eight or ten days these symptoms disappeared rather suddenly, and dysuria with much uneasiness in the region of the bladder supervened. Next day, July 9th, there was complete retention of urine, painand distention of the abdomen, continued vomiting, rapid feeble pulse, and cold skin. On the 10th the vomiting subsided, but the retention continued, and much bloody urine was regularly drawn off by the catheter. This state of the urine ceased in eight or ten days, and it then became highly offensive, depositing pus and slough, and on several occasions a quantity of fetid gas escaped through the catheter. The abdomen continued distended, the motions were liquid and offensive, and on the 28th she died.

Sectio Cadaveris. "The omentum adhered to the bladder and to the ascending colon. The caput coli was greatly enlarged, and the extremity of the ileum adhered to the posterior part of the bladder. The bladder adhered extensively to all the parts within the pelvis, and in attempting to separate it, a large quantity of pus escaped. Its inner surface was sloughy, and shreds of its mucous coat were hanging into its cavity. An opening capable of transmitting a goose quill was found to exist betwixt the bladder and the portion of ileum which adhered to it. The left kidney was healthy; the right was wasted, so as to leave only the calyces and cellular texture without any of the glandular structure."

tion of viscid mucus, night-sweats, and great prostration of strength. In Nov. 1824, she was seized with vomiting of dark matter resembling venous blood partially decomposed, and she discharged large quantities of the same by stool. A hard moveable tumour was felt in the epigastrium, which was painful on pressure. Her strength now sank rapidly, and she died on the 3d of December, the vomiting having ceased several days before her death, but the cough continuing severe, the bowels being obstinate, and the motions as before.

Sectio Cadaveris. "The tumour that had been felt in the epigastrium was found to be a tubercle, the size of an egg, attached to the left lobe of the liver. It adhered firmly to the stomach, near the pylorus; and on the internal surface of the stomach, at the place of the adhesion, there was an ulcer the size of a shilling; this ulcer appeared to have been the source of the black discharge, a considerable quantity of which was still found in the stomach and intestines. The coats of the stomach, along nearly the whole of the smaller arch, were much thickened and indurated, and the pylorus was considerably contracted in its aperture. The tubercle presented, when cut into, a variegated texture, partly a firm white tubercular matter, and partly a reddish substance resembling the structure of the liver; but the white matter was the more abundant. There were four or five similar tumours, the size of walnuts, in various parts of the liver. The left extremity of the pancreas was of a soft cheesy consistence, and adhered to the stomach. The other abdominal viscera were healthy. After the most careful examination, no disease could be discovered in the viscera of the thorax, except a few slight adhesions between the pleura costalis and pulmonalis, which were evidently of long standing." The above is related as an instance of "tubercular disease" of the liver; it was evidently fungus hæmatodes. We lately saw a case of fungus hæmatodes of the stomach in which the coats of the organ at the pyloric extremity and along the lesser curvature were perforated by ulceration, whilst the cavity of the stomach communicated with that

of an abscess situated between it and the liver. In this case the symptoms were so obscure as scarcely to direct suspicion to the affected organ.

CASE 7. (CL.):-Fatal Hæmorrhage from the Spleen. "A woman, aged 20, was admitted into the Infirmary of Edinburgh, on 16th June, 1829, under the care of Dr. Duncan. Her complaints were chiefly of a rheumatic character, with considerable nausea, some fever, anxiety, and restlessness. She stated, that, a fortnight before, she had been suddenly seized with severe pain in the stomach, followed by nausea and vomiting, and that these symptoms continued to recur at intervals for a week. On the 17th, there was vomiting, with much anxiety and restlessness, and she complained of pain on pressure in the left side beneath the false ribs. On the 18th, she became low and cold, and died in the evening.

"Inspection. A quantity of coagulated blood was found in the cavity of the abdomen, which was ascertained to have proceeded from a laceration of the spleen. That organ was of a paler colour than natural, and its substance was soft and easi y torn. There was a sacculated disease of the right ovarium; but no other appearance of recent dis. ease could be detected in any organ."

Such cases as the foregoing are uncommon but not unique. Dr. Abercrombie refers to one mentioned by Fournier, in which a man who had suffered for some months from quartan ague died suddenly, when convalescent, after a hearty supper. The spleen was found enlarged and ruptured, and there was much coagulated blood in the cavity of the abdomen. Within this last fortnight we have heard of a similar case in this metropolis. The patient died after a short illness, and the cause was supposed to be internal hæmorrhage of some kind or other. On dissection the spleen was found to have been ruptured and the blood to have escaped into the peritoneal cavity. Of the history of the case we know nothing, as we only heard of it indirectly.

CASE 8. (CLI.):-Enlargement and mixed State of Disease of the Pancreas.

"A lady, aged about 40, came to Edinburgh in May, 1829, affected with very deep jaundice, which was of several months standing. There was occasional uneasiness in the abdomen, but it was not severe; and the general health was little impaired. No disease could be discovered in the region of the liver in the centre of the abdomen, near the umbilicus, there was a slight feeling of knotty irregularity, but it was obscure, and could only be felt occasionally. I saw her along with Dr. Macwhirter, and a great variety of treatment was adopted without benefit. She at length became dropsical, and returned to the country, where she died, gradually exhausted, in August.-I am indebted to Mr. Syme of Kilmarnock, for the account of the morbid appearances.

Inspection. There was a gallon of fluid in the abdominal cavity. The gall bladder was very large, and was distended with very black bile. The liver was of a deeper colour than natural, but otherwise sound. The whole of the peritonæum was somewhat thickened. The pancreas was enlarged to the size of two fists, and embraced the ductus communis so firmly, that it was found impossible to pass a probe from the gall bladder into the intestine. It was of a mixed texture, some portions being soft, resembling the medullary sarcoma, and others of scirrhous hardness. The other viscera were healthy."

This completes the set of cases appended to the last edition of Dr. Abercrombie's work, and concludes likewise our brief sketch. We have already expressed a very favourable opinion of the volume, and it would almost be superfluous to say, that we recommend it to all branches, and each member of the profession.

XXVIII.

traction of the colon in our esteemed provincial contemporary. This class of affections is not sufficiently rare to be a matter of curiosity, but common enough to be one of practical interest.

Case 1. A gentleman, between 45 and 50 years of age, of sanguine temperament and a free liver, consulted Dr. Burne in February, 1826, on account of troublesome superficial ulcerations in the mouth, heat and dryness in the mouth and pharynx, and some little trouble in deglutition. He was feverish, but the bowels were habitually regular. Our author intimated to his patient a fear of incipient stricture of the œsophagus, and prescribed leeches and saline aperients, under the use of which the ulcers soon healed. In November, and again in February, 1827, the patient applied to Dr. B. for dyspeptic symptoms, after which he saw no more of him until February, 1828, when he still suffered from the dyspepsia, with the addition of a sluggish state of bowels. In July, 1828, he returned with an aggravation of the complaint, and was troubled much with fulness when the bowels were not freely moved, which was now effected with more difficulty. The Cheltenham waters were tried, with great but temporary benefit, for after he left the place, the irregularity of the bowels and dyspepsia were re-established, and his age and sallow face excited an apprehension of organic disease. A consultation was proposed and Dr. Armstrong was called in, but nothing conclusive was elicited. The costiveness continuing, Dr. Burne determined to ascertain by manual exaamination, if any cause of obstruction existed in the rectum. On passing the finger forward as far as was practicable, he met with a hard immoveable tumour, the size of an egg, and still further backwards and upwards the tip of the finger reached a contraction of

OF THE COLON.*

Dr. Burne, of this metropolis, has published two interesting cases of con

1830.

ceeded the exhibition of castor oil, and these again were followed by a sharp attack of inflammation, through which the patient with difficulty struggled. Mr. Copeland, Mr. Brodie, and Sir Astley Cooper were consulted, but all ultimately agreed on the hopelessness of the case, and the inexpediency of surgical interference. The patient lingered on, scarcely ever passing any feculent matter, and suffering from occasional attacks of violent spasm and succeeding inflammation till the 20th of February, 1829, on which day the spasms were followed by sudden pain in the left side of the belly, compared to the discharge of a pistol. The abdomen immediately became tense, the powers sank, and in eleven hours the unfortunate patient expired.

Sectio Cadaveris. "The abdomen being opened, a large quantity of feculent matter, of soft consistence, was seen lying among the intestines and upon the mesentery, and was found to proceed from a transverse rupture of the colon, about an inch long, at the spot from whence the violent pain darted. The whole of the colon was filled with feculent matter of the same kind; the sigmoid flexure was seen stretching across the brim of the pelvis to the right side, when it turned quickly upon itself and terminated in the diseased portion, which was situated directly under the promontory of the sacrum. The diseased part was about the size of an egg, and consisted of a scirrhous degeneration of those strictures of the intestine situated between the mucous and peritoneal coats. The aperture of communication between the colon and the rectum through the diseased part, scarcely equalled the size of a swan quill, and had a curved direction, which proved the correctness of the opinion, that force used in attempts to pass a bougie would be likely to rupture the bowel. The lower opening looked backwards and downwards to the hollow of the sacrum, and its margin was knotted and irregular as has been described. There were adhesions of the sigmoid flexure to the small intestines, and the scirrhous mass was adherent to the sacrum."

Case 2. A female pauper in Covent Garden Workhouse had been admitted, three weeks before her death, in a state of extreme emaciation and with a remarkably distended abdomen; she passed scarcely any feculent matter during the three weeks and was constantly vomiting, so that nothing except brandy and water could be retained upon the stomach. This is all the account of the case that Dr. Burne could procure.

Sectio Cadaveris. "Before the abdomen was opened, traces of the convolutions of the intestines were evident, by corresponding elevations of the integuments: these convolutions were found to be distended with gas, and the colon was full throughout of soft feculent matter; and at the termination of the sigmoid flexure in the rectum, was a circular contraction of the bowel forining the annular stricture. There was no thickening or disease about the part, and the contraction had the appearance of the bowel tied with a ligature, except that there were neither folds nor puckering."

Many interesting observations on the foregoing cases, and on stricture of the colon generally, are made by Dr. Burne. He particularly remarks the soft consistence of the feculent matter, a circumstance which does not appear to have been noticed by systematic writers, but which he believes to be generally present in cases of this disease. Our author looks on it as a special provision of Nature, but we must be excused if we doubt the correctness of his opinion, and hesitate to attribute such an office to the vis medicatrix naturæ. Dr. Burne appears to regret that, in the first case, no attempt was made to establish an artificial anus. We cannot share in his concern, but agree with the late Mr. Wadd, who opposed the proposition. Setting aside the dangers and difficulties of the operation, neither of them inconsiderable, where would have been the service of joining a most loathsome to an incurable disease, of superadding disgust to commiseration in the minds of the patient's family and friends? The following remarks on purgative medicines are judicious.

"All are agreed that the aperients

which must be necessarily given, should be of a mild character, and the recommendations of authors who have treated - on the subject, are limited to castor oil, senna, and sulphur; thus leaving unnoticed saline aperients, which, as will presently be seen, are the most efficacious. These medicines, castor oil, senna and sulphur, although desirable from their mild qualities, are very uncertain and ineffectual in cases of stricture it is true they promote a moderate, and so far, a proper peristaltic action of the intestines, but as they do not render the fæces watery, this action is not followed by sufficient evacuation, and therefore not by sufficient relief. Sulphur is objectionable on other grounds; it has been known to form into balls when taken in large doses, and in this way may add to the mischief. The same objection applies also to magnesia, which has been found accumulated in a large quantity above the stricture.

"While the subject of the first case was at Cheltenham and taking the waters, the evacuations were so thin that the colon emptied itself effectually every day, and under these favourable circumstances the patient lost all complaint and improved surprisingly. This first suggested to me the use of saline aperients, which were given in the form of Seidlitz powders and of sulphate of magnesia, in a very diluted solution; and they were found to operate much more pleasantly and efficiently than other aperients. These, however, and the Cheltenham water itself drunk in town, were by no means so certain in their operation as the waters drunk at Cheltenham, owing, no doubt, to the want of auxiliary circumstances which are known to favour the operation of mineral waters, as change of scene, absence from the fatigue and anxiety of business, early rising, and exercise. On one occasion, when castor oil was substituted for salts, its effect was exceedingly injurious; it duly excited the action of the intestines, but as it did not render the fæces watery, they could not pass the stricture freely, and the consequence was violent spasmodic pain and vomiting.

"Drastic and heating purgatives are

very properly objected to in all cases of stricture; nevertheless, the distress of the patient on one occasion was so great for the want of evacuations, that a person of very great practical attainments was induced to propose the administrations of croton oil, the propriety of which was much discussed, on account of its irritating properties and violent action; but its employment being much urged by the proposer on the score of its unrivalled purgative power in other cases, it was exhibited in the dose of one drop, which was repeated in the space of half an hour. The effect, as was anticipated, was nearly fatal; it produced most violent contractions of the intestines, and spasmodic pains, with a distressing heat along the whole alimentary canal, and constant and urgent, but ineffectual efforts to go to stool, the scanty evacuation consisting of nothing more than a bloody secretion from the rectum, the product of excessive irritation. The violent action of the intestines led one to fear a rupture of the colon, of which the sequel of the case proved there was great danger.

"In the medical treatment of stricture of the large intestine, then, saline aperients are the best and most efficacious; and where the disease does not admit of relief by surgical interference, the physician would best consult the interest of his patient, by urging him to reside at Cheltenham or Leamington, and by the aid of warm bathing and of drinking the waters regularly, to avail himself of the means which will most certainly mitigate his sufferings and prolong his life."